Lesson 13: Co-occurring Disorders - Part 2


Attention

Read and Reflect on this Article on Dual Diagnosis

two circles intersected.  ONe is substance abuse the other is mental illness, the intersecton is dual diagnosis

CLICK HERE


Learning Outcomes

Upon completion of this lesson's material, students will

  • Understand and be able to state the issues with "dual diagnosis" clients and similarities and differences with other SMI clients
  • State how a "recovery" approach works with people who have various disorders
  • State how psychosocial rehabilitation works with people who have disabilities
  • State who is qualified to work with dual diagnosis clients and what qualifications they may possess

Teaching

Stigma and Mental Illness

"Mental Illnesses" have often been considered separately from Substance Use Disorders. This is probably more a reflection of psychiatric politics than empirical fact.

There has been a long struggle to destigmatize mental illness which in the past had often been seen as a shameful problem and a reflection of a weak mind or defective character.

A parallel process was taking place with alcohol and drug problems which had long been seen as primarily "sin" with the remedy being repentance and reform

In the 1980's the "Broken Brain" model began to take over for anxiety, depression and other mental illnesses
By the 1990's many mental illnesses were considered "biologically based", that is to say that the primary determinant was not behavioral or psychological or sociological but neurological

Stigma and Alcohol

A parallel process was taking place about the same time with issues related to alcohol being decriminalized so that people were asked to go to treatment rather than the drunk tank.
Drugs continue to provoke more ire and judgement than alcohol perhaps because we have chosen by-in-large to make their possession and use criminal matters in contradistinction to alcohol (which actually causes more disability)
In any case, the conclusion is that all mental disorders are biologically based with psychological, social, and spiritual dimensions. As we try to understand the causes and seek effective treatments, we begin with the neurological substrate but also include all other dimensions that are relevant to preventing and treating the disorders.

Is it harder to treat "dual diagnosis" than single diagnosis?

  • Treat the person not the disorder
  • Help them to identify what they want and need
  • Help them to set their own priorities and weigh risks and benefits
  • Get and give them the help they need
  • Empower them to do most of what needs to be done
  • Help them find resources

The points made above are all part of the demystification of working with people with co-occurring disorders. We don't treat a person who is alcoholic and schizophrenic but rather the person struggling to live with these as well as other complex issues. Do we need special knowledge or special tools beyond the basic principles of psychosocial rehabilitation? Amazingly enough, "No!" What we need is to find out how the person views him/herself, his/her world and his/her issues and then to help them set their priorities based on what they want out of life. Most people when interviewed in an empathic accepting way will spontaneously affirm that they don't want to live with the consequences of untreated addiction and mental health problems.

If they do not affirm the need for help, we need to accept this and give them space while staying in touch.
What often prevents us from doing this is the anxiety of friends, relatives, agencies, law enforcement, DHHS about how the person is behaving. And we can continue to work with all of these both as advocates for our client and as messengers to our clients for these often very legitimate concerns.

Where special knowledge and special tools come in is as we explore with the client ways to address their concerns. At that point we need to know about medications and therapies and how co-occurring disorders affect one another. But what we do as MHRT/C's is simply to keep on applying the principles of psycho-social rehab whether we are dealing with a person who only has a mental illness or whether they also have a SUD or even a triple diagnosis with a developmental disorder. We help as community support workers to set goals and plans for achieving the goals; we help as case managers to find resources, to support the work of other professionals helping our client, and to plan for the early, middle and late stages of recovery.

Click the graphic to visit Co-Occurring Disorders | SAMHSA

Other professionals you can refer to:

  • Psychiatrists (including psychiatric nurse practitioners) . Before referring you can ask about whether they work with addictions. Some don't.
  • Physicians who are certified to prescribe Suboxone (Click on this to find a Maine Suboxone doctor)
  • Regular physicians. Often the client's Primary Care Physician will be willing to refer or even begin prescribing helpful meds.
  • Therapists/Counselors including LMSWs, LCSWs, LCPCs, LADCs (click on these to find descriptions of these licensed therapists)
  • Alcohol and Drug treatment programs (click on this to find a Maine Treatment Program)

Why has treating dual diagnosis traditionally been considered to be a specialty for "experts"?

  • Stigma. In the past, people who had mental illness and their families did not want them to be classified with drug addicts and alcoholics. They had worked hard enough to shed their own stigma and didn't want to have to go through that again. But the 50% or greater co-occurrence of MI and SUD has forced a re-evaluation.
  • Laziness. Unfortunately providers are people and people generally don't want to do more than they have to. So it's often easier to say, I don't have the expertise than to dig in and start helping the best you can. Don't be that way! But it's also good to humbly know your limits and when you genuinely don't have skills that you appear to need or self-confidence or motivation to back off and help your client find someone else.
  • Ignorance. Sometimes we buy what others are saying about how difficult these people are (and they sometimes do seem more troubled than single diagnosis clients) rather than sorting it out for ourselves. Hopefully after taking this course, you will not fit in this category.
  • The remedy is learning how to do our best to help people where they're at.

Change from ineffective and unhappy and dysfunctional to effective, happy and doing well is the key.

  • May involve meds
  • But also its new habits and a new lifestyle
  • Learning to live with our disease: RECOVERY (read this to find out how recovery describes what we do both with SMIs and SUDs)
  • Recovery is not just an AA term and is not just about abstinence but is all about learning to live the best you can with what you’ve got

The old "wisdom": therapy doesn't work for SMIs

  • New wisdom based on research: cognitive and behavioral therapies can be highly effective in helping people to cope with their disorders
  • Even paranoid schizophrenia can be ameliorated with Motivational Interviewing and helping the person to challenge thoughts that lead them to trouble
  • Changing thoughts, feelings and behaviors to ones that work better is effective for everyone!

The key is a Rehabilitation Approach

  • The person has a disability which may result in handicaps (e.g. a person with Major Depression who has low energy and low expectations for themselves which keep them from work and socialization, or a person with anxiety and alcoholism who can't leave their house to go to OP treatment) and barriers (e.g. people don't want to be around you because you're so gloomy or people won't hire you because you've been convicted of a drug crime)
  • The MHRT works to help the person develop skills and find resources to deal with handicaps and get accommodations to deal with barriers. A resource here are the legal remedies provided by state and Federal Disability Acts (ADA). The MHRT/C can be the link between the client and the Maine Human Rights Commission
  • Same work for dual diagnosis: no mystery, no difference
  • Rehabilitation and Recovery: learning to live life on life's terms

Assessment

Lesson 13 Quiz

  1. Review the six principles that are listed beginning with "Treat the person, not the disorder". Write a paragraph about each principle listed and how you would implement that principle with a client who is currently a heavy drinker and has bipolar disorder (5 points for each principle successfully elucidated up to a total of 30 points).
  2. How are Dual Diagnosis clients similar to and different from single diagnosis SMI clients? (10 points for similarities and 10 points for differences).
  3. Both Alcohol treatment and psychosocial rehab have a "recovery" approach. What does this mean in each case (10 points for AUD and 10 points for psychosocial rehab). What are the similarities and differences between the two "recovery" approaches (5 points for similarities and 5 points for differences).
  4. How can MHRT/Cs work with each of the five categories of  “Other professionals you can refer to” who help people with SUDs  (20 points)

Lesson 13 Discussion

Imagine that you are a person with a co-occurring SMI and SUD. Write a few paragraphs on 1) attitudes, 2) experience and 3) knowledge that you would want from an MHRT/C assigned to your case. What would make you talk to the worker's supervisor or ask to be assigned to a different worker?