TREATING CLIENTS WITH COOCCURRING DISORDERS Mark Haskins 1

TREATING CLIENTS WITH CO-OCCURRING DISORDERS Mark Haskins 1

Co-Occurring Disorders �Substance use disorder + other mental health disorder �DSM-IV TR � 112 Primary mental health disorders (Axis I) � 11 Personality disorders (Axis II) � 13 Primary substance use disorders �Heterogeneous �Each client is unique 2

Rates and Risks Frequency of co-occurrence and increased risk factor �Bi-polar Disorder 60% � 6. 6 times more likely than general population �Schizophrenia 47% � 4. 6 times … �Affective Disorders 32% � 1. 9 times … �Anxiety Disorder 36% � 1. 7 times … �Obsessive-Compulsive Disorder 33% � 2. 5 times … (Epidemiological Catchment Area Study, Regier et al. , 1990) 3

Drugs, Alcohol and SMI Question Do drugs and alcohol work to reduce psychiatric symptoms for individuals with significant mental illness (SMI) ? __Yes __No 4

Drugs, Alcohol and SMI Answer Yes, drugs and alcohol may provide transient (short term) symptom reduction …but, No, long-term effects of drug and alcohol use by individuals with significant mental illness include � symptom exacerbations � increased rate of hospitalization Alcohol Use Disorder and Severe Mental Illness, Drake and Mueser, 1996; Integrated Treatment of Dual Disorders, Mueser et al. , 2003; Acute Effect of Drug Abuse in Schizophrenic Patients: Clinical Observations and Patients’ Self Reports, Dixon et al. , 1990 5

Treatment Challenges � Treatment that is not integrated � Historical models: two separate treatment paths � � Mental Health (deinstitutionalization) Substance Abuse (self-help) � Substance Use Disorders in persons with severe mental illness often unrecognized by MH providers � Lack of standard screening and evaluation procedures � Clinician’s focus on MH or SA � Paucity of resources � Crisis management only 6

Treatment Recommendations �Integrated treatment �Longitudinal �Stage-wise �Start early �Cross-training �Improved screening and evaluation procedures �Increase clinician awareness �Assessment instruments �Teamwork 7

Treatment Methods �Dialectical Behavior Therapy (an example) � Stresses integrated team approach � Longitudinal treatment course � Evidence-based results �Need for prolonged engagement � No quick fixes � Therapeutic engagement based on genuine empathy (Cognitive Behavioral Treatment of Borderline Personality Disorder, M. Linehan, 1993; Dialectical Behavior Therapy in Clinical Practice: Applications across disorders and settings, Dimeff & Koerner, 2007) 8

Treatment Stigma �Effects of incarceration � No increased rates of mental health disorders while incarcerated � Increased risk of health & mental health disorders post release �Overburdened agencies and clinics � Limiting services by blaming clients � Is this a form of rationing? � What is the solution? Enduring Stigma: The Long-Term Effects of Incarceration on Health. Schnittker & John, (2007) 9

Summary �High prevalence of SUD for persons with significant mental illness. �Need to engage in genuinely empathetic and honest therapeutic relationships �Training and Treatment Methods �Integrated Treatment �Shared Community Responsibility 10