Substance Abuse Treatment for Persons With Co-Occurring Disorders PDF
Preview Substance Abuse Treatment for Persons With Co-Occurring Disorders
Substance Abuse Treatment For Persons With Co-Occurring Disorders A Treatment Improvement Protocol TIP 42 Substance Abuse Treatment For Persons With Co-Occurring Disorders A Treatment Improvement Protocol TIP 42 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Acknowledgments Recommended Citation This publication was prepared under contract Substance Abuse and Mental Health Services number 270997072 by the Knowledge Administration. Substance Abuse Treatment Application Program (KAP), a Joint Venture of for Persons With CoOccurring Disorders. The CDM Group, Inc., and JBS International, Treatment Improvement Protocol (TIP) Inc., for the Substance Abuse and Mental Health Series, No. 42. HHS Publication No. (SMA) Services Administration (SAMHSA), U.S. 133992. Rockville, MD: Substance Abuse Department of Health and Human Services and Mental Health Services Administration, (HHS). Karl D. White, Ed.D., and Andrea 2005. Kopstein, Ph.D., M.P.H., served as the Contracting Officer’s Representatives. Originating Office Quality Improvement and Workforce Disclaimer Development Branch, Division of Services The views, opinions, and content of this pub Improvement, Center for Substance Abuse lication are those of the author and do not Treatment, Substance Abuse and Mental necessarily reflect the views, opinions, or Health Services Administration, 1 Choke policies of SAMHSA or HHS. Cherry Road, Rockville, MD 20857. HHS Publication No. (SMA) 133992 Public Domain Notice All material appearing in this report is in the First Printed 2005 public domain and may be reproduced or Revised 2007, 2008, 2011, 2012, and 2013 copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be repro duced or distributed for a fee without the spe cific, written authorization of the Office of Communications, SAMHSA, HHS. Electronic Access and Copies of Publication This publication may be ordered from or downloaded from SAMHSA’s Publications Ordering Web page at http://store.samhsa.gov. Or, please call SAMHSA at 1877SAMHSA7 (18777264727) (English and Español). ii Acknowledgments Contents What Is a TIP? ............................................................................................................ix Consensus Panel...........................................................................................................xi KAP Expert Panel and Federal Government Participants ..................................................xiii Foreword ...................................................................................................................xv Executive Summary....................................................................................................xvii Chapter 1—Introduction ................................................................................................1 Overview......................................................................................................................1 The Evolving Field of Co-Occurring Disorders ......................................................................2 Important Developments That Led to This TIP .....................................................................4 Organization of This TIP................................................................................................16 Chapter 2—Definitions, Terms, and Classification Systems for Co-Occurring Disorders ...........21 Overview ....................................................................................................................21 Terms Related to Substance Use Disorders..........................................................................22 Terms Related to Mental Disorders ...................................................................................23 Terms Related to Clients.................................................................................................26 Terms Related to Treatment ............................................................................................27 Terms Related to Programs .............................................................................................32 Terms Related to Systems ...............................................................................................33 Chapter 3—Keys to Successful Programming...................................................................37 Overview ....................................................................................................................37 Guiding Principles ........................................................................................................38 Delivery of Services.......................................................................................................41 Improving Substance Abuse Treatment Systems and Programs ................................................48 Workforce Development and Staff Support .........................................................................55 Chaper 4—Assessment .................................................................................................65 Overview ....................................................................................................................65 Screening and Basic Assessment for COD ...........................................................................66 The Assessment Process .................................................................................................71 Chaper 5—Strategies for Working With Clients With Co-Occurring Disorders......................101 Overview...................................................................................................................101 Guidelines for a Successful Therapeutic Relationship With a Client Who Has COD ....................102 Techniques for Working With Clients With COD .................................................................112 Chapter 6—Traditional Settings and Models ...................................................................137 Overview...................................................................................................................137 Essential Programming for Clients With COD ....................................................................138 Outpatient Substance Abuse Treatment Programs for Clients With COD ..................................143 Residential Substance Abuse Treatment Programs for Clients With COD ..................................161 iii Chapter 7—Special Settings and Specific Populations ......................................................183 Overview...................................................................................................................183 Acute Care and Other Medical Settings.............................................................................184 Dual Recovery Mutual Self-Help Programs........................................................................190 Specific Populations.....................................................................................................197 Chapter 8—A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues .............213 Overview...................................................................................................................213 Cross-Cutting Issues.....................................................................................................214 Personality Disorders...................................................................................................220 Mood Disorders and Anxiety Disorders.............................................................................226 Schizophrenia and Other Psychotic Disorders ....................................................................231 Attention-Deficit/Hyperactivity Disorder (AD/HD) ..............................................................235 Posttraumatic Stress Disorder (PTSD) .............................................................................238 Eating Disorders .........................................................................................................240 Pathological Gambling..................................................................................................246 Conclusion.................................................................................................................248 Chapter 9—Substance-Induced Disorders ......................................................................249 Overview...................................................................................................................249 Description ................................................................................................................249 Diagnostic Considerations .............................................................................................252 Case Studies: Identifying Disorders .................................................................................253 Appendix A—Bibliography..........................................................................................255 Appendix B—Acronyms..............................................................................................309 Appendix C—Glossary of Terms...................................................................................313 Appendix D—Specific Mental Disorders: Additional Guidance for the Counselor ..................325 Overview...................................................................................................................325 Suicidality .................................................................................................................326 Nicotine Dependence....................................................................................................333 Personality Disorders (Overview) ....................................................................................348 Borderline Personality Disorder .....................................................................................353 Antisocial Personality Disorder ......................................................................................359 Mood and Anxiety Disorders ..........................................................................................369 Schizophrenia and Other Psychotic Disorders ....................................................................385 Attention Deficit-Hyperactivity Disorder (AD/HD) ..............................................................402 Posttraumatic Stress Disorder ........................................................................................408 Eating Disorders .........................................................................................................417 Pathological Gambling..................................................................................................425 Appendix E—Emerging Models ....................................................................................437 Part I: Addresses for Models Referenced in the Text............................................................437 Part II: Other Emerging Models......................................................................................439 Programs ..................................................................................................................457 iv Contents Appendix F—Common Medications for Disorders ...........................................................459 Pharmacologic Risk Factors...........................................................................................459 A Stepwise Treatment Model ..........................................................................................461 Psychotherapeutic Medications 2004: What Every Counselor Should Know...............................463 Appendix G—Screening and Assessment Instruments .......................................................487 Addiction Severity Index (ASI) .......................................................................................487 The Alcohol Use Disorders Identification Test (AUDIT)........................................................488 Beck Depression InventoryII (BDIII) .............................................................................488 CAGE Questionnaire....................................................................................................489 Circumstances, Motivation, and Readiness Scales (CMR Scales) .............................................489 Clinical Institute Withdrawal Assessment (CIWAAr) ...........................................................490 The Drug Abuse Screening Test (DAST)............................................................................490 Global Appraisal of Individual Needs (GAIN).....................................................................491 Level of Care Utilization System (LOCUS).........................................................................491 Michigan Alcoholism Screening Test (MAST)......................................................................492 M.I.N.I. Plus .............................................................................................................492 Psychiatric Research Interview for Substance and Mental Disorders (PRISM) ...........................493 Readiness to Change Questionnaire .................................................................................493 Recovery Attitude and Treatment Evaluator (RAATE) .........................................................494 Structured Clinical Interview for DSMIV Disorders (SCIDIV)..............................................494 Substance Abuse Treatment Scale (SATS) .........................................................................495 University of Rhode Island Change Assessment (URICA) ......................................................495 Appendix H—Sample Screening Instruments ..................................................................497 Mental Health Screening FormIII...................................................................................498 Simple Screening Instrument for Substance Abuse ..............................................................499 Appendix I—Selected Sources of Training .....................................................................513 Sources of Training on Addiction Disorders .......................................................................513 Sources of Training on Mental Health ..............................................................................515 Sources of Training on CoOccurring Disorders ..................................................................515 Listservs and Discussion Groups on CoOccurring Disorders .................................................516 Appendix J—Dual Recovery Mutual SelfHelp Programs and Other Resources for Consumers and Providers...............................................................519 Dual Recovery 12Step Fellowships..................................................................................519 Supported Mutual Help for Dual Recovery........................................................................520 Other Resources for Consumers and Providers...................................................................521 Appendix K—Confidentiality .......................................................................................523 Federal Laws and the Right to Confidentiality ....................................................................523 Appendix L—Resource Panel ......................................................................................527 Appendix M—Cultural Competency and Diversity Network Participants ..............................531 Appendix N—Field Reviewers......................................................................................533 Appendix O—Acknowledgments ...................................................................................539 Index ......................................................................................................................541 SAMHSA TIPs and Publications ...................................................................................561 Contents v Figures 1-1 Persons With Alcohol, Drug Abuse, or Mental Disorder in the Past Year ............................5 1-2 Rates of Antisocial Personality, Depression, and Anxiety Disorder by Drug Dependency ........8 1-3 Substance Abuse Treatment Facilities Offering Special Programs for Clients With COD........11 2-1 Level of Care Quadrants........................................................................................29 3-1 Six Guiding Principles in Treating Clients With COD....................................................38 3-2 Levels of Program Capacity in Co-Occurring Disorders.................................................44 3-3 A Vision of Fully Integrated Treatment for COD..........................................................45 3-4 The Co-Occurring Collaborative of Southern Maine .....................................................49 3-5 Assessing the Agency’s Potential To Serve Clients With COD ..........................................51 3-6 Financing a Comprehensive System of Care for People With COD ...................................52 3-7 Essential Attitudes and Values for Clinicians Who Work With Clients Who Have COD .........57 3-8 Examples of Basic Competencies Needed for Treatment of Persons With COD ....................58 3-9 Six Areas of Intermediate-Level Competencies Needed for the Treatment of Persons With COD ..........................................................................................59 3-10 Examples of Advanced Competencies in the Treatment of Clients With COD ......................60 3-11 Treatment Planning and Documentation Issues for Mental and Substance Use Disorders.......61 3-12 Certification in Health Professions...........................................................................63 3-13 Reducing Staff Turnover in Programs for Clients With COD ..........................................64 4-1 Assessment Considerations .....................................................................................74 4-2 Sample Treatment Plan for George T. (Case 2) ............................................................96 4-3 Considerations in Treatment Matching .....................................................................97 5-1 Stages of Change ................................................................................................116 5-2 Motivational Enhancement Approaches ...................................................................117 5-3 A Four-Session Motivation-Based Intervention ..........................................................119 5-4 Checklist for Designing CM Programs......................................................................123 6-1 Engagement Interventions ....................................................................................165 6-2 Principles of Implementation ................................................................................166 6-3 Sample Training and Technical Assistance Curriculum ................................................167 6-4 Residential Interventions......................................................................................172 6-5 TC Modifications for Persons With COD..................................................................174 7-1 Criteria for Major Depressive Episode.....................................................................206 D-1 Key Questions in a Suicide Risk Review ...................................................................330 D-2 DSM-IV Criteria for Nicotine Withdrawal ................................................................341 D-3 The Fagerstrom Test for Nicotine Dependence...........................................................342 D-4 Brief Strategies for Smoking Cessation.....................................................................344 D-5 Brief Strategies 2. Components of Presriptive Relapse Prevention..................................348 D-6 Characteristics of People With Antisocial and Borderline Personality Disorders ................350 D-7 Step Work Handout for Clients With BPD................................................................360 D-8 Counseling Tips for Clients With APD .....................................................................367 D-9 Antisocial Thinking-Error Work ............................................................................368 D-10 Drugs That Precipitate or Mimic Mood Disorders.......................................................373 D-11 Engaging the Client With Chronic Psychosis .............................................................391 D-12 Biopsychosocial Assessment of High-Risk Conditions ..................................................392 D-13 AD/HD Symptom Cluster: Inattention .....................................................................403 D-14 AD/HD Symptom Cluster: Hyperactivity-Impulsivity ..................................................403 D-15 Grounding: A Coping Skill for Clients With Emotional Pain .........................................413 D-16 How Are Eating Disorders and Substance Use Disorders Related?..................................421 vi Contents D-17 General and Specific Screening Questions for Persons With Possible Eating Disorders ........422 D-18 Diagnostic Criteria for Pathological Gambling Compared to Substance Dependence Criteria..........................................................................................426 D-19 Comparison of Action and Escape Pathological Gamblers ............................................427 H-1 Sources for Items Included in the Simple Screening Instrument for Substance Abuse..........503 H-2 Simple Screening Instrument for Substance Abuse Interview Form.................................506 H-3 Simple Screening Instrument for Substance Abuse Self-Administered Form......................509 H-4 Scoring for the Simple Screening Instrument for Substance Abuse .................................511 Advice to the Counselor Boxes Chapter 2 Antisocial Personality Disorders.......................................................................................24 Psychotic Disorders.......................................................................................................25 Mood and Anxiety Disorders ...........................................................................................25 Chapter 4 Do’s and Don’ts of Assessment for COD .............................................................................67 Chapter 5 Forming a Therapeutic Alliance ......................................................................................103 Maintaining a Recovery Perspective.................................................................................105 Managing Countertransference .......................................................................................106 Monitoring Psychiatric Symptoms ...................................................................................107 Using Culturally Appropriate Methods .............................................................................111 Using Contingency Management Techniques.......................................................................125 Using Relapse Prevention Methods ..................................................................................130 Chapter 6 Recommendations for Providing Essential Services for People With COD .................................141 Treatment Principles From ACT .....................................................................................157 Treatment Principles From ICM .....................................................................................159 Recommended Treatment and Services From the MTC Model ................................................175 Chapter 7 Working With Homeless Clients With COD ........................................................................200 Providing Community Supervision for Offenders With COD ..................................................202 Treatment Principles and Services for Women With COD .....................................................210 Chapter 8 Counseling a Client Who Is Suicidal.................................................................................215 Counseling a Client With Borderline Personality Disorder ....................................................222 Counseling a Client With an Anxiety or Mood Disorder ........................................................229 Counseling a Client With a Psychotic Disorder ...................................................................234 Counseling a Client Who Has AD/HD ...............................................................................237 Counseling a Client With PTSD ......................................................................................241 Counseling a Client With an Eating Disorder......................................................................245 Counseling a Client With Pathological Gambling Disorder.....................................................248 Contents vii What Is a TIP? Treatment Improvement Protocols (TIPs) are developed by the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). Each TIP involves the development of topicspecific bestpractice guidelines for the preven tion and treatment of substance use and mental disorders. TIPs draw on the experience and knowledge of clinical, research, and administrative experts of various forms of treatment and prevention. TIPs are dis tributed to facilities and individuals across the country. Published TIPs can be accessed via the Internet at http://store.samhsa.gov. Although each consensusbased TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that behavioral health is continually evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "frontline" information quickly but responsibly. If research supports a particular approach, citations are provided. ix Consensus Panel Chair Joan E. Zweben, Ph.D. Executive Director Stanley Sacks, Ph.D. The 14th Street Clinic and Medical Group Director East Bay Community Recovery Project Center for the Integration of Research and University of California Practice Berkeley, California National Development and Research Institutes, Inc. Panelists New York, New York Betty Blackmon, M.S.W., J.D. Parker-Blackmon and Associates Co-Chair Kansas City, Missouri Richard K. Ries, M.D. Director/Professor Steve Cantu, LCDC, CADAC, RAS Outpatient Mental Health Services Clinical Program Coordinator Dual Disorder Programs South Texas Rural Health Services, Inc. Harborview Medical Center Cotulla, Texas Seattle, Washington Catherine S. Chichester, M.S.N., R.N., CS Executive Director Workgroup Leaders Co-Occurring Collaborative of Southern Donna Nagy McNelis, Ph.D. Maine Director, Behavioral Healthcare Education Portland, Maine Associate Professor, Psychiatry Colleen Clark, Ph.D. Drexel University Research Associate School of Medicine Department of Community Mental Health Philadelphia, Pennsylvania University of South Florida David Mee-Lee, M.D., FASAM Tampa, Florida DML Training and Consulting Christie A. Cline, M.D., M.B.A. Davis, California Medical Director James L. Sorenson, Ph.D. Behavioral Health Sciences Division Department of Psychiatry New Mexico Department of Health San Francisco General Hospital Santa Fe, New Mexico San Francisco, California Raymond Daw, M.A. Douglas Ziedonis, M.D. Executive Director Director, Addiction Services Na’nizhoozhi Center, Inc. University Behavioral Healthcare System Gallup, New Mexico Piscataway, New Jersey xi
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