TIP #42: Substance Abuse Treatment for Persons with Co-Occurring Disorders

2005·2.1 MB·English

by  Sacks, Stanley, Ries, Richard K.

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
CO-OCCURRING
www.samhsa.gov
DISORDERS
Substance Abuse Treatment
For Persons With
Co-Occurring Disorders
This TIP, Substance Abuse Treatment for Persons With
Co-Occurring Disorders, revises TIP 9, Assessment and Treatment
of Patients With Coexisting Mental Illness and Alcohol and Other
Drug Abuse. The revised TIP provides information about new
developments in the rapidly growing field of co-occurring
substance use and mental disorders and captures the state-of-
the-art in the treatment of people with co-occurring
disorders. The TIP focuses on what the substance abuse treat-
ment clinician needs to know and provides that information in
an accessible manner. The TIP synthesizes knowledge and
grounds it in the practical realities of clinical cases and real situ-
ations so the reader will come away with increased knowledge,
encouragement, and resourcefulness in working with clients
with co-occurring disorders.
Collateral Products
Based on TIP 42
Quick Guide For Clinicians
KAP Keys For Clinicians
Quick Guide for Administrators
Quick Guide for Mental Health Providers
DHHS Publication No. (SMA) 05-3992
Printed 2005
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
CO-OCCURRING
DISORDER
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Substance Abuse Treatment
for Persons With
Co-Occurring Disorders
Stanley Sacks, Ph.D.
Consensus Panel Chair
Richard K. Ries, M.D.
Consensus Panel Co-Chair
A Treatment
Improvement
Protocol
TIP
42
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
1 Choke Cherry Road
Rockville, MD 20857
Acknowledgments document are intended or should be inferred.
The guidelines in this document should not be
Numerous people contributed to the develop-
considered substitutes for individualized client
ment of this TIP (see pp. xi, xiii, and appen-
care and treatment decisions.
dices L, M, and N). This publication was pro-
duced by The CDM Group, Inc. under the
Knowledge Application Program (KAP) con- Public Domain Notice
tract, number 270-99-7072 with the Substance
All materials appearing in this volume except
Abuse and Mental Health Services
those taken directly from copyrighted sources
Administration (SAMHSA), U.S. Department
are in the public domain and may be repro-
of Health and Human Services (DHHS). Karl
duced or copied without permission from
D. White, Ed.D., and Andrea Kopstein,
SAMHSA/CSAT or the authors. Do not repro-
Ph.D., M.P.H., served as the Center for
duce or distribute this publication for a fee
Substance Abuse Treatment (CSAT)
without specific, written authorization from
Government Project Officers. Christina
SAMHSA’s Office of Communications.
Currier served as the CSAT TIPs Task Leader.
Rose M. Urban, M.S.W., J.D., LCSW, CCAC,
CSAC, served as the CDM KAP Executive Electronic Access and Copies
Deputy Project Director. Elizabeth Marsh
of Publication
served as the CDM KAP Deputy Project
Director. Shel Weinberg, Ph.D., served as the Copies may be obtained free of charge from
CDM KAP Senior Research/Applied SAMHSA’s National Clearinghouse for Alcohol
Psychologist. Other KAP personnel included and Drug Information (NCADI), (800) 729-
Raquel Witkin, M.S., Deputy Project 6686 or [phone]; TDD (for hearing
Manager; Susan Kimner, Managing Editor; impaired), [phone], or electronically
Deborah Steinbach, Senior Editor/Writer; and through the following Internet World Wide
Erica Flick, Editorial Assistant. In addition, Web site: www.ncadi.samhsa.gov.
Sandra Clunies, M.S., I.C.A.D.C., served as
Content Advisor. Special thanks go to Susan
Recommended Citation
Hills, Ph.D., for serving as Co-Editor on this
TIP, and Doug Ziedonis, M.D., for his contri- Center for Substance Abuse Treatment.
bution to chapter 8. Jonathan Max Gilbert, Substance Abuse Treatment for Persons With
M.A., Margaret K. Hamer, M.P.A., Randi Co-Occurring Disorders. Treatment
Henderson, B.A., Susan Hills, Ph.D., and Improvement Protocol (TIP) Series 42. DHHS
David Shapiro, M.S., M.Ed., were writers. Publication No. (SMA) 05-3992. Rockville,
Appendix K was prepared by Margaret MD: Substance Abuse and Mental Health
Brooks, J.D., and SAMHSA staff in consulta- Services Administration, 2005.
tion with the Office of the General Counsel, the
U.S. Department of Health and Human
Originating Office
Services, Washington, D.C.
Practice Improvement Branch, Division of
Services Improvement, Center for Substance
Disclaimer
Abuse Treatment, Substance Abuse and Mental
The opinions expressed herein are the views of Health Services Administration, 1 Choke
the Consensus Panel members and do not nec- Cherry Road, Rockville, MD 20857.
essarily reflect the official position of CSAT,
DHHS Publication No. (SMA) 05-3992
SAMHSA, or DHHS. No official support of or
endorsement by CSAT, SAMHSA, or DHHS
Printed 2005
for these opinions or for particular instru-
ments, software, or resources described in this
ii Acknowledgments
Contents
What Is a TIP? ............................................................................................................ix
Consensus Panel ..........................................................................................................xi
KAP Expert Panel and Federal Government Participants ..................................................xiii
Foreword...................................................................................................................xv
Executive Summary ...................................................................................................xvii
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
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
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
4 Assessment..............................................................................................................65
Overview....................................................................................................................65
Screening and Basic Assessment for COD ...........................................................................66
The Assessment Process.................................................................................................71
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
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
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
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
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 Inventory-II (BDI-II).............................................................................488
CAGE Questionnaire....................................................................................................489
Circumstances, Motivation, and Readiness Scales (CMR Scales).............................................489
Clinical Institute Withdrawal Assessment (CIWA-Ar)...........................................................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 DSM-IV Disorders (SCID-IV)..............................................494
Substance Abuse Treatment Scale (SATS).........................................................................495
University of Rhode Island Change Assessment (URICA)......................................................495
Appendix H: Sample Screening Instruments...................................................................497
Mental Health Screening Form-III...................................................................................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 Co-Occurring Disorders..................................................................515
Listservs and Discussion Groups on Co-Occurring Disorders ................................................516
Appendix J: Dual Recovery Mutual Self-Help Programs and
Other Resources for Consumers and Providers...............................................................519
Dual Recovery 12-Step 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
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