Stages of Change in the Treatment of Co-occurring Disorders: Creating a Congruency
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Stages of Change in Stages of Change in the Treatment of the Treatment of Co-occurring Co-occurring Disorders: Disorders: Creating a Creating a Congruency Congruency Curtis Thornton, LMSW, CAADC, SAP Melissa Tinervia, BSW
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Stages of Change in the Treatment of Co-occurring Disorders: Creating a Congruency. Curtis Thornton, LMSW, CAADC, SAP Melissa Tinervia , BSW. The Stages of Change. Precontemplation Contemplation Preparation Action Maintenance Relapse. - PowerPoint PPT Presentation
Transcript of Stages of Change in the Treatment of Co-occurring Disorders: Creating a Congruency
Stages of Change in the Stages of Change in the Treatment of Treatment of
Co-occurring Disorders:Co-occurring Disorders: Creating a Creating a
Congruency Congruency
Stages of Change in the Stages of Change in the Treatment of Treatment of
Co-occurring Disorders:Co-occurring Disorders: Creating a Creating a
Congruency Congruency
Curtis Thornton, LMSW, CAADC, SAPMelissa Tinervia, BSW
The Stages of ChangeThe Stages of ChangeThe Stages of ChangeThe Stages of Change
• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse
Co-occurring Disorders Co-occurring Disorders and Stages of Change: Key and Stages of Change: Key
Points Points
Co-occurring Disorders Co-occurring Disorders and Stages of Change: Key and Stages of Change: Key
Points Points • An individual is not in one stage of change; they are in multiple
stages for multiple areas of life.
• The stages may differ for substance use and mental health.
• Each stage requires a specific type of intervention/technique.
• It is critical for the worker to assist the individual in obtaining SOC congruency for substance use and mental health disorders.
• Complete a comprehensive/Integrated Assessment.
What is Stage of Change What is Stage of Change (SOC) Congruency? (SOC) Congruency?
What is Stage of Change What is Stage of Change (SOC) Congruency? (SOC) Congruency?
• The individual is in the same (or complementary) SOC for mental health and substance use disorders.
• The individual is able to apply skills to address challenges of multiple disorders.
• The individual has a congruency support team consisting of self, family, peers and social service worker (if applicable).
Potential Sources of Potential Sources of Barriers Barriers
to Stage Congruency to Stage Congruency
Potential Sources of Potential Sources of Barriers Barriers
to Stage Congruency to Stage Congruency • Individual (Client, Patient, Member, etc…)
• Support System (Family, Friends, etc…)
• Social Service System (Workers, agencies, policies, etc…)
10 Common Congruency 10 Common Congruency Barriers/Source Impacted Barriers/Source Impacted 10 Common Congruency 10 Common Congruency
Barriers/Source Impacted Barriers/Source Impacted Barrier Name Individual Supports Systemic
Lack of Acceptance
X X X
Lack of Info. X X X
Fear X X X
10 Common Congruency 10 Common Congruency
Barriers/Source Impacted Barriers/Source Impacted
(Cont.) (Cont.)
10 Common Congruency 10 Common Congruency
Barriers/Source Impacted Barriers/Source Impacted
(Cont.) (Cont.) Barrier Name Individual Supports Systemic
Past Experiences
X X X
Past Diagnoses X X X
Cognitive/ Functional
Impairments
X X X
10 Common Congruency 10 Common Congruency
Barriers/Source Impacted Barriers/Source Impacted
(Cont.) (Cont.)
10 Common Congruency 10 Common Congruency
Barriers/Source Impacted Barriers/Source Impacted
(Cont.) (Cont.) Barrier Name Individual Supports Systemic
Lack of Resources
X X X
Lack of Time X X XLack of Trust X X X
Treatment Approaches
X X X
Barrier: Lack of Barrier: Lack of AcceptanceAcceptance
Barrier: Lack of Barrier: Lack of AcceptanceAcceptance
• Unable to accept more than one diagnosis.
• Thoughts and behaviors focused on supporting accepted diagnosis.
• Cognitive distortion/thinking errors prevent acceptance of additional diagnoses.
• Does not believe change is possible; sees self as having little influence.
Effective Methods in Effective Methods in Overcoming Lack of Overcoming Lack of
AcceptanceAcceptance
Effective Methods in Effective Methods in Overcoming Lack of Overcoming Lack of
AcceptanceAcceptance• Be clear about observed symptoms that led to the
diagnoses.
• Allow the client and supports to express thoughts and feelings about the diagnoses.
• Allow time for client to establish integrated thought patterns regarding multiple diagnosis - Utilize Motivational Interviewing.
• Stay away from being forceful with the diagnoses; this comes across as “labeling.”
Barrier: Lack of Info.Barrier: Lack of Info.Barrier: Lack of Info.Barrier: Lack of Info.
• Misinformation.
• Research on internet or through other means supports their accepted diagnosis.
• Experiences do not allow for the shaping of alternative perspectives.
• New information seen as harmful, even though it may be the beginning of growth/improvement.
Effective Methods in Effective Methods in Overcoming Lack of Info.Overcoming Lack of Info.
Effective Methods in Effective Methods in Overcoming Lack of Info.Overcoming Lack of Info.
• Provide easy to understand facts about the diagnoses. WATCH OUT FOR COMPLEX TERMINOLOGY!
• Learn where the client has obtained previous information.
• Maintain cultural diversity among staff - Be Sure to Include Peers.
• Allow safe place for client to explore alternative perspectives without fear of judgment.
• Warn about the dangers of information from the internet.
• Staff MUST be trained on Co-occurring Disorders.
• Teach Mask, Mimic, Exacerbate or Independence of Co-occurring Disorders.
Barrier: FearBarrier: FearBarrier: FearBarrier: Fear• How does this impact my future?
• Does this mean I’m less than?
• Did I do something wrong?
• What will people think?
• Am I capable of providing the appropriate service?
Effective MethodsEffective Methods
in Overcoming Fear in Overcoming FearEffective MethodsEffective Methods
in Overcoming Fear in Overcoming Fear• Explore the impact of diagnoses and treatment on future
goals - Focus on the benefits, as opposed to perceived consequences.
• Staff needs to trust in their abilities. They are hired for a reason. If there is a mutual doubt, discuss, reassess and reassign if needed.
• Provide information.
• Be knowledgeable and prepared to move people through the Stages of Grief.
Barrier: Past ExperiencesBarrier: Past ExperiencesBarrier: Past ExperiencesBarrier: Past Experiences
• “Treatment doesn’t work because it didn’t work before.”
• “They are just going to give me medications.”
• “My brother has Bipolar, what I have is NOT Bipolar.”
Effective Methods in Effective Methods in Overcoming Past Overcoming Past
ExperiencesExperiences
Effective Methods in Effective Methods in Overcoming Past Overcoming Past
ExperiencesExperiences• Explore circumstance, SOC and life events related to previous
attempts at change.
• Discuss ‘what didn’t work’ versus ‘what has worked.’
• Discusses changes in service delivery as a result of Recovery Oriented Systems of Care.
• Discuss the changes of signs/symptoms displayed by individuals.
• Address real life problems initially to build rapport - Don’t be afraid of small talk.
Barrier: Past DiagnosisBarrier: Past DiagnosisBarrier: Past DiagnosisBarrier: Past Diagnosis
• “I am diagnosed with Manic Depression, Bipolar, Depression, Anxiety, PTSD, Opioid Dependence and Vicodin Dependence, and now you say I have Alcohol Dependence?”
• “They tried to diagnose me with the same thing.”
• “That other agency was wrong with their diagnosis.”
Effective Methods in Effective Methods in Overcoming Past Overcoming Past
DiagnosesDiagnoses
Effective Methods in Effective Methods in Overcoming Past Overcoming Past
DiagnosesDiagnoses
• Be patient with diagnosis; don’t over diagnose.
• Assist the client in understanding that diagnoses change over time.
• Assist in understanding the purpose of diagnosing. A diagnosis without a plan is a label.
• Employ a recovery perspective.
Barrier: Cognitive/Function Barrier: Cognitive/Function ImpairmentsImpairments
Barrier: Cognitive/Function Barrier: Cognitive/Function ImpairmentsImpairments
• Individual questions their own abilities.
• Family doubts the individuals abilities and does not allow the individual the opportunity to show capabilities.
• Staff is not comfortable working with the individuals with cognitive impairments.
Effective Methods in Effective Methods in Overcoming Overcoming
Cognitive/Functional Cognitive/Functional ImpairmentsImpairments
Effective Methods in Effective Methods in Overcoming Overcoming
Cognitive/Functional Cognitive/Functional ImpairmentsImpairments
• Make a comprehensive assessment and then meet individuals “where they are at.”o No “should’s” or “need to’s”o Assess the whole person
• Assist individuals in building their self esteem through strength based case planning; maintain family meetings if possible.
• Have materials appropriate for multiple learning levels.
Barrier: Lack of ResourcesBarrier: Lack of ResourcesBarrier: Lack of ResourcesBarrier: Lack of Resources
• Individual does not know how to identify/find the available resources.
• Available resources are outside of the individual’s accessibility.
• Fewer support groups for Co-occurring Disorders - Not always welcome at AA and NA meetings.
Effective Methods in Effective Methods in Overcoming Lack of Overcoming Lack of
ResourcesResources
Effective Methods in Effective Methods in Overcoming Lack of Overcoming Lack of
ResourcesResources• Make services accessible/ remove barriers.
• Ensure continuity of care; Parallel and Sequential methods are least desirable.
• Utilize support systems to maintain and extend service effectiveness.
• Develop programs that fill in service gaps.
• COLLABORATE WITH OTHER PROVIDERS!!!!!!!
Barrier: Lack of TimeBarrier: Lack of TimeBarrier: Lack of TimeBarrier: Lack of Time
• Standardized units may not meet needs of individuals with Co-occurring Disorders(i.e. an hour may be too much or too little time to address the individual needs).
• Transportation may not be readily available.
• Between services and supports, the individual may be overwhelmed with time commitments.
• Services may interfere with other needed services offered elsewhere, or other responsibilities.
Effective Methods in Effective Methods in Overcoming Lack of TimeOvercoming Lack of Time
Effective Methods in Effective Methods in Overcoming Lack of TimeOvercoming Lack of Time• Identify the appropriate level of care: Individual counseling,
group counseling, family intervention, case management, residential treatment, intensive outpatient, contingency management, legal intervention.
• Invite individual into a teamwork relationship - Adapt plan as needed.
• Don’t rush services.
• Be flexible.
Barrier: Lack of TrustBarrier: Lack of TrustBarrier: Lack of TrustBarrier: Lack of Trust
• The individual may have had trusted information disclosed in the past.
• Individual and Supports may be embarrassed about information shared in sessions.
• Providers may assume minimization/maximization of signs/symptoms.
Effective Methods in Effective Methods in Overcoming Lack of TrustOvercoming Lack of Trust
Effective Methods in Effective Methods in Overcoming Lack of TrustOvercoming Lack of Trust
• Non-judgmental approach.
• Maintain confidentiality; discuss with client each time information is shared.
• Share only relevant information.
• Normalize the abnormal - Show individual and supports that what they have experienced is a normal reaction to an abnormal situation.
• Appropriate use of self disclosure (Professional Use).
Barrier: Treatment Barrier: Treatment ApproachesApproaches
Barrier: Treatment Barrier: Treatment ApproachesApproaches
• Individual may have had previous treatment experiences that were less than satisfactory.
• Approaches that are not individualized.
• Judgment on effectiveness of treatment (i.e. wanting a quick fix).
Effective Methods in Effective Methods in Overcoming Treatment Overcoming Treatment
ApproachesApproaches
Effective Methods in Effective Methods in Overcoming Treatment Overcoming Treatment
ApproachesApproaches
• Provide a phased approach/comprehensive array of services.
• Limit your influence on the recovery plan; focus on client’s needs/wants in his/her own words. Include family in recovery planning.
• Utilize multiple models based on individual’s strengths.
In Summary In Summary In Summary In Summary
• Co-occurring Disorders exist. Staff must be trained on how to enhance congruency.
• In order to achieve SOC congruency we cannot only identify barriers - WE MUST CREATE SOLUTIONS TO REMOVE THEM!
• Solutions require a team approach including client, worker, family, community and other social service providers. WE NEED A COMMON LANGUAGE.
BibliographyBibliography BibliographyBibliography • Arias, A. J., & Kranzler, H. R. (2008). Treatment of Co-Occurring
alcohol and other drug use disorders [Electronic version].Alcohol Research & Health, 1-9.
• August, J. L., & Flynn, A. (2007, March 5). Applying stage-wise treatment to a mixed-stage Co-occurring disorders group. American Journal of Psychiatric Rehabilitation, 10(1), 53-63. doi:10.1080.15487760601166357
• DiClemente, C. C., NiDecker, M., & Bellack, A. S. (2008). Motivation and the stages of change among individuals with severe mental illness and substance abuse disorders. Journal of Substance Abuse Treatment, 34, 25-33. doi:10.1016/j.jsat.2006.12.034
Bibliography (cont.)Bibliography (cont.) Bibliography (cont.)Bibliography (cont.) • Drake, R. E., O'Neal, E. L., & Wallach, M. A. (2008). A systematic
review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. Journal of Substance Abuse Treatment, 34, 123-138. doi:10.1016/j.jsat.2007.01.011
• El-Mallakh, P. (1998, April). Treatment models for clients with Co-occurring Addictive and Mental Disorders. Archives of Psychiatric Nursing, 7(2), 71-80.
• Mueser, K. T., & Gingrich, S. Treatment of Co-Occurring psychotic and substance use disorders. Social Work in Public Health,28(3-4), 424-439. doi:10.1080/19371918.2013.774676
BibliographyBibliography (cont.) (cont.)BibliographyBibliography (cont.) (cont.)• Sacks, S. (2007, June 5). Brief Overview of Screening and
Assessment for Co-occurring Disorders. International Journal of Mental Health Addiction, 7-17. doi:10.1007/s11469-007-9098-0
• SAMHSA. (2008). Substance Abuse Treatment for persons with Co-Occurring Disorders (Tip 42 ed., pp. 117-160). Rockville, MD: U.S. Department of Health and Human Services.
