treating addiction and other mental disorders: clinical issues cutting edge 2004 palmerston north,...

Treating Addiction and Other Mental Disorders:

Clinical Issues Cutting Edge 2004

Palmerston North, New ZealandSeptember 3, 2004

Treating Addiction and Other Mental Disorders:

Clinical Issues Cutting Edge 2004

Palmerston North, New ZealandSeptember 3, 2004

Joan E. Zweben, Ph.D.Joan E. Zweben, Ph.D.Executive Director: EBCRP and 14Executive Director: EBCRP and 14thth Street Clinic Street Clinic

Clinical Professor of Psychiatry; University of California, San FranciscoClinical Professor of Psychiatry; University of California, San Francisco



General Treatment ConsiderationsGeneral Treatment Considerations Need for realistic expectationsNeed for realistic expectations Offer appropriate forms of hope to Offer appropriate forms of hope to

counteract despaircounteract despair Accept chronicity of the disorder without Accept chronicity of the disorder without

viewing self as a failure or using this as an viewing self as a failure or using this as an excuseexcuse

Educate about other mental disorders as Educate about other mental disorders as well as AOD usewell as AOD use

Prioritizing Treatment TasksPrioritizing Treatment Tasks

SafetySafety StabilizationStabilization Development/growthDevelopment/growth Maintenance of gains; relapse preventionMaintenance of gains; relapse prevention

Psychosocial Treatment Issues Psychosocial Treatment Issues

client attitudes/feelings about medicationclient attitudes/feelings about medication client attitude about having an illnessclient attitude about having an illness other clients’ reactions: misinformation, other clients’ reactions: misinformation,

negative attitudesnegative attitudes staff attitudesstaff attitudes medication compliancemedication compliance control issues: whose client?control issues: whose client?

History & Current ContextHistory & Current Context

patients referred from other services with patients referred from other services with insufficient attention to motivationinsufficient attention to motivation

no specific arena to address ambivalenceno specific arena to address ambivalence ““Wait until they are ready”Wait until they are ready” AOD programs: discharge for non-AOD programs: discharge for non-

compliance with high expectationscompliance with high expectations discovery that untreated substance abuse is discovery that untreated substance abuse is

expensiveexpensive

Reasons to Resist an Abstinence CommitmentReasons to Resist an Abstinence Commitment

fear of failurefear of failure addiction pattern in family of originaddiction pattern in family of origin self medicationself medication trauma historytrauma history survivor guiltsurvivor guilt

Negotiating an Abstinence CommitmentNegotiating an Abstinence Commitment Connect AOD use with presenting complaintsConnect AOD use with presenting complaints facilitate progress through initial decision facilitate progress through initial decision

making phases of changemaking phases of change blend careful inquiry, giving information, blend careful inquiry, giving information,

gentle confrontationgentle confrontation experiment with abstinence; sobriety samplingexperiment with abstinence; sobriety sampling enhance motivation, vs punish ambivalenceenhance motivation, vs punish ambivalence

Motivational EnhancementMotivational Enhancement

Your relationship is a great asset, in addition to Your relationship is a great asset, in addition to your leverageyour leverage

Identify where people are on the continuum of Identify where people are on the continuum of readiness to change and move them forwardreadiness to change and move them forward

Connect the pain in their life with AOD useConnect the pain in their life with AOD use Explore benefits and problems of AOD useExplore benefits and problems of AOD use Use forthright feedback that is not harsh or Use forthright feedback that is not harsh or

punitivepunitive Offer options for changeOffer options for change

ConfrontationConfrontation Many practices are believed helpful because Many practices are believed helpful because

we don’t follow our dropoutswe don’t follow our dropouts Firm feedback needed in supportive Firm feedback needed in supportive

atmosphereatmosphere More disturbed clients are highly vulnerable More disturbed clients are highly vulnerable

to aggressive exchanges and become to aggressive exchanges and become disorganized; they do better with low levels disorganized; they do better with low levels of expressed emotionof expressed emotion

Educate Clients about Psychiatric ConditionsEducate Clients about Psychiatric Conditions The nature of common disorders; usual The nature of common disorders; usual

course; prognosiscourse; prognosis Important factors: genetics, traumatic and Important factors: genetics, traumatic and

other stressors, environmentother stressors, environment Recognizing warning signsRecognizing warning signs Maximizing recovery potentialMaximizing recovery potential Misunderstandings about medicationMisunderstandings about medication Teamwork with your physicianTeamwork with your physician

Barriers to Accessing Offsite Psychiatric ServicesBarriers to Accessing Offsite Psychiatric Services Distance, travel limitationsDistance, travel limitations Obstacle of enrolling in another agencyObstacle of enrolling in another agency Stigma of mental illnessStigma of mental illness CostCost Fragmentation of clinical servicesFragmentation of clinical services Becoming accustomed to new staffBecoming accustomed to new staff

(COD TIP, in press)(COD TIP, in press)

Prescribing Psychiatrist OnsitePrescribing Psychiatrist Onsite

Brings diagnostic, behavioral and Brings diagnostic, behavioral and medication services to the clientsmedication services to the clients

Psychiatrist learns about substance abusePsychiatrist learns about substance abuse Case conferences, supervision allow Case conferences, supervision allow

counselors to learn more about dx and txcounselors to learn more about dx and tx Better retention and outcomesBetter retention and outcomes


Attitudes and Feelingsabout MedicationAttitudes and Feelingsabout Medication shameshame feeling damagedfeeling damaged needing a crutch; not strong enoughneeding a crutch; not strong enough ““I’m not clean”I’m not clean” anxiety about taking a pill to feel betteranxiety about taking a pill to feel better ““I must be crazy”I must be crazy” medication is poisonmedication is poison expecting instant resultsexpecting instant results

Medication AdherenceMedication Adherence important relationship to positive treatment important relationship to positive treatment

outcomeoutcome reasons for non-compliance: denial of illness, reasons for non-compliance: denial of illness,

attitudes and feelings, side effects, lack of attitudes and feelings, side effects, lack of support, other factorssupport, other factors

role of the counselor: periodic inquiry, role of the counselor: periodic inquiry, exploring charged issues, keeping physician exploring charged issues, keeping physician informedinformed

Work out teamwork, procedures with docsWork out teamwork, procedures with docs

Treating Co-Occurring Mental Disorders: Depression & PTSD

Treating Co-Occurring Mental Disorders: Depression & PTSD





Mood & Anxiety Disorders: Counselor RecommendationsMood & Anxiety Disorders: Counselor Recommendations Distinguish anxiety and mood disorders Distinguish anxiety and mood disorders

from:from: Normal feelings in recoveryNormal feelings in recovery Symptoms of severe mental illnessSymptoms of severe mental illness Medical conditionsMedical conditions Medication side effectsMedication side effects Substance-induced changesSubstance-induced changes

(COD TIP, in (COD TIP, in press)press)

Mood & Anxiety Disorders:Counselor Recommendations (2) Mood & Anxiety Disorders:Counselor Recommendations (2) Maintain calm demeanor, reassuring presenceMaintain calm demeanor, reassuring presence Teach deep breathing, relaxationTeach deep breathing, relaxation Start low, go slowStart low, go slow Respond immediately to any intensification of Respond immediately to any intensification of

symptomssymptoms Understand special sensitivities to social situationsUnderstand special sensitivities to social situations Gradually introduce and teach skills for Gradually introduce and teach skills for

participation in self-help groupsparticipation in self-help groups (COD TIP, in (COD TIP, in

press)press)

SuicidalitySuicidality AOD use is a major risk factor, especially AOD use is a major risk factor, especially

for young peoplefor young people Alcohol: associated with 25%-50%Alcohol: associated with 25%-50% Alcohol & depression = increased riskAlcohol & depression = increased risk Intoxication is associated with increased Intoxication is associated with increased

violence, towards self and othersviolence, towards self and others High risk when relapse occurs after High risk when relapse occurs after

substantial period of sobriety, especially if substantial period of sobriety, especially if it leads to financial or psychosocial lossit leads to financial or psychosocial loss


Suicidality: Counselor RecommendationsSuicidality: Counselor Recommendations Treat all threats with seriousnessTreat all threats with seriousness Assess risk of self harm: Why now? Past attempts, Assess risk of self harm: Why now? Past attempts,

present plans, serious mental illness, protective present plans, serious mental illness, protective factorsfactors

Develop safety and risk management processDevelop safety and risk management process Avoid heavy reliance on “no suicide” contractsAvoid heavy reliance on “no suicide” contracts 24 hour contact available until psychiatric help 24 hour contact available until psychiatric help

can be obtainedcan be obtained

Note: must have agency protocols in placeNote: must have agency protocols in place (COD TIP, in press)(COD TIP, in press)

Elements of PTSD Elements of PTSD Acting or feeling as if the traumatic event were Acting or feeling as if the traumatic event were

recurringrecurring Intense psychological distress at exposure to Intense psychological distress at exposure to

internal or external cues that symbolize or internal or external cues that symbolize or resemble an aspect of the traumatic eventresemble an aspect of the traumatic event

Physiological reactivity on exposure to internal Physiological reactivity on exposure to internal or external cues that symbolize or resemble an or external cues that symbolize or resemble an aspect of the traumatic eventaspect of the traumatic event

Intrusion symptoms and/or numbing symptomsIntrusion symptoms and/or numbing symptoms

Complex PTSDComplex PTSD

Alterations in:Alterations in: Affect regulationAffect regulation ConsciousnessConsciousness Self perceptionSelf perception Perception of perpetratorPerception of perpetrator Relations with othersRelations with others Systems of meaningSystems of meaning

Treatment IssuesTreatment Issues

Relationships between Trauma and Substance AbuseRelationships between Trauma and Substance Abuse Traumatic experiences increase likelihood of Traumatic experiences increase likelihood of

substance abuse, especially if PTSD developssubstance abuse, especially if PTSD develops Childhood trauma increases risk of PTSD, Childhood trauma increases risk of PTSD,

especially if it is multiple traumaespecially if it is multiple trauma Substance abuse increases the risk of Substance abuse increases the risk of

victimizationvictimization Need for linkages between systems: medical, Need for linkages between systems: medical,

shelters, social services, mental health, criminal shelters, social services, mental health, criminal justice, addiction treatmentjustice, addiction treatment

(Zweben et al 1994)(Zweben et al 1994)

PTSDCounselor RecommendationsPTSDCounselor Recommendations Identify clients who are high riskIdentify clients who are high risk Develop a plan for increased safetyDevelop a plan for increased safety Listen to behavior more than wordsListen to behavior more than words Limit questioning about details of the Limit questioning about details of the

traumatrauma Help client de-escalate intense emotionsHelp client de-escalate intense emotions Teach coping skillsTeach coping skills Prepare client for long term treatmentPrepare client for long term treatment


How PTSD Complicates RecoveryHow PTSD Complicates RecoveryMore difficulty:More difficulty: establishing trusting therapeutic alliance establishing trusting therapeutic alliance obtaining abstinence commitment; resistance to obtaining abstinence commitment; resistance to

the idea that AOD use is itself a problemthe idea that AOD use is itself a problem establishing abstinence; flooding with feelings and establishing abstinence; flooding with feelings and

memoriesmemories maintaining abstinence; greater relapse maintaining abstinence; greater relapse

vulnerabilityvulnerability

Impact of Physical/Sexual Abuse on Treatment OutcomeImpact of Physical/Sexual Abuse on Treatment Outcome

N=330; 26 outpatient programs; 61% women and 13% N=330; 26 outpatient programs; 61% women and 13% men experienced sexual abusemen experienced sexual abuse

abuse associated with more psychopathology for both; abuse associated with more psychopathology for both; sexual abuse has greater impact on women, physical sexual abuse has greater impact on women, physical abuse has more impact on menabuse has more impact on men

psychopathology is typically associated with less psychopathology is typically associated with less favorable tx outcomes, however:favorable tx outcomes, however:

abused clients just as likely to participate in counseling, abused clients just as likely to participate in counseling, complete tx and remain drug-free for 6 months post txcomplete tx and remain drug-free for 6 months post tx

(Gil Rivas et al 1997)(Gil Rivas et al 1997)

How Substance Abuse Complicates Resolution of PTSDHow Substance Abuse Complicates Resolution of PTSD early treatment goal: establish safety (address AOD early treatment goal: establish safety (address AOD

use)use) early recovery: how to contain or express feelings and early recovery: how to contain or express feelings and

memories without drinking/usingmemories without drinking/using firm foundation of abstinence needed to work on firm foundation of abstinence needed to work on

resolving PTSD issuesresolving PTSD issues full awareness desirable, vs emotions altered by AOD full awareness desirable, vs emotions altered by AOD

useuse relapse risk: AOD use possible when anxiety-laden relapse risk: AOD use possible when anxiety-laden

issues arise; must be immediately addressedissues arise; must be immediately addressed

Building a FoundationBuilding a Foundation

BEWARE OF DOGMABEWARE OF DOGMA

May need to work with client who continues to drink May need to work with client who continues to drink or use for a long timeor use for a long time

avoid setting patient up for failureavoid setting patient up for failure reduce safety hazards; contract about dangerous reduce safety hazards; contract about dangerous

behaviorbehavior carefully assess skills for coping with feelings and carefully assess skills for coping with feelings and

memories; work to develop themmemories; work to develop them

Possible Meanings of Drug Use in the Context of PTSDPossible Meanings of Drug Use in the Context of PTSD

Access feelings and memoriesAccess feelings and memories Shut off feelings and memoriesShut off feelings and memories Revenge against the abuserRevenge against the abuser Re-abuse of selfRe-abuse of self Slow suicideSlow suicide Learned behaviorLearned behavior

(Najavits, 2001) (Najavits, 2001)

Trauma & Recovery:Stages of HealingTrauma & Recovery:Stages of Healing

““Recovery is based on the empowerment of Recovery is based on the empowerment of the survivor and the creation of new the survivor and the creation of new connections.”connections.”

SafetySafety MourningMourning ReconnectionReconnection

(Herman, 1992)(Herman, 1992)

Seeking Safety:Early Treatment StabilizationSeeking Safety:Early Treatment Stabilization

25 sessions, group or individual format25 sessions, group or individual format Safety is the priority of this first stage txSafety is the priority of this first stage tx Treatment of PTSD and substance abuse are Treatment of PTSD and substance abuse are

integrated, not separate integrated, not separate Restore ideals that have been lostRestore ideals that have been lost

Denial, lying, false self – to honestyDenial, lying, false self – to honesty Irresponsibility, impulsivity – to commitmentIrresponsibility, impulsivity – to commitment

Seeking Safety: (2)Seeking Safety: (2)

Four areas of focus:Four areas of focus: CognitiveCognitive BehavioralBehavioral InterpersonalInterpersonal Case managementCase management

Grounding exercise to detach from emotional painGrounding exercise to detach from emotional pain Attention to therapist processes: balance praise Attention to therapist processes: balance praise

and accountability; notice therapists’ reactionsand accountability; notice therapists’ reactions

Seeking Safety (3):GoalsSeeking Safety (3):Goals Achieve abstinence from substancesAchieve abstinence from substances Eliminate self-harmEliminate self-harm Acquire trustworthy relationshipsAcquire trustworthy relationships Gain control over overwhelming symptomsGain control over overwhelming symptoms Attain healthy self-careAttain healthy self-care Remove self from dangerous situations Remove self from dangerous situations

(e.g., domestic abuse, unsafe sex)(e.g., domestic abuse, unsafe sex)(Najavits, 2002)(Najavits, 2002)

Safe Coping SkillsSafe Coping Skills Ask for helpAsk for help Honesty Honesty Leave a bad sceneLeave a bad scene Set a boundarySet a boundary When in doubt, do what is hardestWhen in doubt, do what is hardest Notice the choice pointNotice the choice point Pace yourselfPace yourself Seek understanding, not blameSeek understanding, not blame Create a new story for yourselfCreate a new story for yourself

( from Handout in Najavits, 2002)( from Handout in Najavits, 2002)

Detaching From Emotional Pain:GroundingDetaching From Emotional Pain:Grounding

Focusing out on external world - keep eyes Focusing out on external world - keep eyes open, scan the room, name objects you seeopen, scan the room, name objects you see

Describe an everyday activity in detailDescribe an everyday activity in detail Run cool or warm water over your handsRun cool or warm water over your hands Plan a safe treat for yourselfPlan a safe treat for yourself Carry a grounding object in your pocket to Carry a grounding object in your pocket to

touch when you feel triggeredtouch when you feel triggered Use positive imageryUse positive imagery

(Najavits, 2002)(Najavits, 2002)

EMDREMDREye Movement Desensitization and Eye Movement Desensitization and

ReprocessingReprocessing information processing modelinformation processing model trauma “freezes” the system, preventing healthy trauma “freezes” the system, preventing healthy

processing; intrusion & numbing symptoms resultprocessing; intrusion & numbing symptoms result AOD use as numbing agent; chemical dissociationAOD use as numbing agent; chemical dissociation eye movements facilitate an altered state in which eye movements facilitate an altered state in which

traumatic experiences can be integrated in a new waytraumatic experiences can be integrated in a new way support from controlled researchsupport from controlled research

EMDR: Basic ComponentsEMDR: Basic Components

the imagethe image the negative cognitionthe negative cognition the positive cognitionthe positive cognition the emotions and their level of disturbancethe emotions and their level of disturbance the physical sensationsthe physical sensations

Integrates cognitive, affective and physicalIntegrates cognitive, affective and physical

EMDR: Phases of TreatmentEMDR: Phases of Treatment Client history and treatment planningClient history and treatment planning PreparationPreparation AssessmentAssessment DesensitizationDesensitization InstallationInstallation Body ScanBody Scan ClosureClosure ReevaluationReevaluation (Shapiro 1995)(Shapiro 1995)

treating addiction and other mental disorders: clinical issues cutting edge 2004 palmerston north,...

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