Integrated Treatment for Co-Occurring Disorders

Treating People, Not Behaviors

Jack Klott

• Publisher: Wiley
• Year: 2013
• ISBN:
  9781118421031
• Edition: 1
• Topic: Psicología
• Subtopic: Asesoramiento psicoterapéutico

The definitive guide to identify, assess, and create individualized treatment plans for high-risk clients who suffer from challenging co-occurring disorders

"Treat the person and not the diagnosis. Respect that all behaviors are purposeful. Remain mindful that nobody changes behaviors without motivation. These essential guiding principles are the framework of this book. They will be repeated quite often as we examine the challenging population of men and women with co-occurring disorders."

—From Integrated Treatment for Co-Occurring Disorders

Annual studies reveal that 70 percent of men and women who died by suicide were diagnosed with a mental illness or personality disorder and used drugs to gain temporary relief from the symptoms. Until now, very little has been written about how to identify, assess, and treat this population. Integrated Treatment for Co-Occurring Disorders: Treating People, Not Behaviors addresses that need.

Respectful of the client and filled with practical advice, this book:

• Examines the guiding principles for treating clients with co-occurring disorders
• Details the methods of formulating an evidence-based individualized treatment plan for the self-medicating mentally ill
• Explores how to assess this population for suicide risk and vulnerability
• Focuses on the person and not a behaviorally defined diagnostic category
• Reflects state-of-the-art knowledge for the treatment of co-occurring disorders
• Illustrates how Motivational Enhancement Therapy can be an effective treatment strategy

With numerous clinical case studies to illustrate key points and reinforce learning, Integrated Treatment for Co-Occurring Disorders encourages a flexible, person-centered treatment approach that focuses on the individual rather than the diagnosis.

Chapter One

Introduction

An Examination of the Guiding Principles for Treating Co-Occurring Disorders

I would like to begin this book with a story. The story is about one of the more important events—and lessons—in my 45-year career as an addiction counselor. At the time, I had been in the profession for 10 years. Most of my efforts with clients resulted in extreme frustration. My practice was marked by noncompliance, relapse, recidivism, confrontation, and, basically, poor outcomes. My clients were getting nothing from me, and I was becoming a poster child for burnout. Perhaps some of you have been to this place. I remember dreaming about working in a flower shop or, my favorite escape fantasy, in a bookstore. During this time I placed the blame for my inadequate results on the clients. After all, I would proclaim to myself, I am appropriately applying the skills that I was taught in my graduate program that would enable these people to surrender the plague of drugs and alcohol from their lives. The problem, therefore, could not possibly be with me. The problem was with the clients and the fact that they were “just not ready.” I am sure that many of you have heard the old mantra in drug counseling that “addicts have to hit rock bottom” before they see their behaviors as problematic. I would do my best to point out to them that their use of drugs and/or alcohol was destroying both themselves and those around them. They would not listen. I would educate them about the effects of drugs and alcohol on their brains and other body functions. They would not listen. I would resort, at times, to emotional blackmail. They would leave counseling. I was not a good counselor.

It was at this point that I was invited to participate in a two-week seminar sponsored by the Veteran’s Administration. The seminar was designed to acquaint us with a new treatment strategy for addiction disorders—Motivational Enhancement Therapy. This strategy, which is discussed at length in Chapter 5, had some glowing research outcomes. I was excited. I knew I could benefit from anything that would help change what I was doing. This training resulted in the watershed event of my career, but it began as a very humbling experience.

Three days into this training, I was gently confronted by one of the presenters regarding my attitude toward the skills being taught. These skills appeared, in my humble estimate, to be enabling. I was also presenting myself as being confused. This was a very appropriate observation because I was, indeed, confused. I was being presented with material that went against most of what I was taught regarding the treatment of addiction disorders. My “slap-face” methods were being attacked, and being put on the defensive did not sit well with me. At any rate, this wonderful gentleman comes to me and says: “Jack, your problem is that you are an addiction counselor.” I responded that this was a marvelous observation. He looked at me and respectfully replied: “Jack, hopefully, what you will learn from us is that we don’t treat addictions; we treat people with addictions.” He was telling me that I was locked into my professional definition. I am sure that those reading this book are very aware and sensitive to this frame of treating people and not behaviors. We don’t treat addicts. We don’t treat alcoholics. We treat people with addiction disorders. We do not define our clients by their DSM diagnosis! These are conditions our clients have, and these conditions do not define people. All of you are aware of this. Sadly, at this time in my career, I was not. I defined myself as an addictions counselor so, therefore, I treated addictions. This was my problem.

I also discovered I had another problem. This person would not leave me alone. He made me his project. Why? To this day I have no answer for this. What I can tell you is he saved my career and, in doing so, helped me help others. He also helped me understand myself and why I became an addiction counselor. This lesson was perhaps the most profound, sobering, and centering message and will be discussed at a later time. He also informed me that people use, abuse, and depend on drugs for a reason. In their view there is a benefit to this behavior. It is essential, he says to me, that we are empathic to this situation. When we look at all dysfunctional, maladaptive, or pathologic behaviors, we will discover that folks engage in these behaviors for a reason. All behaviors are purposeful. One of the goals in counseling is helping the client discover what that benefit or goal is.

Edwin Shneidman and Marsha Linehan, in the realm of suicide, tell us that these behaviors are either operant or respondent. In the respondent frame, we would look at drug or alcohol use as a behavior designed to achieve some control in a threatening situation or stimulus event (Linehan, 1999). An example would be the case of an individual described by others as “shy to a fault.” In reality he or she is experiencing an undetected, untreated social phobia. As the person is presented with the challenging task of a coerced social interaction, he or she uses drugs or alcohol to diminish fear and have a relatively enjoyable social contact. Another case would be the person with psychotic episodes who discovers in cannabis use a calming of those intrusive episodes.

In the operant frame, Linehan tells us that drug use is elicited by a need for people to affect their environment (Linehan, 1999). Operant behaviors are those that are under the control of the consequences. An example is the often-used frame of “bonding with Budweiser.” This would be individuals who continue to use drugs to maintain friendships, and they fear that sobriety and abstinence would result in the loss of those friendships. As we get to know these people, we explore their history of drug and/or alcohol use. We discover with them the operant and/or respondent benefits of their use. We may find they are the self-medicating mentally ill, or they are alone, or they need to escape a terrible reality, or they need to enhance a boring existence, or they need to avoid horrible withdrawal symptoms. Whatever the benefit may be, it is critical that we and the clients discover that benefit.

My presenter, and soon-to-be close friend, told me that in his entire career he never met a person who had the goal—as they began their history of drug or alcohol use—to become addicted. The physical, emotional, psychological addiction to their drug was the terrible consequence of a behavior that had, at the time, a very attractive motivation. The essential question during any evaluation is “What does the drug do for you?”

Regarding the self-medicating mentally ill—people with co-occurring drug/alcohol and mental disorders—Ken Minkoff tells us: “People with serious mental illnesses are vulnerable to substance use because the substance replaces prescribed psychotropic medication in order to bring relief from acute symptoms, remedy feelings of social isolation, and creates a temporary sense of well being” (Minkoff & Regner, 1999). I remember talking to a client who had a significant psychotic condition. We discovered that his cannabis use was designed to gain some relief from his symptoms. As we inched toward encouraging him to give a prescribed medication a chance to do the same thing and achieve the same goal, he says to me: “Well, tell me, can I party on these meds? And will my friends do the meds with me? And can it give me the same mellow feeling that weed does?” Substance use often begins as a “treatment” for an undiagnosed, untreated mental illness. This use evolves to become a persistent management strategy for stressors and the symptoms of the mental illness. Then, depending on multiple factors, the use becomes an addiction.

For a definition and conceptualization of co-occurring disorders, luminaries such as Ken Minkoff and Donald Meichenbaum offer us the following thoughts, which I will, respectfully, summarize. One disorder may, for instance, regularly precede the development of the other disorder. Therefore, the first disorder may be viewed as a significant risk factor or precipitant for the second (co-occurring) disorder. A common example is seen in people with an undiagnosed, untreated Generalized Anxiety Disorder. This condition, which possibly emerged during late childhood or early adolescence, may render the individual vulnerable to the use of cannabis for the purpose of transient, temporary symptom relief. Research cited by Meichenbaum states that for individuals with co-occurring psychiatric and substance-related disorders, the mental health disorders usually precede the substance use disorder about 90% of the time. The median onset age of the psychiatric disorder is 11, with the substance-related disorder usually developing 5 to 10 years after the psychiatric disorder (median age of 21). Many cannabis users have told me: “When I’m stoned, I don’t have a worry in the world. My life is intolerable without weed.” It is not a stretch to conceptualize mental disorders as risk factors and precipitating conditions for the development of substance use disorders.

Another concept is that one disorder may act as a protective factor to another (co-occurring) disorder. When a client tells me that alcohol use allows her to “see another day,” I respect that alcohol use helps her manage the unbearable grief of losing a husband and, actually, protects her from dying by suicide. It is, therefore, not a stretch to view alcohol/drug use, in some circumstances, as keeping a person from acting on suicidal impulses. A young woman in her thirties with significant issues of posttraumatic stress disorder (PTSD) resulting from a history of ritual sexual assault as a child is now heavily addicted to prescription drugs to help her sleep and, according to her, “so I won’t jump off a bridge.”

A final view of co-occurring disorders is when one disorder modifies and/or complicates the presentation of another (co-occurring) disorder. Addiction is a brain disease, and it is chronic. We will discuss the importance of the chronic nature of addictions at a later point in this book. Many of the problematic behaviors we see in people who use drugs are a result of brain dysfunctions. We observe in the process of the DSM, when the issue of substance-induced disorder is examined, that we are urged to diagnose carefully, cautiously, methodically, slowly. We want to differentiate between an individual with schizophrenia and the person with a substance-induced psychotic disorder. We will approach, and treat, the person with dysthymia in a different fashion than the individual with a substance-induced mood disorder. The concern for the co-occurring self-medicating mentally ill person is that the drug that provides them with transient relief from their symptoms could, in a matter of degrees, make their condition more complex. Neuroscience has uncovered how addiction to drugs hijacks different parts of the brain. The chemical dopamine conditions the brain to certain behaviors that are correlated to pleasure. Therefore, while the drug use is designed for symptom relief, the dopamine reaction creates a physiologic and emotional dependency. It is in the dependency and the continued use of the drug that will distort, modify, alter, and complicate symptomatic presentation.

Purposeful Behavior

All behaviors are purposeful. This cycle presents clinicians with, perhaps, their most significant challenge. I remember a client who once proclaimed to me during our first session together: “Telling me to quit my cocaine is like telling me to quit breathing.” For that client, drug use had become an essential part of his existence. The use of drugs had a varied purpose: To assist in the management of the intrusive symptoms of his mental illness, to present him with opportunities for social interaction, and to avoid the terrible reactions of withdrawal created by the dopamine-induced dependency. This person, and many like him, presented a unique challenge in therapy. Treatment effectiveness studies on this matter are quite clear and discouraging: “Non compliance with treatment, recidivism, and multiple relapses in the substance use disorder population have been directly linked to a co-occurring mental illness” (Minkoff, 1999). Donald Meichenbaum adds to this concern: “Relapse rates among chemical addictions (heroin, cocaine, nicotine, alcohol) and across various treatment models are fairly uniform and discouraging—around 75%. The likelihood of life-long abstinence is low” (Meichenbaum, 2010). In 2010 the National Institute on Drug Abuse estimated that in the United States there were approximately 25 million people with a definable substance use disorder. Two million—less than 10%—sought help. But there is hope. I would not be engaged in this writing project if there was no hope. I am not, by nature, a pessimistic person.

Finally, this wise man at the conference tells me: “Nobody changes behaviors without motivation.” That was the purpose of the training—how to motivate our clients toward abstinence and sobriety. I thought I did that. I thought that when I outlined for them how drugs and/or alcohol were destroying their health and educated them about the effects of drugs on their brains that this cognitive input would surely motivate them to quit. I thought that when I confronted them for hurting their family with their drug use that this emotionally charged blackmail would motivate them to quit. I thought that was motivation enough. I was wrong, and to this day I feel a certain shame about this behavior.

What, then, does motivate people to change behaviors? The simple answer, as William Miller and Stephen Rollnick describe it: “Intrinsic motivation for change occurs in an accepting, empathic relationship in which the person discovers that current behaviors keep them from achieving what is wanted and valued in their lives” (Miller & Rollnick, 2002). This is what is called the discrepancy in a person’s life. The person becomes aware of the fact that “this is not the way I wanted my life to be.” As we will discuss in later chapters, this focus should become the primary task of therapy. In the discovery and acknowledgment of this discrepancy, we may find the source of our client’s motivation to change.

Most people who seek our help and guidance and are powerfully motivated have, on their own accord, discovered their discrepancy. They have acknowledged, in paying close attention to life’s messages, that this (drug and/or alcohol use and dependency) is not the way they want life to be. They are motivated to engage, perhaps, in a brutal period of medically supervised detoxification. They are motivated to attend, for the rest of their lives, support groups. They are motivated to engage in counseling to learn and acquire new ways of coping with life’s stressors and demands. They respond to counseling in a positive manner. They are motivated.

Reasons for Seeking Therapy

It has been my experience that there are basically three reasons why people seek out therapy. The first reason is that they are currently experiencing unbearable levels of emotional, psychological, and psychiatric pain. This sense of pain is a great motivator for change. This pain is individually defined by the person. Something is wrong in his or her life. Something is not the way it should be. This pain is often the discrepancy that Miller and Rollnick talk about. The most important feature here, however, is the individual nature of this pain or discrepancy. This pain has to be managed. I remember talking to a young woman who was in her second academic year at a local university. She had recently made a suicide attempt, and while she was in the emergency room, traces of alcohol and cocaine were found in her system. During our initial interview I asked her what the attempt to take her life was designed to accomplish. She looked at me and responded: “I just got my very first B.” Now, that hardly seems to be a good reason to kill oneself. But for this young woman, at this period in her life, and with the individual stressors placed on her by her family for perfection, the decision to die appeared very logical to her. Her individualized definition of this failure was causing her unbearable emotional pain. She feared losing her parents’ love and approval. She told me: “My parents don’t accept failure.” This pain defied her capacity to cope. She tried drugs, but this was not successful in curbing the pain. Finally, suicide was decided on as the ultimate problem solver.

Or consider the woman grieving the sudden loss of her husband of 38 years. To help her sleep and ease her anxiety-driven grieving, “a few” glasses of wine each night appears very appropriate—and helpful. Until, of course, this behavior for coping becomes a dependency—both physical and psychological. A wise man once told me in regards to this pain: “One person’s unbearable pain is another person’s irksome event.” This pain is defined by the client.

Many of you have experienced this situation. When we experience intolerable levels of physical pain, we run to our primary care physician. We are diagnostically clear in indicating to that person the nature of the pain. We tell our healthcare provider everything he or she needs to know about our pain. And, most important, we respond to our physician’s direction to make this pain go away. In the arena of mental health, people in this level of pain usually make for very motivated clients. They are diagnostically clear, wanting us to know as much as possible about their pain. And they will normally respond in a positive fashion to insights and directions from us that they perceive as potentially helpful in the alleviation of their pain.

Edwin Shneidman, the icon of the study of suicide in our society, told us many years ago:

The first task of therapy is to discover the locus of the client’s unbearable pain and to decrease the perturbation associated with that condition. In the context of a caring relationship we assist the person in discovering their pain and help them manage this condition. There are really only two questions we need to ask a person: “Where do you hurt?” and “how can I help you?” (Shneidman, 1973)

I am sure it comes as no surprise to many of you that a significant number of the people we have the privilege to meet are self-medicating an intolerable level of pain. That pain, again, is individually defined by the person and may vary from emotional to physical or mental. For these people, at this time in their lives, these drugs are very beneficial and attractive. Many of them, however, run a significant risk of becoming physically and/or emotionally dependent on this form of coping.

Our responsibility to these folks is to be empathic to the current purpose and benefit involved in their drug/alcohol use. Telling them to quit their drug or mandating abstinence as a contract of therapy can be damaging, harmful, and could motivate them to see therapy as “demanding too much.” The practice of abstinence-mandated therapy could tragically strip them of a defense strategy that opens up significant vulnerability to suicide or other self-harm activities.

The second reason why people seek therapy is that they are being threatened with a loss of something important and meaningful to them if they do not seek counseling. Let us look at an example that many of you are familiar with: It is the person who has been told by a spouse, partner, or mate that if they don’t stop drinking, they will lose that relationship. They appear in counseling with the proclamation: “My wife doesn’t like my drinking. She told me that if I don’t do something about it she is going to leave.” And then they may add: “I need to learn to control my drinking, handle it better, become a social drinker.” These people are ambivalent about abstinence and sobriety. Part of them is motivated by the threat of the loss, and part of them is reluctant to quit entirely because alcohol presents some benefits to them. These benefits could include friendships they have gained over the years at the local pub, that alcohol use calms withdrawal symptoms, or that alcohol has an effect on an undiagnosed, untreated mental illness.

What we do know is that the only reason these ...