Treatment of Persons with Co-Occurring Disorders
Based on SAMHSA TIP 42 Part 3
Host: Dr. Dawn-Elise Snipes
Executive Director: AllCEUs Counselor Education
Podcast Host: Counselor Toolbox and Addiction Counselor Exam Review

~ Identify guiding principles in treatment
~ Identify core components in the delivery of services
~ Explore how to improve substance abuse treatment systems and programs
Guiding Principles
~ For each component, identify how you do, or could apply this in your program
~ Employ a recovery perspective
~ Adopt a multiproblem viewpoint
~ Develop a phased approach to treatment
~ Address specific real-life problems early in treatment
~ Plan for the client’s cognitive and functional impairments
~ Use support systems to maintain and extend treatment effectiveness
~ Community
~ Family
~ Self-Help
Core Components
~ For each component, identify how you do, or could apply this in your program
~ Access
~ Full assessment
~ Appropriate levels of care
~ Integrated treatment
~ Comprehensive Services
~ Continuity of care
~ Access occurs in four main ways:
~ Routine access for individuals seeking services who are not in crisis
~ Crisis access for individuals requiring immediate services due to an emergency
~ Outreach, in which agencies target individuals in great need (e.g., people who are homeless) who are not seeking services or cannot access ordinary routine or crisis services
~ Access that is involuntary, coerced, or mandated by the criminal justice system, employers, or the child welfare system

~ Screening to detect the possible presence of COD in the setting where the client is first seen for treatment
~ Evaluation of background factors (family, trauma history, marital status, health, education and work history), mental disorders, substance abuse, and related medical and psychosocial problems (e.g., living circumstances, employment, family) that are critical to address in treatment planning
~ Diagnosis of the type and severity of substance use and mental disorders
~ Initial matching of individual client to services (often, this must be done before a full assessment is completed and diagnoses clarified; also, the client's motivation to change with regard to one or more of the co-occurring disorders may not be well established)
~ Appraisal of existing social and community support systems
~ Continuous evaluation (that is, re-evaluation over time as needs and symptoms change and as more information becomes available)

Appropriate Level of Care
~ A basic program has the capacity to provide treatment for one disorder, but also screens for the other disorder and can access necessary consultations.
~ A program with an intermediate level of capacity tends to focus primarily on one disorder without substantial modification to its usual treatment, but also explicitly addresses some specific needs of the other disorder.
~ A program with an advanced level of capacity provides integrated substance abuse treatment and mental health services for clients with COD.
~ A program that is fully integrated actively combines substance abuse and mental health interventions to treat disorders, related problems, and the whole person more effectively
Integrated Treatment
~ Integrated treatment can occur on different levels and through different mechanisms. For example:
~ One clinician delivers a variety of needed services.
~ Two or more clinicians work together to provide needed services.
~ A clinician may consult with other specialties and then integrate that consultation into the care provided.
~ A clinician may coordinate a variety of efforts in an individualized treatment plan that integrates the needed services.
~ Multiple agencies can join together to create a program that will serve a specific population.
Integrated Treatment
~ The focus is on preventing anxiety rather than breaking through denial.
~ Emphasis is placed on trust, understanding, and learning.
~ Treatment is characterized by a slow pace and a long-term perspective.
~ Providers offer stagewise and motivational counseling.
~ Self-help groups are available to those who choose to participate and can benefit from participation.
~ Neuroleptics and other pharmacotherapies are indicated according to clients' psychiatric and other medical needs.

Comprehensive Services
~ Mental Health
~ Mood
~ Cognitive/attentional
~ Psychotic
~ Personality
~ Eating Disorder
~ Substance Use
~ Housing
~ Medical/Dental
~ Employment/Education Referrals

Continuity of Care
~ Effective, treatment must address the three features that characterize continuity of care:
~ Consistency between primary treatment and ancillary services
~ Seamlessness as clients move across levels of care (e.g., from residential to outpatient treatment)
~ Coordination of present and past treatment episodes
Assessing Agency Capability
~ Describe the profile of current clients with COD and any potential changes anticipated.
~ Estimate the prevalence of persons with COD among the agency's clients.
~ What are the demographics of persons with COD?
~ What functional problems do they have?
~ 2. Identify services needed by clients.
~ 3. Identify and assess resources available to meet client needs.
~ What services are immediately available to the program?
~ What services could be added within the program?
~ What services are available from the community that would enhance care?
~ How well are outside agencies meeting clients; needs?

Assessing cont…
~ Assess resource gaps.
~ What resources are needed to enhance treatment for persons with COD?
~ What can your agency do to enhance its capacity to serve these clients?
~ Assess capacity to address these resource gaps.
~ Develop a plan to enhance capacity to treat clients with COD.
~ How can the skills of existing staff be increased?
~ Can additional expertise be accessed through consulting agreements?
~ What additional programs or services can be offered?
~ What sources of funding might support efforts to enhance capacity?

Workforce Development–Attitudes
~ Appreciation of the complexity of COD
~ Openness to new information
~ Awareness of personal reactions and feelings
~ Recognition of the limitations of one's own personal knowledge and expertise
~ Recognition of the value of client input into treatment goals
~ Patience, perseverance, and therapeutic optimism
~ Ability to employ diverse theories, concepts, models, and methods
~ Flexibility of approach
~ Cultural competence
~ Belief that all individuals have strengths and are capable of growth
~ Recognition of the rights of clients with COD, including the right and need to understand assessment results and the treatment plan
Workforce Development Competencies
~ Perform a basic screening to determine whether COD might exist and be able to refer the client for a formal diagnostic assessment by someone trained to do this.
~ Conduct a preliminary screening of whether a client poses an immediate danger to self or others and coordinate any subsequent assessment.
~ Engage the client in such a way as to enhance and facilitate future interaction.
~ De-escalate a client who is agitated, anxious, or in a vulnerable state.
~ Manage a crisis involving a client with COD
~ Refer a client to the appropriate mental health or substance abuse treatment facility and follow up to ensure continuity of care.
~ Coordinate care with a mental health counselor serving the same client to ensure that the interaction of the client's disorders is well understood and that treatment plans are coordinated.
Workforce Development Competencies
~ Intermediate competencies
~ Integrated diagnosis
~ Integrated needs assessment
~ Integrated treatment planning
~ Engagement, motivation and education
~ Treatment Methods
~ Relapse prevention
~ Case management
~ Mental health
~ Pharmacotherapy
~ Psychoeducation
~ Reporting requirements and confidentiality
~ Family interventions and education
Workforce Development Competencies
~ Advanced competencies
~ Comprehend the effects of level of functioning and degree of disability related to both substance-related and mental disorders, separately and combined.
~ Recognize the classes of psychotropic medications, their actions, medical risks, side effects, and possible interactions.
~ Remember that relapse is an opportunity for additional learning for all.
~ Involve the person, family members, and other supports and service providers (including peer supports and those in the natural support system) in establishing, monitoring, and refining the current treatment plan.
~ Support quality improvement efforts, including, but not limited to satisfaction surveys, accurate reporting and use of outcome data,
Treatment Planning & Documentation Issues

~ Review the principles and processes that support thorough and accurate assessment and diagnosis, including strengths-based interviewing skills and cultural diversity issues.
~ Examine each step in treatment/service planning & rationale
~ Describe the importance of the person with COD having active involvement and real choice in all treatment planning processes
~ Identify means of writing brief and useful progress notes that support movement toward positive outcomes.
~ Discuss means of using progress notes with the person as a useful piece of the ongoing treatment/service process.
Workforce Development
~ Supervision
~ Shadowing and cross training
~ Regular peer supervision
~ Case conferences
Avoiding Burnout
~ Program directors and supervisors assist counselors to:
~ Work within a team structure rather than in isolation.
~ Build in opportunities to discuss feelings and issues with other staff who handle similar cases.
~ Develop and use a healthy support network.
~ Maintain the caseload at a manageable size.
~ Incorporate time to rest and relax.
~ Separate personal and professional time.
Reducing Turnover
~ Hire staff members who have familiarity with both SAB & MH issues and have a positive regard for clients with either disorder.
~ Hire staff members who are critically minded and can think independently, but who are also willing to ask questions, listen, remain open to new ideas, work cooperatively, and be creative
~ Provide staff with a framework of realistic expectations for the progress of clients with COD.
~ Provide opportunities for consultation among staff members
~ Ensure that supervisory staff are supportive and knowledgeable
~ Provide and support opportunities for further education and training.
~ Provide structured opportunities for staff feedback in the areas of program design and implementation.
Reducing Turnover
~ Provide a desirable work environment through
~ Adequate compensation
~ Salary incentives for COD expertise
~ Opportunities for training and for career advancement
~ Involvement in quality improvement or clinical research activities
~ Efforts to adjust workloads
~ There are a variety of competencies and attitudes unique to treating clients with COD
~ Many avenues exist to integrate care, and all agencies should strive for integrated care since COD are the expectation.
~ Preventing burnout and turnover are essential for several reasons:
~ Program capacity
~ Cost of training new employees
~ Impact on client outcomes
More Videos
~ There are 5 more videos in this series. They will all be on the playlist “TIP 42 Co-Occurring Disorders” on our YouTube channel

~ To earn CEUs for this presentation, go to where you can find a direct link to the class associated with this presentation