299 Special Series -Counseling People with Co-Occurring Disorders SAMHSA TIP 42 Part 5
Counselor Toolbox

 
 
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Treatment of Persons with Co-Occurring Disorders
Based on SAMHSA TIP 42 Part 5
Host: Dr. Dawn-Elise Snipes
Executive Director: AllCEUs Counselor Education
Podcast Host: Counselor Toolbox and Addiction Counselor Exam Review

Objectives
~ Guidelines Working With a Client Who Has COD
~ Develop and Use a Therapeutic Alliance To Engage the Client in Treatment
~ Maintain a Recovery Perspective
~ Manage Countertransference
~ Monitor Psychiatric Symptoms
~ Use Supportive and Empathic Counseling
~ Employ Culturally Appropriate Methods
~ Increase Structure and Support
~ Provide Motivational Enhancement Consistent With the Client's Specific Stage of Change
~ Design Contingency Management Techniques To Address Specific Target Behaviors
~ Use Cognitive-Behavioral Therapeutic Techniques
~ Use Relapse Prevention Techniques
~ Use Repetition and Skills-Building To Address Deficits in Functioning
~ Facilitate Client Participation in Mutual Self-Help Groups

Develop and Use a Therapeutic Alliance To Engage the Client in Treatment

~ Therapeutic alliance may be impacted by counselor’s discomfort with MH or SA issues due to a lack of experience, training, or mentoring
~ Clinicians who experience difficulty forming a therapeutic alliance should consider if it is related to
~ The client's difficulties
~ A limitation in experience and skills
~ Demographic differences between the clinician and the client (cultural, gender, age)
~ Issues involving countertransference
Develop and Use a Therapeutic Alliance To Engage the Client in Treatment

~ Demonstrate an understanding and acceptance of the client.
~ Help the client clarify the nature of his difficulty.
~ Indicate that you and the client will be working together.
~ Communicate to the client that you will be helping her to help herself.
~ Express empathy and a willingness to listen to the client's formulation of the problem.
~ Assist the client to solve some external problems directly and immediately.
~ Foster hope for positive change.
Maintain a Recovery Perspective

~ Consumers with mental disorders may see recovery as the process of reclaiming a meaningful life beyond mental disorder, with symptom control and positive life activity.
~ While “recovery” has many meanings, generally, it is recognized that recovery does not refer solely to a change in substance use, but also to a change in an unhealthy way of living
~ The recovery perspective has two main features:
~ It acknowledges that recovery is a long-term process of internal change
~ It recognizes that these internal changes proceed through various stages
Recovery Perspective
~ Assess the client's stage of change (see section on Motivational Enhancement below).
~ Ensure that the treatment stage (or treatment expectations) is (are) consistent with the client's stage of change.
~ Use client empowerment as part of the motivation for change.
~ Foster continuous support.
~ Provide continuity of treatment.
~ Recognize that recovery is a long-term process and that even small gains by the client should be supported and applauded.
Manage Countertransference

~ Countertransference now is understood to be part of the treatment experience for the clinician.
~ Clinicians are vulnerable to the same feelings of pessimism, despair, anger, and the desire to abandon treatment as the client.
~ The clinician should be aware of strong personal reactions and biases toward the client.
~ The clinician should obtain further supervision where countertransference is suspected and may be interfering with counseling.
~ Clinicians should have formal and periodic clinical supervision to discuss countertransference issues with their supervisors and the opportunity to discuss these issues at clinical team meetings.
Monitor Psychiatric Symptoms

~ Monitor symptoms
~ Do a brief mental status and safety exam at every meeting
~ Document changes in symptoms
~ Monitor medication compliance and side effects
~ Consult with physicians
Use Supportive and Empathic Counseling

~ Communicate respect for and acceptance of clients and their feelings
~ Encourage a nonjudgmental, collaborative relationship
~ Be a supportive and knowledgeable consultant
~ Compliment and reinforce whenever possible
~ Listen rather than tells
~ Gently persuade, with the understanding that the decision to change is the client's
~ Provide support throughout the recovery process
~ Navigate the tension between being empathic and supportive, and having to handle minimization, evasion, dishonesty, and denial (TIP 35)
Employ Culturally Appropriate Methods

~ Do not make assumptions about a client based on culture
~ Examples
~ Some cultures may tend to somaticize symptoms and expect the clinician to relieve physical complaints.
~ Some clients may be offended by too many probing, personal questions early in treatment.
~ Different cultures have different views of
~ The client's role in the family and its cultural significance
~ Perceptions of substance abuse, mental disorders, and healing

Increase Structure and Support

~ Free time is both a trigger for substance use cravings and a negative influence for many individuals with mental disorders
~ Strategies for managing free time include structuring one's day to have meaningful activities and to avoid activities that will be risky
~ Daily activities should also contain opportunities for receiving support and encouragement
Provide Motivational Enhancement
~ This approach involves accepting a client's level of motivation, whatever it is, as the only possible starting point for change
~ Express empathy recognizing that ambivalence is normal. Acceptance facilitates change.
~ Develop discrepancy between present behavior and important personal goals or values.
~ Roll with resistance
~ Avoid arguing for change.
~ Resistance is not opposed directly.
~ New perspectives are invited but not imposed.
~ The client is a primary resource in finding answers and solutions.
~ Resistance is a signal to respond differently.
~ 4. Support self-efficacy. The client, not the counselor, is responsible for choosing and carrying out change.

Design Contingency Management Techniques
~ CM principles for substance abuse treatment have been structured around four central principles (Higgins and Petry 1999):
~ The clinician arranges for regular drug testing to ensure the client's use of the targeted substance is detected readily.
~ The clinician provides positive reinforcement when abstinence is demonstrated. These positive reinforcers are agreed on mutually.
~ The clinician withholds the designated incentives from the individual when the substance is detected.
~ The clinician helps the client establish alternate and healthier activities.

Design Contingency Management Techniques
~ CM techniques are best applied to specific targeted behaviors such as
~ Drug abstinence
~ Clinic attendance and group participation
~ Medication adherence
~ Following treatment plan
~ Attaining particular goals
~ The clinician may use a variety of CM techniques or reinforcers. The most common are
~ Cash
~ Vouchers
~ Prizes
~ Retail items
~ Privileges

Design Contingency Management Techniques
~ Choose a behavior (SMART)
~ Choose a reinforcer
~ Identify intangible rewards, such as frequent positive reports to parole officers, flexibility in methadone dosing, and increased freedom (smoke breaks, passes, etc.).
~ Use behavioral principles for monitoring and reinforcement
~ Prepare a behavioral contract
~ Be specific and consider alternate interpretations; have others review the contract and comment.
~ Implement the contract
~ Ensure consistent application of the contract; devise methods of seeing that staff understands and follows procedures.
~ Remind the client of behaviors and their consequences (their “account balance” and what is required to obtain a bonus)
Use Cognitive-Behavioral Techniques
~ The approach assumes that “substance abusers are deficient in their ability to cope with interpersonal, social, emotional, and personal problems. In the absence of these skills, such problems are viewed as threatening, stressful, and potentially unsolvable
~ Examine cognitive distortions
~ Teach “grounding” and “mindfulness”
Use Relapse Prevention Techniques
~ Relapse as “a breakdown or setback in a person's attempt to change or modify any target behavior”
~ A key factor in preventing relapse is to understand that relapses are preceded by triggers or cues that signal that trouble is brewing and that these triggers precede exposure to events or internal processes
~ Lapses (single episodes or brief returns to drug use) are an expected part of overcoming a drug problem, rather than a signal of failure
Use Relapse Prevention Techniques
~ Explore and identify relapse warning signs and triggers
~ Have a broad repertoire of cognitive and behavioral coping strategies to handle high-risk situations and relapse warning signs. (Emergency card)
~ Make lifestyle changes that decrease vulnerabilities
~ Increase healthy, prosocial activities.
~ Prepare for interrupting lapses, so that they do not end in full-blown relapse.
~ Resume or continue to practice relapse prevention skills even when a full-blown relapse does occur by renewing their commitment to recovery rather than giving up.
Use Repetition and Skills-Building
~ Clients with COD often have cognitive limitations, including difficulty concentrating.
~ These limitations can be transient, persistent (PAWS), or permanent (Schizophrenia)
~ They may require more support in smaller steps with more practice, rehearsal, and repetition.
Facilitate Client Participation in Mutual Self-Help Groups
~ Dual Recovery
~ MH Support Groups
~ SMART Recovery

Summary
~ Develop and Use a Therapeutic Alliance To Engage the Client in Treatment
~ Maintain a Recovery Perspective
~ Manage Countertransference
~ Monitor Psychiatric Symptoms
~ Increase Structure and Support
~ Provide Motivational Enhancement Consistent With the Client's Specific Stage of Change
~ Design Contingency Management Techniques To Address Specific Target Behaviors
~ Use Cognitive-Behavioral and Relapse Prevention Techniques for both mental disorders and substance abuse and their interrelations.
~ Use Repetition and Skills-Building To Address Deficits in Functioning
~ Facilitate Client Participation in Mutual Self-Help Groups