Substance Abuse Treatment For Persons With Co-Occurring Disorders A Treatment Improvement Protocol TIP 42 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment CO-OCCURRING www.samhsa.gov DISORDERS Adopted: 7/16/12 SRC Reviewed: 6/10/14 EMMC Reviewed: 6/16/14 Substance Abuse Treatment For Persons With Co-Occurring Disorders This TIP, Substance Abuse Treatment for Persons With Co-Occurring Disorders, revises TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse. The revised TIP provides information about new developments in the rapidly growing field of co-occurring substance use and mental disorders and captures the state-of- the-art in the treatment of people with co-occurring disorders. The TIP focuses on what the substance abuse treat- ment clinician needs to know and provides that information in an accessible manner. The TIP synthesizes knowledge and grounds it in the practical realities of clinical cases and real situ- ations so the reader will come away with increased knowledge, encouragement, and resourcefulness in working with clients with co-occurring disorders. Collateral Products Based on TIP 42 Quick Guide For Clinicians KAP Keys For Clinicians Quick Guide for Administrators Quick Guide for Mental Health Providers DHHS Publication No. (SMA) 05-3992 Printed 2005 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Adopted: 7/16/12 SRC Reviewed: 6/10/14 EMMC Reviewed: 6/16/14 CO-OCCURRING DISORDER S u b s t a n c e A b u s e T r e a t m e n t f o r P e r s o n s W i t h C o - O c c u r r i n g D i s o r d e r s T I P 4 2 Adopted: 7/16/12 SRC Reviewed: 6/10/14 EMMC Reviewed: 6/16/14 Substance Abuse Treatment for Persons With Co-Occurring Disorders Stanley Sacks, Ph.D. Consensus Panel Chair Richard K. Ries, M.D. Consensus Panel Co-Chair A Treatment Improvement Protocol TIP 42 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Adopted: 7/16/12 SRC Reviewed: 6/10/14 EMMC Reviewed: 6/16/14 Acknowledgments document are intended or should be inferred. The guidelines in this document should not be Numerous people contributed to the develop- considered substitutes for individualized client ment of this TIP (see pp. xi, xiii, and appen- care and treatment decisions. dices L, M, and N). This publication was pro- duced by The CDM Group, Inc. under the Knowledge Application Program (KAP) con- Public Domain Notice tract, number 270-99-7072 with the Substance All materials appearing in this volume except Abuse and Mental Health Services those taken directly from copyrighted sources Administration (SAMHSA), U.S. Department are in the public domain and may be repro- of Health and Human Services (DHHS). Karl duced or copied without permission from D. White, Ed.D., and Andrea Kopstein, SAMHSA/CSAT or the authors. Do not repro- Ph.D., M.P.H., served as the Center for duce or distribute this publication for a fee Substance Abuse Treatment (CSAT) without specific, written authorization from Government Project Officers. Christina SAMHSA’s Office of Communications. Currier served as the CSAT TIPs Task Leader. Rose M. Urban, M.S.W., J.D., LCSW, CCAC, CSAC, served as the CDM KAP Executive Electronic Access and Copies Deputy Project Director. Elizabeth Marsh of Publication served as the CDM KAP Deputy Project Director. Shel Weinberg, Ph.D., served as the Copies may be obtained free of charge from CDM KAP Senior Research/Applied SAMHSA’s National Clearinghouse for Alcohol Psychologist. Other KAP personnel included and Drug Information (NCADI), (800) 729- Raquel Witkin, M.S., Deputy Project 6686 or (301) 468-2600; TDD (for hearing Manager; Susan Kimner, Managing Editor; impaired), (800) 487-4889, or electronically Deborah Steinbach, Senior Editor/Writer; and through the following Internet World Wide Erica Flick, Editorial Assistant. In addition, Web site: www.ncadi.samhsa.gov. Sandra Clunies, M.S., I.C.A.D.C., served as Content Advisor. Special thanks go to Susan Recommended Citation Hills, Ph.D., for serving as Co-Editor on this TIP, and Doug Ziedonis, M.D., for his contri- Center for Substance Abuse Treatment. bution to chapter 8. Jonathan Max Gilbert, Substance Abuse Treatment for Persons With M.A., Margaret K. Hamer, M.P.A., Randi Co-Occurring Disorders. Treatment Henderson, B.A., Susan Hills, Ph.D., and Improvement Protocol (TIP) Series 42. DHHS David Shapiro, M.S., M.Ed., were writers. Publication No. (SMA) 05-3992. Rockville, Appendix K was prepared by Margaret MD: Substance Abuse and Mental Health Brooks, J.D., and SAMHSA staff in consulta- Services Administration, 2005. tion with the Office of the General Counsel, the U.S. Department of Health and Human Originating Office Services, Washington, D.C. Practice Improvement Branch, Division of Services Improvement, Center for Substance Disclaimer Abuse Treatment, Substance Abuse and Mental The opinions expressed herein are the views of Health Services Administration, 1 Choke the Consensus Panel members and do not nec- Cherry Road, Rockville, MD 20857. essarily reflect the official position of CSAT, DHHS Publication No. (SMA) 05-3992 SAMHSA, or DHHS. No official support of or endorsement by CSAT, SAMHSA, or DHHS Printed 2005 for these opinions or for particular instru- ments, software, or resources described in this ii Acknowledgments Adopted: 7/16/12 SRC Reviewed: 6/10/14 EMMC Reviewed: 6/16/14 Contents What Is a TIP? ............................................................................................................ix Consensus Panel ..........................................................................................................xi KAP Expert Panel and Federal Government Participants ..................................................xiii Foreword...................................................................................................................xv Executive Summary ...................................................................................................xvii 1 Introduction..............................................................................................................1 Overview......................................................................................................................1 The Evolving Field of Co-Occurring Disorders......................................................................2 Important Developments That Led to This TIP .....................................................................4 Organization of This TIP................................................................................................16 2 Definitions, Terms, and Classification Systems for Co-Occurring Disorders.........................21 Overview....................................................................................................................21 Terms Related to Substance Use Disorders..........................................................................22 Terms Related to Mental Disorders...................................................................................23 Terms Related to Clients.................................................................................................26 Terms Related to Treatment............................................................................................27 Terms Related to Programs.............................................................................................32 Terms Related to Systems...............................................................................................33 3 Keys to Successful Programming ................................................................................37 Overview....................................................................................................................37 Guiding Principles........................................................................................................38 Delivery of Services.......................................................................................................41 Improving Substance Abuse Treatment Systems and Programs................................................48 Workforce Development and Staff Support.........................................................................55 4 Assessment..............................................................................................................65 Overview....................................................................................................................65 Screening and Basic Assessment for COD ...........................................................................66 The Assessment Process.................................................................................................71 5 Strategies for Working With Clients With Co-Occurring Disorders ..................................101 Overview...................................................................................................................101 Guidelines for a Successful Therapeutic Relationship With a Client Who Has COD ....................102 Techniques for Working With Clients With COD.................................................................112 6 Traditional Settings and Models.................................................................................137 Overview...................................................................................................................137 Essential Programming for Clients With COD....................................................................138 Outpatient Substance Abuse Treatment Programs for Clients With COD ..................................143 Residential Substance Abuse Treatment Programs for Clients With COD..................................161 iii Adopted: 7/16/12 SRC Reviewed: 6/10/14 EMMC Reviewed: 6/16/14 7 Special Settings and Specific Populations....................................................................183 Overview...................................................................................................................183 Acute Care and Other Medical Settings.............................................................................184 Dual Recovery Mutual Self-Help Programs........................................................................190 Specific Populations ....................................................................................................197 8 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues...........................213 Overview...................................................................................................................213 Cross-Cutting Issues ....................................................................................................214 Personality Disorders...................................................................................................220 Mood Disorders and Anxiety Disorders.............................................................................226 Schizophrenia and Other Psychotic Disorders....................................................................231 Attention-Deficit/Hyperactivity Disorder (AD/HD)..............................................................235 Posttraumatic Stress Disorder (PTSD).............................................................................238 Eating Disorders.........................................................................................................240 Pathological Gambling..................................................................................................246 Conclusion.................................................................................................................248 9 Substance-Induced Disorders....................................................................................249 Overview...................................................................................................................249 Description................................................................................................................249 Diagnostic Considerations .............................................................................................252 Case Studies: Identifying Disorders.................................................................................253 Appendix A: Bibliography...........................................................................................255 Appendix B: Acronyms ..............................................................................................309 Appendix C: Glossary of Terms....................................................................................313 Appendix D: Specific Mental Disorders: Additional Guidance for the Counselor...................325 Overview...................................................................................................................325 Suicidality.................................................................................................................326 Nicotine Dependence....................................................................................................333 Personality Disorders (Overview)....................................................................................348 Borderline Personality Disorder.....................................................................................353 Antisocial Personality Disorder ......................................................................................359 Mood and Anxiety Disorders..........................................................................................369 Schizophrenia and Other Psychotic Disorders....................................................................385 Attention Deficit-Hyperactivity Disorder (AD/HD)..............................................................402 Posttraumatic Stress Disorder........................................................................................408 Eating Disorders.........................................................................................................417 Pathological Gambling..................................................................................................425 Appendix E: Emerging Models.....................................................................................437 Part I: Addresses for Models Referenced in the Text............................................................437 Part II: Other Emerging Models......................................................................................439 Programs..................................................................................................................457 iv Contents Adopted: 7/16/12 SRC Reviewed: 6/10/14 EMMC Reviewed: 6/16/14 Appendix F: Common Medications for Disorders ............................................................459 Pharmacologic Risk Factors...........................................................................................459 A Stepwise Treatment Model..........................................................................................461 Psychotherapeutic Medications 2004: What Every Counselor Should Know...............................463 Appendix G: Screening and Assessment Instruments........................................................487 Addiction Severity Index (ASI).......................................................................................487 The Alcohol Use Disorders Identification Test (AUDIT)........................................................488 Beck Depression Inventory-II (BDI-II).............................................................................488 CAGE Questionnaire....................................................................................................489 Circumstances, Motivation, and Readiness Scales (CMR Scales).............................................489 Clinical Institute Withdrawal Assessment (CIWA-Ar)...........................................................490 The Drug Abuse Screening Test (DAST)............................................................................490 Global Appraisal of Individual Needs (GAIN) ....................................................................491 Level of Care Utilization System (LOCUS).........................................................................491 Michigan Alcoholism Screening Test (MAST)......................................................................492 M.I.N.I. Plus.............................................................................................................492 Psychiatric Research Interview for Substance and Mental Disorders (PRISM)...........................493 Readiness to Change Questionnaire .................................................................................493 Recovery Attitude and Treatment Evaluator (RAATE).........................................................494 Structured Clinical Interview for DSM-IV Disorders (SCID-IV)..............................................494 Substance Abuse Treatment Scale (SATS).........................................................................495 University of Rhode Island Change Assessment (URICA)......................................................495 Appendix H: Sample Screening Instruments...................................................................497 Mental Health Screening Form-III...................................................................................498 Simple Screening Instrument for Substance Abuse..............................................................499 Appendix I: Selected Sources of Training......................................................................513 Sources of Training on Addiction Disorders.......................................................................513 Sources of Training on Mental Health ..............................................................................515 Sources of Training on Co-Occurring Disorders..................................................................515 Listservs and Discussion Groups on Co-Occurring Disorders ................................................516 Appendix J: Dual Recovery Mutual Self-Help Programs and Other Resources for Consumers and Providers...............................................................519 Dual Recovery 12-Step Fellowships..................................................................................519 Supported Mutual Help for Dual Recovery........................................................................520 Other Resources for Consumers and Providers...................................................................521 Appendix K: Confidentiality........................................................................................523 Federal Laws and the Right to Confidentiality....................................................................523 Appendix L: Resource Panel.......................................................................................527 Appendix M: Cultural Competency and Diversity Network Participants...............................531 Appendix N: Field Reviewers......................................................................................533 Contents v Adopted: 7/16/12 SRC Reviewed: 6/10/14 EMMC Reviewed: 6/16/14 Figures 1-1 Persons With Alcohol, Drug Abuse, or Mental Disorder in the Past Year............................5 1-2 Rates of Antisocial Personality, Depression, and Anxiety Disorder by Drug Dependency........8 1-3 Substance Abuse Treatment Facilities Offering Special Programs for Clients With COD........11 2-1 Level of Care Quadrants........................................................................................29 3-1 Six Guiding Principles in Treating Clients With COD....................................................38 3-2 Levels of Program Capacity in Co-Occurring Disorders.................................................44 3-3 A Vision of Fully Integrated Treatment for COD..........................................................45 3-4 The Co-Occurring Collaborative of Southern Maine.....................................................49 3-5 Assessing the Agency’s Potential To Serve Clients With COD..........................................51 3-6 Financing a Comprehensive System of Care for People With COD...................................52 3-7 Essential Attitudes and Values for Clinicians Who Work With Clients Who Have COD.........57 3-8 Examples of Basic Competencies Needed for Treatment of Persons With COD....................58 3-9 Six Areas of Intermediate-Level Competencies Needed for the Treatment of Persons With COD..........................................................................................59 3-10 Examples of Advanced Competencies in the Treatment of Clients With COD......................60 3-11 Treatment Planning and Documentation Issues for Mental and Substance Use Disorders ......61 3-12 Certification in Health Professions...........................................................................63 3-13 Reducing Staff Turnover in Programs for Clients With COD..........................................64 4-1 Assessment Considerations.....................................................................................74 4-2 Sample Treatment Plan for George T. (Case 2)............................................................96 4-3 Considerations in Treatment Matching .....................................................................97 5-1 Stages of Change................................................................................................116 5-2 Motivational Enhancement Approaches...................................................................117 5-3 A Four-Session Motivation-Based Intervention..........................................................119 5-4 Checklist for Designing CM Programs .....................................................................123 6-1 Engagement Interventions ....................................................................................165 6-2 Principles of Implementation ................................................................................166 6-3 Sample Training and Technical Assistance Curriculum................................................167 6-4 Residential Interventions .....................................................................................172 6-5 TC Modifications for Persons With COD..................................................................174 7-1 Criteria for Major Depressive Episode.....................................................................206 D-1 Key Questions in a Suicide Risk Review...................................................................330 D-2 DSM-IV Criteria for Nicotine Withdrawal................................................................341 D-3 The Fagerstrom Test for Nicotine Dependence...........................................................342 D-4 Brief Strategies for Smoking Cessation ....................................................................344 D-5 Brief Strategies 2. Components of Presriptive Relapse Prevention..................................348 D-6 Characteristics of People With Antisocial and Borderline Personality Disorders................350 D-7 Step Work Handout for Clients With BPD................................................................360 D-8 Counseling Tips for Clients With APD.....................................................................367 D-9 Antisocial Thinking-Error Work............................................................................368 D-10 Drugs That Precipitate or Mimic Mood Disorders ......................................................373 D-11 Engaging the Client With Chronic Psychosis .............................................................391 D-12 Biopsychosocial Assessment of High-Risk Conditions ..................................................392 D-13 AD/HD Symptom Cluster: Inattention.....................................................................403 D-14 AD/HD Symptom Cluster: Hyperactivity-Impulsivity..................................................403 D-15 Grounding: A Coping Skill for Clients With Emotional Pain .........................................413 D-16 How Are Eating Disorders and Substance Use Disorders Related?..................................421 vi Contents Adopted: 7/16/12 SRC Reviewed: 6/10/14 EMMC Reviewed: 6/16/14 D-17 General and Specific Screening Questions for Persons With Possible Eating Disorders........422 D-18 Diagnostic Criteria for Pathological Gambling Compared to Substance Dependence Criteria..........................................................................................426 D-19 Comparison of Action and Escape Pathological Gamblers ............................................427 H-1 Sources for Items Included in the Simple Screening Instrument for Substance Abuse..........503 H-2 Simple Screening Instrument for Substance Abuse Interview Form.................................506 H-3 Simple Screening Instrument for Substance Abuse Self-Administered Form......................509 H-4 Scoring for the Simple Screening Instrument for Substance Abuse .................................511 Advice to the Counselor Boxes Chapter 2 Antisocial Personality Disorders.......................................................................................24 Psychotic Disorders.......................................................................................................25 Mood and Anxiety Disorders ...........................................................................................25 Chapter 4 Do’s and Don’ts of Assessment for COD.............................................................................67 Chapter 5 Forming a Therapeutic Alliance......................................................................................103 Maintaining a Recovery Perspective.................................................................................105 Managing Countertransference.......................................................................................106 Monitoring Psychiatric Symptoms...................................................................................107 Using Culturally Appropriate Methods.............................................................................111 Using Contingency Management Techniques.......................................................................125 Using Relapse Prevention Methods..................................................................................130 Chapter 6 Recommendations for Providing Essential Services for People With COD.................................141 Treatment Principles From ACT.....................................................................................157 Treatment Principles From ICM.....................................................................................159 Recommended Treatment and Services From the MTC Model................................................175 Chapter 7 Working With Homeless Clients With COD........................................................................200 Providing Community Supervision for Offenders With COD..................................................202 Treatment Principles and Services for Women With COD .....................................................210 Chapter 8 Counseling a Client Who Is Suicidal.................................................................................215 Counseling a Client With Borderline Personality Disorder ....................................................222 Counseling a Client With an Anxiety or Mood Disorder........................................................229 Counseling a Client With a Psychotic Disorder...................................................................234 Counseling a Client Who Has AD/HD...............................................................................237 Counseling a Client With PTSD......................................................................................241 Counseling a Client With an Eating Disorder .....................................................................245 Counseling a Client With Pathological Gambling Disorder.....................................................248 Contents vii Adopted: 7/16/12 SRC Reviewed: 6/10/14 EMMC Reviewed: 6/16/14