Co-occurring Mental Illness and Substance Use Disorders

Evidence-based Integrative Treatment and Multicultural Application

Tricia L. Chandler, Fredrick Dombrowski, Tara G. Matthews, Tricia L. Chandler, Fredrick Dombrowski, Tara G. Matthews

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000562101
• Edition: 1
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

This textbook details how mental health and addiction are interconnected through childhood trauma, how this affects neurobiology and neuropsychology, and the need for an integrated whole-person treatment for those of diverse backgrounds to enhance treatment outcomes.

Using an integrative pedagogy, the book helps readers broaden their understanding of co-occurring disorders through case studies, learning objectives, key terms, quiz questions, suggested resources, and references. By linking to previous knowledge and suggesting practical applications, each chapter provides clear direction for learning more about each treatment approach, diagnosis, and population discussed within the multicultural and biopsychosocial perspective.

Co-occurring Mental Illness and Substance Use Disorders will help graduate students in both substance use and mental health counseling make sense of integrative treatment with co-occurring disorders.

Section III Integrative Treatment Approaches for Those With Co-occurring Disorders

Tricia L. Chandler

DOI: 10.4324/9781003220916-15

Over the course of the twentieth century, there was a separation of how illnesses were treated in the medical and mental health fields, with substance use disorders and mental illness treated as if they were completely separate disorders, and mental health issues treated as if they are separate from overall health care. Since neuropsychology and neurobiology have evolved, there is an increased understanding that these co-occurring disorders are interrelated, and the driving force for this phenomenon is early childhood trauma and abuse. Trauma can be defined in many ways, but when activated by fear of dying, witnessing abuse, experiencing abuse, etc., the limbic brain, known as our survival instinct, takes control. When the limbic brain is activated through an adverse or perceived adverse event, the survival brain takes over and puts the higher executive cognitive functioning found in the prefrontal cortex into a more auxiliary position. This function supports the survival drive but is not what helps an individual function with the rational logical mind. As the mesolimbic brain is so important to understanding the process of addiction, and neurotransmitters are so important in our functioning well as humans, those studying co-occurring disorders need to be cognizant of the complexity of human frailty and how helping people heal requires a holistic and whole-person approach to treatment.

The need for effective integrative treatment for the populations being served with co-occurring disorders is dire in this country. There is no one-size-fits-all way to treat those with co-occurring disorders, but understanding the neurobiology and neuropsychology involved with a variety of mental disorders and trauma can assist the counselor in considering causal issues involved with having substance use and process use disorders, along with mental health disorders to develop individualized treatment that addresses all biopsychosocial issues. This section of the text provides an overview of the traditional therapies and approaches that have been used to treat mental illness and substance abuse disorders, along with the newer approaches that have evolved over the past 30 years. Often, individuals with co-occurring disorders will need to be treated with several different approaches that include nutrition, somatic and creative arts therapies, mindfulness-based therapies, energy psychology approaches, and recovery models to effect real change. The following chapters will address the level of care needed for most effective treatment.

13 Assessment of Co-occurring Disorders, Levels of Care, and ASAM Requirements

Elizabeth Reyes-Fournier, Tara G. Matthews, and Tom Alexander

DOI: 10.4324/9781003220916-16

Introduction

The clinical assessment is a crucial part of ethical, effective, and evidenced-based treatment of cooccurring disorders. Assessments are the first opportunity to hear the client’s history and needs and to lay the foundation for clinical work. While the assessment process can feel invasive, if rooted in respectful curiosity, the counseling professional can gather vital information that will guide future clinical treatment with the whole client. Whether we are determining levels of care, determining readiness for early intervention, or doing an intake with a court-ordered client, assessment seeks to collect data from interviews, observations, histories, and established measurements to accurately diagnose a client so that the practitioner can effectively treat the individual.

The assessment process relies on a practitioner’s ethics and evidenced-based practices and can be dangerous when conducted by individuals who are untrained or biased. The first step in working with individuals with co-occurring disorders is to accurately assess them. Without proper assessment, there is no proper treatment. If the assessment approach is too rigid, short, biased, or dismissive, critical pieces of information can easily be missed such as nutrition, early childhood experiences, current living situation, or cultural influence. The practice of assessment is not a blunt tool but a refined system of data collection that works best when it is organized and founded on evidence that justifies each assertion. The assessment process is the first opportunity to demonstrate professionalism and a genuine curiosity with the client and, done with care, will begin the process of developing a therapeutic rapport, in which the client develops trust in the counselor.

Once assessment is complete and diagnosis, along with severity of symptoms, has been determined, the next part of the process is determining necessary level of care for effective treatment of the individual. The specific levels of care are guided by the American Society of Addiction Medicine (ASAM) criteria, edited by Ries et al. (2014). Each level of care is meant to provide the best possible treatment approach for clients in the least intrusive environment.

Learning Objectives

1. Identify various types of treatment offered to individuals with co-occurring disorders
2. Recognize intrapersonal factors experienced by the client that help provide a path for linkage to the appropriate level of care
3. Understand a current model of integrated co-occurring disorders treatment to assist with linking clients to the correct level of care based on their unique needs

Key Terms

• Detox Services: This is the unofficial name provided to medical services provided to individuals to help remove all traces of alcohol or other substances from their bodies. This service is designed to assist in managing symptoms of withdrawal, often through medicine, primarily completed at inpatient hospital units.
• Inpatient Treatment: A level of care often provided at a hospital in which an individual stays for a duration of 10 to 28 days. The purpose of this level of care is to decrease the most severe symptoms associated with substance use or mental illnesses while allowing patients to transition to long-term treatment.
• Outpatient Treatment: Treatment module that is provided within the community, usually allowing the individual to stay with their families, engage in work, and engage with self-help while also obtaining ongoing treatment for mental health or substance use disorders.
• Residential Treatment: Treatment provided at a shared home or apartment building to which the individual has 24-hour access. This level of care assists the individual with obtaining skills of basic living while also translating tools of recovery for long-term use.

Assessment in Substance Abuse Counseling

All assessments in substance abuse counseling need to be rooted in genuine curiosity about how best to serve the client and be guided by professional competencies and ethical considerations. ‘Addiction counselors encounter clients with CODs [co-occurring disorders] as a rule, not an exception’ (Substance Abuse and Mental Health Services Administration (SAMHSA), 2020a, p. xi). Clinical evaluation is the first practice dimension of a professional substance abuse counselor (Center for Substance Abuse Treatment, 2006). The role of the substance abuse counselor must always be to assess the individual’s current state and possible risk. Guided by the NAADAC Code of Ethics Principle V (NAADAC, 2021), the tools used to assess the client must be reliable, be effective, and take personal and cultural influences into consideration.

The ability to screen and assess a client is key to providing them effective treatment. This process ideally will begin with collecting data concerning the individual’s behavior and history from the client, their significant others, and referral agencies. This data, in combination with established, reliable, and valid measures, forms the basis of a comprehensive diagnosis. Assessment is an ongoing process that does not end with one clinical interview. The initial session will have the counselor establish rapport to assess a client’s level of functioning; history, include information like their mental health and use disorder issues; and family, social, and medical information. Every session will contain an assessment of the client’s current status, progress, and risk (Center for Substance Abuse Treatment, 2006). Clients with co-occurring disorders are at a greater risk for harming themselves or others. A practice of risk assessment at every session is best practice for the clinician (SAMSHA, 2020a).

It is estimated that approximately 3.3% of the population of the United States has co-occurring substance use and mental health disorders. More than half of those 7.7 million individuals will not receive any treatment, and less than 10% receive integrated treatment (Han et al., 2017). The difficulty in assessing co-occurring disorders begins with ignoring the prevalence of this phenomenon. From the perspective of treating severe mental illness, there has been a tendency to omit questions regarding potential use with clients (Chen et al., 1992). From the perspective of the substance abuse counselor, many indicators of severe mental illness may appear as severe use or withdrawal symptoms (Mueser & Gingerich, 2013). The reality is that exclusion of either the mental illness or the substance abuse in the treatment of those with co-occurring disorders results in a considerable risk that the individual will relapse, reoffend, or be hospitalized (Perry et al., 2019). Understanding that any assessment in a substance abuse setting must include a mental health screening is key to properly diagnosing the individual. Additionally, any mental health assessment would need to rule out substance use disorders to better understand the symptomatology presented.

Categorical Versus Dimensional Concepts in Diagnosing

Unlike medical conditions that are diagnosed with a laboratory test separating a bacteria or virus from normal cells, mental disorders are not distinct categories but rather a range of symptoms with an overarching hallmark of disability (Widiger & Samuel, 2005). For example, a client complains of sleep disturbances, fatigue, difficulty concentrating, and feeling agitated. What category would you automatically assume that this client’s diagnosis would fall under? These symptoms are not unique, and, as has been noted by psychological professionals for decades, the overlap of symptoms can result in faulty assessments. (See Table 13.1.) This is but one example of several from previous iterations of the DSM.

Table 13.1 Biopsychosocial data collection table

Domain	Area	Collected Information
Biological	Medical Information	History of illness, surgeries, injuries, disabilities, hospitalizations
	Genetic Information	Family history of illness, diseases, deaths, use disorders, mentalillness, homicidal/suicidal ideation and attempts, family criminal background
	Developmental Information
	Substance Use Information	Developmental delays in speech, milestones, type of birth, other developmental delays
		Use of legal and illegal substances, age of first use, current use, administration, frequency, and amount
Psychological	Mental Status	Current diagnosis, current presentation
	History	Age of onset, trauma, and family trauma
	Hospitalizations	Any commitment due to mental health (voluntary and involuntary)
	Medications	Use of prescribed medications for mental health treatment
	Strengths/ Limitations	Client’s self-perception of strengths and areas in need of development
Social	Social	Friends, supports, family connections including parents, siblings,and extended family
	Cultural
	Education/Vocation	Family culture, languages, foods, rituals
	Criminal	Education level (including GED), work history, current work, andvocational goals
	Religious/Spiritual
		Detailed personal criminal history, including juvenile history
		Client’s connection to spirituality or religion (passive or active)

The categorical model of diagnosing was based on symptoms belonging to categories that created distinct diagnosing. The goal of the model was to present diagnoses that were unique and distinct from other diagnoses in the DSM (Widiger & Samuel, 2005). The obvious limitations of this model were that many symptoms in the DSM are ubiquitous. Also, the attempt to present a diagnosis as separate and apart from other abnormal moods, behaviors, or disturbances limited the detection of co-occurring disorders (Blashfield, 1998). Despite the previous iterations of the DSM attempting to quash issues by providing guidance in differential diagnostics, separating one diagnosis from another, the similar symptoms, and the tendency to stick with faulty diagnosing, this system of viewing mental disorders is faulty and results in poor and ineffective treatment for our clients (Widiger & Samuel, 2005).

When comparing major depressive disorder and general anxiety disorder criteria in the DSM-5 (APA, 2013...

Table of contents

• Cover
• Endorsements
• Half Title
• Title
• Copyright
• Contents
• About the Editors
• About the Contributors
• Editor’s Note
• Acknowledgements
• Section I Disorders of Mental Health and Addiction
• Section II Populations
• Section III Integrative Treatment Approaches for Those With Co-occurring Disorders
• Conclusion
• Index