A Unique Approach for the Treatment of Co-Occurring Disorders

Transcription

1 A Unique Approach for the Treatment of Co-Occurring Disorders Presented by Paula DeSanto Minnesota Alternatives LLC Presentation copyright 2012 Minnesota Alternatives Can we support goals other than abstinence? In 2001/2002, (NIAAA) conducted the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the largest study ever conducted. (sample size of n = 43,093) Twenty years after onset of alcohol dependence, about three-fourths of individuals are in full recovery; more than half of those who have fully recovered drink at low-risk levels without symptoms of alcohol dependence. Many heavy drinkers do not have alcohol dependence. For example, even in people who have 5 or more drinks a day (the equivalent of a bottle of wine) the rate of developing dependence is less than 7 percent per year. NIDA: Drug abuse starts early, peaks in teen years, and rarely occurs in older adults. 1

2 SAMHSA definition of recovery: 2009: Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life. 2011: Recovery from Mental Disorders and Substance Use Disorders: A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. According to the SAMSHA the following are evidence-based practices for co-occurring disorders: Motivational interviewing Cognitive-behavioral therapy Stage-wise treatment Relapse prevention Knowledge of psychotropic medications Treatment often requires clients to attend self help meetings, and according to Integrated Treatment for Dual Disorders: A Guide to Effective Practice by Mueser et al(2003): during the engagement stage, referral to selfhelp groups is clearly inappropriate. And, involvement in self help groups MUST BE VOLUNTARY. Based on an internet search: As of 2009 coerced AA has been ruled unconstitutional in 16 states. Client desire for alternatives 2

3 What is Harm Reduction? Harm Reduction (HR) first emerged as a public health alternative and became accepted in the US in the late 1980 s as a set of strategies for reducing the spread of HIV and other risks associated with active substance use. Syringe exchange Condom distribution Methadone/Suboxone Designated Driver Ignition Interlock (Benzos, strategies to slow BAC, marijuana) Acknowledges drug use is part of our world & chooses to minimize its harmful effects rather than condemn them. Recognizes that poverty, racism, past trauma, and other social inequalities affect people's vulnerability and capacity to manage drug related harms. Understands drug use as a complex phenomenon and acknowledges that some ways of using drugs are clearly safer than others. Goals other than abstinence are reasonable. Focus on quality of life & well-being. Non-judgmental, non-coercive service providers can be effective helpers with clients anywhere along the continuum of drug use. Ensures users have a real voice in the creation of programs and policies designed to serve them. Affirms users themselves may know best what they need to reduce the harms of their drug use. 3

4 10/24/12 Why Do People Change? They hurt enough they have to. They learn enough they want to. 4

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6 Autonomic Nervous System The bodies automatic, self-regulating control system: Sympathetic Nervous System: Mobilizes energy during times of stress and arousal. Heart rate accelerates, blood pressure increases, respiration quickens, adrenalin is released, energy moved toward arms and legs. Parasympathetic Nervous System: Conserves and restores body s energy and resources. Slows the heart rate, increase energy to digestives system, relaxes the body and moves blood flow to internal organs to support growth and maintenance. Impact on Dopamine levels: (U of Calif. LA Integrated Substance Abuse Program) Food 50% Sexual arousal, nicotine, alcohol 100% Cocaine 300% Meth 1,200% Impact on brain: Gray matter cell bodies White matter connecting fibers covered by fatty white tissue Normally as we age we develop more active connections, hence more white matter. With cocaine addiction age-related expansion of white matter is absent, meaning less learning capacity. Gray matter density reduced in cerebral cortex. Diminished gray matter with heroin and alcoholism correlated with years of use. The longer the use, the greater loss of volume. OFC (processing of sensory info) shows malfunctions in patterns of blood flow, energy use and activation in people who abuse drugs. 6

7 The role of environment - what is going on up river: prevention In utero Brain development - Early childhood Attachment/Attunement Stress/over stimulation Trauma Loneliness ACE Study Epigenetics Brain Information: We have far more power to alter our brain, our behavior, and our personality than previously thought possible (neuroplasticity). Where we place your attention defines us at a neurological level. The brain is so powerful because it is so sensitive to experience. (FYI -Stress eats holes in your brain.) Brains develop and function according to the environments that they develop and function in. Creating an Optimal Internal Environment: The optimal point of entry into the body s major systems (endocrine (hormonal), cardiovascular, immune, gastrointestinal, is the Autonomic Nervous System (ANS). The ANS is intertwined with and helps regulate every other system and: Mental activity has greater direct influence over the ANS than any other bodily system. 7

8 Diaphragm How to activate the circuitry of the Parasympathetic Nervous System: Relaxation Diaphragm Breathing Big Exhalation Time inhalation to match exhalations Mindfulness Imagery Meditation Touch your lips Mindfulness Makes the Brain Immune to Temptation Interestingly, mindfulness didn't just reduce activity; it functionally disconnected the different regions of the brain that make up the "craving network. Paying mindful attention to the trigger of the craving interrupted this complex brain response, and ultimately protected smokers from their own desire. McGonigal, K (2011) 8

9 Benefits of Meditation: Increases gray matter. Improves psychological functions including attention, compassion, and empathy. Reduces cortical thinning. Increases activation in left frontal regions, which lifts mood. Decreases stress-related cortisol. Strengthens the immune system. Helps cardiovascular disease, asthma, type II diabetes, PMS, chronic pain. Helps numerous psychological conditions; insomnia, anxiety, phobias, and eating disorders. Model Includes: Support/Counseling Education/Inspiration Accountability Philosophy/Culture Support/Counseling: Priority on engagement Person centered - vision of recovery Understanding Motives for Use Pros and Con s Empathy skills Individual counseling/therapy (EMDR) Practical hands on assistance Holistic activities Long-term support 9

10 Education/Inspiration: Empowerment vs. powerless Neuroscience -Brain functioning and capacity Drugs and alcohol affects on the body/ brain. Consequences of use. Mindfulness, imagery, mental rehearsal Key Skills Development Mental Health Education, Seeking Safety, IMR, CBT, DBT integration Accountability: Individual Treatment Planning Harm reduction goals and build into treatment plan Regular goal review for monitoring and reinforcement Define parameters - What is too much? Self monitoring of use measuring a health behavior often changes it Agreements Managing high risk situations Philosophy/Culture: Core principles help develop a culture that is safe and authentic. Acceptance Flexible Tolerant Fun Generalizable Individualized Honest Lying in the program is like lying on an eye test. It only means you will not get the help you need. 10

11 Key Skills: Practicing Basic Self Care Calming Self Creating an Optimal Environment Experiencing Emotions Building Positive Experiences Cultivating Hope and Gratitude Reframing Practicing Acceptance Understanding Impermanence Practicing Attached Detachment Focusing on Effectiveness Demonstrating Understanding Developing Meaningful Activity SAMHSA (TIP 42) Co-Occurring Disorders: Central attitudes or skills needed by staff: Develop a therapeutic alliance A (newly defined)recovery perspective Monitor client psychiatric symptoms Use motivational enhancement related to client stage of change Behavioral techniques; what are we reinforcing? Skill building and repetition to target deficits An attitude of client responsibility for their own recovery Recognize and build on existing strengths Staff exudes a sense of hope I would add: The medicinal value of mindfulness, self calming and laughter. Self care, self care, self care. Trauma informed Positive experiences can be used to soothe, balance, and even replace negative ones. When 2 things are held in mind at the same time, they start to connect with each other Thought disorders observing the voices/ thoughts and mindfully deciding how to respond. Identifying warning signs when well. Validating medication issues. High Risk/Crisis planning 11

12 Staff Characteristics: Ability to demonstrate mindfulness and regulate their emotions. Strong sense of compassion. Strong empathy skills (not prone to problem solving) -the ability to demonstrate understanding and sit with the pain of others. Good sense of humor and able to laugh easily. A general sense of well-being and confidence so clients feel safe "unloading". Ability to lead meditations and use imagery. Mental Health knowledge and experience. Flexibility and comfort with ambiguity. Willingness to think outside the box and take calculated risks. Managing Risk: Focus on customer satisfaction Engage relevant others Be clear about what you are doing Document the important stuff and when possible use a team approach Incorporate legal language that calls for will abstain from problematic use instead of will abstain from all use, or will follow recommendations of Minnesota Alternatives Have adequate staff: client ratios Be skillful at deescalating a crisis Staff is cross trained in mental health Informed Consent Working in a Zero Tolerance System: The value of service coordination is understood, and everyone desires client success. Our client is not the courts, the social worker or the probation officer. Clients are assured they are in control of what information gets shared with any outside organizations. If a client does not authorize communication, this must be honored. Confidentiality is a right and failure to respect this is a MAJOR violation. John Doe was admitted on this date and is making good progress on his goals. John Doe continues to participate in treatment and is making good progress on his goals. John Doe successfully completed treatment on this date 12

13 Conclusion: As of Sept. 2012, 63% have completed the program successfully (compared to 56% statewide 2011 outpatient average). Outcomes include; progression in stage change or maintaining action, a higher quality of life, less consequences/harm from substance use, and reduced or no use. 95% percent of people who have completed report very high satisfaction with the program and 5% report overall satisfaction. Over 90% maintain abstinence or nonproblematic use 12 months after completion. There is a lot of work to be done to define and measure success, but there is one consistent finding: If a program engages and retains people, they show positive change. Reference List: Dr. Kevin Turnquist Bill M. Kelly PhD, Dept. of Psychological Brain Science, Dartmouth College National Institute of Drug Abuse and NIAAA Evolve Your Brain Dr. Joe Dispenza SAMHSA TIP 35 and 42 McGonigal, K (2011)How Mindfulness Makes the Brain Immune to Temptation Gabor Mate In the Realm of Hungry Ghosts WR Miller and Rollnick Motivational Interviewing The Harm Reduction Coalition Illness Management and Recovery (IMR) DBT Skills Marsha Linehan s work The Practical Neuroscience of Buddha s Brain - Rick Hanson and Richard Mendius. 13