A Venn Diagram Framework to Evaluate and Treat Co-Occurring Disorders and Trauma in Healthcare Professionals and Executives

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1 A Venn Diagram Framework to Evaluate and Treat Co-Occurring Disorders and Trauma in Healthcare Professionals and Executives Julio I. Rojas, LADC, Ph.D. Assistant Professor Director, OU Physicians ExecuCare Program Department of Psychiatry & Behavioral Sciences OU College of Medicine

2 Presentation Goals List three components of the Venn diagram for understanding co-occurring disorders and trauma treatment with healthcare professionals and executives Describe three specific ways to use this framework clinically to engage patients in the evaluation, treatment and aftercare phases of treatment.

3 Obstacles for Professionals Belief that intelligence and advanced training are protective factors Reliance on own resources rather than seeking assistance Ignore the problem b/c it threatens sense of competency and professional identity Overdeveloped cog, underdev emotionally Difficulty with transition from provider to patient Stigma Shamed, Broken, Wretched Fear loss of status and respect from colleagues and pts

4 Obstacles for Professionals Symptoms misattributed to work-related stress Other stressors conceal problem (e.g., grief, illness) Professional enabling Conspiracy of silence leads to delayed intervention Loss of income Time away for treatment Cost of treatment

5 Reasons Colleagues give for not confronting No tangible evidence Belief that addiction in off hours is not detrimental to job performance/risk to pts Confrontation would do no good None of my business Fear of reprisal He/she is going through a phase or stressor

6 Reasons Colleagues give for not confronting Fear of ruining one s career Misattribution of symptoms Using one s own definition of impairment I know him/her and he/she is smarter than that Betrayal

7 Progression By the time we get a healthcare professional or executive they are progressed (chronicity and severity). Usually with multiple condition(s). Therefore, the evaluation and diagnostic process is at best very difficult.

8 Why a Venn Diagram? A Venn diagram helps makes something complex more understandable. It serves as an aid to learning and discovery. It allows us to examine both the unique and interrelated aspects of things we choose to examine. This process of education and understanding of the condition(s) is important for the patient since it moves them toward the first part of Acceptance.

9 A Venn Diagram Model for Conceptualizing Co-Occurring Recovery Julio I. Rojas, Ph.D., The Board of Regents of the University of Oklahoma 2011

10 Integrated Treatment It is estimated that approximately 2% of individuals with COD receive truly integrated services Two contributing factors (from a workforce perspective): Training and our clinical experiences It is difficult to conceptualize in an integrated and individualized way Failure to diagnose and treat CODs leads to progression of these disorders and higher mortality

11 Tulsa World, March 2012 The sky is (still) falling: State officials still trying to solve the puzzle of Oklahoma s mental health crisis

12 Self-Assessment (0-10 rating) Rate your knowledge and skill set for each domain Addiction Chemical and Process Behavioral Psychiatric Disorders Trauma Personality Disorders What about the inter-related aspects?

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14 Evaluation and Diagnosis There is a relationship between SUDs and Axis I and II disorders (to include the trauma-based disorders) Many symptoms of SUD mimic psychiatric symptoms SUD can mask psychiatric illness Psychiatric illness can exacerbate SUDs and vice versa Psychiatric illness with polythetic criteria makes it challenging to Dx Testing is helpful, but in early sobriety many scales are elevated due to demoralization factor

15 Evaluation and Dx Issues CODs and trauma can share common manifestations and symptoms (e.g., emotional dysregulation, racing thoughts), which further complicate dx and tx of any one, let alone all Our pts can be affected by one or more at a given time and manifest these in diff ways (BioPsychoSocial) resulting in different sx expression, intensity/chronicity and outcomes. It is important to remember that each disorder has its characteristic effects on thinking, emotions, behaviors and relationships with others

16 A Venn Diagram Model for Conceptualizing Co-Occurring Recovery Julio I. Rojas, Ph.D., The Board of Regents of the University of Oklahoma 2011

17 The Gold Standard Extended Evaluations 3-5 day Clinical interviews Medical evaluation Psychological testing Urine and Hair follicle testing Collateral interviews Peer interaction Milieu monitoring Final report with diagnostic impressions and treatment recommendations Feedback to the patient is usually the weakest link in the process in terms of providing a conceptual understanding

18 Assessment Provide the feedback to the patient using the Venn Diagram Starting with an overview of their addiction hx and citing biopsychosocial factors Move to psychiatric illness Work toward trauma Discuss role of personality features Discuss areas to address, issues that concern me and themes that emerge

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20 Clinical Application of the Venn EDUCATION Venn Knowledge of the problem(s) Specific and inter-related aspects Based on patient s life story or narrative SKILLS (Solution) inventory what they possesses and what they need to manage chronic conditions Cognitive Affective Behavioral Relationship MONITOR application and mastery

21 Teaching Strategies by Domains Cognition skills/strategies Mental grounding (interventions across disorders), Challenging relapse/criminogenic thinking, acronyms HALT, KISS Emotional skills/strategies Labeling, verbalizing and sitting in feelings (emotional tolerance), radical acceptance Behavioral skills/strategies Distress tolerance, healthy coping, exercise, Stick with the winners Relationship skills/strategies shifting from I to We, working on 3 dimensions of existence, addressing character defects

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24 Aftercare Symptoms of Recovery in each domain (0-10) Thinking Feelings Behaviors Relationships Acceptance of the condition and more importantly the medicine! Monitor for COD and Trauma relapse symptoms using Venn.

25 Summary Remarks Integrated and individualized treatment CODs and trauma is necessary and possible. Like we often tell our patients, putting it on paper seems to help a great deal. This has been my experience with the Venn diagram. The framework helps me and my patients make sense of these chronic, complex and co-occurring disorders.

26 Quiz What famous individual suffered from: Alcohol Dependence Nicotine Dependence Major Depressive Disorder Narcissistic Personality Disorder Traumas in his life that include Abandonment by father and mother Loss of teenage first love resulting in a resentment toward his higher power at the time

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