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Dual Diagnoses. Principles of the Minkoff model for treating co-occurring mental health & substance use disorders. “ Dual diagnoses are an expectation, not an exception”.
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Dual Diagnoses Principles of the Minkoff model for treating co-occurring mental health & substance use disorders
“Dual diagnoses are an expectation, not an exception” • According to epidemiological studies, approximately 50% of people with a diagnosis of severe mental illness also meet lifetime criteria for a diagnosis of substance use disorder. (Drake, 1995)
Prevalence of substance use disorders with mental illness Regier et al, JAMA 1990
“Dual diagnoses are an expectation, not an exception” • According to the National Comorbidity Study, people with mania are 9.7 times as likely as the general population to meet the lifetime criteria for alcohol dependence. (Kessler et al, 1996)
Prevalence of Co-Occurring Substance Use Disorders with Schizophrenia (ECA Study) % of respondents Regier et al., JAMA, 1990
“Dual diagnoses are an expectation, not an exception” • In community studies evaluated for the Epidemiologic Catchment Area (ECA) study, 33.7% of people diagnosed with schizophrenia or schizophreniform disorder and 42.6% of people with bipolar disorder also met the lifetime criteria for an alcohol use disorder (AUD) diagnosis, compared with 16.7% of people in the general population. (Regier et al, 1990)
“Use the Four-Quadrant model to understand & inform effective treatment”
“Emphasize the empathic, hopeful, integrated aspects of the treatment relationship” • The most significant predictor of treatment success is an: (1) empathic, (2) hopeful, (3) continuous treatment relationship in which (4) integrated treatment and (5) coordination of care can take place through multiple treatment episodes. • Within this context, (6) case management / care and (7) empathic detachment / confrontation are appropriately balanced at each point in time.
“Consider both disorders primary and integrated, and treat accordingly” • Both treatment systems (Mental Health & Substance Abuse) have myths that clinicians can’t treat one illness while also treating the other.
“Consider both disorders primary and integrated, and treat accordingly” • In fact, treatments for each condition work well together, and staff can learn to integrate both. • Both substance disorders and mental illness fit into the disease-management / recovery model.
“Apply the Disease / Recovery model with diagnosis-specific and stage-of-change-specific interventions”(r/d-1) • Leads to lack of control of behavior &/or emotion • Symptoms can be controlled with treatment • Physical, mental and spiritual disease • Progressive illness w/o treatment • Disease miscast as a moral issue • Affects the entire family • Depression & despair • Shame and stigma • Hereditary factors • Biological Illness • Guilt and failure • Denial factor • Incurable • Chronic
“Apply the Disease/Recovery model with diagnosis-specific & stage-of-change-specific interventions”(d/r-1) • Initial phase is stabilization, which may require hospitalization, &/or medication (detox), &/or psychotropic medication • Following stabilization, the next phase is rehabilitation • Rehabilitation involves maintaining stability by following a long-term program (don’t use, attend meetings, work the 12 Steps, etc / take meds, use therapy or other helpful supports / services, etc.) • Denial needs to be overcome
“Apply the Disease/Recovery model with diagnosis-specific & stage-of-change-specific interventions”(d/r-1) • Powerlessness over the disease needs to be acknowledged • Help must be asked for, from a power greater than the self, in order to control symptoms (higher power, AA, NA, sponsor, meds, therapist, doctor, case manager, etc) • Recovery proceeds ‘One Day At A Time’ • Recovery is never done, but gradual progress can be made
“Apply the Disease / Recovery model with diagnosis-specific & stage-of-change-specific interventions”(d/r-2) • Relapse is always a risk • Families / friends benefit from involvement in a program to get help for themselves in dealing with the disease • Education about the disease is an important piece • Treatment must include focus on feelings about the disease, and feeling good about oneself • Recovery is a physical, mental, emotional and spiritual process
“Apply the disease / recovery model with diagnosis-specific and stage-of-change-specific interventions”(Prochaska, Norcross, & DiClemente) Precontemplation Relapse / Recycle Contemplation Maintenance Preparation Action
Evaluating Stages of Change • Precontemplation(Denial) • “What problem? I’m not thinking about it.” • Contemplation(Ambivalence) • “I wonder if I might have a problem? I’m thinking about it but not ready to decide anything yet.” • Preparation / Determination(Admission) • “I have a problem.”
Evaluating Stages of Change • Action(Taking steps / Making changes) • “I have a problem and I’m ready to do something about it.” • Maintenance(Continuing what works) • “I’m stabilized and doing well. How can I support my ongoing recovery?” • Relapse / Recycle(Trying again) • “I’m stabilized but have relapsed. How can I get back into active recovery?”
“There is no single correct intervention!”Individualize treatment per . . . • . . . Quadrant designation (see) • . . . Diagnoses (DSM-IV) • . . . Level of functioning (evaluate – GAF, other tools) • . . . External constraints (Assessment, Tx plan) • . . . External supports (Assessment, Tx plan) • . . . Phase of Recovery / Stage of Change (see) • . . . Multidimensional assessment of level-of- care requirements (ASAM PPC-2R)
“There is no single correct destination!”Individualize outcome expectations per . . . • . . . Quadrant designation (see) • . . . Diagnoses (DSM-IV) • . . . Level of functioning (evaluate – GAF, other tools) • . . . External constraints (Assessment, Tx plan) • . . . External supports (Assessment, Tx plan) • . . . Phase of Recovery / Stage of Change (see) • . . . Multidimensional assessment of level-of- care requirements (ASAM PPC-2R)
