November 2003
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In this issue
-- SAVVY
-- SKILLS
-- SOUL
-- STUMP THE SHRINK
-- Until next time......

WELCOME!

Welcome to November's edition of TIPS and TOPICS. Thanks to all of you who take the time to write to tell me how you are appreciating and using the TIPS and TOPICS with your team and agency. I may not have written you back, but I do read all your messages and am very grateful for your comments and questions.

SAVVY
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It is difficult to read any addiction or mental health publication or conference brochure these dayswithout seeing an article or presentation on Co-Occurring Mental and Substance-Related Disorders.Certainly at the Federal level, funding and initiatives are very focused on co-occurring disorders. Ihope this is not a passing fad that gets the buzz of the day, but fades away before real change in attitudes, access and services can be established.


Tips:

** Pay attention to any blindspots about the "dual" issues of addiction and mental illness.

Unfortunately many mental health clinicians have not received training in the addictions, and vice versa. Any lack of training in addiction or mental health may have created blindspots that can distort your assessments. As inexact a term as "dual diagnosis" is, the duality upholds the importance of both disorders. And "diagnosis" suggests that we do sufficient assessment to try to tease out substance use problems from mental health problems.

I realize that "co-occurring disorders" is the "in" term, but as I go around the country, it is curious to see the regional variations in terminology. For example it seems to be Mentally Ill Chemically Addicted (MICA) or Chemically Abusing Mentally Ill (CAMI) in the New York, New Jersey area. In Illinois, the term used has been Mentally Ill Substance Abuser (MISA) or Substance Abusing Mentally Ill (SAMI). Minnesota has used Mentally Ill Chemically Dependent (MICD). It's a bit hard to say CDMI - it doesn't flow as nicely as CAMI and SAMI.

Ken Minkoff in Boston said they floated ICOPSS - Individuals with Co-Occurring Psychiatric and Substance Symptomatology. That's descriptive, but doesn't flow nicely from the tongue either. I heard that in Southern California the term to use might be "People with Multiple Vulnerabilities". Over the years, we have seen co-existing disorders, co-morbid disorders, dual disorders, double trouble, and the one that seems most enduring and nationally used (before the term du jour, co-occurring disorders) is "dual diagnosis". Whatever term you use, remember the spirit of "dual diagnosis".

**Here are a few free and easily accessible resources for all of you who, like me, have trouble keeping up with all the books, journals and resources out there.

>> In 2002, the Substance Abuse and Mental Health Services Administration (SAMHSA) presented "A Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders". It provides a summary of practices for preventing substance use disorders among individuals who have mental illness and also a summary of evidence-based practices for treating co-occurring disorders. Resource: www.samhsa.gov/reports/congress2002/foreword.htm

>> A 2003 publication, "Strategies for Developing Treatment Programs for People with Co-Occurring Substance Abuse and Mental Disorders" is also available on the SAMHSA website or though the SAMHSA National Mental Health Information Center at (800) 789-2647. SAMHSA Publication No. 3782, SAMHSA

>> Co-Occurring Dialogues is an Electronic Discussion List that specifically focuses on issues related to dual diagnosis. A subscription to the Co-Occurring Dialogues Discussion List is free and unrestricted and can be done simply by sending an e-mail to dualdx@treatment.org.

SKILLS
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Mental health clinicians have often not been specifically trained in addiction treatment. This may result in ignoring the substance use; or being too ready to see the substance use problems as a result of underlying mental health problems. Addiction treatment clinicians can have the opposite problem. They can view mental health problems as a symptom of an addiction problem e.g., assuming the depression will disappear when the person is off cocaine crash; or seeing the restlessness as just post acute withdrawal and neglecting the adult Attention Deficit Hyperactivity Disorder.

Tips:

**Don't understimate the power of careful phrasing of questions!

When taking a substance use history, tweak the way you ask questions. It may increase the validity of the answers.
For example:
Rather than: "Do you drink alcohol?", try "How much do you drink a day?" This may increase the chance to solicit more accurate amounts.

Rather than: "Have you had any family arguments over drinking or drugging?", try "How many times a week do you get into family fights over alcohol or other drugs?" This may bring back the flood of memories over arguments so that the person answers candidly.


** Focus on person-centered assessment and individualized treatment, and you will indeed be doing integrated co-occurring disorders treatment.

Whatever terminology we use to call people struggling with both substance use and mental health problems, we really are just talking about people with two or more problems. Dual diagnosis clients are not a homogenous special target population. Because of the interaction of various mental disorders with often multiple substances used, there is no one co-occurring disorders presentation.

The six assessment dimensions of the ASAM Patient Placement Criteria provide a common language of assessment and treatment services to focus on the person's multiple needs:

1. Acute intoxication and/or withdrawal potential - detoxification services
2. Biomedical conditions and complications - physical health services
3. Emotional/behavioral/cognitive conditions and complications - mental health services
4. Readiness to Change - motivational enhancement for both addiction and mental disorders
5. Relapse/Continued Use/Continued Problem potential - relapse prevention services
6. Recovery environment - family, legal, vocational, housing, transportation etc. services


** Uphold the principle of "no wrong door" AND utilize a common language and assessment process like the ASAM Criteria.

Without a common language and assessment process as in the ASAM Criteria (I am biased of course), "no wrong door" can be an empty promise. Who would not want to meet people where they are, and welcome them into treatment no matter where they entered the system?
> But when the emergency room physician fixes the broken leg from the car wreck, will she also assess the upset family distressed by their family member's repeated drinking and driving accidents? (Dimension 6, Recovery Environment).

> When the therapist in the secure psychiatric unit counsels the suicidal patient admitted with an overdose, will he also assess the person's readiness to change her substance abuse? (Dimension 4, Readiness to Change).

> As the addiction counselor addresses serenity and sobriety, will he also deal with the long-term panic disorder that got the person addicted to benzodiazepines in the first place? (Dimension 3, Emotional, Behavioral or Cognitive Conditions and Complications).

> And will the chronic pain also be adequately addressed? (Dimension 2, Biomedical Conditions and Complications).

Is a common language and assessment process too idealistic? If we cannot find some common reference point, how will we ever overcome the "cultural" differences between a hospital medical unit, an emergency room, a secure psychiatric unit, an outpatient and residential addiction program? Could we ever get to "Every Door is the Right Door"?

SOUL
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Working in the behavioral health world has it rewards and its struggles too. Every day, many of you face people with mental status instability of psychosis, mania, depression, panic and anxiety. It is easy to feel hopeless or write off severe and persistently mentally ill people as chronic schizophrenics and manic-depressives etc. For those of you who see people cycle through the revolving door of multiple detoxifications and relapses, it is easy to feel equally hopeless and write those clients off as chronic alcoholics or addicts. In other words, it is hard to truly see a person under that easy, quick and convenient diagnostic label which defines them in our minds and -counterproductively I would add - in theirs.

When I was in medical school, we engaged in a somewhat ghoulish equivalent of not seeing a person for who they are/were. In anatomy class, we would dissect a cadaver and poke at the cold lifeless body, forgetting that this was once a vibrant, active father or son or someone's co-worker or lover.

Gradually I am shifting my own language away from diagnostic labels to talk of people suffering from alcohol dependence - not alcoholics in denial. This is a son or daughter, a brother or sister, a spouse or partner struggling with psychotic symptoms - not a chronic schizophrenic. I try not to get too self-conscious about this, nor jump on some strident activist bandwagon. But it is subtle how easily we become hardened to the pain of the people we serve.

For example, when we think of people as alcoholics and addicts who lie and con, there is almost an automatic dismissal of every positive piece of information they share.
Counselor: "Oh you stayed sober without going to AA or working a recovery program did you?"
Counselor's unexpressed thought: ("Yeah, right!" the skeptical counselor mutters to himself.)
Counselor: "So you only use alcohol and a little marijuana?"
Counselor's unexpressed thought: ("Tell me another story, will you?" she says to herself, eyes rolling.)

Those are just the addiction treatment examples. Remember all the times we yucked it up over those "borderlines", "chronic schizophrenics" and "sociopaths", not to mention the "narcissistic manipulators" and those "passive-aggressives"! It is always challenging to see 'the person', not the label.

Understanding people suffering with cancer or leukemia or Parkinson's seems easier. Perhaps it helps that we don't think of them as the breast cancer who lives next door, or the leukemic, or the Parkinson's in the next apartment upstairs.

STUMP THE SHRINK
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Question:

"This is a DSM-IV clarification-type question that arose during a case staffing. A diagnosis of substance dependence was rendered and a piece of criteria used involved: "there is a persistent desire or unsuccessful effort to cut down or control substance use." The clinical proof used to support this had to do with the patient being incarcerated for probation violations related to substance use. The question that arose was: Does this piece of criteria indicate that the patient has to make these attempts on his/her own? I don't see incarceration as a "voluntary effort" in attempting to cut down or control substance use. What is your read on this?"

Mike Mikulski, M.Ed., LAC, ACRPS
Great Falls, MT

Response:

Mike:
Thanks for your question. The criterion: "there is a persistent desire or unsuccessful efforts to cut down or control substance use" as I understand it, relates to a person's loss of control of their drug use. If the probation violations had to do with persistent positive drug screens in a person who was trying hard not to use, then the persistent positive drug results would be the appropriate and relevant issue, not the fact of incarceration.

But if the person wasn't trying to cut down or control use and then got positive drug screen results, then the probation violations wouldn't be relevant. Or if the incarceration and probation violations were to do with not following through with treatment or some other requirement not related to cutting down or controlling substance use, then again, it wouldn't be relevant.

In other words, I agree with you that the person needs to be making the attempts to cut down or control their substance use on their own, not just because they are forced to do so via incarceration. If the person were incarcerated and has access to substances even while incarcerated, and has trouble cutting back or controlling substance use, then the incarceration situation would be appropriate to the DSM -IV criterion. But the issue then is still inability to cut down or control, not the fact of incarceration alone.

Is this making sense? If not, come back at me.

David Mee-Lee, M.D.

Until next time......
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Thanks for being part of TIPS & TOPICS. I am looking for any Stump the Shrink questions or your Success Stories or vignettes on implementing any of the TIPS and TOPICS. Tell us how much identifying data you are comfortable sharing here in this forum.

Talk to you next month.
David.

Contact Information
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email: info@dmlmd.com
voice: 530-753-4300
web: http://www.dmlmd.com
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