Integrated Dual Diagnosis Treatment

CLINICAL ELEMENTS

Integrated Treatment

• Core Components– Integration of Services– Comprehensiveness– Assertiveness– Reduction of Negative consequences– Long-Term Perspective – Motivation-Based Treatment– Multiple Psychotherapeutic Modalities

CORE COMPONENTS

Integration of Services

• When providing IDDT, one wants to provide services for both mental illness and substance abuse simultaneously

• These services should be provided by the same clinician(s) or team within the same organization– Helps to avoid gaps of service delivery– Helps to ensure that both types of disorders are

treated effectively

Comprehensiveness

• IDDT attempts to provide services directed not only at the problems of substance abuse and mental illness, but also the broad array of other areas of functioning that are frequently impaired in the lives of the dually diagnosed client– Housing -Vocational Functioning– Family/Social relationships– Ability to manage psychiatric illness

Assertiveness

• This addresses the location of service provision and how a client is engaged in treatment

• Effective treatment programs for the dually diagnosed client does not wait for often reluctant clients seeking treatment on their own

• Effective treatment programs use assertive outreach and legal mechanisms to involve the client in treatment

Reduction of Negative Consequences

This is the philosophical dimension of integrated treatment

• Due to the damaging impact dual disorders have on the lives of clients, the first and foremost goal of the clinician is to reduce harmful effects– Do this without judging or imposing your personal

values on the client regarding the causes or the moral responsibility for the consequences

Long-Term Perspective

• This addresses the need for time-unlimited services

Motivation-Based Treatment

• This orients the clinician as to specific interventions to use depending of the clients desire to change their behavior

• This avoids unnecessary and potentially destructive conflict between the client and clinician

• This helps to maximize treatment gains through collaborative work

Multiple Psychotherapeutic Modalities

• Provide psychological treatment services for the dually diagnosed client in as many formats as are needed (and several usually are)– Individual – Group– Family Therapy Modalities

STAGES

Motivation

• IDDT is a STAGE BASED approach to treatment• In order to most effectively treat the dually

disordered client, interventions must by MOTIVATION BASED– Adapted to clients motivation for change

• Stages of treatment is CENTRAL, it provides a framework for assessing the clients – Motivational states -Setting goals– Selecting interventions appropriate to achieving those

goals

Stages of Treatment

• 4 stages– Engagement– Persuasion– Active Treatment– Relapse Prevention

Stages of Treatment vs. Stages of Change

Stages of Treatment Stages of Change

Engagement Precontemplation

Persuasion Contemplation

Preparation

Active Treatment Action

Relapse Prevention Maintenance

Stages of Treatment

• IDDT uses Stages of Treatment because it is specific to changes that occur over the course of treatment for clients who experience dual disorders

Stages of Treatment

• Engagement– Definition:

• The client does not have regular contact with their dual diagnosis clinician

– Goal:• Establish a working alliance with the client

Engagement Interventions

• Outreach• Practical assistance (food, clothing, housing,

benefits, transportation, medical care)• Crisis intervention• Stabilization of psychiatric symptoms

(medication management)• Help in avoiding legal penalties• Help with arranging visitation with family or

family meetings• Support and assistance to social networks

Stages of Treatment

• Persuasion– Definition:

• The client has regular contact with the clinician, but doesn’t want to work on reducing their substance use/abuse

– Goal:• To develop the clients awareness that

substance use is a problem and increase their motivation to chabnge

Persuasion Interventions

• Motivational Interviewing• Peer Groups (persuasion groups)• Social skills training (for non-substance related

situations)• Individual and family education• Psychological preparation for lifestyle changes

necessary to achieve remission• Sampling constructive social and recreational

activities• Safe “damp” housing

Stages of Treatment

• Active Treatment– Definition:

• The client is motivated to reduce their substance use, as indicated by a reduction for at least 1 month, but less than 6 months

– Goal:• To help the client further reduce their

substance use and, if possible, attain abstinence

Active Treatment Interventions

• Social skills training to address substance-related situations

• Peer groups (active treatment groups)• Self-help groups (12 step, RR, DRA)• Individual Cognitive-Behavioral counseling• Psycho-education• Stress management and coping skills• Family and individual problem solving

Stages of Treatment

• Relapse Prevention– Definition:

• The client has not experienced problems related to substance use for at least 6 months (or is abstinent)

– Goal:• To maintain awareness that relapse can

happen and to extend recovery to other areas (social relationships, work…)

Relapse Prevention Interventions

• Expanding involvement in supported or independent employment

• Groups (active treatment or relapse prevention, 12-step, DRA, RR)

• Social skills training• Family problem solving• Lifestyle improvements (smoking cessation,

diet, exercise, stress management techniques) • Independent housing

IDDT

• As seen, IDDT is COMPREHENSIVE• It is also FLEXABLE

– You do need;• To use a stage based approach to treatment• To use Cognitive Behavioral treatment• To select what you have a capacity to do based on how

you prioritize FIDELITY components of the model and what you as an agency or institution are able to do

SPECIFIC TOOLS

• Differential Diagnosis

• Payoff Matrix

• Formulation

Learning Curve of the Staff

• There was in our case initial resistance• Use of the Payoff Matrix offered face validity,

with it staff members were more willing to try and use various tools of IDDT

• It is important to practice, practice, practice the tools– In order to make IDDT work, you need consistent

and appropriate supervision/consultation to help to improve staff’s ability to use the tools and to acquire the skills required to effectively implement IDDT

Benefits of Using the Tools

• Appropriate treatment for dually diagnosed clients– IDDT helps to meet the client where they

are in their specific stage of recovery– IDDT helps to improve outcomes for

treatment• This helps to motivate the clienty to continue to

engage in treatment

Benefits of Using the Tools (cont’d)

• Using IDDT helps make staff feel more successful and improves their motivation to work with this population previously seen as unrewarding

• The IDDT tools have broad applicability and generalizability beyond the dually diagnosed population

• Using IDDT helps to instill hope– Hope for the clients, hope for the staff