 Hi everybody and welcome to today's class on the models of treatment for co-occurring disorders. Over the next little while we're going to identify the most common settings for co-occurring disorders treatment. Now you remember co-occurring disorders means that person has an addiction and mental health issue among other things. A lot of times there's also physical stuff going on but we want to look at the fact that addiction and mental health are both co-occurring as the name implies. We'll differentiate between the levels of treatment from intervention to residential level four. Identify specific characteristics of treatment in problem-solving courts and jails and we're going to talk about you know the caveats the benefits and the drawbacks to each type of treatment and each treatment setting. So settings health departments and social services centers. A lot of times that is just your regular outpatient. Now I've had the privilege of working in all of these settings so we're going to talk about some of the my experiences that you know may help you figure out where you might want to work. In health departments and social services I was stationed at the food stamps office in order to be able to connect with people who were receiving services you know food stamps and TANF services who also needed counseling. So that was really rewarding and I enjoyed working with those people. They came in like we'll talk about when we get down to jails there was a reason there was an emphasis there was a consequence if they didn't come see me. So it helped a little bit to ensure people were coming. Now whether we we were ensuring that they were interactive is a little bit of a different story and if you like working with involuntary clients then jails and social services are really good places to be and I happen to enjoy that population because it's it's always sort of a I don't want to say game because this is people's lives but it's always sort of a puzzle to me to try to figure out what's going to motivate somebody to continue to do the next right thing at least for as long as they're required to. Behavioral health care centers now this is by far the most common most of you have probably done internships at some sort of behavioral health care center residential treatment facility and obviously you can serve a whole bunch of different types of services where I worked we had a crisis stabilization unit a detoxification unit a methadone clinic residential intensive outpatient regular outpatient and regular outpatient mental health. So we had a whole range of services that we offered and you could kind of move between the different departments if you decided you wanted to change a pace for a while. Private practice offices are another place that you can see clients and a lot of clinicians in private practice LMHC's LCSW's LMFT's see people who present primarily for depression or anxiety or something like that but there is a strong rate of co-occurrence between mental health issues and substance abuse issues. So you know it's important that clinicians in private practice at least be aware of the fact that there is a good chance that the person you're working with has an addiction of some sort or will struggle with that during some period in their life. What does that mean? That means clinicians ideally should have a general understanding of addiction addiction treatment recovery principles because they work together cognitive behavioral works really well with addiction as well as as well as mental health. So what we want to do with addiction is help people identify the reasons that they're using and find better ways because a lot of times addictive behaviors are ways of dealing with emotional or physical pain. Now that emotional pain can come when people start using you know maybe they're using recreationally then they start using a little bit more when things get tough or whatever. Their brain chemistry changes so now their brain is used to having that substance in in their body in order to regulate the neurotransmitters. So in order for the person to feel what they consider to be normal baseline for them they need to have that substance which is going to prompt them to want to use and to crave the drug until the body gets used to not having it anymore. So it's important to help people figure out you know what's prompting these cravings some of it's physiological but some of it is often psychological. Different people places things emotional states may trigger people to want to use but that's a whole different presentation. Hospitals provide co-occurring disorders treatment. A lot of hospitals have a wing for patients with psychiatric or addictive issues that have to be monitored 24 hours a day seven days a week by medical staff because they are that medically unstable. Schools when I worked at the schools it was great I would go in and meet with the guidance counselor who would set me up in an office they'd go get the kid the kid would come we would talk for a while and you know do our thing. Now schools are wonderful and providing co-occurring disorders treatment in schools is helpful because a lot of times juveniles can't drive so even if they want to get to appointments they can't because you know a lot of times mom and dad are busy they're working they're doing something else. So this removes one of the accessibility barriers and I found that when I would go to work with kids in schools they enjoyed it because number one they were getting pulled out of class so bonus and number two they didn't feel like okay mom's on the other side of the wall is she listening in so they felt a little bit more relaxed than they would in a clinic sort of setting. So schools can be a really good place to provide interventions and jails. Now I really happen to like working with the correctional population people who are in jail or who are on probation and parole you know they're on what we call papers they have to participate they have to stay clean they cannot test dirty but when people are in let's let's talk about jail and prison specifically when they're still on lockdown a lot of jails and prisons unfortunately will discontinue medication when somebody is admitted to the jail or prison just to see how they make it when they're not on meds because the jail or prison does not want to pay for their medicine which means people tend to destabilize pretty quickly in jail. So okay let's say this is a good jail and the people who came in on meds stay on meds even if that's the case you can imagine what it's like living with the same people day in and day out and most of the people there probably have some interpersonal skills deficits. So there's going to be tension there's going to be occasional anger there's going to be depression when you because the person who's incarcerated may be missing their kids graduation or whatever. So there are a lot of situational mental health issues that come up as well as just the fact that people may have already been depressed or anxious. On top of that you've got substances and I would like to say that jails are substance free but I'm a realist and I've worked in them long enough to know that substances do get in you know sometimes it's cocaine, PCP, LSD, morphine you know there I've seen pretty much every drug get into the jail you know they can't have the things that can be they have to be smoked so it has to either be able to be snorted or eaten most of the time because it's hard for them to get access to needles as well so smoking and injecting methods are out but the point being when people are in in jail it doesn't mean they're necessarily clean the people who are clean the people who aren't using you know their brain may be re-stabilizing and getting used to being without the drug but they've got a lot of stuff to deal with they need to develop alternate coping skills so when life hands them lemons they don't want to relapse they need to be provided the skills and tools that they need so when they get out when they do have access to those substances again freely they're not tempted to use them and so while they're in jail when they do have access to the substances they're not tempted to use them so jails provide an opportunity to provide in a relatively controlled environment to provide people with the skills and tools they need now well we'll talk about these when we get a little bit further but I will say with residential treatment in a behavioral health care center hospitals and jails the skills people are learning are wonderful but when they're in those environments those are very controlled environments they're not having to pay bills they're not dealing with traffic they're not dealing with landlords or significant others or other things that could trigger them so going from a controlled environment to being released like once a week outpatient is really not a good idea people need to step down and the best analogy I can make for most people is think about when you went from high school to college you know that was just culture shock and you went from having a curfew and having mom and dad supervising you living under their roof having teachers you know hand peck you for your homework every day and all that kind of stuff to nobody really took attendance it didn't matter if you went to to class or not and you could stay up until two or three in the morning partying if you wanted so it was very tempting and it was very easy to not do what you were supposed to do when you got to college if you didn't have some structure going into it when I was a freshman in my sorority we had to put in a certain number of study hours every week and we had to maintain a certain gpa so that helped me learn better study habits and you know eventually when I got out of my sorority I didn't have somebody telling me you have to study for two hours today but I already had those habits ingrained so it didn't it wasn't a big deal to me to continue with those things we want to see the same thing with people who are coming out of jails or residential facilities we want them to step down it may only be for a month or so where they're an intensive outpatient and they're checking in every single day and then they can step down maybe check in twice a week and then step down again to one once a week individual therapy or something but it's always good to scaffold that step down to make sure that they can deal with life on life's terms in the world out there so prevention is one level of treatment and it's not really treatment it's obviously prevention but there are multiple types of prevention now prevention like most people think about it is don't ever get the problem okay that's your traditional prevention and yes it's great the goal is to avert problems before they begin through modifying risk and protective factors in the following domains individual risk and protective factors like we want to modify the depression we want to make sure they've got good coping and interpersonal skills we want to make sure we screen for any learning disabilities etc family risk and protective factors they found that families that are closer knit where there's stability where there's consistency in parenting and where there's adequate social support is obviously a protective factor schools we want schools that encourage interaction we want schools that encourage students to partake in activities and feel like they're connected with the school and we want schools that emphasize helping students learn and in the community prevention can start out with working with law enforcement and legal officials to make sure that the community enforces the drug-free standard in the community it can work to clean up drug-ridden areas in the community not only getting rid of the drugs but we want to give people something else to do we can start having social events we can start having movies on the lawn at the you know downtown plaza we can start having activities at the library in order to get people engaged and again feel connected those are all ways that we can help prevent problems along with this we can do some education about drugs and substances and how easy it is to get addicted and that it's not just willpower once people start using it actually changes their brain chemistry which can revert but it takes time so it's important that people are aware of that so that's prevention and you can use this you other examples are educating children about drugs and their effects of improving communication among families ensuring children are able to engage in school that doesn't mean just go that means engage they are they've got enough clothing they're warm enough or cool enough is the case maybe and they've got enough food in their bellies that they're not hungry um and they're able to they're they have a safe home environment so they're not exhausted when they get to school because they were just too terrified to sleep all night long because they were sleeping in the car or in the middle of a domestic violent out um domestic violence episode or something so we want to make sure that children are happy healthy and engaged and we can improve community stability organization and attachment by offering things that the community can do and we can also make sure that things like transportation are available to help people get to work and that there are jobs available I know around here right now there are jobs just everywhere I go there are signs up saying you know high now hiring and there almost always are unfortunately in this community where I live now there's no transportation so and it's a pretty rural community so unless you've got a friend who can drive you or you live in close and there aren't very many apartments so you know it's is a double whammy um but you know we want to make sure people not only can earn a living to keep a roof over their head but they can also get to that job to earn a living so those are all things we can do for primary prevention we can also educate the community about mental health issues the chances of somebody developing an addiction increase if they have depression or anxiety or bipolar disorder so these are things that we want to make sure that the community is aware of and that they know where resources are another type of prevention is called secondary prevention which means okay we didn't prevent the first thing from happening that that stinks but we can keep it from getting any worse you know let's stop it in its tracks prevent it from getting worse and this is when we have intervention level services outpatient services available hotlines available you know this is when the services at the social services offices as well as schools can become really helpful to stop it in its tracks before it becomes a big problem the third type of prevention is called tertiary prevention and that means we're going to prevent this problem from causing more problems in other areas of the person's life so okay maybe they've developed a full blown addiction and you know they're really struggling with it all right that's a problem but tertiary prevention would say let's make sure we prevent you from getting hepatitis because that's going to be a whole nother ball game let's make sure we prevent you from going to jail because legal issues are going to complicate the picture let's make sure we prevent you from becoming homeless because again that'll complicate the picture let's deal with this addiction you know we didn't prevent it we didn't stop it in its tracks but let's prevent other problems from happening because you've developed this addiction now so prevention has primary tertiary or primary secondary and tertiary aspects to it intervention provides resources to prevent worsening of an addiction or other biopsychosocial issues that could lead to addiction methods include psycho-educational groups and classes when you do the groups on self-esteem development and coping skills and dialectical behavior therapy acceptance and commitment therapy and those can be done they don't have to be clinic based things a lot of times people don't feel comfortable going to a clinic so if you offer workshops and you call them workshops in community education offer workshops at libraries offer go to different festivals and have tables where you provide handouts that help people learn about resources that are available early identification of persons with risk factors for mental health stress related or substance abuse issues are also effective methods of intervention early intervention this is when you know they might be using but it's not a problem yet or they might be getting kind of blue but they're not clinically depressed yet early identification can happen at the doctor's office it can happen at schools you know the school counselors or even the teachers it can happen at wellness fairs at employers employers wellness fairs it can happen at you know any sort of festival that the community has if you have a table out there then people are able to you know come up and get information you can also identify people early nowadays online if your facility has a online screening that people can take and if they score a certain level it sends a referral to you know whomever or it gives them a referral so they know that they can call a clinic in town and get services intervention services are typically either once like in a screening or once a week you're not going to have something that's meeting a whole lot and it's generally in a group situation so it's affordable for people whether it's free you know offered at a library or a church or a community center or it is you know something that is low cost and you know generally five to fifteen dollars per group is seems to be the steady going rate I know around here sometimes they charge like forty dollars per group but for intervention we really want people to come we don't want finances to be a barrier so you know it's better to have fifteen people in a group at fifteen dollars per group than to have six people in a group at forty dollars per group as far as reaching people and actually doing prevention you know the money you could I didn't check the math on that but either way you can you can kind of make it work you can also do intervention via the phone or online you know by telehealth so if you have people if you live in a rural area like I do you know you can reach out to people this way and obviously you have to have their account you know you have to be able to connect with them so they would have had to reach out to you because they got a referral from their doctor or their pharmacist or somebody but you can provide intervention services that way you can even do psychoeducational groups online through something like zoom or go-to meeting as long as you get a business associate agreement signed in order to ensure HIPAA compliance. Outpatient is individual and group counseling sessions and this typically meets one to three times per week and depending on the level of impairment of the individual sometimes you can get insurance companies to pay for up to three times per week but a lot of times they want you to move them down to traditional once a week outpatient pretty quickly. Now the caveat with that is you can often get one hour groups three times a week so if somebody really needs to be checking in a couple times a week trying to implement groups in your practice can be a way to do it to make sure you can serve the most people and get reimbursed for it and all that kind of stuff. Outpatient groups can be held in a clinic at a school online like I said you can do groups or in the person's home now group in the home is going to be more like a family multi-family group where the primary family mom and dad are there and then maybe grandma and grandpa come and you have that kind of counseling session but there you can do outpatient counseling in a variety of ways I even know one therapist who got an RV and converted it to an office and she drives around to different neighborhoods and provides training or provides counseling so people don't have to worry about finding transportation. Issues that can be handled in outpatient include coping skills maladaptive emotions or reactions thoughts or behaviors so pretty much anything that you qualify as a mental illness or a mental health issue relationships and interpersonal issues and past traumas and losses in addition to addiction outpatient counseling can address addiction everything from internet addiction to smoking cessation to alcohol and drug addiction intensive outpatient involves both individual and group counseling sessions generally it meets three to five times per week for a minimum of three hours per day so how does that work well generally in IOP it's you start out at five days a week for three hours a day plus an individual with your primary therapist each week and then as you have a certain number of clean urine the longer you're clean then you get to step down so you're not having to come as often so if you go a month and you haven't relapsed then you may get stepped down so you're only coming four days a week and then the individual with your therapist and then three days a week and two days a week etc the biggest thing is the clinician wants to see and make sure that you are that the person is safe this can be done in a clinic or online the substance abuse and mental health services administration has done a lot of research with the effectiveness of online counseling and they found that for doing IOP if you do it online you want to have video for every single participant that way you can see how people are doing and how they're reacting and you're not losing the nonverbals and they have to have a good internet connection so there's not a big lag but other than that online can work pretty well issues for intensive outpatient the same things that you would treat in regular outpatient just for people who are struggling and and have a more acute problem coping skills mental health issues substance abuse issues relationship and personal issues and past traumas and losses partial hospitalization now this is a little bit more intense so instead of being five days a week for three hours this is five days a week for typically six to eight hours the patient sleeps on campus this is always offered either in a hospital or a clinic setting and it treats mental health and substance abuse issues interpersonal issues and trauma short-term residential has individual and group counseling sessions now if you've been in residential um or if you've worked in the residential you know that their residential facilities are required to provide a certain number of group hours per day where I worked it was four hours of group per day seven days a week and one individual counseling session minimum per week with their primary therapist short-term residential is considered short-term up to 60 days the patient sleeps on campus in short-term residential there is awake staff 24 7 but a lot of times the nighttime staff are technicians there is not counseling staff it's not a doctor some states require that there's an lpn on the premises um during that period of time other states only require that the medical staff be reachable during during the night so depending on your situation but short-term residential is just what it sounds like the person is living there for up to 60 days short-term residential is really helpful for people who are struggling to stay clean and sober who are struggling with suicidal ideation or their anxiety issues we want to make sure that they're in a safe environment and this provides supervision 24 hours a day seven days a week long-term residential provides individual and group counseling sessions with the same frequency you know about four hours a group a day seven days a week and at least one meeting with a primary therapist every week it can last for up to a year and places like um oh golly phoenix house and some other therapeutic communities qualify under long-term residential and there are some non therapeutic community long-term residential programs they're fewer and farther between long-term residential is really good for people who have had difficulty they've been in other programs before they haven't succeeded they really need that kind of structure it's beneficial for people who have cognitive difficulties in addition to their mental other mental health and substance abuse issues in long-term residential the person can get their medication managed a little bit better short-term residential you know a lot of your ssri's and things are just really getting into your system and getting stabilized in 60 days so the doc's really not sure at this point whether it's the right set of medications for the person if they're on medication in long-term residential the doctor has a much longer period to see is this the right set of medications for this person and will it work long-term and in long-term residential people are also able to establish wraparound services generally after about the sixth month the person is encouraged to go out and start looking for part-time employment and establishing themselves they have time to figure out where they're going to live and do those sorts of things so there are a lot of other things that can be accomplished in long-term residential because you're not having to cram you know so much treatment like we do in short-term residential short-term residential is a lot of treatment in a very short period of time long-term residential can space it out a little bit more so people can solidify their skills in the criminal justice environment individual and group counseling sessions can be offered it's daily is sometimes appropriate sometimes you meet with the person once a week a lot of times in the criminal justice environment the criminal justice system is paying for this kind of service so it's not what the insurance company is saying it's is warranted it's what the probation officers or the or the jail is saying is warranted this can happen in the jail or intensive outpatient like with problem-solving courts or even just regular outpatient in the jails we talked about a little bit earlier groups can be done one of the caveats in with providing treatment in the jail is the fact that not everybody's getting the treatment so you're going to have you know 90 of the population in the jail who is not functioning healthfully and then you're going to have this other 10 that's trying not to adopt criminogenic behaviors and they're trying to change their ways and they're trying to improve their life and so it's they're they're kind of fighting against the milieu that exists so providing treatment in jail can be a real challenge so you want to make sure you set reasonable achievable goals and help the person embrace those goals you also want to make sure that they know that what they're learning now it may be hard to apply in jail you know hopefully it'll help them be put in solitary less often but a lot of it will be extremely useful when they get when they get out intensive outpatient you know problem-solving courts are like your mental health court your domestic violence court and your drug courts they are courts that basically require the person to go to intensive outpatient stay clean and if they don't when they report for their their weekly report in front of the judge if they haven't stayed clean then they can go to jail for a certain period of time to be determined by the judge so it has some teeth to it for mental health courts generally the requirement is the person stay on their medication and attend all of their sessions for domestic violence courts obviously it's avoiding having another domestic violence incident a lot of times domestic violence and substances go hand in hand so domestic violence may also require the person to be staying clean and sober in regular outpatient and I worked with people in probation and parole in regular outpatient and you know most of them did not want to be in my program and I don't blame them you know they didn't want to be in my program because they didn't see where they had a problem or they didn't think I understood or didn't think I could help them so what I did was tell them you know what in order for you to get off probation which is what you want you have to go through this and you know it's just one of those things so let's make it as pleasurable as possible you know tell me what it is if anything you want to work on you know we don't have to focus on drugs do you want to work on your self-esteem your parenting skills communication skills what is it you know since the court is paying for you to see a therapist for 16 weeks what is it that I can help you with and how can I help this benefit your life when we would talk about staying clean you know I'm not talking about stopping using forever if that's not what you want to do what I am talking about is you need to stay clean while you're on probation or you're going to get violated and go back to jail so let me help you stay clean while you're on probation and then when you're off papers you can make whatever decision you want to make and putting the power back into their court really helped a lot in the criminal justice system issues like everything else it can work with coping skills mental health substance abuse issues relationship and interpersonal issues traumas and losses now in the criminal justice system there's also that the additional issue of changing criminogenic thinking and there are a lot of thinking styles and cognitive distortions that go along with being involved in the criminal justice system so that's something else that needs to be addressed and reintegration services are another huge part of providing services to the criminal justice population they need case management and linkages with wraparound services a lot of times people are discharged from jail and they've got $10 in their pocket they've got no job they may not have anywhere to go back to or if they do it may be a problematic situation so we want to make sure we try to get people started off right we want to make sure they've got a good resume we want to make sure they've got good interviewing skills we want to make sure that they've connected somewhere so they've got decent clothes to go interview for a job we want to make sure that they know where they're going to go to start interviewing for a job we want to make sure they've got transportation we want to you know all those things that a person needs you know you basically have to think of somebody coming out of jail as starting with nothing and you've got to say okay what do you need to function you need food you need shelter you need employment to pay for electricity and shelter and all that stuff so let's figure out how to get you signed up that way they have everything they need when they walk out instead of just $10 in their pocket and a wish and a prayer along with reintegration services and case management we want to provide job and life skills they may not know how to manage their money very well people who've been in and out of the criminal justice system most of their life have become institutionalized if you will and they may not know how to function as well on the outside they may feel more comfortable in jail because they know the routines and they know how to get three hots in a cot and it's important that we make sure that we help people figure out you know what's going to make living you know not in jail beneficial and productive and a good experience for you and how can I help you achieve that problem solving courts were created to assist consumers whose illegal behaviors or problematic behaviors are thought to be the result of an underlying substance abuse or mental health issue it involves weekly monitoring by the court daily contact with a counselor provision of sanctions based on non-compliance remember I said if they weren't compliant the judge could sentence them to 30 days in up to 30 days in jail and progression through phases based on demonstrated improvements in behaviors reactions and relationships the nice thing with problem solving courts is it tends to have some teeth to it and so you get a little bit more compliance and buy-in consumers should be placed in the least restrictive environment and when you do the asam checklist you know there are a lot of dimensions that you're looking at from relapse potential to recovery environment to behavioral issues emotional issues physical issues you know all of those things add up and you want to figure out at what level can this person be managed and you know start out with the lowest level and say you know can we do it with early intervention you know a group a couple of times a week for a few weeks will that do it if not do we need to go with individual if we meet once a week for individual counseling will this person be able to stay okay you know clean sober and you know their mental health stuff stable the other six days of the week if not move up to intensive outpatient can they do it if they're meeting three three hours a day for five days a week if so great if not and a lot of my clients really would benefit from partial hospitalization initially because the weekends used to be their bugaboo the two days they didn't come in where their bugaboo and they would end up relapsing getting into some drama um whatever that would trigger problems so you know we really want to look at can this person get get by on the weekends because most programs don't offer IOP services on the weekend so clients are not only not at work but they're also not in treatment so they've got a lot of free time um if you don't think they can make that then look at partial hospitalization or short-term residential if they've been through short-term residential multiple times and haven't succeeded then you may consider long-term residential and long-term residential isn't you know an option for a lot of people because insurance often doesn't cover it but especially for the criminally criminal justice involved long-term residential often is an option so look at what may be available sometimes you can get sentences reduced for people if they do their last year at a long-term residential facility instead of doing it in jail which means you know they're getting out of jail a year early but they're going to this facility that's going to set them up for success there are benefits and drawbacks to all levels of care an outpatient you know it's cheaper it's less traveling for the person it is less imposition on them but it may not be enough intensity intensive outpatient a lot of people struggle because it requires so much time that they don't feel like they can do it in addition to their family and their jobs and everything else short-term residential it's great because it provides people a break from the stresses out there where they can just focus on their recovery but the bad thing is it doesn't transition them unless they step down to intensive outpatient it doesn't transition them and prepare them as well to handle life on life terms long-term residential does a better job of transitioning people but a lot of people don't want to be away from their families for an entire year so you want to look at the benefits and the drawbacks and again really consider what is the least restrictive environment that your client can maintain sobriety and meant and their mental health issues problem-solving courts have demonstrated a lot of success so if you have a client who has done okay an intensive outpatient before but you know not wonderfully if they can get involved in a problem-solving court and obviously this is only if they're criminally just involved in the criminal justice system but if they are then a problem-solving court might be the next step before residential if they don't want to go to residential alrighty well that is our summary of models of treatment or basically where you can get treatment and hopefully you learned a few things and you've started to figure out what might be a good fit for you as a clinician if you enjoy this podcast please like and subscribe either in your podcast player or on youtube you can attend and participate in our live webinars with dr snipes by subscribing at allceus.com slash counselor toolbox this episode has been brought to you in part by allceus.com providing 24-7 multimedia continuing education and pre-certification training to counselors therapists and nurses since 2006 use coupon code counselor toolbox to get a 20 discount off your order this month