Module 1

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Module 1

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Title: Module 1

1
Module 1

Substance Abuse Treatment for Persons with
Co-Occurring DisordersInservice Training
Based on A Treatment Improvement Protocol
TIP 42

2
What is a TIP?

Best-practice guidelines for treatment of
substance use disorders
Developed by Center for Substance Abuse
Treatment (CSAT)
Draws on experience and knowledge of clinical,
research, and administrative experts in a
particular topic area
Consensus Panel for TIP 42, page xi

3
ATTC Network 2001-2006
4
IntroductionModule 1
The Evolving Field of Co-Occurring Disorders
5
In This Module . . .

Overview of the evolving field of Co-Occurring
Disorders
Understanding of the important developments that
led to TIP 42
Initial exploration of TIP 42 and how it is
organized.

6
TIP ExerciseTerms

Read the left column on Page 27
Discuss with your partner
Which of these terms have you ever used or heard?
Which of these terms are used in your programs?
What advantages does the term co-occurring
disorders have over dual diagnosis and dual
disorder? Over the other terms?

7
Co-Occurring Disorders

Co-occurring disorders
Refers to co-occurring substance use (abuse or
dependence) and mental disorders.
Clients said to have co-occurring disorders have
one or more disorders relating to the use of
alcohol and/or other drugs of abuse and one or
more mental disorders.
Diagnosis of co-occurring disorders (COD) occurs
when
at least one disorder of each type can be
established independent of the other and is not
simply a cluster of symptoms resulting from the
one disorder.

8
Co-Occurring DisordersYour setting

1. Do these definitions describe clients in your
practice/program? (Estimate percentage or
describe prevalence)
2. How has serving clients with COD affected your
practice/program?
3. What challenges do clients with COD present to
your clinical knowledge and skills?

9
Co-Occurring DisordersImplications

Treatment
Prevalence of COD, multiple problems they create,
impact on treatment and treatment outcome, new
models/strategies are receiving attention and
encouraging treatment innovation
Clinicians Knowledge Dissemination
Knowledge of both mental health and substance
abuse is essential and dissemination of knowledge
has become widespread

10
Why a new TIP on Co-Occurring Disorders?

Availability of data
Treatment innovations for other populations with
COD
Changes in treatment delivery
Advances in treatment
Recent developments

11
Prevalence of COD

In 2002, 4 million adults met the criteria for
both serious mental illness (SMI) and substance
dependence and abuse.
An estimated 10 million Americans of all ages and
in both institutional and non-institutional
settings have COD in any given year.

12
Prevalence of COD among SMI and SA Adult
Populations
13
Prevalence and Other Data

Data now show
COD are common in general adult population.
Increased prevalence of people with COD and
programs for people with COD.
People with COD are more likely to be
hospitalized and the rate may be increasing.
Rates of mental disorders increase as the number
of substance use disorders increase.

14
Why a new TIP on Co-Occurring Disorders?

Availability of data
Treatment innovations for other populations with
COD
Changes in treatment delivery
Advances in treatment
Recent developments

15
Advances in Treatment of COD

No wrong door policy
Mutual self-help for people with COD
Integrated care as a priority for people with
severe and persistent mental illness
Development of effective approaches, models, and
strategies
Pharmacological advances

16
Recent Developments

National Registry of Effective Programs and
Practices (NREPP)
Co-Occurring Disorders State Incentive Grants
(COSIG)
Co-Occurring Center for Excellence (COCE)
Report to Congress on the Prevention and
Treatment of Co-Occurring Substance Use Disorders
and Mental Disorders
Co-Occurring Disorders Integrated Dual Disorders
Treatment Implementation Resource Kit

17
Module 2

Introduction
Definitions, Terms and Classification Systems
for Co-Occurring Disorders

18
In This Module . . .

Review and discuss terms related to
Substance Use Disorders
Mental Disorders
Clients
Treatment
Programs
Systems

19
The Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR)

Produced by the American Psychiatric Association
(APA).
Establishes criteria for diagnosing specific
disorders.
Used by the medical and mental health fields as a
reference for diagnosing substance use and mental
health disorders.
Provides for a common language for communicating
about disorders.

20
Terms Related to Substance Use Disorders

Substance Abuse
Substance Dependence
addiction

21
Terms Related to Mental DisordersPersonality
Disorders

Cluster A
Involve odd or eccentric behavior.
Includes paranoid, schizoid, and schizotypal
personality disorders.
Cluster B
Involve dramatic, emotional, or erratic behavior.
Includes antisocial, borderline, histrionic, and
narcissistic personality disorders.
Cluster C
Involve anxious, fearful behavior.
Includes avoidant, dependent, and
obsessive-compulsive personality disorders.

22
Psychotic Disorders

Delusions
Hallucinations
These clients constitute what is commonly
referred to as the serious and persistent
mentally ill population
Schizophrenia
Paranoid type
Disorganized type
Catatonic type
Undifferentiated type
Residual type

23
Mood and Anxiety Disorders

Mood disorders
Depression
Mania
Bipolar disorder
Anxiety disorders
Social phobia
Panic disorders
Post traumatic stress disorder (PTSD)

24
Terms Related to Clients

Person-centered terminology
Terms for co-occurring disorders
Diagnosis vs. symptoms

25
Terms Related to TreatmentLevels of Service
American Society of Addiction Medicines Patient Placement Criteria American Society of Addiction Medicines Patient Placement Criteria
Level 0.5 Early Intervention
Level I Outpatient Treatment
Level II Intensive Outpatient/ Partial Hospitalization
Level III Residential/ Inpatient
Level IV Medically Managed Intensive Inpatient Treatment
26
Terms Related to Treatment Quadrants of Care
27
Terms Related To Treatment

Interventions
Integrated Interventions
Episodes of Treatment
Integrated Treatment
Culturally Competent Treatment
Integrated Counselor Competencies

28
Terms Related to Programs

Key Programs
Mental health-based programs
Substance abuse treatment programs
Program Types
Addiction only services
Dual diagnosis capable
Dual diagnosis enhanced

29
Terms Related to Systems

Substance Abuse Treatment System
Mental Health Services System
Interlinking Systems
Comprehensive Continuous Integrated System of
Care

30
Discussion

From a client or clinician or system perspective
How does terminology help and hinder service to
clients with co-occurring disorders?
Which of the terms mentioned are most useful to
you? Which do you want to know more about?

31
Module 3A

Introduction
Keys to Successful Programming
Guiding Principles and Core Components

32
TIP Chapter 3

Module 3A
Guiding principles in treatment
Core components in delivery of services
Module 3B
Improving substance abuse treatment systems and
programs
Workforce development and staff support

33
In This Module . . .

Effective Treatment
Guiding Principles for effective treatment of
clients with COD

Effective Delivery
Core Components for ideal delivery of services
for clients with COD

34
Delivery of Services Core Components
Guiding Principles for Effective Treatment Core Components for Effective Delivery of Services
Employ a recovery perspective 1 Providing Access
Adopt a multi-problem viewpoint 2 Completing a full assessment
Develop a phased approach 3 Providing an appropriate level of care
Address real-life problems early 4 Achieving integrated treatment
Plan for cognitive and functional impairments 5 Providing comprehensive services
Use support systems to maintain and extend treatment effectiveness 6 Ensuring continuity of care
35
TIP ExerciseGuiding Principles Core Components

1. In your own words explain your assigned
Guiding Principle.
Give examples of how you apply (or need to apply)
this principle in your practice or program.
2. In your own words explain your assigned Core
Component.
Is this an area of strength or challenge for your
agency? Explain.

(15 minutes)
36
Quick TIP Exercise Levels of Program Capacity

With your group
1. Review Figure 3-2 on page 44 and explanatory
text on page 43 (left column).
2. Where on the graph would you place your
agency? Why?

(5 minutes)
37
Module 3B

Introduction
Keys to Successful Programming
Improving Substance Abuse Treatment
Systems Programs and Workforce
Development Staff Support

38
Delivery of ServicesCore Components
Guiding Principles for Effective Treatment Core Components for Effective Delivery of Services
Employ a recovery perspective 1 Providing Access
Adopt a multi-problem viewpoint 2 Completing a full assessment
Develop a phased approach 3 Providing an appropriate level of care
Address real-life problems early 4 Achieving integrated treatment
Plan for cognitive and functional impairments 5 Providing comprehensive services
Use support systems to maintain and extend treatment effectiveness 6 Ensuring continuity of care
39
TIP Chapter 3

Module 3A
Guiding principles in treatment
Core components in delivery of services
Module 3B
Improving substance abuse treatment systems and
programs
Workforce development and staff support

40
Improving Substance Abuse Treatment Systems
Programs

Challenges include
How do we organize a system that will provide
continuity of care?
How do we access funding for program improvement?
How do we integrate research and practice to give
clients the benefit of proven treatment
strategies?

41
TIP ExerciseAttitudes ValuesSelf-Assessment

For each item in Figure 3-7 (p. 57) assess
yourself based on your observable behavior, the
way you think an outside evaluator would assess
you.

Excels in this area
- Needs to work on
OK Adequate
(3 minutes)
42
TIP ExerciseBasic Competencies Self-Assessment

For each item in Figure 3-8 (p. 58) assess
yourself based on your observable behavior, the
way you think an outside evaluator would assess
you

Excels in this area
- Needs to work on
OK Adequate
(5 minutes)
43
TIP ExerciseAvoiding BurnoutSelf-Assessment

For each item bulleted on page 62 assess how well
you take care of yourself by complying with these
recommendations

Excels in this area
- Needs to work on
OK Adequate
Which two are most difficult?
(3 minutes)
44
Module 4A

Introduction
Assessment
Screening and Step 1 Step 2

45
TIP Chapter 4 Assessment

Module 4A
Introduction, terminology, Step 1Step 2
Module 4B
The Assessment Process Step 3Step 7
Module 4C
The Assessment Process Step 8Step 12
Case studies, review of relevant appendices, and
key considerations in treatment matching.

46
Screening

Screening for COD seeks to answer a yes or no
question
Does the substance abuse client being screened
show signs of a possible mental health problem?
OR
Does the mental health client being screened show
signs of a possible substance abuse problem?

47
TIP Exercise Screening Instruments

Option 1 Behavioral Rehearsal DiscussionWith
your partner, take turns administeringwhichever
instrument is least familiar

Mental Health Screening Form-III (p. 500)
Simple Screening Instrument for Substance Abuse
(p. 506)
You have 10 minutes total!

48
TIP Exercise Screening Instruments

Option 2 Review Discussion

Review instruments in
Appendix H (p. 497) and Appendix G (p. 487).
Discuss with your partner
Which instruments have you used?
What, in your experience, are advantages and
disadvantages of each?
Which would you recommend? Why?
You have 10 minutes total!

49
Screening Protocol

A professionally designed screening process or
protocol establishes precisely . . .
How any screening tools or questions are scored
What constitutes scoring positive for a
particular possible problem (establishing
cut-off scores)
What happens if a client scores in the positive
range
and provides the standard forms to document
Results of all later assessments
That each staff member has carried out his or her
responsibilities in the process

50
ScreeningAssessment Tx Plan

Screening is a process for evaluating the
possible presence of a particular problem.
Assessment is a process for defining the nature
of that problem and developing specific treatment
recommendations for addressing the problem.
A comprehensive assessment serves as the basis
for an individualized treatment plan. The
treatment plan must be matched to individual
needs.

51
Step 1 Engage the Client

No wrong door
Empathic detachment
Person-centered assessment
Sensitivity to culture, gender, and sexual
orientation
Trauma sensitivity

52
Module 4B

Introduction
Assessment
Step 3Step

53
TIP Chapter 4 Assessment

Module 4A
Screening and Step 1Step 2
Module 4B
The Assessment Process Step 3Step 7
Module 4C
The Assessment Process Step 8Step 12

54
12 Step Assessment Process

1 Engage the client
2 Identify contact collaterals to gather
additional information
3 Screen for detect COD
4 Determine quadrant locus of responsibility
5 Determine level of care
6 Determine diagnosis

7 Determine disability functional
impairment 8 Identify strengths
supports 9 Identify cultural linguistic needs
supports 10 Identify problem
domains 11 Determine stage of change 12 Plan
treatment
55
Screening

Screening for COD seeks to answer a yes or no
question
Does the substance abuse client being screened
show signs of a possible mental health problem?
OR
Does the mental health client being screened show
signs of a possible substance abuse problem?

56
Step 3 Screen and Detect COD

Screen for
Acute safety risk
Past and present mental health symptoms/disorders
Past and present substance abuse disorders
Cognitive and learning deficits
Past and present victimization and trauma

57
Screening for Substance Use Disorder (Mental
Health settings)

Substance abuse symptom checklists
Substance abuse severity checklists
Formal screening tools that work around denial
Screening of urine, saliva, or hair samples

58
12 Step Assessment Process

1 Engage the client
2 Identify contact collaterals to gather
additional information
3 Screen for detect COD
4 Determine quadrant locus of responsibility
5 Determine level of care
6 Determine diagnosis

What is the States criteria for SMI?
How is eligibility established?
Is the client already receiving mental health
priority services?
Does the client appear to be eligible?

61
Step 4 Determine Quadrant and Locus of
Responsibility
62
TIP Exercise Cases Quadrants of Care

With your partner
Select one case (Maria M., or George T., or Jane
B.) on pp. 69 and 70.
Change or add information that would result in
assignment of that case to a different quadrant.

(1 minute)
63
12 Step Assessment Process

1 Engage the client
2 Identify contact collaterals to gather
additional information
3 Screen for detect COD
4 Determine quadrant locus of responsibility
5 Determine level of care
6 Determine diagnosis

ASAM PPC 2R - Dimensions
Acute Intoxication and/or Withdrawal Potential
Biomedical Conditions and Complications
Emotional, Behavioral, or Cognitive Conditions
and Complications (includes risk)
Readiness to Change
Relapse, Continued Use, or Continued Problem
Potential
Recovery/Living Environment

LOCUS - Dimensions
Risk of Harm
Functionality
Comorbidity (Medical, Addictive, Psychiatric)
Recovery Support and Stress
Treatment Attitude and Engagement
Treatment History

65
12 Step Assessment Process

1 Engage the client
2 Identify contact collaterals to gather
additional information
3 Screen for detect COD
4 Determine quadrant locus of responsibility
5 Determine level of care
6 Determine diagnosis

Principle 1Diagnosis is established more by
history than by current symptom presentation.
Principle 2It is important to document prior
diagnoses and gather information related to
current diagnoses.
Principle 3It is almost always necessary to tie
mental symptoms to specific periods of time in
the clients history, in particular times when
active substance use disorder was not present.

67
12 Step Assessment Process

1 Engage the client
2 Identify contact collaterals to gather
additional information
3 Screen for detect COD
4 Determine quadrant locus of responsibility
5 Determine level of care
6 Determine diagnosis

Review with your partner the case on p. 89 OR
the case on p. 90.
In your opinion, how useful was the determination
of disability and functional impairment
For the counselor?
For the client?

(3 minutes)
69
Assessing Functional Capability

Is the client capable of living independently?
If not, what types of support are needed?
Is the client capable of supporting himself
financially? Through what means? If not, is the
client disabled or financially dependent on
others?
Can the client engage in reasonable social
relationships? Are there good social supports?
If not, what interferes, and what supports are
needed?
What is the clients level of intelligence? Is
there a developmental or learning disability?
Cognitive or memory impairments? Limited ability
to read, write, or understand? Difficulties
focusing and completing tasks?

70
Module 4C

Introduction
Assessment
Step 8Step 12

71
TIP Chapter 4 Assessment

Module 4A
Screening and Step 1Step 2
Module 4B
The Assessment Process Step 3Step 7
Module 4C
The Assessment Process Step 8Step 12

72
12 Step Assessment Process

1 Engage the client
2 Identify contact collaterals to gather
additional information
3 Screen for detect COD
4 Determine quadrant locus of responsibility
5 Determine level of care
6 Determine diagnosis

1 Engage the client
2 Identify contact collaterals to gather
additional information
3 Screen for detect COD
4 Determine quadrant locus of responsibility
5 Determine level of care
6 Determine diagnosis

1 Engage the client
2 Identify contact collaterals to gather
additional information
3 Screen for detect COD
4 Determine quadrant locus of responsibility
5 Determine level of care
6 Determine diagnosis

Three important issues for those with COD
Not fitting into the treatment culture (do not
fit into either substance abuse or mental health
treatment culture) and conflict in treatment
Cultural and linguistic service barriers
Problems with literacy

76
12 Step Assessment Process

1 Engage the client
2 Identify contact collaterals to gather
additional information
3 Screen for detect COD
4 Determine quadrant locus of responsibility
5 Determine level of care
6 Determine diagnosis

1 Engage the client
2 Identify contact collaterals to gather
additional information
3 Screen for detect COD
4 Determine quadrant locus of responsibility
5 Determine level of care
6 Determine diagnosis

Using the case on p. 94, what stage of readiness
to change would you and your partner(s) assign
the client regarding her
Mental disorder?
Substance use disorder?
Give reasons

Stages of Change
Precontemplation
Contemplation
Preparation
Action
Maintenance

(3 minutes)
79
12 Step Assessment Process

1 Engage the client
2 Identify contact collaterals to gather
additional information
3 Screen for detect COD
4 Determine quadrant locus of responsibility
5 Determine level of care
6 Determine diagnosis

With your group, use format on p. 96 to . . .
Plan treatment for
Maria M. (pp. 69, 87, 89, 92) or Jane B. (pp.
70, 83, 91)
Address at least two (2) problems
Include for each
Related information (strengths, cultural issues,
etc.)
Stage of readiness to change
Recommended interventions
Goals

(10 minutes)
81
Module 5A

Introduction
Strategies for Working with Clients
with Co-Occurring Disorders
Guidelines for a Successful Therapeutic Alliance

82
12 Step Assessment Process

1. Engage the client
2. Identify contact collaterals to gather
additional information
3. Screen for detect COD
4. Determine quadrant locus of responsibility
5. Determine level of care
6. Determine diagnosis

7. Determine disability functional
impairment 8. Identify strengths
supports 9. Identify cultural linguistic needs
supports 10. Identify problem
domains 11. Determine stage of change 12. Plan
treatment
83
In This Module . . .

Module 5A
Review guidelines for maintaining a successful
therapeutic relationship with a client who has
COD
Module 5B
Examine techniques for working with clients with
COD

84
TIP ExerciseAdvice to the Counselor

With your partner(s)
1. Imagine you are a person with COD receiving
services.
2. Review your assigned Advice to the Counselor
text box.
3. Which two (2) recommendations would you most
want your provider to follow? Why?

(8 minutes)
85
TIP ExerciseReport Out

State the Guideline you examined.
Read aloud all of the recommendations.
State which two (2) your group chose.
Give reasons for your groups choice and
summarize any discussion that took place.

(2 minutes)
86
Guidelines for Developing Successful Therapeutic
Relationships

1. Develop and use a therapeutic alliance to
engage the client in treatment
2. Maintain a recovery perspective
3. Manage countertransference
4. Monitor psychiatric symptoms
5. Use supportive and empathic counseling
6. Employ culturally appropriate methods
7. Increase structure and support

87
Guidelines for Developing Successful Therapeutic
Relationships

1. Develop and use a therapeutic alliance to
engage the client in treatment
2. Maintain a recovery perspective
3. Manage countertransference
4. Monitor psychiatric symptoms
5. Use supportive and empathic counseling
6. Employ culturally appropriate methods
7. Increase structure and support

88
Guidelines for Developing Successful Therapeutic
Relationships

1. Develop and use a therapeutic alliance to
engage the client in treatment
2. Maintain a recovery perspective
3. Manage countertransference
4. Monitor psychiatric symptoms
5. Use supportive and empathic counseling
6. Employ culturally appropriate methods
7. Increase structure and support

89
Guidelines for Developing Successful Therapeutic
Relationships

1. Develop and use a therapeutic alliance to
engage the client in treatment
2. Maintain a recovery perspective
3. Manage countertransference
4. Monitor psychiatric symptoms
5. Use supportive and empathic counseling
6. Employ culturally appropriate methods
7. Increase structure and support

90
Potential for Harm

Ask explicitly about suicide or the intention to
do harm to someone else when the client
assessment indicates that either is an issue.
Monitor clients who express such thoughts
closely.
Ask about suicidal thoughts and plans as a
routine part of every session with a suicidal or
depressed person.
Immediately follow up appointments missed by an
acutely suicidal person.
Review discussion of suicidality in Chapter 8 and
in Appendix D of TIP 42.

91
Guidelines for Developing Successful Therapeutic
Relationships

1. Develop and use a therapeutic alliance to
engage the client in treatment
2. Maintain a recovery perspective
3. Manage countertransference
4. Monitor psychiatric symptoms
5. Use supportive and empathic counseling
6. Employ culturally appropriate methods
7. Increase structure and support

92
Confrontation

The heart of confrontation is not the aggressive
breaking down of the client and his or her
defenses, but feedback on behavior and the
compelling appeal to the client for personal
honesty, truthfulness in interacting with others,
and responsible behavior.

TIP 42, p. 110
93
Guidelines for Developing Successful Therapeutic
Relationships

1. Develop and use a therapeutic alliance to
engage the client in treatment
2. Maintain a recovery perspective
3. Manage countertransference
4. Monitor psychiatric symptoms
5. Use supportive and empathic counseling
6. Employ culturally appropriate methods
7. Increase structure and support

94
Guidelines for Developing Successful Therapeutic
Relationships

1. Develop and use a therapeutic alliance to
engage the client in treatment
2. Maintain a recovery perspective
3. Manage countertransference
4. Monitor psychiatric symptoms
5. Use supportive and empathic counseling
6. Employ culturally appropriate methods
7. Increase structure and support

95
Module 5B

Introduction
Strategies for Working with Clients
with Co-Occurring Disorders
Techniques for a Working with Clients with COD

96
In This Module . . .

Module 5A
Guidelines for a successful Therapeutic
Relationship with a Client who has COD
Module 5B
Techniques for Working with Clients with CO

97
Key Techniques for Working With Clients Who Have
COD

1. Motivational enhancement consistent with the
clients stage of change.
2. Contingency management techniques to address
specific target behaviors.
3. Cognitive-behavioral therapeutic techniques.
4. Relapse prevention techniques.
5. Repetition and skills-building to address
deficits in functioning.
6. Facilitate client participation in mutual
self-help groups.

98
Motivational Interviewing (MI)

Motivational Interviewing (MI) is
aclient-centered, directive method for
enhancing intrinsic motivation to change by
exploring and resolving ambivalence.

Source Miller and Rollnick 2002, p. 25.
99
Key Techniques for Working With Clients Who Have
COD

1. Motivational enhancement consistent with the
clients stage of change.
2. Contingency management techniques to address
specific target behaviors.
3. Cognitive-behavioral therapeutic techniques.
4. Relapse prevention techniques.
5. Repetition and skills-building to address
deficits in functioning.
6. Facilitate client participation in mutual
self-help groups.

100
Key Techniques for Working With Clients Who Have
COD

1. Motivational enhancement consistent with the
clients stage of change.
2. Contingency management techniques to address
specific target behaviors.
3. Cognitive-behavioral therapeutic techniques.
4. Relapse prevention techniques.
5. Repetition and skills-building to address
deficits in functioning.
6. Facilitate client participation in mutual
self-help groups.

101
Key Techniques for Working With Clients Who Have
COD

1. Motivational enhancement consistent with the
clients stage of change.
2. Contingency management techniques to address
specific target behaviors.
3. Cognitive-behavioral therapeutic techniques.
4. Relapse prevention techniques.
5. Repetition and skills-building to address
deficits in functioning.
6. Facilitate client participation in mutual
self-help groups.

102
Relapse Prevention

. . . a central element of all clinical
approaches to relapse prevention is anticipating
problems that are likely to arise in maintaining
change and labeling them as high-risk situations
for resumed substance use, then helping clients
to develop effective strategies to cope with
those high-risk situations without having a
lapse.

TIP 42, p. 128
103
Key Techniques for Working With Clients Who Have
COD

1. Motivational enhancement consistent with the
clients stage of change.
2. Contingency management techniques to address
specific target behaviors.
3. Cognitive-behavioral therapeutic techniques.
4. Relapse prevention techniques.
5. Repetition and skills-building to address
deficits in functioning.
6. Facilitate client participation in mutual
self-help groups.

104
Key Techniques for Working With Clients Who Have
COD

1. Motivational enhancement consistent with the
clients stage of change.
2. Contingency management techniques to address
specific target behaviors.
3. Cognitive-behavioral therapeutic techniques.
4. Relapse prevention techniques.
5. Repetition and skills-building to address
deficits in functioning.
6. Facilitate client participation in mutual
self-help groups.

105
Module 6A

Introduction
Traditional Settings and Models
Essential Programming for Clients with COD

106
Review 5B TechniquesWorking with Clients Who
Have COD

Motivational enhancement
Contingency management
Cognitive-behavioral techniques

Relapse prevention techniques
Repetition and skills-building
Client participation in mutual self-help groups

107
In This Module . . .

Module 6A
Essential Programming General Considerations
for Treatment of Clients with COD
Module 6B
Outpatient Substance Abuse Treatment Programs for
Clients with COD
Module 6C
Residential Substance Abuse Treatment Programs
for Clients with COD

108
Discussion Modifications to Group Work

With your partner or small group discuss
What 3 modifications would you advise a novice
counselor to make when conducting group therapy
with clients with COD?

(2 minutes)
109
Modifications to Group

Reduced intensity
Stronger direction
Co-leaders
Shorter duration
Regular schedules

Smaller groups
Varied participation
Brief, simple, concrete, repetitive
Emphasis on affirmation

110
Quick TIP Exercise 7 Recommendations

With your group
Rank-order the seven (7) recommendations in order
of importance.
Be prepared to give your reasons.

1. Screening, assessment, referral for persons
with COD 2. Physical mental health
consultation 3. Prescribing onsite
psychiatrist 4. Medication medication
monitoring 5. Psychoeducational classes 6. Double
trouble groups (onsite) 7. Dual recovery
self-help groups (offsite)
(2 minutes)
111
DiscussionList Revision

With your partner or group
1. Renumber your groups list of seven (7)
recommendations in order of importance (if you
wish to change the order).
2. Are there any essential program elements you
would add?

(2 minutes)
112
DiscussionList Revision Option for
Administrators

With your partner or group
1. Renumber your groups list of seven (7)
recommendations in order of importance (if you
wish to change).
2. Does your program reflect these seven (7)
recommendations? In this order?

(2 minutes)
113
Module 6B

Introduction
Traditional Settings and Models
Outpatient Substance Abuse Treatment
Programs for Clients with COD

114
Chapter 6 Modules

Module 6A
Essential Programming General Considerations
for Treatment of Clients with COD
Module 6B
Outpatient Substance Abuse Treatment Programs for
Clients with COD
Module 6C
Residential Substance Abuse Treatment Programs
for Clients with COD

115
7 Essential Elements General Considerations

Working in groups
Involving clients in treatment and program design
Family education

Outpatient Substance Abuse Treatment Programs for
Clients with COD
Designing
Implementing
Evaluating
Sustaining
Examples of programs

117
Designing Outpatient Programs for Clients with
COD

Screening and assessment
Centralized intake
Reassessment
Referral and Placement
Engagement
Discharge Planning
Continuing Care

118
Quick TIP Exercise

Review Improving Adherence of Clients with COD
in Outpatient Settings (p. 147).

1. Which have been used in your agency? 2. In
your experience, what has been most successful in
improving engagement in treatment for clients
with COD?
(3 minutes)
119
Discharge Planning

Housing
Case management services
Medication management
Relapse prevention
Positive peer networks
Mutual self help groups
Advocacy involvement

120
Continuing Care

Clients with COD often require long-term
continuity of care that

Supports their progress
Monitors their condition
Responds to a return to substance use or return
to symptoms of mental disorder
Describes steps for when how to reconnect with
services

121
Evaluating Outpatient Programs for Clients with
COD

1. Define operational goals in terms of the
client behaviors
2. Decide on study clients and sampling
3. Locate and/or develop instruments
4. Develop plan for data collection
5. Develop plan for analysis and reporting

122
Nine Essential Features of ACT

1. Services provided in the community
2. Assertive engagement with active outreach
3. High intensity of services
4. Small caseloads
5. Continuous 24-hour responsibility
6. Team approach
7. Multidisciplinary team, reflecting integration
of services
8. Close work with support systems
9. Continuity of staffing

Source Drake et al. 1998a.
123
ICM Activities and Interventions

Engage client to facilitate process connect
with community-based treatment programs
Assess needs, identify barriers facilitate
access to treatment
Offer practical assistance facilitate linkages
Make referrals
Advocate for client
Monitor progress
Provide counseling support
Crisis intervention
Assist in facilitating communication between
service providers

124
TIP ExerciseAct / ICM Grid

In small groups, use the information in your TIP
text to complete the handout grid for the model
you have been assigned (ACT or ICM).

(5 minutes)
125
Module 6C

Introduction
Traditional Settings and Models
Residential Substance Abuse Treatment
Programs for Clients with COD

126
Chapter 6 Modules

Module 6A
Essential Programming General Considerations
for Treatment of Clients with COD
Module 6B
Outpatient Substance Abuse Treatment Programs for
Clients with COD
Module 6C
Residential Substance Abuse Treatment Programs
for Clients with COD

127
7 Essential Elements General Considerations

Working in groups
Involving clients in treatment and program design
Family education

Residential Substance Abuse Treatment for Clients
with COD
Designing
Implementing
Evaluating
Sustaining
Examples of programs

129
Designing Residential Programs for Clients with
COD

Intake
Assessment
Engagement
Continuing Care
Discharge Planning

130
TIP ExerciseDesign

In groups or with partners
1. Read recommendations on your topic.
2. Think about how these activities are conducted
in your programs.
3. Describe what could stay the same and what
would need to change in your program to meet the
recommendations for COD programs.

(8 minutes)
131
Intake Steps

1. Written referral
2. Intake interview
3. Program review
4. Team meeting

132
Assessment Areas

Substance abuse evaluation
Mental health evaluation
Health and medical evaluation
Entitlements
Client status

133
Continuing Care

Goals
sustaining abstinence
continuing recovery
community living
vocational skills
gainful employment
deeper understanding
increase responsibility
family difficulties
consolidating changes

Key Services
life skills education
relapse prevention
12-Step or double trouble groups
case management (especially for housing)
vocational training and employment

134
Discharge Planning

Housing
Case management services
Medication management
Relapse prevention
Positive peer networks
Mutual self help groups
Advocacy involvement

135
Staffing Recommendations

Program director
Secretary
Program supervisor
10 line staff
Clinical coordinator
Nurse practitioner (half-time)
Entitlements counselor (half-time)
Vocational rehabilitation counselor (half-time)
Consultive arrangements for medical, psychiatric,
and psychological input or care

136
Quick TIP ExerciseTraining

1. With your partner, look over the questions in
Figure 6-3 (pp. 167168).
2. Substitute the treatment model used in your
workplace for each TC in the questions.
3. Which questions can you answer easily?
4. Which are you less sure of?

(2 minutes)
137
Evaluating Residential Programs for Clients with
COD

1. Define operational goals in terms of the
client behaviors
2. Decide on study clients and sampling
3. Locate and/or develop instruments
4. Develop plan for data collection
5. Develop plan for analysis and reporting

138
Sustaining Residential Programs for Clients with
COD

For quality control, the CQI staff uses
Observation
Key informant interviews
Resident focus groups
Standardized instruments
Staff review

139
Therapeutic Community (TC)

Goals
Promote abstinence
Decrease antisocial behavior
Effect a global change in lifestyle, including
attitudes and values

View
Drug abuse is a disorder of the whole person,
reflecting problems in conduct, attitudes, moods,
values, and emotional management
The community is the healing agent

140
Module 7A

Introduction
Special Settings and Specific Populations
Acute Care and Other Medical Settings, and
Dual Recovery Mutual Self-Help Groups

141
Chapter 6 Modules

Module 6A
Essential Programming General Considerations
for Treatment of Clients with COD
Module 6B
Outpatient Substance Abuse Treatment Programs for
Clients with COD
Module 6C
Residential Substance Abuse Treatment Programs
for Clients with COD

142
In This Module . . .

Module 7A
Acute care and other medical settings
Dual recovery and mutual self help programs
Module 7B
Specific populations with COD homeless, criminal
justice, women

143
TIP Resources

TIP 16Alcohol and Other Drug Screening of
Hospitalized Trauma Patients
TIP 19Detoxification from Alcohol and Other
Drugs
TIP 24A Guide for Substance Abuse Services for
Primary Care Physicians
TIP 34Brief Interventions and Brief Therapies
for Substance Abuse

144
TIP ExerciseDual Recovery

In groups review your assigned topic, then
answer
1. Is this topic ever an issue for COD clients in
your agency?
2. If any participate in 12-Step groups, what has
been their experience with this issue?
3. What could be done to address this issue in
your agency? In your community?

(10 minutes)
145
Module 7B

Introduction
Special Settings and Specific Populations
Homeless, Criminal Justice, Women

146
In This Module . . .

Module 7A
Acute care and other medical settings
Dual recovery and mutual self help programs
Module 7B
Specific populations with COD homeless, criminal
justice, women

147
TIP Resources

TIP 17Planning for Alcohol and Other Drug Abuse
Treatment for Adults in the Criminal Justice
System
TIP 21Combining Alcohol and Other Drug Abuse
Treatment With Diversion for Juveniles in the
Justice System
TIP 30Continuity of Offender Treatment for
Substance Use Disorders From Institution to
Community
Upcoming TIPs
Substance Abuse Treatment for Adults in the
Criminal Justice System
Substance Abuse Treatment Addressing the
Specific Needs of Women
http//www.treatment.org/

148
TIP ExercisePopulation Jigsaw

1. Read about your assigned population and answer
handout questions.
2. Regroup so there is a 1, 2, 3, and 4 in your
small group.
3. Take turns teaching each other what youve
learned.
4. Report out on groups discussion.

(10 minutes)
(3 minutes each)
149
Module 8A

Introduction
A Brief Overview of Specific Mental Disorders
and Cross-Cutting Issues
Suicidality, Nicotine Dependence,
and Personality Disorders

150
Module 7

Module 7A
Acute care and other medical settings
Dual recovery and mutual self help programs
Module 7B
Specific populations with COD homeless, criminal
justice, women

151
Chapters Format

Disorder category (i.e. Personality, Mood,
Anxiety, Psychotic)
What counselors should know about this category
and substance abuse
Specific disorders within each category
What counselors should know about substance abuse
and the specific disorder
Diagnostic features and criteria from the
DSM-IV-TR
Case study
Advice to the counselor

152
In This Module . . .

Module 8A
Cross-Cutting Issues Suicidality, Nicotine
Dependence
Personality Disorders
Module 8B
Mood and Anxiety Disorders
Schizophrenia and Other Psychotic Disorders

Module 8C
Attention Deficit/Hyperactivity Disorder (AD/HD)
Posttraumatic Stress Disorder (PTSD)
Eating Disorders
Pathological Gambling
Appendix D

153
TIP ExerciseGroup Assignments

Group 1Suicidality (pp. 214216)
Appendix D, pp. 326333
Group 2Nicotine Dependence (pp. 216220)
Appendix D, pp. 333347
Group 3Borderline Personality (pp. 220224)
Appendix D, pp. 353359
Group 4Antisocial Personality (pp. 224226)
Appendix D, pp. 359368

(15 minutes)
154
TIP Exercise

What Counselors Should Know, Diagnostic Features
Criteria, Advice to the Counselor, Case Study

With your group
Read the text section on your assigned diagnosis.
Answer the handout questions.
Prepare to teach the larger group.

(15 minutes)
155
Module 8B

Introduction
A Brief Overview of Specific Mental Disorders
and Cross-Cutting Issues
Mood Anxiety Disorders, Schizophrenia
Other Psychotic Disorders

156
Chapters Format

Disorder category (i.e. Personality, Mood,
Anxiety, Psychotic)
What counselors should know about this category
and substance abuse
Specific disorders within each category
What counselors should know about substance abuse
and the specific disorder
Diagnostic features and criteria from the
DSM-IV-TR
Case study
Advice to the counselor

157
In This Module . . .

Module 8A
Cross-Cutting Issues Suicidality, Nicotine
Dependence
Personality Disorders
Module 8B
Mood and Anxiety Disorders
Schizophrenia and Other Psychotic Disorders

Module 8C
Attention Deficit/Hyperactivity Disorder (AD/HD)
Posttraumatic Stress Disorder (PTSD)
Eating Disorders
Pathological Gambling
Appendix D

158
TIP ExerciseAssignments

Group 1Mood Disorder
Diagnosis pp. 227228
Discussion pp. 226230 and 369383
Group 2Anxiety Disorder
Diagnosis p. 230
Discussion pages same as Mood Disorder
Group 3Schizophrenia
Discussion pp. 231235 and 385400

159
TIP ExerciseRole Play

With your group
Review the texts sections on your assigned
diagnosis and related information.
Create a 35 minute role-play script that
illustrates key information.
A scene likely to play out in your practice
All group members must have a role
Teach us by performing your role play.

(20 minutes)
160
Module 8C

Introduction
A Brief Overview of Specific Mental Disorders
and Cross-Cutting Issues
ADHD, PTSD, Eating Disorders,
Pathological Gambling

161
In This Module . . .

Module 8A
Cross-Cutting Issues Suicidality, Nicotine
Dependence
Personality Disorders
Module 8B
Mood and Anxiety Disorders
Schizophrenia and Other Psychotic Disorders

Module 8C
Attention Deficit/Hyperactivity Disorder (AD/HD)
Posttraumatic Stress Disorder (PTSD)
Eating Disorders
Pathological Gambling
Appendix D

162
TIP ExerciseAssignments

Group 1AD/HD (pp. 235237)
Appendix D, pp. 402408
Group 2PTSD (pp. 238240)
Appendix D, pp. 408416
Group 3Eating Disorders (pp. 240246)
Appendix D, pp. 417425
Group 4Pathological Gambling (pp. 246248)
Appendix D, pp. 425436

163
TIP Exercise Panel Presentation

With your group
Review the texts sections on your assigned
diagnosis and related information.
Create a 35 minute panel presentation on
How to Recognize and Work with Substance
Abuse Clients Who Also Have ______ Disorder
Features to look for
Prevalence, assessment, and engagement
Practical information on working with client

(18 minutes)
164
Module 9