tip42 | Antisocial Personality Disorder | Substance Abuse

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TIP 42
Dawn-Elise Snipes PhD, LMHC, CRC, NCC

GUIDING PRINCIPLES
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Employ a Recovery Perspective Adopt a Multi-Problem Viewpoint Develop a Phased Approach to Treatment

Address Specific Real-Life Problems Early in Treatment

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Essential Attitudes
Desire and willingness to work with people with COD  Appreciation of the complexity of COD  Openness to new information  Awareness of personal reactions and feelings  Recognition of one’s own limitations  Recognition of the value of client input  Patience, perseverance, and therapeutic optimism  Ability to employ diverse theories, concepts  Flexibility of approach  Cultural competence  Belief that all individuals are capable of growth  Copyright 2008-2012 AllCEUs.com a subsidiary of of clients with COD Recognition of the rights CDS Ventures, LLC

Assessment Areas
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Background Substance use Psychiatric problems

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Assessment Process

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Engage the client  Universal Access/No Wrong Door  Empathy/Acceptance of Client Choice  Person-Centered Assessment  Culture Sensitivity  Trauma Sensitivity Identify other sources of information (collaterals) Screen and detect COD Determine diagnosis and symptom severity Determine Level of Care (LOCUS/ASAM) Determine disability and functional impairment
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Identify strengths and supports  Identify problem areas  Determine stage of change  Plan treatment  Assessment is about getting to know a person with complex and individual needs  Do not rely on tools alone for a assessment.  Make every effort to obtain collateral information  Don’t allow preconceptions about addiction to interfere with learning about what the client really needs  Know diagnostic criteria  Don’t assume that there is one correct treatment approach  Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC Empathy and hope are the most valuable components

Techniques

Stage specific motivational enhancements
 Express

empathy  Develop discrepancy  Roll with resistance  Support self-efficacy

Use contingency management techniques to target specific behaviors Use cognitive-behavioral techniques
 Visual

aids  Role playing/practice  Outline sessions with specific behavioral objectives
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Use relapse prevention techniques
 Daily

inventory group participation

 Recovery  Coping

skills training adherence

 Medication

Skill building to address functional deficits

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Precontemplation
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Express concern about the client’s substance use, or the client’s mood State nonjudgmentally that substance use (or mood, anxiety, self-destructiveness) is a problem. Agree to disagree about the severity of the issues Consider a trial of abstinence to clarify the issue Suggest bringing a family member to an appointment. Explore the client’s perception of the problems. Emphasize the importance of seeing the client again and that you will try to help. For involuntary clients, develop mutually acceptable goals
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Contemplation

Elicit positive and negative aspects of substance use or psychological symptoms. Ask about positive and negative aspects of past periods of abstinence and remission Summarize the client’s comments Make explicit discrepancies between values and actions. Consider a trial of abstinence and/or
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psychological evaluation.

Preparation

Acknowledge the significance of the decision to seek treatment Support self-efficacy Help the client decide on appropriate, achievable action for each issue Caution that the road ahead is tough Explain that relapse should not disrupt the client–clinician relationship.
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Action
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Be a source of encouragement and support Remember that the client may be in different stages of readiness for change for different issues

Acknowledge the uncomfortable aspects of withdrawal and/or psychological symptoms.

Reinforce the importance of remaining in recovery from both problems.

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Maintenance
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Anticipate and address difficulties Recognize the client’s struggle with either or both problems

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Support the client’s resolve. Reiterate that relapse or psychological symptoms should not disrupt the counseling relationship.

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Relapse

Explore what can be learned from the relapse

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Express concern about the relapse. Emphasize the positive aspect of the effort to seek care.

Support the client’s self-efficacy

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Special Populations
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Women Homeless Criminal Justice

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Women
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Identify and build on each woman’s strengths. Avoid confrontational approaches. Arrange for daily needs such as childcare and transportation. Have a strong female presence on staff. Promote bonding among women in the program. Help women reduce the stress associated with parenting Develop programs for both women and children. Provide interventions that focus on trauma and abuse. Foster family reintegration and family building
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Pregnancy

Careful planning for helping woman address mental health issues during pregnancy and postpartum Parenting often retriggers childhood traumas. Focus on the woman’s interest in and desire to be a good mother. Screen for dependence on substances that can produce a life-threatening withdrawal for the mother: alcohol, benzodiazepines, and barbiturates.

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Homeless
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Address housing needs. Teach clients skills for maintaining housing.

Work closely with shelter workers and other providers for the homeless.

Address real-life issues

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Criminal Justice Offenders
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Recognize special service needs. Give positive reinforcement for small successes and progress. Clarify expectations regarding supervision. Use flexible responses to infractions. Give concrete directions. Design highly structured activities. Provide ongoing monitoring of symptoms.

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Suicidality

Abuse of alcohol and other drugs is a major risk factor in suicide. Alcohol abuse is associated with 25 to 50 percent of suicides. Comorbidity of alcoholism and depression increases suicide risk. Substance intoxication is associated with increased violence toward others and self.
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What to do
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Take all suicide threats seriously. Assess the client’s risk of suicidality/homicidality Develop a safety and risk management plan Provide availability of contact 24 hours a day Refer high-risk clients for psychiatric intervention. Monitor and develop strategies to ensure medication adherence. Develop long-term recovery plans
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Personality Disorders

Borderline Personality Disorder Characteristics
 pervasive
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pattern of instability of

interpersonal relationships self-image emotions,

 along 

with marked impulsivity

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Anticipate that client progress will be slow and uneven. Assess the risk of self-harm Set clear boundaries and expectations regarding roles and behavior

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Antisocial Personality Disorder

Essential features of antisocial personality disorder
a

pervasive disregard for and violation of the rights of others  an inability to form meaningful interpersonal relationships

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The prevalence of co-occurring antisocial personality disorder and substance abuse is high Most people diagnosed as having antisocial personality disorder are not true psychopaths

ASPD cont…

What to do:
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Confront dishonest and antisocial behavior Stress immediate learning experiences that teach corrective responses. Hold clients responsible for their behavior and Use peer communities to confront behavior and foster change. Assess and correct antisocial and criminal thinking. Foster longer-term individual value change and the establishment of new peer reference groups

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Mood Disorders

Among women with a substance use disorder, mood disorders may be prevalent. Women are more likely than men to experience clinical depression or anxiety Certain populations are at higher risk such as clients with HIV, clients maintained on methadone, and older adults.

Older adults are at highest risk for combined mood disorder and substance problems.
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What to do

Differentiate among the following:
 anxiety

and mood disorders  commonplace expressions of anxiety and depression  anxiety and depression associated with more serious mental illness  medical conditions and medication side effects  substance-induced changes.
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Start low, go slow Combine addiction counseling with medication and mental health treatment

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Schizophrenia
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There is no clear pattern of drug choice among clients with schizophrenia. What looks like resistance or denial may in reality be negative symptoms of schizophrenia. An accurate understanding of the role of substance use disorders in the client’s illness requires a multiple-contact, longitudinal assessment. Clients with COD involving psychosis have a higher risk for self-destructive and violent behaviors, homelessness, victimization, poor nutrition, and poverty

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What to do
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Obtain a working knowledge of the signs and symptoms of the disorder. Work closely with a psychiatrist or mental health professional. Expect crises associated with the mental disorder Assist the client to obtain social services, housing, vocational services. Monitor medication and promote medication adherence. Provide frequent breaks and shorter sessions or meetings. Employ structure and support. Present material in simple, concrete terms with examples and use multimedia methods. Encourage participation in social clubs Teach the client skills for detecting early signs of relapse for both mental illness and addiction Involve family in psychoeducational groups Monitor clients for signs of relapse and a return of psychotic symptoms
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AD/HD
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AD/HD in 5 to 25 percent of people. Approximately 1/3 of adults with AD/HD have histories of alcohol abuse or dependence Adults with AD/HD have been found primarily to use alcohol or marijuana The client may use self-medication for AD/HD as an excuse The presence of AD/HD complicates the treatment of substance abuse, since these clients may have more difficulty engaging in treatment and learning abstinence skills,
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Clarify for the client repeatedly what elements of a question he or she has responded to and what remains to be addressed. Eliminate distracting stimuli (e.g., noise, desktop items) from the environment. Use visual aids Reduce the length of meetings Encourage the client to use organization tools Refer the client for evaluation for medication. Enhance the client’s knowledge about AD/HD and substance abuse. Examine with the client any false beliefs about the history of both AD/HD and substance abuse difficulties.
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PTSD
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The rate of PTSD among people with substance use disorders is 12 to 34 percent. For women with substance use disorders, it is 30 to 59 percent 55 to 99 percent of women with addictions report a lifetime history of physical and/or sexual abuse Repeated trauma is common in domestic violence, child abuse, and some substance-using lifestyles People with PTSD tend to abuse the most serious substances (cocaine and opioids); however, abuse of prescription medications, marijuana, and alcohol are also common.
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Proceed slowly Develop a plan for increased safety. Establish both perceived and real trust. Attend to behavior even more than words. Limit questioning about details of trauma. Recognize that trauma injures an individual’s capacity for attachment Recognize the importance of one’s own trauma history and countertransference Help the client learn to de-escalate intense emotions. Help the client to link PTSD and substance abuse. Provide psychoeducation about PTSD and substance abuse. a subsidiary of CDS Ventures, LLC Copyright 2008-2012 AllCEUs.com Teach coping skills to control PTSD symptoms.

Eating Disorders

Approximately 15 percent of women and 1 percent of men in inpatient substance abuse treatment centers have had an eating disorder Individuals with eating disorders are significantly more likely to use stimulants and significantly less likely to use opioids Many individuals alternate between substance abuse and eating disorders. Nicotine and caffeine must also be considered when assessing substance abuse in people with eating disorders. Individuals with eating disorders experience urges (or cravings) for binge-foods similar to urges for drugs.
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Develop a treatment plan for both the eating and substance use disorder. Conduct a behavioral analysis of the foods and substances of choice; high-risk times and situations for engaging in disordered eating and substance abuse behaviors

Employ psychoeducation and cognitive– behavioral techniques for bulimia nervosa.
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Summary

Co-occurring disorders are the rule not the exception Mental health issues, especially trauma and eating disorders may not be revealed during the initial assessment Be alert for “substitute” addictions Adequate treatment must address the person as a whole
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