Dually Diagnosed Mentally Ill and Substance Misuse Population - Coursework Example

Relapse Prevention in the Dually Diagnosed Mentally Ill and Substance Misuse Population and/or ID # Teacher The Document chosen for review and analysis is: ‘Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide.’(2001) Department of Health. Retrieved 4 June 2008. (www.doh.gov.uk/mentalhealth) This document provides a general overview of the current practices and policies of the mental health professionals treating a population with the comorbid diagnosis of severe mental health problems coupled with quite problematic issue of substance abuse. The substances refereed to include addition to both legal and illegal drugs, alcohol as well as solvents (tobacco addiction is not addressed). These particular dual diagnosis guidelines are necessary as Professor Louis Appleby, the National Director of Mental Health states in the forward, ‘Substance misuse is usual rather than exceptional amongst people with severe mental health problems and the relationship between the two is complex. Individuals with these dual problems deserve high quality, patient focused and integrated care.’ (‘Mental Health Policy’ 2001: 4) This document was chosen for its direct relevance to my upcoming placement at Charles House. Charles House specialises in the care of all-male clients with a wide range of mental health issues from moderate to severe. Since there is an extremely high incidence of mental health issues and substance abuse often dually diagnosed in this population, this particular document offers insight and information in coping with this condition. The particular area of the document under review in this paper will be section 3.2.5 Relapse Prevention, although further on references will be made to other related areas of this document as they directly relate to the subject. However, the need to be proactive about relapse will be my main concern. It is not only important to treat the patient while they are in care at the facility, but it is almost more imperative that they have the tools to succeed with the rest of their lives. Charles House has implemented several plans in regards to this. Charles House partners with families of the clients, community organisations, social services departments, and so on, in an effort to support their treatment of Person Centred Care Planning. This treatment takes into account the social, emotional, cultural and spiritual needs of the client. Much of this is discussed in the document and throughout this paper. The particular section on relapse prevention is listed under the main category of assessments and treatment. For the purposes of this document the dual diagnosis population is defined by the following description: A primary psychiatric illness precipitating or leading to substance misuse, substance misuse worsening or altering the course of a psychiatric illness, intoxication and/or substance dependence leading to psychological symptoms, and substance misuse and/or withdrawal leading to psychiatric symptoms or illnesses. (‘Mental Health Policy’ 2001: 6) This document in general and this section that I am reviewing in particular will be of great benefit and value in my future placement and within the practice of understanding and treating those with varying levels of psychiatric disorders as well as a dependency and / or misuse of different substances. This document is extremely relevant to treating the comorbid group described and points out several particular traits and characteristic relevant and unique to treatment of this population. It becomes obvious after review that treating each issue separately in clients is quite different when the dual diagnosis of both is present. Substance abuse and relapse takes on an entirely different scope when coupled with clients who have differing levels of severe metal illness. Given the chronic relapsing nature of substance misuse it is important once a client has reduced their misuse, or become abstinent, to offer interventions aimed at the prevention and management of future relapses to problematic substance misuse or to mental health problems. (‘Mental Health Policy’2001:p. 2) Furthermore, the relapse section of this document states that, ‘This approach aims to identify high-risk situations for substance misuse and rehearse coping strategies proactively. Attention is also given to the development of action plans should the client return to damaging substance misuse.’ (‘Mental Health Policy’ 2001: 21) This paper will review the current literature in this particular area and expand upon these issues in order to present a more coherent grasp of this issue. While getting a client with a substance abuse problem to the point where they do initially stop misusing drugs or alcohol is certainly a difficult journey and a significant milestone to reach, preventing them from relapsing is often even more complicated and this journey will most probably continue for his or her lifetime. Relapse prevention can take on many forms and by necessity often needs to be tailored to the specific client by using the assessments gathered during the initial rehabilitation period. These assessments are a vital insight into the character, weaknesses and strengths of the client and can help to assess possible triggers and other relapse issues in the future. There are four general categories of relapse generating events: While these are rather broad and wide-ranging, they give a broad-spectrum insight into the complex nature of relapse. It can be triggered by both negative and positive events, as well as personal as well as more public occurrences. This combined with mental illness presents even more complex issues. By referring back to earlier assessments and treatment notes, the mental health practitioner can better evaluate an individual client’s risk for relapse and assist him or her in their long-term recovery efforts. It is important to be able to identify risk areas such as certain lifestyle factors, for example high-risk criminal or sexual behaviour, as well as an insight into the urges and cravings that the particular client has revealed in the past assessments for the problem. Also the level of understanding that the severely mentally ill client has is another important aspect to be evaluated by the practitioner here. By doing so the counsellor / therapist can more readily assess a plan of ongoing relapse care and prevention for the future. Not only does the ongoing treatment need to identify these high-risk situations, but it also needs to find out what strategies worked best in the past initial treatment and utilise them for ongoing long-term life maintenance. A thorough analysis of the stage and type of mental illness is absolutely necessary at this juncture. While these areas of high risk are considered to be the most dangerous relapse triggers, it must be remembered that it is really the way the client copes with them that is at issue. It is they way that they respond to these issues that will be the determining factor as to whether or not he or she will relapse. A persons coping behavior in a high-risk situation is a particularly critical determinant of the likely outcome. Thus, a person who can execute effective coping strategies (e.g., a behavioral strategy, such as leaving the situation, or a cognitive strategy, such as positive self-talk) is less likely to relapse compared with a person lacking those skills. Moreover, people who have coped successfully with high-risk situations are assumed to experience a heightened sense of self-efficacy (Mccance-Katz and Clark 2004: 4) This sense of self-efficacy is one of the most important factors in determining a client’s risk of future relapse. Improving a client’s self-esteem and self –efficacy is becoming one of the most crucial goals in the area of relapse prevention. There are several methods and technique available for this, but again they must be evaluated in terms of the clients’ level of understanding. Cognitive Restructuring is often one of the most effective methods and treatments used to assist clients in their long-term battle with substance misuse . (Mccance-Katz and Clark 2004: 4) By attempting to change the way they view themselves and their relationships with others, will create greater feelings of control and self worth. The technique of Cognitive restructuring can eventually help the client to cope on his or her own difficulties with misuse and relapse in the future, independent of the therapist or other treatments. It may also help them to know when they cannot cope and need to reach out to seek help. Their sense of self-efficacy will begin to grow as the changes create more opportunities for success and eventually a level of maintenance and strength will be achieved. That being said, there are very few substance abuse recoveries, especially those dually diagnosed with sever mental illnesses, which never relapse at least once. By being prepared for this consequence, the therapist can better help the client to mange a lapse and recover from it by having a set of instructions available: These instructions reiterate the importance of stopping alcohol [or drug, etc.] consumption and (safely) leaving the lapse-inducing situation. Lapse management is presented to clients as an ‘emergency preparedness’ kit for their ‘journey’ to abstinence. Many clients may never need to use their lapse-management plan, but adequate preparation can greatly lessen the harm if a lapse does occur. (Mccance-Katz and Clark 2004: 11) Cognitive Restructuring may also come into play here. Helping the client to reframe a lapse incident and view it as a key learning opportunity, cognitive restructuring can help them further evaluate better coping strategies for that particular situation. This technique can also give the client more of a sense of personal empowerment rather than a feeling of letting themselves down which could lead to further negative emotional states. ‘This reframing of a lapse episodes can help decrease the clients tendency to view lapses as the result of a personal failing or moral weakness and remove the self-fulfilling prophecy that a lapse will inevitably lead to relapse.’ (Mccance-Katz and Clark 2004: 12) However, while cognitive restructuring may work well in situations where the client does not have comorbidity with a severely mentally ill dual diagnosis, it may not be so with patients so presented: Given the high prevalence and severe consequences of substance use disorders in the severely mentally ill population, it is particularly important to examine whether severely mentally ill patients self-evaluation of readiness to change can reliably predict behavioral changes in substance use. (Zhang, Harmon, Werkner, and Mccormick 2004: 393) This self-evaluation is often a crucial element in any therapeutic situation, without this realisation by the client any talk therapy may be, unfortunately, pointless. If the dually diagnosed client cannot understand the severity of his or her situation than other steps may be necessary in order to initially treat and then prevent relapse of abuse. However, other studies have disputed this: It might seem intuitively obvious that persons with severe mental illness give less reliable self-reports of their past behaviors than those who do not have such disorders. Our data and previous research, however, do not support this hypothesis. The test-retest reliability coefficients obtained in this study compare favorably with those reported in samples of college students (Sobell et al., 1986), drinkers from the general population (Sobell et al., 1988) and persons with drug use disorders (e.g., Fals-Stewart et al., 2000). (Carey, Carey, Maisto, and Henson 2004: 788) Another factor that impacts the dual diagnosis situation is the fact that the abuse of alcohol, drugs, etc can also amplify the existing psychiatric symptoms and increase the severity of the indicators of mental illness that are already present. . (Zhang, Harmon, Werkner, and Mccormick 2004: 340) This can certainly play a part in the many difficulties encountered during the initial treatment phase, but during relapse this can also cause more severe problems. In this light the relapse occurrence may require more carefully applied treatment and prevention then would normally be utilised. Another treatment method for treating initial and long-term substance abuse issues is Solution Focused Counselling (SFC): Because they do not adhere to the belief that all problems have one objective definition or cause, solution-focused MHCs [Mental Health Counselor] assert that an understanding of the problem is not necessary in order to change it and that the problem and its solution may not even be related. Taking special care not to reify client problems, MHCs using SFC concentrate on positive aspects of clients lives and seek to expand on them (OHanlon & Weiner-Davis, 2003). In addition, this positive, strength-based approach assumes that change is constant. As a result, solution-focused MHCs assist clients in directing naturally occurring change, generating new perspectives on problems, identifying strengths, and finding parsimonious solutions that work (Linton 2005: 27) Solution Focused Counselling may have some advantages in regards to treating the comorbid situation of drug abuse and mentally ill disorders. Furthermore, the flexibility and longitudinal course that that this type of counselling focuses upon will certainly relate well to this particular population. There are also many clinical implications regarding the dual diagnosis that this document describes. In particular, relapse in this cadre is greater due to the comorbid nature of the disorder. This group is prone to, ‘worsening psychiatric symptoms, increased use of institutional services, poor medication adherence, homelessness, increased risk of HIV infection. poor social outcomes including impact on careers and family, contact with the criminal justice system.’ (‘Mental Health Policy’ 2001: 9) Their locus of control is dual as well, one must ascertain whether or not the drug use has created the psychiatric symptoms or has the psychiatric symptoms prompted the use of drugs. Generally it is considered to be the latter, but there are certainly cases to be made in regards to the former condition. The client in this group also has a tendency to self medicate, and this urge is certainly one of the main causes of relapse in this population. Drug therapy is often used in conjunction with talk therapies in order to achieve the fastest, if not best results for this genre of patients. This is also true of the single diagnosis drug abuser. Apparently, by waiting until drug treatment improved the patients’ symptoms, the researchers had been able to get good results with briefer psychotherapy than usual and reduce the need for long-term drug use. (Drug-free relapse 7) It was noted that this protein increased between 30% and 100% in the rats going through withdrawal stages. It is also believed that treatment focused on reducing this protein could assist the recovering addict with the cravings associated with his or her withdrawal period and beyond. This type of treatment has also been in used in relation to treatment of recovering alcoholics. Acamprosate and naltrexone are two drugs that have helped these clients to maintain their sobriety. Naltrexone is an opioid receptor antagonist, which blocks the endogenous opioid reward system. It thereby may reduce the rewarding effect of alcohol. Acamprosate, on the other hand, normalizes the dysregulation of NMDA-mediated glutamatergic neurotransmission that occurs during chronic alcohol consumption and withdrawal and thus attenuates one of the physiological mechanisms that may prompt relapse. (Mason 2005: 150) Research has shown that up to 20% of recovering alcoholics are given one or the other or a combination of both of these medications in order to help prevent them from relapsing. (Correy, et. al.2004: 522) In the community of psychiatric disorder the medication for the disorder itself, whether schizophrenia, bipolar, etc., needs to be adequately addressed prior to starting any successful drug abuse treatment plan. During the initial withdrawal stages the types and dosages of the prescribed medications are altered and monitored as the patient’s biochemistry changes. When they are released for in-patient care, similar follow ups are always necessary to ascertain continuing correct dosages, otherwise the onset of symptoms for the psychiatric disorder may reoccur and even intensify. This can also lead to a relapse to non-prescribed drug use as well as alcohol abuse in the hopes of self-medicating. The section on assessments in this document begins with the following important statement: Since substance misuse among those with mental health problems is usual rather than exceptional and results in poorer treatment outcomes, it is necessary to consider its presence in all assessments undertaken by mental health services. To do otherwise may result in misdiagnosis, over treatment with psychiatric medication and the neglect of appropriate interventions. (‘Mental Health Policy’ 2001: 17) This makes not only the issue of drug misuse a difficult one to address, but it also makes the issue of relapse all the more complex as well. Not only does the counsellor or therapist have to monitor for proper psychiatric medication but he or she also has to attempt to differentiate between substance misuse and the onset of further psychiatric problems resulting either from prescribed medication or the development of new symptoms. In this respect the document goes on to say that: Specialised assessments are undertaken to determine the nature and severity of substance misuse and mental health problems, and to identify corresponding need. The more comprehensive and focused the assessment the better the understanding will be of the relationship between the two disorders. (‘Mental Health Policy’ 2001: 17) In many cases laboratory test are necessary in order to really determine not only the proper levels of the psychiatric medication prescribed but also the detection of substance misuse in the client. Since most cases of substance misuse are rarely self reported it is often incumbent upon the mental health professional to seek more objective means to determine the correct treatment The document further goes on to break out certain lifestyle risk assessments for different groups: Young people, Homeless people, Offenders including prisoners, Women, People from ethnic minorities (‘Mental Health Policy’ 2001: 18-19) So aside from the complications of the comorbidity of mental illness and substance misuse, these issues must also be addressed in order to provide effective treatment. There is also the individual nature of a client’s case that will create unique circumstances and characteristics for each individual. The mental health professional must therefor be flexible in their approach and adopt a very long-term view of treatment in order to be of greatest benefit the client. Fortunately, the very nature of the counselling arrangement is quite fluid and changing, as any member of the profession would tell you. Listening is perhaps the most important skill required as well: Narratives are the primary form in which peoples experiences take on meaning (Merchant & Dupuy, 1996), and tolerance for ambiguity is one of the most valuable qualities of a counselor (Merchant, 1997). By reason of their training, counselors are very attentive to ambiguity and the unpredictable nature of the processes of counseling; (Berrios & Lucca 2006:174-175) In fact the relapse section of this document specifically states that, ‘Flexibility and adaptation are essential skills for a workforce charged with providing treatment and care for this client group’ (‘Mental Health Policy’2001: 21) In doing the research and review of this document I have found many ideas and techniques that will be directly applicable to my future placement at Charles House. Since the clientele at Charles House are patients with a wide range of mental health issues coupled with substance misuse, many of the issues they will face will be complex, especially after discharge. One of these difficulties will be the prevention of relapse into the continued abuse of drugs and alcohol. By using initial assessments of the client to guide in not only their current treatment but provide ongoing advice and assistance to them after discharge, many of the techniques presented in the research will be of great value. In order to understand the unique nature of this population one must not only address the issue of substance abuse and mental illness, but understand how the two interact with each other. Doing so provides insights and creative techniques that may help to handle this situation. I have learned that the most valuable tool in this arsenal is flexibility. Prior to doing dome of this research I many have been a little too single-minded in may approach to substance abuse and relapse prevention. Without understanding the impact of mental illness in regards to relapse, many avenues for assistance may have been overlooked. It would not be enough to merely tell the client to go to a twelve step group and other traditional methods to prevent relapse. Instead there would need to be follow up mental counselling and increase monitoring of not only illicit substance abuse but correctly monitor the levels of prescribed medications. This multifaceted approach is absolutely necessary in order to help the patient cope with the dual diagnosis issues of relapse. Incorporating strategies such as Cognitive Restructuring and Solution focused counselling will also help me to adhere to the Charles House guidelines of Person Centred Care Planning upon which they base their practice for the clients. I have also discovered the importance in ascertaing wheter or not the patient has the capacity for self evaluation or self reflection. Depending on the type and severity of the mental disorder this is an important diagnosis in regards to the future self-treatment of the patient. In other words, can the patient have a beneficial part in his own care or not? This is possible one of the most important questions to ask especially in the prevention of relapse when the patient is no longer in the facility. This document provides an excellent overview for the mental health professional that is dealing with the dual diagnosis of substance misuse and severe mental illness. The normal course of treatment for one or the other may be completely different when combined. The mental health professional that is not properly prepared for this my find himself or herself in a quandary as to how to proceed or how to adapt to such a complex situation. While this document is by no means thorough, it can certainly send the practitioner in the right direction for more information and assistance, looking to the signs and symptoms of the comorbidity in order to more correctly address the situation. Works Cited Berrios, Reinaldo, and Nydia Lucca. (2006) ‘Qualitative Methodology in Counseling Research: Recent Contributions and Challenges for a New Century.’ Journal of Counseling and Development 84.2 p. 174-177. Carey, Kate B., Michael P. Carey, Stephen A. Maisto, and James M. Henson. 2004. ‘Temporal Stability of the Timeline Followback Interview for Alcohol and Drug Use with Psychiatric Outpatients.’ Journal of Studies on Alcohol 65:774-789 Corry, Justine, Kristy Sanderson, Cathy Issakidis, Gavin Andrews, and Helen Lapsley. 2004. ‘Evidence-Based Care for Alcohol Use Disorders Is Affordable.’ Journal of Studies on Alcohol 65:521-530. ‘Drug-free relapse prevention.’ (2005) Harvard Mental Health Letter, 21.9. p. 7 ‘Counselors Help Stop Cycle of Addiction.’ 2004. The Register-Guard (Eugene, OR), November 8, p. b1. Linton, Jeremy M. 2005. ‘Mental Health Counselors and Substance Abuse Treatment: Advantages, Difficulties, and Practical Issues to Solution-Focused Interventions.’ Journal of Mental Health Counseling 27:297 Mason, Barbara J. 2005. ‘Rationale for Combining Acamprosate and Naltrexone for Treating Alcohol Dependence.’ Journal of Studies on Alcohol 66:148 ‘Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide.’(2001) Department of Health. Retrieved 4 June 2008. (www.doh.gov.uk/mentalhealth) Mccance-Katz, Elinore F. and H. Westley Clark, eds. 2004. Psychosocial Treatments. New York: Brunner-Routledge. Zhang, Amy Y., Julie A. Harmon, Janet Werkner, and Richard A. Mccormick. 2004. ‘Impacts of Motivation for Change on the Severity of Alcohol Use by Patients with Severe and Persistent Mental Illness.’ Journal of Studies on Alcohol 65:392-341 Read More