Download Professional Practices: Assessment

Co-Occurring
Disorders: Part 2
Melody Kipp, PhD, LMHC
Life & Work Soulutions, Inc.
Co-Occurring Disorders: Part 2

Evans, E.K. & Sullivan, J.M. (2001).
Dual Diagnosis: Counseling the Mentally
Ill Substance Abuser, (2nd ed.). New
York: The Guilford Press.
The Psychotic &
Cognitive Disorders

“There are those too who suffer from
great emotional and mental disorders.
They too are able to recover if they
have the capacity for honesty.”

Alcoholics Anonymous
The Psychotic &
Cognitive Disorders
 Before
you begin this section about
schizophrenia, list below your
understanding of schizophrenia. For
example, answer these questions:
What does a person was schizophrenia
look like?
 How do they behave?

The Psychotic &
Cognitive Disorders
Do I have prejudices or stereotypes
about people with schizophrenia?
 How do I feel interacting with someone
with a psychotic disorder?
 Do I feel comfortable treating clients
with those diagnoses?

The Psychotic &
Cognitive Disorders
 Cardinal
features of schizophrenia
include substantial impairment of
clients’ thought processes as well as
the bizarre content of their thoughts.
The Psychotic &
Cognitive Disorders
 Symptoms
of schizophrenia as noted
in the DSM-IV:
Delusions
 Hallucinations
 Disorganized speech
 Grossly disorganized or catatonic
behavior
 “Negative” symptoms

The Psychotic &
Cognitive Disorders
 Positive
symptoms are a problem
because of what is there and
negative symptoms are problem
because of what is not there.
The Psychotic &
Cognitive Disorders
 Symptoms
must be present for at
least 6 months.
 Symptoms often manifest themselves
during late adolescence and early
adulthood.
 Complete remission is uncommon.
The Psychotic &
Cognitive Disorders
5
other psychotic disorders:
Schizophreniform disorder
 Schizoaffective disorder
 Brief psychotic disorder
 Delusional disorder
 Psychotic conditions that are substanceinduced or due to a medical condition

The Psychotic &
Cognitive Disorders
 Neurological
sensitization is when less
and less of a drug is needed to
provoke the desired response.
 Cross sensitization is when responses
to other drugs and stressors in
general are exaggerated.
 How would these events complicate
your client’s treatment?
The Psychotic &
Cognitive Disorders
3
key issues for managing the person
with schizophrenia:
Medication compliance
 Marked deficits in role performance
 The need for abstinence from alcohol
and drugs

The Psychotic &
Cognitive Disorders
 About
50% of people with a
diagnosis of schizophrenia also have
a substance use disorder.
 Even moderate drinking appears to
be unsafe for this population
 Stressful situations and high demands
often cause clients with schizophrenia
to disorganize
The Psychotic &
Cognitive Disorders
 Using
lots of visual aids and keeping
materials simple and concrete will
help clients with schizophrenia
change their behaviors.
 Groups that use classroom methods
to teach topical issues are more
helpful during treatment than process
groups
The Psychotic &
Cognitive Disorders
 What
may happen when a person
with schizophrenia abuses alcohol
and discontinues their medications?

The alcohol further disorganizes them
and exacerbates the side effects of their
medication.
The Psychotic &
Cognitive Disorders
 Heavy
confrontation of the person
with schizophrenia who is in denial
should be avoided.

Slowly and painfully build into the
clients’ worldview that he/she is
chemically dependent and cannot use
drugs or alcohol at all, ever, under any
circumstances.
The Psychotic &
Cognitive Disorders
 Going
quickly through the 12 steps of
recovery with a person with
schizophrenia is an unrealistic
expectation.
 Personal therapy is most likely to
benefit clients with schizophrenia to
prevention relapse.
The Psychotic &
Cognitive Disorders

3 phases of Personal Therapy


Phase 1 involves supportive counseling,
psychoeducation, problem-solving, social skills
practice, and medication management.
Phase 2 involves identifying individual
indicators of negative affect and skills, such as
relaxation techniques, to manage negative
feelings, as well as continued social skills
training.
The Psychotic &
Cognitive Disorders

Phase 3 involves social and vocational
initiatives in the community, awareness
of triggers for problems and other selfmonitoring skills, and work on clients’
social impact on others
 Clients
not living with families or in a
stable living situation will not benefit
from Personal Therapy.
The Psychotic &
Cognitive Disorders
 Do
not expect miracles, but do not
leave prematurely. ???
 The term Cognitive Disorders refers
to:

Delirium, dementia, and amnesic
disorders
The Psychotic &
Cognitive Disorders
 Cognitive
with:

A
disorders are associated
A significant deficit in cognition or
memory that represents a change from
previous functioning.
general medical condition, a
substance, or some combination of
the 2 may cause a cognitive disorder
The Psychotic &
Cognitive Disorders
 Memory
difficulties and other
cognitive impairments as well as
profound personality deterioration are
the essential features of dementia.
The Psychotic &
Cognitive Disorders
 Abstinence
is the only goal for the
person with a cognitive disorder.
 Keeping the step work concrete and
simple will help in the treatment of
someone dually diagnosed with a
cognitive disorder.
The Affective &
Anxiety Disorders
 Bipolar
disorder is the more recent
term for manic depression.
 The distinctive features of bipolar
disorder are:

A distinct period of extreme swings of
mood ranging from manic euphoria and
hyperactivity to depressed sadness and
immobility.
The Affective &
Anxiety Disorders
 Hypomania
is defined as having only
mild highs.
 The first criterion for bipolar disorder
is a distinct period of abnormal and
persistently elevated, expansive, or
irritable mood lasting at least one
week.
The Affective &
Anxiety Disorders
 The
other symptoms a person may
exhibit during the manic phase are:
Inflated self-esteem
 Decreased need for sleep
 Greater talkativeness than usual or
pressure to keep talking

The Affective &
Anxiety Disorders
Flight of ideas or racing thoughts
 Distractibility
 Increase in goal-directed activity or
psychomotor agitation
 Excess of involvement in pleasurable
activities that potentially have negative
consequences such as buying sprees or
promiscuity.

The Affective &
Anxiety Disorders
 The
difference between Bipolar I and
Bipolar II is:

Bipolar I type refers to classic manicdepressive illness. Bipolar II type
involves a history of one or more
episodes of major depression
accompanied by at least one hypomanic
episode.
The Affective &
Anxiety Disorders

3 key treatment issues people suffering
with bipolar disease encounter are:



Medication compliance.
A need for a balanced lifestyle, with a
reasonable mixture of work, play, love, and
proper attention to nutrition and exercise.
Abstinence from all substance use or abuse.
The Affective &
Anxiety Disorders
 What
do mania and chemical
dependency have in common?

Both are out-of-control behaviors.
 Hospitalization
may become
necessary to stabilize behavior and
ensure initial abstinence for someone
with bipolar when the mania is acute.
The Affective &
Anxiety Disorders
 Manic
behavior may be redirected to
something positive, such as taking
notes, during treatment.
 What other ways can you think of to
redirect manic behavior?
The Affective &
Anxiety Disorders
 The
recovery approach can help
clients deal not only with their
chemical dependency but also their
bipolar illness.

Both are diseases, both involve issues of
out-of-control behavior, and both
provide a way of doing grief work and
repairing the personal and interpersonal
damage associated with these diseases.
The Affective &
Anxiety Disorders
 Sensation-seeking
and impulsive use
should be the focus for a person with
bipolar disorder when planning for
relapse.
 There is hope for people with bipolar
disease to recover well and maintain
abstinence from substance abuse.
The Affective &
Anxiety Disorders
 Symptoms
of ADHD can sometimes
mimic the symptoms of mania.
 A comprehensive drug/alcohol
assessment is now required by many
school districts in assessing ADHD in
students.
The Affective &
Anxiety Disorders
 Using
stimulants to treat ADHD
should be avoided if the client is also
suffering from a disease of addiction.
 Antidepressants are an alternative to
using stimulants to treat ADHD.
The Affective &
Anxiety Disorders
 The
cardinal feature of Major
Depression is feeling deeply sad,
down, or having an irritable mood.
 What are the other symptoms of
major depression as indicated by the
DSM-IV? (Must have at least 5 of the
following for at least 2 weeks)
The Affective &
Anxiety Disorders
A
depressed or irritable mood most of
the day, nearly every day.
 Markedly diminished interest or
pleasure.
 Significant weight lost while not
dieting or significant weight gain.
The Affective &
Anxiety Disorders
 Insomnia
or hypersomnia.
 Psychomotor agitation or retardation
nearly every day.
 Fatigue or loss of energy nearly every
day.
The Affective &
Anxiety Disorders
 Feelings
of worthlessness or
excessive or inappropriate guilt.
 Diminished ability to think or
concentrate, or indecisiveness.
 Recurrent thoughts of death,
recurrent suicidal ideation without a
specific plan, or a suicide attempt or
a specific plan for committing suicide.
The Affective &
Anxiety Disorders
 Dysthymia
is a chronic low-grade
depression.
 The following are symptoms of
dysthymia:
A depressed or irritable mood for most
of the day, for more days than not for at
least 2 years.
 Poor appetite or overeating.

The Affective &
Anxiety Disorders
Insomnia or hypersomnia.
 Low-energy or fatigued condition.
 Low self-esteem.
 Poor concentration or difficulty making
decisions.
 Feelings of hopelessness.

The Affective &
Anxiety Disorders
 Approximately
33% of people with a
lifetime history of major depression
also have a lifetime history of a
substance use disorder.
The Affective &
Anxiety Disorders
 For
those with substance use
disorders, the following factors are
likely to be causally linked to the
development of major depression:
Low self-esteem
 Chronic stress
 Severely threatening life events

The Affective &
Anxiety Disorders
A positive family history of major
depression
 The perception of having no control in
one's life
 External attribution for positive and
negative events
 Sleep abnormalities

The Affective &
Anxiety Disorders
 Negative
life events not only can
trigger a major depression, but a
major depression can create negative
life events in a vicious cycle.
The Affective &
Anxiety Disorders

The following types of treatment are
suggested for the following types of
depression:
Mild depression: psychotherapy.
 Moderate to severe depression: a
combination of medication and
psychotherapy plus ongoing maintenance
treatment of monthly counseling sessions
and medication follow-up as needed.

The Affective &
Anxiety Disorders
 You
should refer the client who
presents with serious suicidal ideation
for a medication evaluation to a
qualified psychiatrist.
The Affective &
Anxiety Disorders


People with Major Depression show
significant cognitive impairments; and
those in early addiction recovery also show
cognitive impairments.
Be prepared to engage in some very basic
and extensive problem-solving with your
depressed dually diagnosed client.

Target, in particular, relationship and job
issues.
The Affective &
Anxiety Disorders
 How
can you help those clients
remember the solutions and tasks
you agreed upon during your
session?

Write them down.
 Symptoms
of anxiety very commonly
accompany major depression and
require attention.
The Affective &
Anxiety Disorders
 Why
do you believe that helping a
client to build or rebuild their social
support system would help their
levels of depression?
 Why do you think that the
hopelessness that accompanies major
depression might lead to relapse?
The Affective &
Anxiety Disorders
 The
chances of recovery for the
clinically depressed dually diagnosed
client with appropriate treatment are
good.
 Abstinence alone will not remove the
depression, and psychotherapy and
antidepressants alone will not
eliminate substance dependence.
The Affective &
Anxiety Disorders


Anxious arousal and Avoidance of the
anxiety-provoking situation are the
cardinal features of anxiety disorders.
8 specific conditions that fall under the
classification of anxiety disorders:.



Panic disorder with or without agoraphobia
Agoraphobia
Social phobia
The Affective &
Anxiety Disorders
A simple phobia
 Obsessive-compulsive disorder (OCD)
 Post-traumatic stress disorder (PTSD)
 Acute stress disorder
 Generalized anxiety disorder (GAD)

The Affective &
Anxiety Disorders
 When
the trigger for one of the
above anxiety disorders is very
focused the disorder is generally less
incapacitating.
 Specific behavioral interventions can
be used when the trigger is focused.
The Affective &
Anxiety Disorders
 The
anxiety disorders tend to be
chronic in half or more of individuals.
 The diagnostic criteria for Generalized
Anxiety Disorder are:

Excess of anxiety and worry occurring
more days than not for at least 6
months about a number of events or
activities.
The Affective &
Anxiety Disorders
Difficulty in controlling the worry.
 Association of the anxiety and worry
with three or more of the following
symptoms:

Restlessness or feeling keyed up or on edge
 Being easily fatigued

The Affective &
Anxiety Disorders
Difficulty in concentrating or the mind going
blank
 Irritability
 Muscle tension
 Sleep disturbance

The Affective &
Anxiety Disorders
 PTSD
involves exposure to a
traumatic event and is characterized
by these 3 symptoms:
Intense fear
 Horror
 Helplessness

The Affective &
Anxiety Disorders

What other symptoms might a person with
PTSD experience?


Reexperiencing of the trauma, such as
flashbacks, intense memories, and distressing
dreams
The general numbing and avoidance of stimuli
associated with the trauma, including
amnesia, and diminished interest in pleasure,
and feeling detached from others.
The Affective &
Anxiety Disorders

The person may also have sleep
disturbance, irritability, difficulty in
concentrating, hypervigilance, and an
exaggerated startle response.
The Affective &
Anxiety Disorders
 The
term Panic Attack refers to: A
discrete period of intense fear or
discomfort in which 4 or more of the
following symptoms develop abruptly
and peak within 10 minutes:

Heart palpitations and pounding heart
The Affective &
Anxiety Disorders
Sweating
 Trembling or shaking
 Sensations of shortness of breath or
smothering
 Feeling of choking
 Chest pain or discomfort
 Nausea or abdominal distress
 Feeling dizzy or faint

The Affective &
Anxiety Disorders
Feeling as if things are unreal or being
detached from oneself
 Fear of losing control or going crazy
 Fear of dying
 Numbness or tingling sensation
 Chills or hot flashes.

The Affective &
Anxiety Disorders
 Abstinence
will resolve the anxiety of
many substance abusers.
 Alcohol and the other sedativehypnotics are commonly used by
alcoholics.
The Affective &
Anxiety Disorders
 Relaxation
techniques and Mental
hygiene skills such as identifying and
challenging catastrophic fear-based
thinking are two therapeutic
techniques are often used when
treating an anxiety disorder.
The Affective &
Anxiety Disorders

The authors of your text state that letting
clients “borrow the counselor’s brain” is
also a helpful technique.


What type of technique do you think this is?
Codependents trying to manage the
unmanageable, including an addictive or
abusive family member, will be anxious.
The Affective &
Anxiety Disorders
 People
with anxiety disorders are at a
high risk for relapse.
Antisocial & Borderline
Personality Disorders
 Personality

disorder is defined as:
Enduring patterns of perceiving, relating
to, and thinking about oneself in the
world that manifest themselves in a
wide range of important situations.
Antisocial & Borderline
Personality Disorders
 When
does a personality pattern
become distorted?
When the pattern is inflexible and
maladaptive,
 Leads to substantial subjective distress
or functional impairment,
 Characterizes the person's long-term
functioning in a variety of situations.

Antisocial & Borderline
Personality Disorders

What does the term “acting out” referred
to?



Behavioral patterns that have an angry, hostile
tone,
A mindset that denies, blames, and justifies,
Behavior that is impulsive and violates social
conventions regarding appropriate ways to
relate to others.
Antisocial & Borderline
Personality Disorders
 The
key affects for those individuals
with either borderline or antisocial
personality disorders are:
Anger
 Chronic feelings of unhappiness

Antisocial & Borderline
Personality Disorders
 You
have double denial and strong
needs for control with the client
dually diagnosed with chemical
dependency and a personality
disorder.
Antisocial & Borderline
Personality Disorders

What must the counselor be aware of
about their own objectivity when working
with the personality-disorder client as
opposed to someone with schizophrenia?


The provider may attribute malicious motives
to these clients, since such behaviors seem
deliberate, willful, and/or controllable.
Such attributions can lead providers to blame
their clients, become frustrated, and lose their
objectivity.
Antisocial & Borderline
Personality Disorders
 The
essential feature of antisocial
personality disorder is:

7

A pervasive pattern of disregard for, in
violation of, the rights of others occurring since the age of 15.
indicators of such a pattern:
Repeatedly performing acts that are
grounds for arrest
Antisocial & Borderline
Personality Disorders
Lying and conning
 Impulsivity or failure to plan ahead
 Irritability and aggressiveness
 Reckless disregard for the safety of self
or others
 Consistent irresponsibility
 Lack of remorse

Antisocial & Borderline
Personality Disorders
 The
person with an antisocial
personality feels little guilt over the
trail of wreckage left in his/her wake.
 Such individuals feel they are never
responsible because it's always
someone else's faults or there was a
good reason why they did what they
did.
Antisocial & Borderline
Personality Disorders
 What
are the prime motivators of the
antisocial personality?
An inflated sense of self.
 Having power and control.
 Thrill and excitement seeking.

 Boredom
is the greatest enemy of the
person with an antisocial personality
disorder.
Antisocial & Borderline
Personality Disorders
 Life
is a game where the object is to
win, preferably in the most exciting,
grandiose style possible.
 They want others to lose and for the
loser to acknowledge this.
Antisocial & Borderline
Personality Disorders

Why might those with antisocial
personality disorder have a higher rate of
substance abuse disorders?


These individuals are attempting to increase
their overall arousal and excitement level.
They also will experience a lifestyle with the
ups and downs of heavy chemical involvement
and the money, violence, and criminal status
of illegal drug trafficking.
Antisocial & Borderline
Personality Disorders
Antisocial personality disorder predicts a
poor outcome in chemical dependency
treatment.
 The goal of therapy with someone who
has an antisocial personality disorder is to:


adapt so that the antisocial clients come to
believe that playing by the rules of society can
actually make them look better in the long
run, giving them greater success and helping
them to stay out of trouble.
Antisocial & Borderline
Personality Disorders
A
major challenge for the provider is
to convince the antisocial that it is in
their best interest to change.
Antisocial & Borderline
Personality Disorders
 The
3 C’s that summarize the
treatment strategies suggested by
the authors of your text when
working with the antisocial
personality:
Corral them.
 Confront them.
 Provide consequences for behavior.

Antisocial & Borderline
Personality Disorders
 The
“King baby” syndrome refers to
the puffed up ego with no true
underlying self-esteem.
 “I am unique and the center of the
universe” is the perspective that
antisocials tend to view themselves in
relationship to the universe.
Antisocial & Borderline
Personality Disorders
 When
providing consequences for the
behaviors of the antisocial personality
disorder, what should you keep in
mind?

The consequences need to be
immediate, concrete, and to make use
of the antisocial’s need to look good and
feel excited.
Antisocial & Borderline
Personality Disorders
 There
may be little that is true about
the data supplied by clients with
antisocial personality during the
assessment.

Use collateral contacts and subsequent
information by obtaining a release of
information form signed by the client to
gain truthful information.
Antisocial & Borderline
Personality Disorders

5 keys to recovery that need to be stated
over and over as you treat the antisocial
personality disorder client are:





Don't take the first drink
Don't drink between meetings
Go to meetings
Get a sponsor
Work the steps
Antisocial & Borderline
Personality Disorders
 The
key relapse triggers for
antisocials are:
Boredom
 The need for excitement
 Any challenge to the overly high but
unstable self-esteem

Antisocial & Borderline
Personality Disorders
 The
diagnostic features of individuals
with borderline personality disorder:

They are semi permanently unstable,
with wide-ranging persistent instability
of self image, interpersonal
relationships, affect, and marked
impulsivity.
Antisocial & Borderline
Personality Disorders

The indicators of this Borderline
Personality disorder are:




Frantic efforts to avoid real or imagined
abandonment
A pattern of unstable and intense
interpersonal relationships alternating between
extremes idealization and its opposite,
devaluation
Identity disturbance
Impulsivity
Antisocial & Borderline
Personality Disorders






Recurrent suicidal behavior, or gestures,
threats, or self relating behavior
Marked reactivity of mood
Chronic feelings of emptiness
Intense inappropriate anger or difficulty in
controlling anger
Transient stress-related paranoid ideation or
severe dissociative symptoms
There must be 5 or more of the above
indicators to make a diagnosis.
Antisocial & Borderline
Personality Disorders


Females are more often diagnosed with
borderline personality disorder.
Theoretical speculations and research
suggest that the underlying cause of the
borderline condition is a severely
dysfunctional family that would include
physical and sexual abuse, neglect, hostile
conflicts, the early parental loss or
separation.
Antisocial & Borderline
Personality Disorders
 Fearful/disorganized
type of
attachment has been identified as
associated with borderline personality
disorder.
Antisocial & Borderline
Personality Disorders
 “Disorder
of Extreme Stress (DES)”
be used for individuals who have
experienced prolonged, repetitive,
and severe trauma.
Antisocial & Borderline
Personality Disorders

Symptoms of DES:





Impairment in the regulation of affective
arousal
Dissociation and amnesia
Alterations in self-perceptions, especially guilt
and shame
Alterations in relations with others, including
trust difficulties
Alterations in systems of meaning, such as
despair and hopelessness
Antisocial & Borderline
Personality Disorders
A
deprived, damaged, fragile child
who is typically traumatized by a very
dysfunctional family situation is at the
core level of the borderline client.
 Ambivalence is the essence of the
borderline person's existence.
 The goal is to help the victim become
a survivor.
Antisocial & Borderline
Personality Disorders
 The
3 S’s that the authors of your
text suggest in helping treat the
client with borderline personality
disorder:
Safety
 Skills
 Survivor

Antisocial & Borderline
Personality Disorders

Dissociation is an important symptom
associated with borderline personality and
other trauma-based syndromes.





Prolonged breaks in eye contact
Fixed or darting eyes
Shallow, rapid, constricted breathing
Tight, repetitive, or young sounding voice
A rigid, guarded, or fleeing posture, and
spacey, flooding with strong feelings or
numbed affect
Antisocial & Borderline
Personality Disorders
 Simply
stating “look at me and
breathe” is a simple grounding
technique that will help the client
reorient him or herself.
 Sobriety equals safety is the bottom
line for the dual diagnosis counseling
with the borderline client.
Antisocial & Borderline
Personality Disorders

Common triggers for relapse with this
population:



Perceived abandonment
Lack of support and fear
Getting into a relationship with someone who
undermines their recovery either directly,
through chemical use or indirectly, by
minimizing the need for an ongoing dual
recovery program
Antisocial & Borderline
Personality Disorders
 Some
techniques that can minimize
the frequency of relapse:
Building social support
 Learning self-soothing skills
 Prevention planning

Antisocial & Borderline
Personality Disorders
 What
are some tools that might help
you as a counselor from becoming
discouraged when working with this
population?
Collegial support
 Self-care
 Having policies and procedures about
relapse and other safety issues.

Working with Families
 True

or false.
Families only play a small role in the
causes and conditions associated with
substance abuse and psychiatric
disorders.
 Why
might family members also
benefit from treatment?
Working with Families
 The
three approaches to family
therapy are:
The systems model
 Behavioral model
 The family disease model

Working with Families


The systems model suggests that each
family adopts its own Family Rules
(myths), Family Roles, and has its own
Boundaries and Functioning.
Think about your own family of origin and
your current family, if that is different.
After reading about the Family Rules in
your text reflect on the following questions
Working with Families

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What were/are the family rules in your family?
Did/will you adopt those rules for a family of
origin into your current family now?
How did those/do those rules affect you now?
What rules help/ed you? What rules hinder/ed
you?
If you employ dysfunctional rules now, can
you or will you change them?
Working with Families

What are the traditional 6 roles identified
in the family with a chemically dependent
member?
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The chemically dependent person
The chief enabler
The family hero
The scapegoat
The lost child
A mascot
Working with Families
 What
types of boundaries are
typically found in the family with a
chemically dependent person?
Enmeshed
 Disengaged
 Overly rigid or chaotic
 Inappropriate alliances
 Out Of Balance Power Differentials

Working with Families

The Behavior Model suggests:
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That skill deficits and inappropriate
reinforcement of using behavior maintain and
perpetuate the problem in the family.
The behavioral model be used in treating
addictions by teaching family members
how to use positive reinforcement of sober
behaviors and extinguish drinking
behaviors.
Working with Families

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Family Disease Model suggests that family
members suffer from codependency.
Some of behaviors a codependent person
may exhibit are:
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Unsuccessful attempts to control the addict
Development of tolerance for deviant behavior
Preoccupation with the addict
Giving up important relationships and activities
because of the addict
Working with Families
 What
is the recommended remedy in
the Family Disease Model?

Detaching with love
Enhancing the Motivation of
Clients (and Counselors, Too!)
 Alcoholics
Anonymous: “Don't quit
five minutes before the miracle.”
What does that quote mean to you?
 What does that quote say about
treatment?

Enhancing the Motivation of
Clients (and Counselors, Too!)
 The
key issue that providers of
services to dually diagnosed clients
face is Motivating clients for change.
 Efficient change depends upon
persons doing the right things at the
right time and on providers providing
interventions managed to client's
stage of change.
Enhancing the Motivation of
Clients (and Counselors, Too!)

Influential stage model of motivation
specifically for clients with dual disorders:

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Engagement, where providers work to
convince clients that treatment has something
of value for them.
Persuasion, a long-term process of attempting
to convince clients of the need for abstinence.
Active treatment phase, where the emphasis is
on developing skills and attitudes needed to
maintain sobriety.
Relapse prevention.
Enhancing the Motivation of
Clients (and Counselors, Too!)
 List
the events as mentioned in your
text for prompting abstinence:
Illness or accident
 Extraordinary events
 Religious or conversion experience
 Alcohol induced financial problems
 Intervention by immediate family

Enhancing the Motivation of
Clients (and Counselors, Too!)
Alcohol related death or illness of a
friend
 Intervention by friends
 Education about alcoholism
 Alcohol related legal problems
 Legally mandated treatment by the
courts or employers

Enhancing the Motivation of
Clients (and Counselors, Too!)
 Generally,
what has research
consistently found to be an important
motivating factor for substance
dependence and mental-health
clients?

The quality of the therapeutic
relationship.
Enhancing the Motivation of
Clients (and Counselors, Too!)
8
specific principles that can be used
in session to enhance motivation to
change the clients drinking:
Give personalized feedback about the
impact of client’s behavior on their lives.
 Offer direct advice on how to change.
 Provide a menu of options for how
change might be accomplished.

Enhancing the Motivation of
Clients (and Counselors, Too!)
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Express empathy for the clients’ situation.
Developed discrepancy by pointing out to
clients the distance between their current
status and their goals.
Avoid arguments.
Roll with resistance and defensiveness.
Support self-efficacy, the clients’ sense of
being able to cope with or manage a situation.
Enhancing the Motivation of
Clients (and Counselors, Too!)
 Working
with the social system of
clients is another way to enhance
motivation.
Enhancing the Motivation of
Clients (and Counselors, Too!)

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Why do you believe it is important for the
provider to maintain his/her own
motivation while treating dually diagnosed
clients?
Why do you believe it is necessary to be
on the alert for burnout?
What do you believe you can do to
maintain your own motivation and avoid
burnout?