co-occurring disorders: part 2 melody kipp, phd, lmhc life & work soulutions, inc

Co-Occurring Co-Occurring Disorders: Part 2Disorders: Part 2

Melody Kipp, PhD, LMHCMelody Kipp, PhD, LMHC

Life & Work Life & Work SoulSoulutions, utions, Inc.Inc.

Co-Occurring Disorders: Co-Occurring Disorders: Part 2Part 2

Evans, E.K. & Sullivan, J.M. (2001). Evans, E.K. & Sullivan, J.M. (2001). Dual Diagnosis: Counseling the Dual Diagnosis: Counseling the Mentally Ill Substance Abuser, (2Mentally Ill Substance Abuser, (2ndnd ed.).ed.). New York: The Guilford Press. New York: The Guilford Press.

The Psychotic & The Psychotic & Cognitive Disorders Cognitive Disorders

““There are those too who suffer There are those too who suffer from great emotional and mental from great emotional and mental disorders. They too are able to disorders. They too are able to recover if they have the capacity recover if they have the capacity for honesty.” for honesty.” Alcoholics AnonymousAlcoholics Anonymous


Before you begin this section Before you begin this section about schizophrenia, list below about schizophrenia, list below your understanding of your understanding of schizophrenia. For example, schizophrenia. For example, answer these questions: answer these questions: What does a person was What does a person was

schizophrenia look like? schizophrenia look like? How do they behave? How do they behave?


Do I have prejudices or stereotypes Do I have prejudices or stereotypes about people with schizophrenia? about people with schizophrenia?

How do I feel interacting with How do I feel interacting with someone with a psychotic someone with a psychotic disorder? disorder?

Do I feel comfortable treating Do I feel comfortable treating clients with those diagnoses?clients with those diagnoses?


Cardinal features of Cardinal features of schizophrenia include substantial schizophrenia include substantial impairment of clients’ thought impairment of clients’ thought processes as well as the bizarre processes as well as the bizarre content of their thoughts. content of their thoughts.


Symptoms of schizophrenia as Symptoms of schizophrenia as noted in the DSM-IV:noted in the DSM-IV: DelusionsDelusions HallucinationsHallucinations Disorganized speechDisorganized speech Grossly disorganized or catatonic Grossly disorganized or catatonic

behaviorbehavior ““Negative” symptoms Negative” symptoms


Positive symptoms are a problem Positive symptoms are a problem because of what because of what is thereis there and and negative symptoms are problem negative symptoms are problem because of what because of what is not thereis not there. .


Symptoms must be present for at Symptoms must be present for at least 6 months. least 6 months.

Symptoms often manifest Symptoms often manifest themselves during late themselves during late adolescence and early adulthood.adolescence and early adulthood.

Complete remission is uncommon.Complete remission is uncommon.


5 other psychotic disorders:5 other psychotic disorders: Schizophreniform disorderSchizophreniform disorder Schizoaffective disorderSchizoaffective disorder Brief psychotic disorderBrief psychotic disorder Delusional disorderDelusional disorder Psychotic conditions that are Psychotic conditions that are

substance-induced or due to a substance-induced or due to a medical condition medical condition


Neurological sensitizationNeurological sensitization is when is when less and less of a drug is needed to less and less of a drug is needed to provoke the desired response. provoke the desired response.

Cross sensitizationCross sensitization is when is when responses to other drugs and responses to other drugs and stressors in general are stressors in general are exaggerated.exaggerated.

How would these events How would these events complicate your client’s treatment? complicate your client’s treatment?


3 key issues for managing the 3 key issues for managing the person with schizophrenia:person with schizophrenia: Medication complianceMedication compliance Marked deficits in role performanceMarked deficits in role performance The need for abstinence from The need for abstinence from

alcohol and drugsalcohol and drugs


About 50% of people with a About 50% of people with a diagnosis of schizophrenia also diagnosis of schizophrenia also have a substance use disorder.have a substance use disorder.

Even moderate drinking appears Even moderate drinking appears to be unsafe for this population to be unsafe for this population

Stressful situations and high Stressful situations and high demands often cause clients with demands often cause clients with schizophrenia to disorganize schizophrenia to disorganize


Using lots of visual aids and Using lots of visual aids and keeping materials simple and keeping materials simple and concrete will help clients with concrete will help clients with schizophrenia change their schizophrenia change their behaviors. behaviors.

Groups that use classroom Groups that use classroom methods to teach topical issues methods to teach topical issues are more helpful during treatment are more helpful during treatment than process groups than process groups


What may happen when a What may happen when a person with schizophrenia person with schizophrenia abuses alcohol and discontinues abuses alcohol and discontinues their medications?their medications? The alcohol further disorganizes The alcohol further disorganizes

them and exacerbates the side them and exacerbates the side effects of their medication. effects of their medication.


Heavy confrontation of the Heavy confrontation of the person with schizophrenia who is person with schizophrenia who is in denial should be avoided. in denial should be avoided. Slowly and painfully build into the Slowly and painfully build into the

clients’ worldview that he/she is clients’ worldview that he/she is chemically dependent and cannot chemically dependent and cannot use drugs or alcohol at all, ever, use drugs or alcohol at all, ever, under any circumstances. under any circumstances.


Going quickly through the 12 Going quickly through the 12 steps of recovery with a person steps of recovery with a person with schizophrenia is an with schizophrenia is an unrealistic expectation.unrealistic expectation.

Personal therapy is most likely to Personal therapy is most likely to benefit clients with schizophrenia benefit clients with schizophrenia to prevention relapse.to prevention relapse.


3 phases of Personal Therapy 3 phases of Personal Therapy Phase 1Phase 1 involves supportive counseling, involves supportive counseling,

psychoeducation, problem-solving, social psychoeducation, problem-solving, social skills practice, and medication skills practice, and medication management.management.

Phase 2Phase 2 involves identifying individual involves identifying individual indicators of negative affect and skills, indicators of negative affect and skills, such as relaxation techniques, to manage such as relaxation techniques, to manage negative feelings, as well as continued negative feelings, as well as continued social skills training.social skills training.


Phase 3Phase 3 involves social and vocational involves social and vocational initiatives in the community, initiatives in the community, awareness of triggers for problems awareness of triggers for problems and other self-monitoring skills, and and other self-monitoring skills, and work on clients’ social impact on work on clients’ social impact on others others

Clients not living with families or in Clients not living with families or in a stable living situation will not a stable living situation will not benefit from Personal Therapy. benefit from Personal Therapy.


Do not expect miracles, but do Do not expect miracles, but do not leave prematurely. ???not leave prematurely. ???

The term Cognitive Disorders The term Cognitive Disorders refers to:refers to: Delirium, dementia, and amnesic Delirium, dementia, and amnesic

disorders disorders


Cognitive disorders are Cognitive disorders are associated with:associated with: A significant deficit in cognition or A significant deficit in cognition or

memory that represents a change memory that represents a change from previous functioning. from previous functioning.

A general medical condition, a A general medical condition, a substance, or some combination substance, or some combination of the 2 may cause a cognitive of the 2 may cause a cognitive disorderdisorder


Memory difficulties and other Memory difficulties and other cognitive impairments as well as cognitive impairments as well as profound personality profound personality deterioration are the essential deterioration are the essential features of dementia.features of dementia.


Abstinence is the only goal for the Abstinence is the only goal for the person with a cognitive disorder. person with a cognitive disorder.

Keeping the step work concrete Keeping the step work concrete and simple will help in the and simple will help in the treatment of someone dually treatment of someone dually diagnosed with a cognitive diagnosed with a cognitive disorder. disorder.

The Affective & The Affective & Anxiety Disorders Anxiety Disorders

Bipolar disorder is the more Bipolar disorder is the more recent term for manic recent term for manic depression. depression.

The distinctive features of The distinctive features of bipolar disorder are:bipolar disorder are: A distinct period of extreme swings A distinct period of extreme swings

of mood ranging from manic of mood ranging from manic euphoria and hyperactivity to euphoria and hyperactivity to depressed sadness and immobility. depressed sadness and immobility.


Hypomania is defined as having Hypomania is defined as having only mild highs.only mild highs.

The first criterion for bipolar The first criterion for bipolar disorder is a distinct period of disorder is a distinct period of abnormal and persistently abnormal and persistently elevated, expansive, or irritable elevated, expansive, or irritable mood lasting at least one week. mood lasting at least one week.


The other symptoms a person The other symptoms a person may exhibit during the manic may exhibit during the manic phase are:phase are: Inflated self-esteemInflated self-esteem Decreased need for sleepDecreased need for sleep Greater talkativeness than usual or Greater talkativeness than usual or

pressure to keep talkingpressure to keep talking


Flight of ideas or racing thoughtsFlight of ideas or racing thoughts DistractibilityDistractibility Increase in goal-directed activity or Increase in goal-directed activity or

psychomotor agitationpsychomotor agitation Excess of involvement in pleasurable Excess of involvement in pleasurable

activities that potentially have activities that potentially have negative consequences such as negative consequences such as buying sprees or promiscuity. buying sprees or promiscuity.


The difference between Bipolar I The difference between Bipolar I and Bipolar II is:and Bipolar II is: Bipolar IBipolar I type refers to classic type refers to classic

manic-depressive illness. manic-depressive illness. Bipolar IIBipolar II type involves a history of one or type involves a history of one or more episodes of major depression more episodes of major depression accompanied by at least one accompanied by at least one hypomanic episode. hypomanic episode.


3 key treatment issues people suffering 3 key treatment issues people suffering with bipolar disease encounter are:with bipolar disease encounter are: Medication compliance.Medication compliance. A need for a balanced lifestyle, with a A need for a balanced lifestyle, with a

reasonable mixture of work, play, love, and reasonable mixture of work, play, love, and proper attention to nutrition and exercise.proper attention to nutrition and exercise.

Abstinence from all substance use or abuse. Abstinence from all substance use or abuse.


What do mania and chemical What do mania and chemical dependency have in common?dependency have in common? Both are out-of-control behaviors. Both are out-of-control behaviors.

Hospitalization may become Hospitalization may become necessary to stabilize behavior necessary to stabilize behavior and ensure initial abstinence for and ensure initial abstinence for someone with bipolar when the someone with bipolar when the mania is acute.mania is acute.


Manic behavior may be Manic behavior may be redirected to something positive, redirected to something positive, such as taking notes, during such as taking notes, during treatment. treatment.

What other ways can you think What other ways can you think of to redirect manic behavior?of to redirect manic behavior?


The recovery approach can help The recovery approach can help clients deal not only with their clients deal not only with their chemical dependency but also their chemical dependency but also their bipolar illness.bipolar illness. Both are diseases, both involve issues Both are diseases, both involve issues

of out-of-control behavior, and both of out-of-control behavior, and both provide a way of doing grief work and provide a way of doing grief work and repairing the personal and repairing the personal and interpersonal damage associated with interpersonal damage associated with these diseases. these diseases.


Sensation-seeking and impulsive Sensation-seeking and impulsive use should be the focus for a use should be the focus for a person with bipolar disorder when person with bipolar disorder when planning for relapse.planning for relapse.

There is hope for people with There is hope for people with bipolar disease to recover well bipolar disease to recover well and maintain abstinence from and maintain abstinence from substance abuse. substance abuse.


Symptoms of ADHD can Symptoms of ADHD can sometimes mimic the symptoms sometimes mimic the symptoms of mania. of mania.

A comprehensive drug/alcohol A comprehensive drug/alcohol assessment is now required by assessment is now required by many school districts in many school districts in assessing ADHD in students.assessing ADHD in students.


Using stimulants to treat ADHD Using stimulants to treat ADHD should be avoided if the client is should be avoided if the client is also suffering from a disease of also suffering from a disease of addiction.addiction.

Antidepressants are an Antidepressants are an alternative to using stimulants to alternative to using stimulants to treat ADHD.treat ADHD.


The cardinal feature of Major The cardinal feature of Major Depression is feeling deeply sad, Depression is feeling deeply sad, down, or having an irritable mood. down, or having an irritable mood.

What are the other symptoms of What are the other symptoms of major depression as indicated by major depression as indicated by the DSM-IV? (Must have at least 5 of the DSM-IV? (Must have at least 5 of the following for at least 2 weeks)the following for at least 2 weeks)


A depressed or irritable mood A depressed or irritable mood most of the day, nearly every most of the day, nearly every day.day.

Markedly diminished interest or Markedly diminished interest or pleasure.pleasure.

Significant weight lost while not Significant weight lost while not dieting or significant weight gain.dieting or significant weight gain.


Insomnia or hypersomnia.Insomnia or hypersomnia. Psychomotor agitation or Psychomotor agitation or

retardation nearly every day.retardation nearly every day. Fatigue or loss of energy nearly Fatigue or loss of energy nearly

every day.every day.


Feelings of worthlessness or Feelings of worthlessness or excessive or inappropriate guilt.excessive or inappropriate guilt.

Diminished ability to think or Diminished ability to think or concentrate, or indecisiveness.concentrate, or indecisiveness.

Recurrent thoughts of death, Recurrent thoughts of death, recurrent suicidal ideation without recurrent suicidal ideation without a specific plan, or a suicide attempt a specific plan, or a suicide attempt or a specific plan for committing or a specific plan for committing suicide. suicide.


Dysthymia is a chronic low-grade Dysthymia is a chronic low-grade depression.depression.

The following are symptoms of The following are symptoms of dysthymia:dysthymia: A depressed or irritable mood for A depressed or irritable mood for

most of the day, for more days most of the day, for more days than not for at least 2 years.than not for at least 2 years.

Poor appetite or overeating.Poor appetite or overeating.


Insomnia or hypersomnia.Insomnia or hypersomnia. Low-energy or fatigued condition.Low-energy or fatigued condition. Low self-esteem.Low self-esteem. Poor concentration or difficulty Poor concentration or difficulty

making decisions.making decisions. Feelings of hopelessness. Feelings of hopelessness.


Approximately 33% of people Approximately 33% of people with a lifetime history of major with a lifetime history of major depression also have a lifetime depression also have a lifetime history of a substance use history of a substance use disorder. disorder.


For those with substance use For those with substance use disorders, the following factors disorders, the following factors are likely to be causally linked to are likely to be causally linked to the development of major the development of major depression:depression: Low self-esteemLow self-esteem Chronic stressChronic stress Severely threatening life eventsSeverely threatening life events


A positive family history of major A positive family history of major depressiondepression

The perception of having no control The perception of having no control in one's lifein one's life

External attribution for positive and External attribution for positive and negative eventsnegative events

Sleep abnormalities Sleep abnormalities


Negative life events not only can Negative life events not only can trigger a major depression, but a trigger a major depression, but a major depression can create major depression can create negative life events in a vicious negative life events in a vicious cycle.cycle.


The following types of treatment The following types of treatment are suggested for the following are suggested for the following types of depression:types of depression: Mild depression: psychotherapy.Mild depression: psychotherapy. Moderate to severe depression: a Moderate to severe depression: a

combination of medication and combination of medication and psychotherapy plus ongoing psychotherapy plus ongoing maintenance treatment of monthly maintenance treatment of monthly counseling sessions and medication counseling sessions and medication follow-up as needed.follow-up as needed.


You should refer the client who You should refer the client who presents with serious suicidal presents with serious suicidal ideation for a medication ideation for a medication evaluation to a qualified evaluation to a qualified psychiatrist.psychiatrist.


People with Major Depression show People with Major Depression show significant cognitive impairments; significant cognitive impairments; and those in early addiction recovery and those in early addiction recovery also show cognitive impairments.also show cognitive impairments.

Be prepared to engage in some very Be prepared to engage in some very basic and extensive problem-solving basic and extensive problem-solving with your depressed dually with your depressed dually diagnosed client. diagnosed client. Target, in particular, relationship and job Target, in particular, relationship and job

issues. issues.


How can you help those clients How can you help those clients remember the solutions and remember the solutions and tasks you agreed upon during tasks you agreed upon during your session?your session? Write them down. Write them down.

Symptoms of anxiety very Symptoms of anxiety very commonly accompany major commonly accompany major depression and require attention. depression and require attention.


Why do you believe that helping a Why do you believe that helping a client to build or rebuild their client to build or rebuild their social support system would help social support system would help their levels of depression?their levels of depression?

Why do you think that the Why do you think that the hopelessness that accompanies hopelessness that accompanies major depression might lead to major depression might lead to relapse? relapse?


The chances of recovery for the The chances of recovery for the clinically depressed dually clinically depressed dually diagnosed client with appropriate diagnosed client with appropriate treatment are good.treatment are good.

Abstinence alone will not remove Abstinence alone will not remove the depression, and the depression, and psychotherapy and psychotherapy and antidepressants alone will not antidepressants alone will not eliminate substance dependence. eliminate substance dependence.


Anxious arousal and Avoidance of the Anxious arousal and Avoidance of the anxiety-provoking situation are the anxiety-provoking situation are the cardinal features of anxiety disorders.cardinal features of anxiety disorders.

8 specific conditions that fall under the 8 specific conditions that fall under the classification of anxiety disorders:. classification of anxiety disorders:. Panic disorder with or without Panic disorder with or without

agoraphobiaagoraphobia AgoraphobiaAgoraphobia Social phobiaSocial phobia


A simple phobiaA simple phobia Obsessive-compulsive disorder Obsessive-compulsive disorder

(OCD)(OCD) Post-traumatic stress disorder Post-traumatic stress disorder

(PTSD)(PTSD) Acute stress disorderAcute stress disorder Generalized anxiety disorder (GAD)Generalized anxiety disorder (GAD)


When the trigger for one of the When the trigger for one of the above anxiety disorders is very above anxiety disorders is very focused the disorder is generally focused the disorder is generally less incapacitating.less incapacitating.

Specific behavioral interventions Specific behavioral interventions can be used when the trigger is can be used when the trigger is focused.focused.


The anxiety disorders tend to be The anxiety disorders tend to be chronic in half or more of chronic in half or more of individuals.individuals.

The diagnostic criteria for The diagnostic criteria for Generalized Anxiety Disorder are:Generalized Anxiety Disorder are: Excess of anxiety and worry Excess of anxiety and worry

occurring more days than not for at occurring more days than not for at least 6 months about a number of least 6 months about a number of events or activities.events or activities.


Difficulty in controlling the worry.Difficulty in controlling the worry. Association of the anxiety and Association of the anxiety and

worry with three or more of the worry with three or more of the following symptoms:following symptoms: Restlessness or feeling keyed up or on Restlessness or feeling keyed up or on

edgeedge Being easily fatiguedBeing easily fatigued


Difficulty in concentrating or the mind Difficulty in concentrating or the mind going blankgoing blank

IrritabilityIrritability Muscle tensionMuscle tension Sleep disturbanceSleep disturbance


PTSD involves exposure to a PTSD involves exposure to a traumatic event and is traumatic event and is characterized by these 3 characterized by these 3 symptoms: symptoms: Intense fearIntense fear HorrorHorror HelplessnessHelplessness


What other symptoms might a person What other symptoms might a person with PTSD experience?with PTSD experience? Reexperiencing of the trauma, such as Reexperiencing of the trauma, such as

flashbacks, intense memories, and flashbacks, intense memories, and distressing dreamsdistressing dreams

The general numbing and avoidance of The general numbing and avoidance of stimuli associated with the trauma, stimuli associated with the trauma, including amnesia, and diminished including amnesia, and diminished interest in pleasure, and feeling detached interest in pleasure, and feeling detached from others.from others.


The person may also have sleep The person may also have sleep disturbance, irritability, difficulty in disturbance, irritability, difficulty in concentrating, hypervigilance, and concentrating, hypervigilance, and an exaggerated startle response.an exaggerated startle response.


The term Panic Attack refers to: The term Panic Attack refers to: A discrete period of intense fear A discrete period of intense fear or discomfort in which 4 or more or discomfort in which 4 or more of the following symptoms of the following symptoms develop abruptly and peak within develop abruptly and peak within 10 minutes:10 minutes: Heart palpitations and pounding Heart palpitations and pounding

heartheart


SweatingSweating Trembling or shakingTrembling or shaking Sensations of shortness of breath Sensations of shortness of breath

or smotheringor smothering Feeling of chokingFeeling of choking Chest pain or discomfortChest pain or discomfort Nausea or abdominal distressNausea or abdominal distress Feeling dizzy or faintFeeling dizzy or faint


Feeling as if things are unreal or Feeling as if things are unreal or being detached from oneselfbeing detached from oneself

Fear of losing control or going Fear of losing control or going crazycrazy

Fear of dyingFear of dying Numbness or tingling sensationNumbness or tingling sensation Chills or hot flashes. Chills or hot flashes.


Abstinence will resolve the Abstinence will resolve the anxiety of many substance anxiety of many substance abusers.abusers.

Alcohol and the other sedative-Alcohol and the other sedative-hypnotics are commonly used by hypnotics are commonly used by alcoholics. alcoholics.


Relaxation techniquesRelaxation techniques and and Mental hygiene skillsMental hygiene skills such as such as identifying and challenging identifying and challenging catastrophic fear-based thinking catastrophic fear-based thinking are two therapeutic techniques are two therapeutic techniques are often used when treating an are often used when treating an anxiety disorder.anxiety disorder.


The authors of your text state that The authors of your text state that letting clients “borrow the counselor’s letting clients “borrow the counselor’s brain” is also a helpful technique. brain” is also a helpful technique. What type of technique do you think this is? What type of technique do you think this is?

Codependents trying to manage the Codependents trying to manage the unmanageable, including an addictive unmanageable, including an addictive or abusive family member, will be or abusive family member, will be anxious. anxious.


People with anxiety disorders are People with anxiety disorders are at a high risk for relapse. at a high risk for relapse.

Antisocial & Borderline Antisocial & Borderline Personality Disorders Personality Disorders

Personality disorder is defined Personality disorder is defined as:as: Enduring patterns of perceiving, Enduring patterns of perceiving,

relating to, and thinking about relating to, and thinking about oneself in the world that manifest oneself in the world that manifest themselves in a wide range of themselves in a wide range of important situations. important situations.


When does a personality pattern When does a personality pattern become distorted?become distorted? When the pattern is inflexible and When the pattern is inflexible and

maladaptive,maladaptive, Leads to substantial subjective Leads to substantial subjective

distress or functional impairment,distress or functional impairment, Characterizes the person's long-Characterizes the person's long-

term functioning in a variety of term functioning in a variety of situations. situations.


What does the term “acting out” What does the term “acting out” referred to?referred to? Behavioral patterns that have an angry, Behavioral patterns that have an angry,

hostile tone, hostile tone, A mindset that denies, blames, and A mindset that denies, blames, and

justifies, justifies, Behavior that is impulsive and violates Behavior that is impulsive and violates

social conventions regarding appropriate social conventions regarding appropriate ways to relate to others. ways to relate to others.


The key affects for those The key affects for those individuals with either borderline individuals with either borderline or antisocial personality or antisocial personality disorders are:disorders are: AngerAnger Chronic feelings of unhappiness Chronic feelings of unhappiness


You have double denial and You have double denial and strong needs for control with the strong needs for control with the client dually diagnosed with client dually diagnosed with chemical dependency and a chemical dependency and a personality disorder. personality disorder.


What must the counselor be aware of What must the counselor be aware of about their own objectivity when working about their own objectivity when working with the personality-disorder client as with the personality-disorder client as opposed to someone with schizophrenia?opposed to someone with schizophrenia? The provider may attribute malicious motives The provider may attribute malicious motives

to these clients, since such behaviors seem to these clients, since such behaviors seem deliberate, willful, and/or controllable. deliberate, willful, and/or controllable.

Such attributions can lead providers to blame Such attributions can lead providers to blame their clients, become frustrated, and lose their clients, become frustrated, and lose their objectivity. their objectivity.


The essential feature of The essential feature of antisocial personality disorder is:antisocial personality disorder is: A pervasive pattern of disregard A pervasive pattern of disregard

for, in violation of, the rights of for, in violation of, the rights of others - occurring since the age of others - occurring since the age of 15. 15.

7 indicators of such a pattern:7 indicators of such a pattern: Repeatedly performing acts that Repeatedly performing acts that

are grounds for arrestare grounds for arrest


Lying and conningLying and conning Impulsivity or failure to plan aheadImpulsivity or failure to plan ahead Irritability and aggressivenessIrritability and aggressiveness Reckless disregard for the safety of Reckless disregard for the safety of

self or othersself or others Consistent irresponsibilityConsistent irresponsibility Lack of remorseLack of remorse


The person with an antisocial The person with an antisocial personality feels little guilt over personality feels little guilt over the trail of wreckage left in his/her the trail of wreckage left in his/her wake. wake.

Such individuals feel they are Such individuals feel they are never responsible because it's never responsible because it's always someone else's faults or always someone else's faults or there was a good reason why they there was a good reason why they did what they did. did what they did.


What are the prime motivators of What are the prime motivators of the antisocial personality?the antisocial personality? An inflated sense of self.An inflated sense of self. Having power and control.Having power and control. Thrill and excitement seeking. Thrill and excitement seeking.

Boredom is the greatest enemy Boredom is the greatest enemy of the person with an antisocial of the person with an antisocial personality disorder.personality disorder.


Life is a game where the object Life is a game where the object is to win, preferably in the most is to win, preferably in the most exciting, grandiose style exciting, grandiose style possible. possible.

They want others to lose and for They want others to lose and for the loser to acknowledge this. the loser to acknowledge this.


Why might those with antisocial Why might those with antisocial personality disorder have a higher rate personality disorder have a higher rate of substance abuse disorders?of substance abuse disorders? These individuals are attempting to These individuals are attempting to

increase their overall arousal and increase their overall arousal and excitement level.excitement level.

They also will experience a lifestyle with They also will experience a lifestyle with the ups and downs of heavy chemical the ups and downs of heavy chemical involvement and the money, violence, and involvement and the money, violence, and criminal status of illegal drug trafficking. criminal status of illegal drug trafficking.


Antisocial personality disorder predicts a Antisocial personality disorder predicts a poor outcome in chemical dependency poor outcome in chemical dependency treatment. treatment.

The goal of therapy with someone who The goal of therapy with someone who has an antisocial personality disorder is has an antisocial personality disorder is to: to: adapt so that the antisocial clients come to adapt so that the antisocial clients come to

believe that playing by the rules of society believe that playing by the rules of society can actually make them look better in the can actually make them look better in the long run, giving them greater success and long run, giving them greater success and helping them to stay out of trouble. helping them to stay out of trouble.


A major challenge for the A major challenge for the provider is to convince the provider is to convince the antisocial that it is in their best antisocial that it is in their best interest to change. interest to change.


The 3 C’s that summarize the The 3 C’s that summarize the treatment strategies suggested treatment strategies suggested by the authors of your text when by the authors of your text when working with the antisocial working with the antisocial personality:personality: Corral them.Corral them. Confront them.Confront them. Provide consequences for behavior. Provide consequences for behavior.


The “King baby” syndrome refers The “King baby” syndrome refers to the puffed up ego with no true to the puffed up ego with no true underlying self-esteem. underlying self-esteem.

““I am unique and the center of I am unique and the center of the universe” is the perspective the universe” is the perspective that antisocials tend to view that antisocials tend to view themselves in relationship to the themselves in relationship to the universe.universe.


When providing consequences When providing consequences for the behaviors of the for the behaviors of the antisocial personality disorder, antisocial personality disorder, what should you keep in mind?what should you keep in mind? The consequences need to be The consequences need to be

immediate, concrete, and to make immediate, concrete, and to make use of the antisocial’s need to look use of the antisocial’s need to look good and feel excited. good and feel excited.


There may be little that is true There may be little that is true about the data supplied by clients about the data supplied by clients with antisocial personality during with antisocial personality during the assessment.the assessment. Use collateral contacts and Use collateral contacts and

subsequent information by obtaining subsequent information by obtaining a release of information form signed a release of information form signed by the client to gain truthful by the client to gain truthful information. information.


5 keys to recovery that need to be 5 keys to recovery that need to be stated over and over as you treat the stated over and over as you treat the antisocial personality disorder client antisocial personality disorder client are:are: Don't take the first drinkDon't take the first drink Don't drink between meetingsDon't drink between meetings Go to meetingsGo to meetings Get a sponsorGet a sponsor Work the steps Work the steps


The key relapse triggers for The key relapse triggers for antisocials are:antisocials are: BoredomBoredom The need for excitementThe need for excitement Any challenge to the overly high Any challenge to the overly high

but unstable self-esteem but unstable self-esteem


The diagnostic features of The diagnostic features of individuals with borderline individuals with borderline personality disorder:personality disorder: They are semi permanently They are semi permanently

unstable, with wide-ranging unstable, with wide-ranging persistent instability of self image, persistent instability of self image, interpersonal relationships, affect, interpersonal relationships, affect, and marked impulsivity. and marked impulsivity.


The indicators of this Borderline The indicators of this Borderline Personality disorder are: Personality disorder are: Frantic efforts to avoid real or imagined Frantic efforts to avoid real or imagined

abandonmentabandonment A pattern of unstable and intense A pattern of unstable and intense

interpersonal relationships alternating interpersonal relationships alternating between extremes idealization and its between extremes idealization and its opposite, devaluationopposite, devaluation

Identity disturbanceIdentity disturbance ImpulsivityImpulsivity


Recurrent suicidal behavior, or gestures, Recurrent suicidal behavior, or gestures, threats, or self relating behaviorthreats, or self relating behavior

Marked reactivity of moodMarked reactivity of mood Chronic feelings of emptinessChronic feelings of emptiness Intense inappropriate anger or difficulty Intense inappropriate anger or difficulty

in controlling angerin controlling anger Transient stress-related paranoid Transient stress-related paranoid

ideation or severe dissociative symptomsideation or severe dissociative symptoms There must be 5 or more of the above There must be 5 or more of the above

indicators to make a diagnosis.indicators to make a diagnosis.


Females are more often diagnosed Females are more often diagnosed with borderline personality disorder.with borderline personality disorder.

Theoretical speculations and Theoretical speculations and research suggest that the underlying research suggest that the underlying cause of the borderline condition is a cause of the borderline condition is a severely dysfunctional family that severely dysfunctional family that would include physical and sexual would include physical and sexual abuse, neglect, hostile conflicts, the abuse, neglect, hostile conflicts, the early parental loss or separation.early parental loss or separation.


Fearful/disorganized type of Fearful/disorganized type of attachment has been identified attachment has been identified as associated with borderline as associated with borderline personality disorder.personality disorder.


““Disorder of Extreme Stress Disorder of Extreme Stress (DES)” be used for individuals (DES)” be used for individuals who have experienced who have experienced prolonged, repetitive, and severe prolonged, repetitive, and severe trauma.trauma.


Symptoms of DES:Symptoms of DES: Impairment in the regulation of affective Impairment in the regulation of affective

arousalarousal Dissociation and amnesiaDissociation and amnesia Alterations in self-perceptions, especially Alterations in self-perceptions, especially

guilt and shameguilt and shame Alterations in relations with others, Alterations in relations with others,

including trust difficultiesincluding trust difficulties Alterations in systems of meaning, such Alterations in systems of meaning, such

as despair and hopelessness as despair and hopelessness


A deprived, damaged, fragile child A deprived, damaged, fragile child who is typically traumatized by a who is typically traumatized by a very dysfunctional family situation is very dysfunctional family situation is at the core level of the borderline at the core level of the borderline client.client.

Ambivalence is the essence of the Ambivalence is the essence of the borderline person's existence.borderline person's existence.

The goal is to help the victim The goal is to help the victim become a survivor. become a survivor.


The 3 S’s that the authors of The 3 S’s that the authors of your text suggest in helping your text suggest in helping treat the client with borderline treat the client with borderline personality disorder:personality disorder: SafetySafety SkillsSkills SurvivorSurvivor


Dissociation is an important symptom Dissociation is an important symptom associated with borderline personality associated with borderline personality and other trauma-based syndromes. and other trauma-based syndromes. Prolonged breaks in eye contactProlonged breaks in eye contact Fixed or darting eyesFixed or darting eyes Shallow, rapid, constricted breathingShallow, rapid, constricted breathing Tight, repetitive, or young sounding voiceTight, repetitive, or young sounding voice A rigid, guarded, or fleeing posture, and A rigid, guarded, or fleeing posture, and

spacey, flooding with strong feelings or spacey, flooding with strong feelings or numbed affect numbed affect


Simply stating “look at me and Simply stating “look at me and breathe” is a simple grounding breathe” is a simple grounding technique that will help the client technique that will help the client reorient him or herself.reorient him or herself.

Sobriety equals safety is the Sobriety equals safety is the bottom line for the dual diagnosis bottom line for the dual diagnosis counseling with the borderline counseling with the borderline client. client.


Common triggers for relapse with this Common triggers for relapse with this population:population: Perceived abandonmentPerceived abandonment Lack of support and fearLack of support and fear Getting into a relationship with someone Getting into a relationship with someone

who undermines their recovery either who undermines their recovery either directly, through chemical use or directly, through chemical use or indirectly, by minimizing the need for an indirectly, by minimizing the need for an ongoing dual recovery program ongoing dual recovery program


Some techniques that can Some techniques that can minimize the frequency of minimize the frequency of relapse:relapse: Building social supportBuilding social support Learning self-soothing skillsLearning self-soothing skills Prevention planning Prevention planning


What are some tools that might What are some tools that might help you as a counselor from help you as a counselor from becoming discouraged when becoming discouraged when working with this population?working with this population? Collegial supportCollegial support Self-careSelf-care Having policies and procedures Having policies and procedures

about relapse and other safety about relapse and other safety issues.issues.

Working with Families Working with Families

True or false. True or false. Families only play a small role in Families only play a small role in

the causes and conditions the causes and conditions associated with substance abuse associated with substance abuse and psychiatric disorders. and psychiatric disorders.

Why might family members also Why might family members also benefit from treatment? benefit from treatment?


The three approaches to family The three approaches to family therapy are:therapy are: The systems modelThe systems model Behavioral modelBehavioral model The family disease model The family disease model


The systems model suggests that The systems model suggests that each family adopts its own Family each family adopts its own Family Rules (myths), Family Roles, and has Rules (myths), Family Roles, and has its own Boundaries and Functioning. its own Boundaries and Functioning.

Think about your own family of origin Think about your own family of origin and your current family, if that is and your current family, if that is different. After reading about the different. After reading about the Family Rules in your text reflect on Family Rules in your text reflect on the following questions the following questions


What were/are the family rules in your What were/are the family rules in your family?family?

Did/will you adopt those rules for a family of Did/will you adopt those rules for a family of origin into your current family now?origin into your current family now?

How did those/do those rules affect you How did those/do those rules affect you now?now?

What rules help/ed you? What rules What rules help/ed you? What rules hinder/ed you?hinder/ed you?

If you employ dysfunctional rules now, can If you employ dysfunctional rules now, can you or will you change them? you or will you change them?


What are the traditional 6 roles What are the traditional 6 roles identified in the family with a identified in the family with a chemically dependent member?chemically dependent member? The chemically dependent personThe chemically dependent person The chief enablerThe chief enabler The family heroThe family hero The scapegoatThe scapegoat The lost childThe lost child A mascot A mascot


What types of boundaries are What types of boundaries are typically found in the family with typically found in the family with a chemically dependent person?a chemically dependent person? EnmeshedEnmeshed DisengagedDisengaged Overly rigid or chaoticOverly rigid or chaotic Inappropriate alliancesInappropriate alliances Out Of Balance Power Differentials Out Of Balance Power Differentials


The Behavior Model suggests:The Behavior Model suggests: That skill deficits and inappropriate That skill deficits and inappropriate

reinforcement of using behavior reinforcement of using behavior maintain and perpetuate the problem in maintain and perpetuate the problem in the family.the family.

The behavioral model be used in The behavioral model be used in treating addictions by teaching treating addictions by teaching family members how to use positive family members how to use positive reinforcement of sober behaviors and reinforcement of sober behaviors and extinguish drinking behaviors. extinguish drinking behaviors.

Working with Families Working with Families Family Disease Model suggests that Family Disease Model suggests that

family members suffer from family members suffer from codependency.codependency.

Some of behaviors a codependent person Some of behaviors a codependent person may exhibit are:may exhibit are: Unsuccessful attempts to control the addictUnsuccessful attempts to control the addict Development of tolerance for deviant Development of tolerance for deviant

behaviorbehavior Preoccupation with the addictPreoccupation with the addict Giving up important relationships and Giving up important relationships and

activities because of the addictactivities because of the addict


What is the recommended What is the recommended remedy in the Family Disease remedy in the Family Disease Model?Model? Detaching with loveDetaching with love

Enhancing the Motivation of Enhancing the Motivation of Clients (and Counselors, Clients (and Counselors, Too!)Too!)

Alcoholics Anonymous: “Don't Alcoholics Anonymous: “Don't quit five minutes before the quit five minutes before the miracle.”miracle.” What does that quote mean to What does that quote mean to

you?you? What does that quote say about What does that quote say about

treatment? treatment?


The key issue that providers of The key issue that providers of services to dually diagnosed services to dually diagnosed clients face is Motivating clients clients face is Motivating clients for change.for change.

Efficient change depends upon Efficient change depends upon persons doing the right things at persons doing the right things at the right time and on providers the right time and on providers providing interventions managed providing interventions managed to client's stage of change. to client's stage of change.


Influential stage model of motivation Influential stage model of motivation specifically for clients with dual disorders: specifically for clients with dual disorders: EngagementEngagement, where providers work to , where providers work to

convince clients that treatment has convince clients that treatment has something of value for them.something of value for them.

PersuasionPersuasion, a long-term process of attempting , a long-term process of attempting to convince clients of the need for abstinence.to convince clients of the need for abstinence.

Active treatment phaseActive treatment phase, where the emphasis , where the emphasis is on developing skills and attitudes needed is on developing skills and attitudes needed to maintain sobriety.to maintain sobriety.

Relapse preventionRelapse prevention. .


List the events as mentioned in List the events as mentioned in your text for prompting your text for prompting abstinence:abstinence: Illness or accidentIllness or accident Extraordinary eventsExtraordinary events Religious or conversion experienceReligious or conversion experience Alcohol induced financial problemsAlcohol induced financial problems Intervention by immediate familyIntervention by immediate family


Alcohol related death or illness of a Alcohol related death or illness of a friendfriend

Intervention by friendsIntervention by friends Education about alcoholismEducation about alcoholism Alcohol related legal problemsAlcohol related legal problems Legally mandated treatment by the Legally mandated treatment by the

courts or employerscourts or employers


Generally, what has research Generally, what has research consistently found to be an consistently found to be an important motivating factor for important motivating factor for substance dependence and substance dependence and mental-health clients?mental-health clients? The quality of the therapeutic The quality of the therapeutic

relationship. relationship.


8 specific principles that can be used 8 specific principles that can be used in session to enhance motivation to in session to enhance motivation to change the clients drinking:change the clients drinking: Give personalized feedback about the Give personalized feedback about the

impact of client’s behavior on their impact of client’s behavior on their lives.lives.

Offer direct advice on how to change.Offer direct advice on how to change. Provide a menu of options for how Provide a menu of options for how

change might be accomplished.change might be accomplished.


Express empathy for the clients’ situation.Express empathy for the clients’ situation. Developed discrepancy by pointing out to Developed discrepancy by pointing out to

clients the distance between their current clients the distance between their current status and their goals.status and their goals.

Avoid arguments.Avoid arguments. Roll with resistance and defensiveness.Roll with resistance and defensiveness. Support self-efficacy, the clients’ sense of Support self-efficacy, the clients’ sense of

being able to cope with or manage a being able to cope with or manage a situation. situation.


Working with the social system Working with the social system of clients is another way to of clients is another way to enhance motivation. enhance motivation.


Why do you believe it is important for Why do you believe it is important for the provider to maintain his/her own the provider to maintain his/her own motivation while treating dually motivation while treating dually diagnosed clients?diagnosed clients?

Why do you believe it is necessary to Why do you believe it is necessary to be on the alert for burnout?be on the alert for burnout?

What do you believe you can do to What do you believe you can do to maintain your own motivation and maintain your own motivation and avoid burnout? avoid burnout?

co-occurring disorders: part 2 melody kipp, phd, lmhc life & work soulutions, inc

Documents

psychotic disorders

cooccurring disorders

mental disorders

diagnosis of schizophrenia

understanding of schizophrenia

schizophrenia abuses

clients treatment

substance use disorder