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BY:
Rhonda McKillip M.Ed., LMHC, MAC, CCDC III, CDP (Ret)
Psychotherapist, International Trainer, Consultant NAADAC Approved Education Provider
Member of the Motivational Interviewing Network of Trainers (MINTie) Author of THE BASICS, SECOND EDITION:
A CURRICULUM FOR CO-OCCURRING PSYCHIATRIC AND SUBSTANCE DISORDERS Foreword by Kenneth Minkoff, MD
Officially Endorsed Text by the IC&RC (International Certification & Reciprocity Consortium) as the Study Guide for the CCDP, CCDPD, and AADC Exams
Website: rhondamckillipandthebasics.com Email: [email protected]
Behavioral Health Services Department Learning Partnership
The Treatment of Co-Occurring Disorders
Presents
County of Santa Clara Behavioral Health Services
Behavioral Health Services Department Learning Partnership
November 15th, 2019; San Jose, California
The Treatment of Co-Occurring Disorders
Psychoeducation + Consistency + Groups + Implementation
BY: RHONDA MCKILLIP, M.ED., LMHC, MAC, CCDCIII, CDP (RET)
Training Material Developed & Presented By: Rhonda McKillip M.Ed., LMHC, MAC, CCDCIII, CDP (Ret)
All rights remain with Rhonda McKillip LLC; rhondamckillipandthebasics.com; [email protected]
The Treatment of Individuals With
Co-Occurring Disorders
Behavioral Health
Services Department
Learning Partnership
•
•
•
•
•
Kenneth Minkoff; Dennis Daley
• Integrated System of Care
• Universal Dual Diagnosis
Capabilities
• Principles of Empathy and
Hope
• Motivational Interviewing
Approach
• Stages of Change Model
Design
• Neurochemistry Based
Disorders
• Strength Based
• Skill Building
• Solution Focused
• Symptom
Identification
• Symptoms
Management
• Best Practices
Psychoeducation
• Group Therapy
Is a fundamental component in the integrated
treatment of individuals with co-occurring
psychiatric and substance use disorders. It’s the
only way a person can understand their
disorders, develop an individual plan of
treatment, and be empowered with the skills to
live with their disorders, as well as protect
themselves from renewed occurrences.
Yet, how can a professional present evidence-
based integrated treatment without the tools to
provide it?
Why do we even care about the causes of substance use disorders and psychiatric disorders
Ca
use
s
Understanding Disorder
Treatment of Disorder
Managing Symptoms
County of Santa Clara Behavioral Health Services
Behavioral Health Services Department Learning Partnership
November 15th, 2019; San Jose, California
The Treatment of Co-Occurring Disorders
Psychoeducation + Consistency + Groups + Implementation
BY: RHONDA MCKILLIP, M.ED., LMHC, MAC, CCDCIII, CDP (RET)
Training Material Developed & Presented By: Rhonda McKillip M.Ed., LMHC, MAC, CCDCIII, CDP (Ret)
All rights remain with Rhonda McKillip LLC; rhondamckillipandthebasics.com; [email protected]
Organ
Defect
Adapted from: Kevin McCauley, MD; The Institute
for Addiction Study; addictiondoctor.com
Symptoms
Heart
Lack of Oxygen
Blocked
Arteries
1. Pain
2. Cell Destruction
3. Heart Attack
4. Other
Pancreas
Islet Cell
Death
No Insulin
Adapted from: Kevin McCauley, MD; The Institute for Addiction Study; addictiondoctor.com
1. Elev. Blood
Glucose
2. Blurred Vision
3. Coma
4. other
Pancreas
Islet Cell
Death
No Insulin
1. Elev. Blood
Glucose
2. Blurred Vision
3. Coma
4. other
CAUSE
Insulin
Replacement
Depression
Defect?
Adapted from: Kevin McCauley, MD; The Institute
for Addiction Study; addictiondoctor.com
Naturally
Unstable?
Wounded?
Weakness?
Addiction
Defect?
Badness?
Willpower?
Character?
Morals?
e le c t r ica l im p u lse e le c t r ica l im p u lse
N e u r o nN e u r o n
N e u r o t r a n sm it t e r
Sy n a p se
R e c e p t o rReuptake
MAO
Cortisol
ACE, DA, NE, GABA, ENK, END, SE
Synapse
County of Santa Clara Behavioral Health Services
Behavioral Health Services Department Learning Partnership
November 15th, 2019; San Jose, California
The Treatment of Co-Occurring Disorders
Psychoeducation + Consistency + Groups + Implementation
BY: RHONDA MCKILLIP, M.ED., LMHC, MAC, CCDCIII, CDP (RET)
Training Material Developed & Presented By: Rhonda McKillip M.Ed., LMHC, MAC, CCDCIII, CDP (Ret)
All rights remain with Rhonda McKillip LLC; rhondamckillipandthebasics.com; [email protected]
Neurotransmitter Functioning Disrupted
Acetycholine thinking, memory.
mental alertness
confusion, unable to
concentrate or remember
Dopamine pleasure, emotional
stability, reward
depression, anhedonia,
lack of remorse
Norepinephrine energy, motivation,
drive, confidence
Depression, lack of
ambition, energy & drive
Serotonin mood stability,
self-esteem
lack of rational emotion,
irritable, tearfulness
GABA tranquilizer, stress
management
free-floating anxiety,
fearfulness, insecurity
Endorphins &
Enkephalins
physical & emotional
pain management,
stress control
inadequate pain
management, feeling
incomplete & inferior
• Pre-Diagnosis & Pre-Using: Low P300 Brain
Levels; Elevated Levels of Anxiety & Tension to Non-Stressful &
Stressful Stimuli; Neurochemical Imbalanced Base-Line Levels;
Excessive High-Frequency EEG Brain Activity…
• Acute System & Using: Low Initial Response to
Intoxication; Difficulties Prioritizing External Stimulus; Greater
Reduction in Stress Reactions; Exceptionally Rewarding Using
Experience; Significant Increased Endorphin Levels; Reduced
MAO; Enhanced Neurotransmitter Activity for Longer Time; Re-
Uptake Interruption; Neo-Adaptation; Development of Tolerance;
Reduced Cortisol Levels; Brain Chemistry Changes & Cravings
• Re-Occurring & Post-Using: Down Regulation
of “Feel Good” Neurotransmission; Acute & Post Acute WD
• Major Depression: serotonin & norepinephrine
deficiencies; dysregulation of neural circuits responsible for
regulating mood, thinking, sleep, appetite, behavior…
• Bipolar Disorder: irregularities & imbalances in
activity of certain brain circuits; higher than average overall brain
metabolic activity yet reduced activity in the left prefrontal activity;
increased activity in NE & dopamine
• Anxiety Disorders: Significant irregularities and
dysfunctions in the brain; lower levels of Cortisol resulting in
overabundance of Epinephrine & NE; High levels of CRF…
• Schizophrenia: irregular neuron connections in fetal
development; over-activity in dopamine receptors; mis-
communication between frontal lobes & other parts of brain…
County of Santa Clara Behavioral Health Services
Behavioral Health Services Department Learning Partnership
November 15th, 2019; San Jose, California
The Treatment of Co-Occurring Disorders
Psychoeducation + Consistency + Groups + Implementation
BY: RHONDA MCKILLIP, M.ED., LMHC, MAC, CCDCIII, CDP (RET)
Training Material Developed & Presented By: Rhonda McKillip M.Ed., LMHC, MAC, CCDCIII, CDP (Ret)
All rights remain with Rhonda McKillip LLC; rhondamckillipandthebasics.com; [email protected]
• Nutrition
• Relaxation
• Exercise
• Talk Therapy
• Balance in All Areas
• Expressing Emotions
• Active & Positive Life
• Support Groups
• Stress Management
Cerebral Cortex:
Controls Thinking, Speech,
Judgment, Information
Processing
Midbrain:
Controls Emotion
Primitive Brain:
Controls Breathing,
Heartbeat, Survival
Brain
“Wakes Up”
From
Bottom Up
Drugs
Suppress
Brain Activity
From Top
Down
County of Santa Clara Behavioral Health Services
Behavioral Health Services Department Learning Partnership
November 15th, 2019; San Jose, California
The Treatment of Co-Occurring Disorders
Psychoeducation + Consistency + Groups + Implementation
BY: RHONDA MCKILLIP, M.ED., LMHC, MAC, CCDCIII, CDP (RET)
Training Material Developed & Presented By: Rhonda McKillip M.Ed., LMHC, MAC, CCDCIII, CDP (Ret)
All rights remain with Rhonda McKillip LLC; rhondamckillipandthebasics.com; [email protected]
Characteristics of Self-Esteem
Self-Acceptance Self-Nurturing
Self-Worth Self-Guidance
Self-Feeling Self-Determination
Self-Focus Self-Healing
Self-Growth Self-Love
Values & Boundaries
•
•
•
•
1 Have a Sense of Humor
2 Learn to Laugh
3 Stay In Touch With Your “Inner Clown”
4 Learn to Play
5 Read or Expose Yourself to Humorous
Material
County of Santa Clara Behavioral Health Services
Behavioral Health Services Department Learning Partnership
November 15th, 2019; San Jose, California
The Treatment of Co-Occurring Disorders
Psychoeducation + Consistency + Groups + Implementation
BY: RHONDA MCKILLIP, M.ED., LMHC, MAC, CCDCIII, CDP (RET)
Training Material Developed & Presented By: Rhonda McKillip M.Ed., LMHC, MAC, CCDCIII, CDP (Ret)
All rights remain with Rhonda McKillip LLC; rhondamckillipandthebasics.com; [email protected]
Stressors – Importance and Control
Important & Uncontrollable
________________
Important & Controllable
________________
Unimportant & Uncontrollable
________________
Unimportant & Controllable
_________________
“How important is it?” “Can I control this event?”
• Symptom Management
• Treat as if Never Clear
• Connections with Docs
• Client Connection & Preparation
Emotional Recovery
Attending Meetings
Getting a Sponsor
Working the Twelve Steps
Reading Inspirational Literature
Being of Service to Others
Deepen Contact With Spiritual Side and Higher Power
• Honesty
• Trust
• Kindness
• Forgiveness
• Cooperation
• Patience
County of Santa Clara Behavioral Health Services
Behavioral Health Services Department Learning Partnership
November 15th, 2019; San Jose, California
The Treatment of Co-Occurring Disorders
Psychoeducation + Consistency + Groups + Implementation
BY: RHONDA MCKILLIP, M.ED., LMHC, MAC, CCDCIII, CDP (RET)
Training Material Developed & Presented By: Rhonda McKillip M.Ed., LMHC, MAC, CCDCIII, CDP (Ret)
All rights remain with Rhonda McKillip LLC; rhondamckillipandthebasics.com; [email protected]
S
• If distrust has been earned – expect It.
• Help your family learn about your recovery.
• Invite family to join in group meetings.
• Be open yourself to “meeting” your family again.
• Make opportunities for the family to meet some of your
new friends in recovery.
• Make one family member a “partner in recovery.”
• Do as much as you can for yourself. But when there is
a legitimate need, don’t be too proud to ask the family
for help.
• Remember: Recovery depends on the person in
recovery, not on the attitudes or actions of their family.
Essential in any profession – most especially in
the treatment of chronic disorders. Consistency
must include the educational content, treatment
focus, and the therapeutic approach from one
professional to another, from agency to agency,
and from group to group. Yet, how can we
connect the evidence-based science to the
service delivery?
Clients rated the
alliance as the best predictor of
engagement and outcome
(William Miller & Steve Rollnick – 2013)
County of Santa Clara Behavioral Health Services
Behavioral Health Services Department Learning Partnership
November 15th, 2019; San Jose, California
The Treatment of Co-Occurring Disorders
Psychoeducation + Consistency + Groups + Implementation
BY: RHONDA MCKILLIP, M.ED., LMHC, MAC, CCDCIII, CDP (RET)
Training Material Developed & Presented By: Rhonda McKillip M.Ed., LMHC, MAC, CCDCIII, CDP (Ret)
All rights remain with Rhonda McKillip LLC; rhondamckillipandthebasics.com; [email protected]
• Sounds like…• What I’m hearing
is…• Must be…• I would think you…• Like a…• Almost as if…• You…• You are…• Your belief is that…• Your fear is that..
• You’re thinking…
• So you are saying…• Your feeling that…• For you, it’s a matter of…• I would imagine you…• It seems to you…• Through your eyes…• From your point of view…• The thing that bothers you is…• You’re not terribly happy about..
• You’re not much concerned
about…• I’m really getting that you… Prochaska & DiClemente, 1992
• Justified Uncertainty
• Unjustified Certainty
• Justified Certainty
• Unjustified UncertaintyDr. Shaw, Kitsap County, Washington
I have not the right to want to
change another is I am not
open to be changed.
(Martin Burber)
Prochaska & DiClemente, 1992
• Pre-contemplation: You may think this is an
issue, but I don’t, and even if I do, I don’t want to deal
with it, so don’t bug me.
• Contemplation: I’m willing to think with
you, and consider if I want to change, but have no
interest in changing, at least not now.
• Preparation: I’m ready to start changing but I
haven’t started, and I need some help to know how to
begin.
By Chris Cline, M.D., MBA & Kenneth Minkoff, M.D.; ziapartners.com
• Early Action: I’ve begun to make some
changes, and need some help to continue, but I’m
not committed to maintenance or to following all
your recommendations.
• Late Action: I’m working toward maintenance,
but I haven’t gotten there, and I need some help to
get there.
• Maintenance: I’m stable and trying to stay that
way, as life continues to throw challenges in my
path.
By Chris Cline, M.D., MBA & Kenneth Minkoff, M.D.; ziapartners.com
County of Santa Clara Behavioral Health Services
Behavioral Health Services Department Learning Partnership
November 15th, 2019; San Jose, California
The Treatment of Co-Occurring Disorders
Psychoeducation + Consistency + Groups + Implementation
BY: RHONDA MCKILLIP, M.ED., LMHC, MAC, CCDCIII, CDP (RET)
Training Material Developed & Presented By: Rhonda McKillip M.Ed., LMHC, MAC, CCDCIII, CDP (Ret)
All rights remain with Rhonda McKillip LLC; rhondamckillipandthebasics.com; [email protected]
Precontemplation
Contemplation
Action
Maintenance
Preparation
Empathy
Explore and Amplify
Ambivalence
Clarify, Plan &
Set Goals
Relapse Prevention
Monitor & Set
New Goals
Relapse Reframe & Drop Back
• How important is it for you right now to make
this change (the specific target behavior)?
• On a scale from 0-10 (where 1 is not important & 10 is
extremely important?) …what number would you give
yourself?
0__ 1___2___ 3__ 4___ 5___ 6____7____8____9___10
Follow-up Importance Scale Questions
• “And why are you at ____ and not a ____(a lower
number than stated)?”
• Example: “A six? Could you talk more about why you
are at a six and not a four?” “What might happen that
could move you from ____to (a higher number)?”
• If you did decide to change, how confident are you that
you would succeed?
• On a scale from 0-10 …what number would you give
yourself?
0__ 1___2___ 3__ 4___ 5___ 6____7____8___9___10Follow-up Confidence Scale Questions
“You are a four? What would it take
for you to move from a four to a five?”
• Today, how sure (self-efficacy) are you if you decide to
make this change that you will be able to do that? Rate 0-
10: 0- I’m not sure at all; 10- I’m very sure.
• Today, how ready are you to change your _______?
• Today, how willing are you to change your_______?
• Today, how able are you to change your _________?
Not so good things
about _?_(not
changing):
Good things
about__?__
(not changing):
1.____________________
2.____________________
Not so good things
about ______?____
(changing):
Good things
about___?___
(changing):
1.____________________
2.____________________
1.______________________
2.______________________
1.______________________
2.______________________
Crucial in the treatment setting and their
importance can’t be overemphasized. Group
interaction allows a person to “experience”
recovery in a group of their peers. What is
successfully learned, practiced, and internalized
in a group setting can be transferred into the
living community post-treatment. Yet, how do we
provide treatment to individuals with varying
diagnoses, acuity, and severity of symptoms?
• Keeps Honesty & Accountability
• Gives New Perspectives
• Breaks Through Isolation & Shame
• Gets the Story Right
• Sheds Illusions
• Produces Lasting Benefits of Telling a Truthful Story
County of Santa Clara Behavioral Health Services
Behavioral Health Services Department Learning Partnership
November 15th, 2019; San Jose, California
The Treatment of Co-Occurring Disorders
Psychoeducation + Consistency + Groups + Implementation
BY: RHONDA MCKILLIP, M.ED., LMHC, MAC, CCDCIII, CDP (RET)
Training Material Developed & Presented By: Rhonda McKillip M.Ed., LMHC, MAC, CCDCIII, CDP (Ret)
All rights remain with Rhonda McKillip LLC; rhondamckillipandthebasics.com; [email protected]
• Listening
• Clarifying
• Saying
• Feedback
• Direct
Communication
• Openness
• Taking Responsibility
• Trust
• Involvement
• Staying in the Here &
Now
• Give and Take
Listening Skills
Listen From the Heart
Listen for Details
Pay Attention If the Person Is Expressing
Facts or Feelings
Use Silence When You Do Not
Know What to Say
Listen for More Than Words
Listen to What Is Not Being Said
Listen Objectively Use Short Responses
Listen for the Main Idea Listen Twice as Much
Focus Fully on What Someone is Saying
• Awareness of My Own
Behavior
• Applying Insight Of Own
Behavior
• Experiment With Own
Behavior
• Contribute to The
Group’s Awareness of
Itself
• Problem Solving
Effectiveness
• Group Maintenance
• Making The Group a Part of
Life
• Contribute to Others Sharing
• Contribute to the Process of
Group
• Group Diagnostic Ability
• Overall Effectiveness as a
Group
These principles, treatment focus,
educational content, and therapeutic
approach are only helpful to those
seeking services when they are
implemented.
Rhonda McKillip, LLC
M.Ed., LMHC, MAC, CCDCIII, CDP (RET)
rhondamckillipandthebasics.com