Whole Person Approaches to Co-Occurring Disorders Treatment

When someone has a mental illness and a substance use disorder, it’s called a co-occurring disorder. 

But the term might obscure the fact that we are talking about a whole person, not a group of problems. That’s why behavioral health professionals are using an integrated approach to the screening and treatment of co-occurring disorders.

How can behavioral health professionals use this approach to screen, diagnose, and treat co-occurring disorders? 

Who Experiences Co-Occurring Disorders?

Many Americans struggle with the dual challenge of mental health disorders and substance use disorders. 

The Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey of Drug Use and Health reports that: 

• 43.7 million people in the US (18.6% of the population) have at least one mental health disorder
• 17 million people are heavy drinkers (6.5% of the population)
• 23.7 million people have used illicit drugs in the last month 
• 9.2 million people have a co-occurring disorder — both a mental illness and a substance use disorder

Many of these disorders occur at unequal rates in the population. For example, men have almost double the rate of alcohol use disorders, but women develop serious negative outcomes of alcohol use disorders 10 years earlier than men. Women are twice as likely to experience depression as men, and they are more likely to die from drug-related causes.

Examples of Co-Occurring Disorders

The CWC course Whole Person Approaches to Co-occurring Disorders presents a matrix of co-occurring disorders and lists some of the following as examples of the complex ways that these issues intersect. 

People with co-occurring disorders could include:

• An executive with OCD who drinks heavily
• An unhoused person who smokes cannabis frequently and has lived in and out of psychiatric institutions
• A mother with PTSD and a dangerous opioid habit
• A person with bipolar disorder who uses booze to quiet her racing mind so she can sleep
• Someone with avoidant personality disorder who can only leave the house when high

The Consequences of Untreated Co-Occurring Disorders

People with co-occurring disorders are more likely to be hospitalized than those with a mental health or substance use disorder. They generally have poorer physical health, lower quality of life, and increased suicidality. They also face more legal problems and arrests.

Treating co-occurring disorders is critical, and research shows that treatment of either disorder will improve the other. Behavioral health professionals can start by understanding the ways that addiction and mental health issues interact and intersect. 

For example, anxiety disorders often precede substance use problems. There is some evidence showing that cannabis use may be connected with schizophrenia-spectrum disorders. And 20% to 30% of people with depressive disorders and alcohol use disorders will experience substance-induced depression. 

Understanding Addiction

Addiction is when someone uses a substance (or engages in a behavior) despite knowing the negative consequences. The brain’s reward system is as ancient as humans. It is triggered in response to things we find pleasurable: food, sex, substances, anything that can bring a shot of pleasure to our brains. When someone has an addiction, the reward system is hijacked, and people continually seek the reward. When people begin to use substances early, they are more likely to experience addiction.

One complicating factor is that most people who need treatment for drug or alcohol use do not feel they need treatment. Of the 20.2 million who need treatment for illicit drug or alcohol use, only 2.9% felt they needed treatment and did not make an effort. Only 1.6% made an effort to get treatment.

There are lots of reasons why someone might not want to disclose they have issues with addiction, or with mental health. They may fear losing custody of their kids, their job, their housing, or other things they need to survive.

A Troubled History

When state-run psychiatric hospitals began closing in the 1950s and 1960s, some experts believe that a large number of people were released into society with inadequate support for problems with substances, mental health, homelessness, and serious health issues. 

People who experienced multiple challenges were left to struggle. Many traditional mental health clinics and programs were not equipped to assess and treat substance use disorders, and many substance use programs excluded people with mental health concerns.

That’s another reason why treatment should consider the whole person and use an integrated approach.

SAMHSA’s “No Wrong Door” Policy

In response to the lack of resources and the scattershot approach, SAMHSA developed what they call a “no wrong door” policy.  No matter where someone looks for services, they should be identified, assessed, and treated for both substance use and mental health disorders. 

The agency released best practice guidelines to help clinicians manage these overlapping issues.

The Importance of Assessment

In order to solve a problem, we first need to understand it. That’s why data is so important when treating co-occurring disorders. In general, an assessment for co-occurring disorders will include the following elements:

• General information on the client
• Current stresses: Why are they there? Why today? (listen for their goals)
• Past psychiatric and substance use history
• Family, social, vocational, and legal history
• Medical history and current medical issues
• Mental status
• Risk assessment
• Level of motivation for change
• Lab work
• Additional sources of information

Which Screenings?

There are a number of tools that are helpful to screen for both substance use and mental disorders. 

• Patient Health Questionnaire-9
• Beck or Hamilton Depression screens
• Mood Disorder Questionnaire
• Trauma screens, such as the PTSD Checklist-5
• Anxiety disorders
• ADHD and attentional problems
• SBIRT
• The Alcohol Use Disorders Identification Test
• The CAGE questionnaire
  • Have you ever felt you needed to Cut down on your drinking?
  • Have people Annoyed you by criticizing your drinking?
  • Have you ever felt Guilty about drinking?
  • Have you ever felt you needed an Eye-opener first thing in the morning?

By gathering as much information (data) as possible, behavioral health professionals can understand the context of the person’s life. That makes for a better treatment approach and leads to better outcomes.

Integrated Treatments, Inside and Outside the Office

SAMHSA lists three possible models for caring for someone with co-occurring disorders: coordinated, co-located, and fully integrated. The fully integrated approach is one that is most likely to lead to reduced or discontinued substance use, improvement in psychiatric symptoms, and improved quality of life. 

Treatment for co-occurring disorders follows a general pattern of choosing the least restrictive level of care, giving the client the power to choose among options, addressing imminent safety issues (including withdrawal), and deciding whether to treat the disorders in parallel (multiple providers), sequentially, or in a fully integrated manner.

In addition, the most successful recoveries happen both inside and outside the office or clinic. 

When people are engaged in a full range of activities and treatments that support their mind, body, and spirit, they are more likely to succeed and thrive. 

This integrated approach can include:

• Wellness: nutrition, movement, restorative sleep, attention to medical issues
• Cognitive behavioral therapy (CBT)
• Mutual self-help programs like Co-Occurring 12-Step (Double Trouble in Recovery)
• Mindfulness-based therapies
• Faith-based resources
• Peer support groups
• Informal support from family and friends
• Meaningful work and hobbies
• Medication

Resources for Treatment

For behavioral health professionals seeking to learn more about co-occurring disorders treatment, SAMHSA has myriad resources on specific disorders and treatment protocols. 

The CWC course Whole Person Approaches to Co-Occurring Disorders explores the complex topic and points clinicians to effective assessment and treatment tools. 

The ultimate goal is for people seeking help with the dual challenges of mental health and substance use issues to find that any of our doors open up a path to wellness and recovery.