Chapter 3: Philosophical and Treatment Approaches for Mental Health and Addiction

Philosophical and Addiction Treatment Approaches Regarding Mental Health and Addiction

Professionals mostly find it easy to addiction treatment for people who have a single disorder. But this does not happen in some cases. Some people have more than one disorders at a time. Like some people consume alcohol and use drugs as well as suffer from different mental health disorders at the same time. For people with dual disorders, the attempt to obtain professional help or addiction treatment can be bewildering and confusing. They may have problems arising within themselves as a result of their psychiatric and AOD use disorders as well as problems of external origin that derive from the conflicts, limitations, and clashing philosophies of the mental health and addiction treatment systems.

For example, internal problems such as frustration, denial, or depression may hinder their ability to recognize the need for help and diminish their ability to ask for help.

Most of the times do not share their problems with anyone. This results in more frustration sometimes. A typical external problem might be the confusion experienced when individuals need services but lack knowledge about the different goals and processes of various types of available services. Other problems of external origin may be very fundamental, such as the inability to pay for child care services or the lack of transportation to the only available outpatient program. Due to all these small problems, the patient suffers a lot and needs addiction treatment.

Historically, for addiction treatment when patients in AOD treatment exhibited vivid and acute psychiatric symptoms, the symptoms were either: 1) unrecognized, 2) observed but not described as toxicity or “acting-out behaviour,” or 3) accurately identified, prompting the patients to be discharged or referred to a mental health program.

Virtually the same process of addiction treatment occurred for patients in mental health treatment who exhibited vivid and acute symptoms of AOD use disorders. Mislabeling, rejecting, failing to recognize, or automatically transferring patients with dual disorders can result in inadequate addiction treatment, with patients falling between the cracks of addiction treatment systems. The symptoms of psychiatric and AOD use disorders often fluctuate in intensity and frequency. Current symptom presentation may reflect a short-term change in the course of long-term dual disorders. Thus, even when patients receive traditional professional help or addiction treatment, treatment may address only selected aspects of their overall problem unless treatment is coordinated among services including AOD, mental health, social, and medical programs.

As a result, the addiction treatment system itself may be a stumbling block for some people attempting to receive ongoing, appropriate, and comprehensive treatment for combined psychiatric and AOD use disorders.

Thus, addiction treatment services for patients with dual disorders must be sensitive to both the individual’s and the addiction treatment system’s impediments to the initiation and continuation of treatment.

Treatment Systems Linked with Mental Health, Addiction, and Medical

Different problems require addiction treatment by different professionals and different medical systems. So that is why people with dual disorders who want to engage in the treatment process (or who need to do so) frequently encounter not one but several treatment systems, each having its own strengths and weaknesses. These treatment systems have different clinical approaches.

The Mental Health System

Actually, there is no single mental health system related to addiction treatment, although most States have a set of public mental health centers. Rather, mental health services are provided by a variety of mental health professionals including psychiatrists; psychologists; clinical social workers; clinical nurse specialists; other therapists and counselors including marriage, family, and child counselors (MFCCs); and paraprofessionals.

This mental health personnel work in a variety of settings, using a variety of theories about the addiction treatment of specific psychiatric disorders.

Different types of mental health professionals (for example, social workers and MFCCs) have differing perspectives; moreover, practitioners within a given group often use different approaches.

A major strength of the mental health system is the comprehensive array of services offered, including counselling, case management, partial hospitalization, inpatient treatment, vocational rehabilitation, and a variety of residential programs. The mental health system has a relatively large variety of addiction treatment settings. These settings are designed to provide addiction treatment services for patients with acute, subacute, and long-term symptoms.

Acute services are provided by personnel in emergency rooms and hospital units of several types and by crisis-line personnel, outreach teams, and mental health law commitment specialists. Subacute addiction treatment is provided by hospitals, day addiction treatment programs, mental health center programs, and several types of individual practitioners. Long-term settings include mental health centers, residential units, and practitioners’ offices.

Clinicians vary with regard to academic degrees, styles, expertise, and training. Another strength of the mental health system is the growing recognition at all system levels of the role of case management as a means to individualize and coordinate services and secure entitlements in relation with addiction treatment.

Medication is more often used in psychiatric treatment than in addiction treatment, especially for severe disorders. Medications used to treat psychiatric symptoms include psychoactive and non-psychoactive medications. Psychoactive medications cause an acute change in mood, thinking, or behavior, such as sedation, stimulation, or euphoria.

Psychoactive medications (such as benzodiazepines) prescribed to the average patient with psychiatric problems are generally taken in an appropriate fashion and pose little or no risk of abuse or addiction.

In contrast, the use of psychoactive medications by patients with a personal or family history of an AOD use disorder is associated with a high risk of abuse or addiction.

Some medications for addiction treatment used in psychiatry that have mild psychoactive effects (such as some tricyclic antidepressants with mild sedative effects) appear to be misused more by patients with an AOD disorder than by others. Thus, a potential pitfall is prescribing psychoactive medications to a patient with psychiatric problems without first determining whether the individual also has an AOD use disorder.

While most clinicians in the mental health system working for addiction treatment generally have expertise in a biopsychosocial approach to the identification, diagnosis, and treatment of psychiatric disorders, some lack similar skills and knowledge about the specific drugs of abuse, the biopsychosocial processes of abuse and addiction, and AOD treatment, recovery, and relapse. Similarly, AOD treatment professionals may have a thorough understanding of AOD abuse treatment but not psychiatric treatment.

The Addiction Treatment System

As with mental health treatment, no single addiction treatment system exists. Rather, there is a collection of different types of addiction treatment services such as social and medical model detoxification programs, short- and long-term treatment programs, methadone detoxification and maintenance programs, long-term therapeutic communities, and self-help adjuncts such as the 12-step programs that aim at helping the patients in their recovery from different problems like substance addictions, compulsions and addiction-related to behaviour These programs can vary greatly with respect to treatment goals and philosophies. For example, abstinence is a prerequisite for entry into some programs, while it is a long-term goal in other programs. Some AOD treatment programs are not abstinence oriented. For example, some methadone maintenance programs have the overt goal of eventual abstinence for all patients, while others addiction treatment programs promote continued methadone use to encourage psychosocial stabilization.

As with mental health treatment, addiction treatment is provided by a diverse group of practitioners, including physicians, psychiatrists, psychologists, certified addiction counselors, MFCCs, and other therapists, counselors, and recovering paraprofessionals.

There can be a wide difference in experience, expertise, and knowledge among these diverse providers. As with mental health treatment, most States have public and private AOD treatment systems. These AOD treatment centers have best professional that provide their services to any of the patient suffering from drug related problems

The strengths of addiction treatment services include the multidisciplinary team approach with a biopsychosocial emphasis, and an understanding of the addictive process combined with knowledge of the drugs of abuse and the 12-step programs. In typical addiction treatment, medications are used to treat the complications of addiction, such as overdose and withdrawal. However, few medications that directly treat or interrupt the addictive process, such as disulfiram and naltrexone, have been identified or regularly used.

Maintenance medications such as methadone are crucial for certain patients. However, most addiction treatment professionals attempt to eliminate patients’ use of all drugs. And after the treatment is finished they keep a check on his activities through different post treatment programs. In such programs, the family and the friends of the patient are taken into discussion and are asked to monitor the activities of the patient. This helps the patient in maintaining their abstinence.

Similarities of Mental Health and Addiction Treatment Systems

• Variety of treatment settings and program types
• Public and private settings. This involves making changes in his daily life routine and trying to make his environment according to that as well; to get benefits from addiction treatment
• Multiple levels of care. This involves proper medication and attention by the members of family and friends
• Biopsychosocial models
• Increasing use of case and care management. This method is actually very important. As this involves care at different level. Problem is nipped in the bud. Whenever there is a need of consulting the doctor it is done immediately to get addiction treatment
• Value of self-help adjuncts: This is the most important point. At the end of the day patient is the one who will have to do it for himself if he wants a good life ahead. He himself has to dissuade from everything that serves as a trigger factor for his destructive behavior. This can be done by a strong will power

Many who work in the addiction treatment field have only a limited understanding of medications used for psychiatric disorders. Historically, some people have mistakenly assumed that all or most psychiatric medications are psychoactive or potentially addictive. Many addiction treatment staff tend to avoid the use of any medication with their patients, probably in reaction to those whose addiction included prescription medications such as diazepam (Valium). Many staff have a lack of training and experience in the use of such medications. In the treatment of dual disorders, a balance must be made between behavioral interventions and the appropriate use of no addicting psychiatric medications for those who need them to participate in the recovery process. Withholding medications from such individuals increases their chances of AOD relapse.

An important adjunct to addiction treatment services is the massive system of consumer-developed groups, such as the 12-step program of Alcoholics Anonymous (AA).

Participants in AA and other self-help groups (Narcotics Anonymous [NA], Cocaine Anonymous [CA], etc.) can provide needed support and encouragement for patients in treatment. Importantly, these services are widespread nationally and internationally. While self-help programs are not considered treatment per se, they are integral adjuncts to professional treatment services.

However, patients in self-help groups may give others inappropriate advice for addiction treatment and regarding medication compliance, based on personal experience, fears of medication, or incomplete knowledge about the role of addiction treatment and medication in dual disorders.

In many urban areas, there are specialized 12-step groups for people with dual disorders. In these so-called “Double Trouble” meetings, medication compliance is a part of addiction treatment “working the program.”

The Medical System

Primary health care providers (physicians and nurses) have historically been the largest single point of contact for patients seeking help with addiction treatment and psychiatric and AOD use disorders. Physicians and nurses are uniquely qualified to manage life-threatening crises and to treat medical problems related and unrelated to addiction treatment, psychiatric and substance use disorders. And because they are in contact with such large numbers of patients, they have an exceptional opportunity to screen and identify patients with psychiatric and AOD disorders.

However, physicians — especially primary care physicians — are able to devote very little time to each patient for addiction treatment. Pressured for time, these physicians may prescribe such addiction treatment and psychiatric medications as antidepressants or anxiolytics or medication such as disulfiram or naltrexone as a primary approach, rather than as an adjunctive approach. Indeed, primary care physicians are the largest single prescriber of antianxiety medications. Some of these medications, such as benzodiazepines, are psychoactive and can be abused.

Also, physicians and nurses have historically been trained to focus on the addiction treatment and medical consequences of addiction, such as withdrawal, overdose, or hepatitis, without assessing, treating, or actively referring the individual for the addiction treatment of the addiction itself.

The role of physicians with regard to addiction treatment is changing through the leadership of national organizations such as the American Society of Addiction Medicine, the American Academy of Psychiatrists on Alcohol and Addiction, and the Association of Medical Education and Research on Substance Abuse.

Similar groups exist for nurses and allied health care professionals for addiction treatment. Such groups can provide medical professionals with important information and education about the biopsychosocial nature of addiction treatment, especially regarding patients with dual disorders.

Differing Approaches Related to Individual Responsibility and Treatment Process

Traditionally, patients in mental health settings have had the responsibility of getting themselves to addiction treatment services and appointments as a sign of treatment motivation for addiction treatment. More recently, and in recognition that many severely mentally ill patients are unwilling or unable to use traditional community-based services, the mental health field has emphasized the role of case management. Case management (also called care management) can help to engage, link, and support patients in needed community services.

Case management can help to reduce the negative consequences to the individual from lack of follow up and participation in addiction treatment. Without case management, many severely ill patients would decompensate, need to be hospitalized, or become homeless.

The case management model identifies individual limitations, deficits, and strengths and aggressively attempts to provide patients with what they need. When a patient rejects professional assistance, the case manager assumes the responsibility for finding a different way to get the individual to accept assistance. The case manager may minimize the negative consequences to the individual in order to engage or maintain the patient in treatment. This activity might be seen as “enabling” by traditional addiction treatment personnel.

In contrast, the addiction treatment system focuses on individual responsibility, including the responsibility of accepting help. Motivation for recovery is enhanced through confrontation of the adverse consequences of addiction. Further, addiction intervention and treatment involve diminishing the individual’s denial about the presence and severity of the addiction through direct but therapeutic confrontation of examples of addiction-related behaviors.

Thus, traditionally, patients in the addiction treatment system who did not want help or could not tolerate confrontation might not get help.

Mental health personnel might regard this situation as an abandonment of the neediest. More recently, the addiction treatment system has been developing case management models to better address treatment-resistant patients.

AOD and mental health disorders are much closely related to each other so many of the professional addiction treatment of patients with dual disorders must blend both mental health and AOD addiction treatment models, with each applied at appropriate times and inappropriate situations according to patients’ needs. There should be a balance between clinician and patient acceptance of responsibility for treatment and recovery from dual disorders.

For example, in AOD treatment, clinical staff and fellow patients often aggressively confront patients who deny that they have an AOD problem or who minimize the severity of their problem. But this aggression is not taken immediately into the addiction treatment. So, addiction treatment of individuals with dual disorders first requires innovative approaches to engage them in treatment as a prerequisite to confrontation.

The role of confrontation may need to be substantially modified, particularly in the treatment of disorganized or psychotic patients, who may tolerate confrontation only in later stages of treatment (when their symptoms are stable and they are engaged in the treatment process).

In addiction treatment, the focus is often on the “here and now,” while in mental health treatment, the focus is often on past developmental issues. Mental health practitioners may identify AOD abuse as a symptom of a prior trauma rather than an illness in its own right. The focus of addiction treatment may be on developmental issues, with the assumption that the AOD use disorder will improve automatically once these issues are treated. Inadvertently, the mental health therapist can enable AOD use to continue.

Abstinence and Its Role

Within parts of the addiction treatment system, abstinence from psychoactive drugs is a precondition to participate in treatment. For the more severely ill patients with dual disorders (such as patients with schizophrenia), abstinence from AODs is often considered a goal, possibly a long-term goal, similar to the approach at some methadone maintenance programs.

On the other hand, addiction treatment of less severe dual psychiatric conditions, such as depression or panic disorder, should require AOD abstinence, since AOD use compromises both diagnosis and treatment (see individual chapters).

For some patients with dual disorders, requiring abstinence as a condition of entering addiction treatment may hinder or discourage engagement in the treatment process. For these patients, abstinence may be redefined as a goal, with encouragement provided for incremental steps in the reduction of amount and frequency of drug use. For example, patients who experience homelessness and housing instability likely do not live in drug-free environments. For such patients, it may be unrealistic to mandate abstinence as a requirement for treatment. Describes some of the addiction treatment strategy differences for managing patients in mental health, addiction, and dual disorder treatment approaches.

Treatment Models: Sequential, Parallel, or Integrated

As the field of medicine is developing every new day mental health and AOD addiction treatment fields have also become increasingly aware of the existence of patients with dual disorders. So different researches are being made on finding the proper treatment methods for the dual disorders and various attempts have also been made to adapt a proper addiction treatment to the special needs of these patients (Baker, 1991; Lehman et al., 1989; Minkoff, 1989; Minkoff and Drake, 1991; Ries, 1993a). These attempts have reflected philosophical differences about the nature of dual disorders, as well as differing opinions regarding the best way to treat them. These addiction treatment attempts also reflect the limitations of available resources, as well as differences in addiction treatment responses for different types and severities of dual disorders.

Three approaches have been taken to addiction treatment:

1. Sequential Treatment

The first and historically most common model of dual disorder addiction treatment is sequential treatment. In this model of treatment, the patient is treated by one system (addiction or mental health) and then by the other. Indeed, some clinicians believe that addiction treatment must always be initiated first, and that the individual must be in a stage of abstinent recovery from addiction before treatment for the psychiatric disorder can begin. On the other hand, other clinicians believe that treatment for the psychiatric disorder should begin prior to the initiation of abstinence and addiction treatment.

Still, other clinicians believe that symptom severity at the time of entry to treatment should dictate whether the individual is treated in a mental health setting or an addiction treatment setting or that the disorder that emerged first should be treated first. So it can be seen that the opinions vary to a great extent in this regard

The term sequential treatment describes the serial or no simultaneous participation in both mental health and addiction treatment settings.

For example, a person with dual disorders may receive treatment at a community mental health center program during occasional periods of depression and attend a local AOD treatment program following infrequent alcoholic binges. Systems that have developed serial treatment approaches generally incorporate one of the above orientations toward the treatment of patients with dual disorders.

2. Parallel Treatment

A related approach involves parallel treatment: the simultaneous involvement of the patient in both mental health and addiction treatment settings. For example, an individual may participate in AOD education and drug refusal classes at an program, participate in a 12-step group such as AA, and attend group therapy and medication education classes at a mental health centre.

Both parallel and sequential treatment involve the utilization of existing treatment programs and settings. Thus, mental health treatment is provided by mental health clinicians, and addiction treatment is provided by addiction treatment clinicians. Coordination between settings is quite variable. But still this coordination is very important as both sides must know the progress and reports of the patient so that they can take the further steps in accordance with that.

3. Integrated Treatment

A third model, called integrated treatment, is an approach that combines elements of both mental health and addiction treatment into a unified and comprehensive treatment program for patients with dual disorders. Ideally, integrated treatment involves clinicians cross-trained in both mental health and addiction, as well as a unified case management approach, making it possible to monitor and treat patients through various psychiatric and AOD crises.

So in such treatments professionals can treat the problems by mixing them up according to the nature of the patient

There are advantages and disadvantages in sequential, parallel, and integrated addiction treatment approaches. Differences in dual disorder combinations, symptom severity, and degree of impairment greatly affect the appropriateness of an addiction treatment model for a specific individual. For example, sequential and parallel treatment may be most appropriate for patients who have a very severe problem with one disorder, but a mild problem with the other. In this way they can be properly treated by the professionals, according to the level and severity of problem. However, patients with dual disorders who obtain addiction treatment from two separate systems frequently receive conflicting therapeutic messages; in addition, financial coverage and even confidentiality laws vary between the two systems.

Treatment Models

• Sequential: The patient participates in one system, then the other. This system consists of two or three different steps but both the steps are mutually so much interrelated with other that the success of one is important for the success of other
• Parallel: The patient participates in two systems simultaneously. Both the drug usage issues and the mental health problems are treated at the same time by different professionals at different places. This method is of quintessential importance in AOD and addiction treatment
• Integrated: The patient participates in a single unified and comprehensive treatment program for dual disorders or addiction treatment

In contrast, integrated treatment places the burden of treatment continuity on a case manager who is expert in both psychiatric and AOD use disorders. Further, integrated treatment involves simultaneous treatment of both disorders in a setting designed to accommodate both problems. Integrated treatment can sometime be hectic for the doctor as in this case a single person becomes responsible for both different problems

Critical Treatment Issues for Dual Disorders

Programs for mental health and alcohol care that are tailored to handle patients with dual conditions should be updated to meet the unique needs of these patients.
Despite the fact that there are many different dual disorder treatment models, all of them must discuss a few core problems that are essential for effective treatment.

These issues include:

1. Treatment engagement
2. Treatment continuity and comprehensiveness
3. Treatment phases
4. Continual reassessment and rediagnosis

Treatment Engagement

Treatment commitment, in general, refers to the process of initiating and maintaining a patient’s involvement in a long-term drug treatment programme.
Such enticements as offering assistance with the provision of social services like food, housing, and medical services may be used to entice people to engage. Engagement can also include eliminating obstacles to care and making it more affordable and appropriate, such as by offering day and evening addiction treatment options. Providing adjunctive resources that tend to be unrelated to the disorders, such as child care, work skills counselling, and leisure activities may improve engagement. It may also be manipulative, as in the case of involuntary commitment or a specified payee.

Engagement begins with efforts that are designed to enlist people into addiction procedure, but it is a long-term process with the goals of keeping patients in addiction treatment and helping them manage ongoing problems and crises.

Essential to the engagement process is:

• A personalized relationship with the individual
• Over an extended period of time, with
• A focus on the stated needs of the individual

For patients with dual disorders, engagement in the addiction treatment process is essential, although the techniques used will depend upon nature, severity, and disability caused by an individual’s dual disorders.

An employed person with panic disorder and episodic alcohol abuse will require a different type of engagement than a homeless person with schizophrenia and polysubstance dependence. With respect to severe conditions such as psychosis and violent behaviours, therapeutic coercive engagement techniques may include involuntary detoxification, involuntary psychiatric treatment, or court-mandated acute treatment.

Treatment Continuity

It is important to develop consistency between addiction recovery systems and addiction treatment elements, as well as treatment continuity over time, when treating patients with dual disorders. In practise, a large number of patients are involved at various locations. Many patients need different medical services during different stages of treatment, including in integrated treatment programmes. As a result, care could include an integrated dual condition case management service, which may be housed in a mental health facility, an alcohol treatment facility, or a joint programme.

Treatment Comprehensiveness

An overall system for treating dual disorders includes mental health and addiction treatment programs, as well as collaborative integrated programs. Programs should be designed to:

• Engage clients
• Accommodate various levels of severity and disability
• Accommodate various levels of motivation and compliance
• Accommodate patients in different phases of treatment

There should be access to abstinence-mandated programs and abstinence-oriented programs, as well as to drug maintenance programs. Different levels of care, ranging from more to less intense treatment, should be available.

Phases of Treatment

In fact, the medical term acute refers to events that occur suddenly and necessitate immediate action. The terms “acute” and “chronic” are used interchangeably. Acute stabilisation of patients with dual conditions is most often used to describe the treatment of physical, psychological, or drug toxicity crises. Suicidal, aggressive, impulsive, or psychotic acts are among them, as are injury, sickness, AOD-induced toxic or withdrawal states, and suicidal, violent, impulsive, or psychotic behaviour.

In addiction treatment, detoxification, such as inpatient detoxification for patients with severe withdrawal or outpatient detoxification for mild to moderate withdrawal, as well as nonmedical withdrawal, such as that seen in social-model detoxification services, is usually the first step in the acute recovery of AOD use disorders. Patients addicted to opioids will also benefit from the start of methadone maintenance as an outpatient treatment option for acute stabilisation.

Acute psychological symptom recovery is most common in a mental health or emergency care environment, but it can require a variety of treatment intensities. Patients with extreme symptoms, such as psychosis, violence, or impulsive behaviour, typically undergo acute medical inpatient addiction care and psychiatric drugs, while individuals with less severe symptoms may be treated in rehabilitation or day treatment environments.

Dual disorder programs that provide stabilization to patients with acute needs should have the capability to:

• Identify medical, psychiatric, and AOD use disorders
• Treat a range of illness severity
• Provide drug detoxification, psychiatric medications, and other biopsychosocial levels of treatment
• Provide a range of intensities of service.

These services should be able to encourage patients to participate in the drug recovery system. They should be able to quickly establish connections with other services that can include continued care and involvement.

Medical term: Subacute Stabilization

The medical term subacute describes the state of a medical illness between the acute and either the resolution or chronic states. The subacute phase of a medical condition occurs when the acute course of the problem starts to fade, or when symptoms arise or reappear but are not serious enough to be classified as acute.

For example, patients recently detoxified from AODs frequently experience subacute symptoms such as insomnia and anxiety that may linger for a few days or weeks.

Recently detoxified patients with dual disorders, on the other hand, can experience subacute symptoms of insomnia and anxiety as subacute withdrawal symptoms or as a precursor to relapse with depression. Although the subacute phase is not considered a crisis time, ignoring these symptoms and failing to assess and treat them can result in symptom worsening, decompensation, and relapse.

As the AOD-induced harmful or withdrawing symptoms fade, reassessment and diagnosis are needed on a regular basis. To inform patients about their disorders and symptom severity during this process, a psychoeducational and psychological approach should be used. Treatment providers should conduct an evaluation and develop a strategy for coping with long-term problems such as accommodation, long-term treatment, and financial stability during this process. As a result, mental health and addiction can be resolved using philosophical and dependency treatment methodologies, depending on the preferences. So, contact now for addiction treatment.