Counseling Chapter 25 The Client With Cooccurring Disorders Substance Use Disorders And Mental Illness

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CHAPTER 25

The Client with Co-Occurring Disorders: Substance Use Disorders and Mental Illness

LEARNING OBJECTIVES

After studying this chapter, students should be able to:

•

25.2: Identify the causal considerations for co-occurring disorders

•

25.4: Understand the scope of the problem of co–occurring disorders

•

25.6: Review the struggles that may be encountered in working with clients

with co-occurring disorders

•

25.7: Identify current treatment approaches to working with those with co-

occurring disorders

CHAPTER OVERVIEW

Definitions

Coexisting Substance Use and Medical Disorders

Etiology of Co-Occurring Disorders

Clients with Co-Occurring Disorders: A Diagnostic Challenge

Why Worry About Clients with Co-Occurring Disorders?

Scope of the Problem

Psychopathology and Drug of Choice

Attention Deficit Hyperactivity Disorder (ADHD)

Schizophrenia

Anxiety Disorders

The Dissociative Disorders

Obsessive-Compulsive Disorder (OCD)

Bipolar Affective Disorders

Depression

Eating Disorders

Compulsive Gambling

Personality Disorders

Antisocial Personality Disorder and Substance Use Disorders

Borderline Personality Disorder and SUDs

Mixed Personality Disorders

Co-Occurring Disorders/Victimization Issues

Posttraumatic Stress Disorder

Problems in Working with the Client with Co-Occurring Disorders

Traumatic Brain Injury and SUDs

Post-Concussion Syndrome (PCS)

Clients with Co-Occurring Diagnoses and Medication Compliance

Treatment Approaches with Clients with Co-Occurring Disorders

The Stages of Treatment

The Outcome of Treatment

Ancillary Issue: Smoking

CHAPTER OUTLINE

Although in the recent past, the occurrence of substance use disorders (SUDs) and mental illness

was considered rare, it is understood to be common now. In this chapter, students will learn

what it means for an individual to have co-occurring disorder as well as consider the causes of

such disorders. The challenges with diagnosis will be discussed, as well as considerations of the

scope of the issue of co-occurring disorders with those who have SUDs. The student will also

discover some of the struggles that may be encountered in working with these individuals, as

well as the treatment approaches that are commonly used in working with those with co-

occurring disorders.

DISCUSSION QUESTIONS

Break-Out Discussion #1:

Free floating denial: In your text, it is noted that clients with co-occurring disorders often

demonstrate different forms of denial, depending in part on the skills and training of the

professional interviewing them. Contrast the following two hypothetical interviews. The client is

a man who is assumed to be 25-year old and is recovering from the aftereffects of a head injury

he suffered while intoxicated:

Counselor: So, we are meeting here to discuss your substance use, to try and determine

whether you have a substance problem.

Client: Can you speak up a bit? The accident left me with a hearing problem.

Counselor (speaking more loudly): In the year before your accident, how often would you

say you would drink alcohol in the typical week?

Client: I can’t remember much of the year before the accident. I was told by the doctors that

I probably won’t be able to regain any of those memories back.

Counselor: All right, how far back does your memory allow you to recall things clearly?

Client: Two or three years back.

Counselor: Then describe what your alcohol use pattern was like 2–3 years ago.

Client: Oh, it was not a problem back then. I hardly ever used alcohol. But I can’t remember

clearly, because of my head injury. Sorry.

Now contrast this with the following hypothetical interview between a physician and the same

client the next day:

Physician: Well, you seem to be recovering quite well. But your alcohol and drug misuse

bothers me.

Client: Oh. The counselor told me that I don’t have a problem. We discussed this yesterday

and he said that I did not even seem to misuse alcohol. I never use drugs, so that is

not a problem. But my shoulder still hurts me a lot.

Physician: Does it hurt when you move your shoulder in a specific way, or does it hurt all the

time?

Client: All the time. Can you give me something for the pain?

In this hypothetical set of conversations, you can see how the client shifted the focus away from

his substance use to his medical condition when meeting with the counselor, and then away

from his substance use to a physical problem when meeting with the physician (with a ploy to

obtain painkillers tossed in for good measure). Thus, clear and continuous communications

between the professionals who are involved in the patient’s treatment is always necessary. For

example:

Counselor: So, we are meeting here to discuss your substance use, to try and determine

whether you have a substance problem.

Client: Can you speak up a bit? The accident left me with a hearing problem.

Counselor (speaking more loudly): Really? Dr. Smith did not mention that in his notes. I will

have to mention it to Dr. Smith when we meet later this afternoon and Dr. Smith

will want to discuss that problem with you. But let us move on. In the year before

Questions

1. What changes do you notice between the third dialogue and the first pair of dialogues?

2. What practices caused those changes?

Break-Out Discussion #2:

The personality disorders: The topic of personality disorders is very complex, and worthy of a

textbook devoted just to this topic. We will only have time to briefly review the personality

disorders here, although they are a fascinating subject in their own right. For further

(1) Adaptive inflexibility. While a normal person can adapt to the changing demands of the

environment, personality disordered clients demonstrate rigid and inflexible coping

(2) Their behavior is ego syntonic; they do not view their behavior as being unreasonable or

inappropriate. It is for this reason that they are quite unresponsive to therapeutic

interventions aimed at assisting personality change and growth. After all, why change if you

see nothing wrong in your behavior?

Questions

1. Do you know anybody who has been diagnosed as having a personality disorder? How does

their behavior differ from the behavior of normal persons?

2. Do you find their behavior to be acceptable, or does it sometimes cause you to feel used or

abused? Explain your response.

3. Do you view these persons as being capable of change? Why or why not?

4. Do you know of any stereotypes concerning people who have personality disorders, especially

in relation to their substance use? Are any of these stereotypes based in scientific data? Explain.

Break-Out Discussion #3:

Does psychopathology even exist? During the post-World–War-II period, as pharmaceutical

companies began to provide medications to control or even cure previously untreatable

disorders, psychiatry was left behind. It had few supported treatments and was viewed by many

as an unwanted stepchild of medicine. In response to this crisis, psychiatry had to reinvent itself

to appear as much of a science as the other specialties in medicine. Panels of experts spoke at

length about the glories of the medical model of psychiatry and were touted as experts in their

century. In the early days of psychiatry, depression or schizophrenia did not have the same

lifelong disabling prognosis that it does in the era of modern pharmacotherapy (Whitaker,

2010). The pharmaceutical revolution did not cause the state hospitals and asylums to open

their doors and discharge thousands of patients back into the community; rather, it was the

introduction of Medicaid and Medicare programs in 1965 that did so. These programs provided

for the reimbursement for the care of the chronically mentally ill in community nursing homes

but not in state hospitals or asylums. Thus, the patients were discharged to community nursing

homes, where their care was paid for through Medicare and Medicaid (Whitaker, 2010).

The purpose of any professional medical organization, Whitaker (2010) noted, is to increase the

profits of practitioners in that organization. This creates a situation in which (a) pharmaceutical

companies produce a wide range of compounds that affect the function of the brain, (b) the

public (and to a large degree the medical community) has been educated to believe that these

psychopharmaceuticals are effective, (c) the pharmaceutical industry claims that these

It might be argued that the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)

(American Psychiatric Association 2013), like its predecessors, helped to define the various

forms of mental illness, helping to legitimize psychiatry.

Questions

1. Is there a conflict of interest in this process? Why or why not?

2. Do you agree with the author’s perspective? What experience or evidence do you have to

support your argument?

References

will “mature out” of this condition each year, the result being that for many individuals ADHD

continues well into adulthood.

Saul (2014) argues persuasively that ADHD is frequently misdiagnosed. In his work, he discusses

a number of conditions that can produce ADHD-like behaviors in children that are rarely

considered when a health care professional is making the differential diagnosis. If the cause of

these AHDH-like behaviors is misdiagnosed, the treatment is likely to be ineffective. In his book

he argues that the diagnosis of ADHD should be one of exclusion, in which these other

conditions are ruled out before the possibility of attention deficit hyperactivity disorder is

considered

Conduct disorders: A childhood condition marked by behavioral dyscontrol, acting out

behaviors, and sometimes poor academic achievement in a child of normal intelligence

Oppositional defiant disorder: A behavioral disorder in which a child demonstrates temper

outbursts, actively refuses to comply with rules, and engages in annoying behaviors far in excess

of what one would expect from the child on the basis of chronological age. There is an enduring

pattern of negativistic, hostile, and defiant behaviors involving violations of social norms or the

rights of others

Schizophrenia: A disorder that is often characterized by difficulty understanding what is

imagined from reality, speech or behavior that may be unusual, often showing withdrawn

behaviors, and difficulties with typical daily activities

Personality disorders: Disorders characterized by inflexible patterns that significantly impact

relationships with others on a long-term basis

Antisocial personality disorder: A disorder characterized by inflexible pattern of

manipulating/exploiting others, including possibly violating others’ rights, which shows a

significant impact on relationships with others on a long-term basis

Borderline personality disorder: A disorder characterized by instability in relationships, sense of

self, and emotions, that significantly impacts relationships with others on a long-term basis

Serial treatment approach: A treatment approach that focuses on treating the most serious

issue until that condition is stabilized, and then the client is transferred so that the other

disorder(s) might be addressed

Parallel treatment model: A treatment approach that focuses on treating the issues

simultaneously, in different sections of the facility, but without a team approach

LO/STANDARDS CORRELATION CHART

A-head

Standard—CACREP

Definitions

25.1:

Understand

and explain

what

constitutes

co-occurring

disorders of

SUDs and

other mental

1a: history and philosophy of the

counseling profession and its specialty

areas

3d: theories and etiology of addictions

and addictive behaviors

Etiology of Co-Occurring

Disorders

25.2: Identify

the causal

considerations

for co-

occurring

disorders

3d: theories and etiology of addictions

and addictive behaviors

Clients with Co-Occurring

Disorders: A Diagnostic

Challenge

25.3: Consider

the diagnostic

challenges of

determining

accurate

diagnoses

when co-

occurring

disorders are

present

3d: theories and etiology of addictions

and addictive behaviors

Why Worry About Clients

with Co-Occurring

Disorders?

Scope of the Problem

25.4:

Understand

the scope of

the problem

of co-

occurring

disorders

1e: advocacy processes needed to

address institutional and social barriers

that impede access, equity, and success

for clients

2h: strategies for identifying and

eliminating barriers, prejudices, and

processes of intentional and

unintentional oppression and

discrimination

3d: theories and etiology of addictions

and addictive behaviors

Psychopathology and Drug

of Choice

25.5: Consider

the

relationship

between drug

of choice and

psychiatric

diagnosis

3d: theories and etiology of addictions

and addictive behaviors

Problems in Working with

the Client with Co-

Occurring Disorders

25.6: Review

the struggles

that may be

encountered

with co-

2h: strategies for identifying and

eliminating barriers, prejudices, and

processes of intentional and

unintentional oppression and

discrimination

and addictive behaviors

occurring

disorders

Treatment Approaches

with Clients with Co-

Occurring Disorders

25.7: Identify

current

treatment

approaches to

working with

those with co-

occurring

disorders

3d: theories and etiology of addictions

and addictive behaviors

5a: theories and models of counseling