SAMHSA TIP 42 Treatment of Co-Occurring Disorders Part 5 | Addiction Counselor Exam Review

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com counselortoolbox you hey everybody and welcome to Treatment of Persons with Co Occurring Disorders based on SAMHSA tip 42. And this is part five. So we're gonna keep plugging through this treatment improvement protocol. If you haven't been with us through the other parts, remember you can always Download the entire Tip 42 and let's see, I have a copy of it here. It's a big boy, you know, few hundred pages, but you can download that for free from SAMHSA@store.samsa.gov so let's get started. Today we're going to be talking about guidelines for working with a client who has a co occurring disorder. We're going to talk about developing and using a therapeutic alliance, maintaining a recovery perspective, how how to manage countertransference and monitor psychiatric symptoms, how to use supportive and empathic counseling, employ culturally appropriate methods, increase structure and support, provide motivational enhancement, design contingency management, use cognitive, behavioral and relapse prevention techniques, repetition and skills building to address deficits in functioning and finally, how to facilitate client participation in mutual self help groups. Sounds like a lot. So let's get started. So the first thing we need to do, whether it's mental health or substance abuse, we know this from Counseling101 is to develop and use a therapeutic alliance to engage the client in treatment. With a lot of clinicians who are working with people with co occurring disorders, it's important to remember that the background training of the clinician may impact the therapeutic alliance. So for example, if the person was trained in mental health, they may be uncomfortable working with substance abuse. If they're trained in substance abuse, they may not know how to work with mental health. So difficulties in developing this therapeutic alliance may be impacted by the counselor's discomfort with mental health or substance abuse issues, usually just due to a lack of experience, training or mentoring. These are things that can be adjusted and addressed. Clinicians who experience difficulty forming a therapeutic alliance should consider if it is related to the client's difficulties. You know, you're just the client is struggling. Maybe they have antisocial personality disorder, maybe they have uncontrolled schizophrenia and it's harder to develop a relationship. You know that that could be one. It could be due to the clinician's limitation in experience and skills. It could be due to demographic differences between the clinician and the client and this could be cultural, like race and ethnicity. It could be socioeconomic status, it could be education level. I mean, by the time we get to the point of being licensed therapists, most of us have a master's degree and a lot of the clients we're working with. So it's really important to stay away from jargon and to talk to the person like they are your friend, not like they are your client. You don't need to sound super smart and important. You need to sound supportive and empathic. Wow, can't talk today. Our gender can also impact the therapeutic alliance. You know, some people are more comfortable with women, others with men. There could be some transference issues going on, who knows? And our age, our age can be because if you're working with a client who's significantly older than you are, they may feel like, you know, what does this person that's the same age as my grandchild really know. They could also be reluctant to develop a therapeutic alliance because your experiences are just so different and they don't know how to relate to you. So that could be causing problems. And the issues could also involve countertransference. And that is the clinician's reaction toward the client, either based on client characteristics or diagnosis or, you know, who knows what. So you need to check it and say, you know, what is really causing the breakdown in us being able to form a therapeutic alliance. And one thing the book didn't mention that I'll throw out there too, is the clinician's approach. And some of us are more, you know, kind of to the point, cognitive behavioral, this is what's going on. And other people tend to be more passive and humanistic, you know, touchy feely, if you will. And different people prefer different styles. So it's important to talk with the client about what works for them and what feels most comfortable. We need to be able to demonstrate an understanding and acceptance of the client. And you know, we don't want them to feel like we are pitying them. We want them to feel empathy. And the best example that or analogy that I've ever been told is imagine there's this guy that is stuck down in a well and it is cold and it is dark and it is wet and the sun's going down. And he's like, I'm never going to get out of here. Well, sympathy is leaning over the edge of the well and going, wow, sucks to be you. Must be cold down there. You know, empathy is if you strap on that rappelling gear and go down there. So you're experiencing it with him now. You can still pull on the rope and get back out with your own rappelling gear. But empathy is really walking in that client's shoes. Not looking down, going, well, that must really be awful. We want to help the client clarify the nature of his difficulty. What brings you here? What are the symptoms? What makes it worse? What makes it better? Clients generally have an idea or a guess about what might have caused it. Indicate that you and the client will be working together and communicate to the client that you will be helping him or her help him or herself. I usually start out by saying, you know what? I've been doing this for a long time. But you have been living in your own skin a whole lot longer than I have. I've known you for four minutes. You've been living in your skin for 40 years. So you're the expert on you. I'm the expert on techniques and tools. So let's work together, and you can tell me what works and you can tell me what doesn't. I won't get my feelings hurt. We need to express empathy and willingness to listen to the client's formulation of the problem. Assist the client in solving some external problems directly and immediately. So you know, what brought them there, and what is the most pressing thing in their mind that needs to start changing, and what can we do to help facilitate that. This will foster positive momentum and hope for positive changes. Don't let clients walk out of that assessment without some sort of activity, something to do before the next session that will help them make positive movement forward, even if it's just keeping a baseline journal of what's going on. If they feel like they're doing something, it will encourage hope and momentum. Consumers with mental disorders may see recovery as the process of reclaiming a meaningful life beyond the mental disorder or with symptom control and positive life activity. So a recovery perspective doesn't necessarily mean abstinence. It means creating a rich and meaningful life, as the client defines it, with whatever disorder they happen to have. You know, if a person has schizophrenia, okay, you know, we're not going to be able to make that go away, but we can help a person with schizophrenia have a rich and meaningful life. So that's what we're talking about. While recovery has many meanings, generally it's recognized that it does not refer solely to a change in substance use, but also to a change in unhealthy ways of living. So with substance use or mental health, you know, unhealthy ways of living, like using Too much caffeine or nicotine, not getting enough sleep. You know, things that make you vulnerable to stress and anxiety and exhaustion will contribute to depression and anxiety and anger and potentially trigger substance use. So we want to encourage people to embrace a recovery lifestyle, which means living healthfully. That's all it means. The recovery perspective has two main features. It acknowledges that recovery is a long term process of internal change. You know, there's only so much we can do externally. The person has to really have this internal change where they start feeling better about themselves, more confident, develop new skills. And it's recognized that these internal changes proceed through various stages. You know, the infancy stages and then they're more solidified and then they are, you know, actually usable. Think about when you go to a conference and you learn a new therapeutic technique or skill. You know, you learn it at the conference and you're like, wow, this is a really cool skill. This is awesome. And the first time you go into a treatment session, you go back to your own way of doing things. The reason that happens a lot of times is because we are not solidified, if you will. We haven't mastered that technique. So we go back to what we know. Until we've practiced it enough that it becomes second nature, we're probably going to have to really force ourselves to use that new technique. The same thing with this recovery lifestyle. It's easy to go back to the old way of doing things. So people are going to have to be encouraged to identify one or two things they want to change, change those, get it? So those things are easy, they're second nature, and then change a couple more things. The recovery perspective assesses the client's stage of change. And we're going to talk about motivational enhancement. But for more on that, there are videos on motivation on allce.com YouTube or you can go to the SAMHSA website and download TIP 35. That's Treatment Improvement Protocol 35. But back to the recovery perspective. We need to ensure that the treatment stage is consistent with the client's stage of change. So if the client is in pre contemplation, which means they don't think they have a problem, then asking them to do in depth activities to change are kind of futile because they don't think they need to change. So why are they going to do those activities they're in pre contemplation? We need to have them doing activities that can help them develop discrepancy between how they define a rich and meaningful life and what they're currently doing. We want to use client empowerment as part of the motivation for change. We want to help them how they can achieve their goals. This is not about doing what I want them to do. This is about helping them do what they want to do to have a rich and meaningful life. And we do this partly by fostering continuous support and providing continuity of treatment. If they are working with multiple treatment providers, we need to help make sure that everybody's on the same page. And we need to recognize that recovery is a long term process. Even small gains, or maybe more importantly especially small gains, should be supported and applauded. You know, every step is really important. When your kids were growing up, you didn't say, well, you know, I'll give you a pat on the back once you're, you know, walking on your own. No, when they started scooting, you were like, oh, yay. And then they started crawling at, oh, that was awesome. And then they pulled themselves up on furniture and we were applauding every small step along the way. We were applauding them for. And we forget to applaud ourselves and we forget to applaud adults for the small things, which means that they don't give themselves credit for the small things. So it's really important to applaud every single step along this path because it's hard. As clinicians, we do need to manage countertransference and it's understood now that countertransference is part of the treatment experience for clinicians. We're going to experience it. We're vulnerable to the same feelings of pessimism, despair, anger and the desire to abandon treatment as the client. And most of us, if you've been working with clients for a while, have been there at one time or another, you just kind of throw your hands up in the air and you're like, just, I don't even know what to do next. And that's when we need to seek consultation. That's also when we need to be authentic with the client and validate the fact that if you're feeling pessimistic and angry and frustrated, they're probably feeling that plus times 10. So it's important to be authentic with the client. You don't want to say, well, I don't think you can get better because if you do that, you're going to foster a self fulfilling prophecy. You need to maintain that therapeutic optimism and believe they can. It's just a matter of backing up and going, okay, what did we miss? The clinician needs to be aware of strong personal reactions and Biases toward the client for any reason and the clinician should obtain further supervision. Where countertransference is suspected and may be interfering with counter. I remember working with a group of involuntary consumers at one point and you know, they were all court ordered and none of them wanted to be there. And of course, you know, this was my first job out of college. So I didn't know the whole motivational interviewing and stages of change thing. So they were there, they didn't want to change, and I was trying to teach them how to change. And of course that was falling flat. And I went in and I talked to my supervisor because I was like, I don't know how to engage these people. And he said, you watch Star Trek? I said, yeah. He said. And he called out the name of the episode, I can't remember it now, but the episode with the Borg. He said, show that to them. Okay. And so I showed it to them. And he was a big one for showing movies to communicate ideas. We use Pinocchio and the wizard of Oz and lots of other things. But so I showed it to them and basically the take home message was resistance is futile. They were all on probation, they were all court ordered. In order to get off probation, they had to complete our groups. So what mutually agreeable goal could we work towards? And generally the mutually agreeable goal was getting them through the 10 weeks. But I had certain stipulations. For me to pass them, they had to have clean urines, they had to be on time, they had to participate those sorts of things. So we started having this understanding and then I switched my approach. Instead of trying to teach them how to not use substances, I started asking them about the stresses in their life and started providing practical tools for them to start addressing some of the things that might be triggering a desire to use. So we do need to seek consultation because a lot of times an objective set of eyes or somebody with more experience will have really awesome suggestions. We should have formal periodic clinical supervision to discuss countertransference issues with supervisors and discuss issues at clinical team meetings. You know, it's always good to consult. We do need to monitor psychiatric symptoms. If they're in a substance abuse program or in a mental health program, it doesn't really matter. We got to monitor them. One of the ways that I did this because I've done a lot of group work and worked in a lot of IOP programs and it's hard to do a mental status exam on every single person, every single contact in group. So one of the things that I would have people do is fill out a check in sheet or when they got there about how they were doing, what their plans were for the week, any problematic symptoms they were having, yada, yada, yada. During the break I would review the check in sheets to make sure that nobody was having any glaring problems and they had plans for the future and that sort of thing. I was also able, during group I had their sheets, I was also able to make eye contact with them, note how they were presenting, whether they were flat or excited or sleepy or whatever in order to add to that symptom assessment. But that way for every person in my IOP groups, I was getting a brief mental status and safety exam every single day. You do want to document any changes in symptoms for the better or for the worse because remember, documentation is so important. Monitor medication compliance and side effects. And I had this on the check sheet as well. If they had changed their meds, if they were taking their meds, problems getting their meds, and most of my stuff was yes, no check sheets, yes, no check blocks, so they didn't have to do a lot of writing. And the check in sheet took less than five minutes. And it's important to consult with physicians and other treatment providers on the multidisciplinary team. When working with people with co occurring disorders, we need to use supportive and empathic counseling. That's kind of true with anything. We want to encourage non judgmental collaborative relationship and communicate respect and acceptance for the clients and their feelings. We don't have to agree with them, but, but we do want to respect that those are their feelings. We need to be a supportive and knowledgeable consultant, but that doesn't mean we know everything. You know, my clients teach me stuff every single day and I love that. So it's important for us to be able to know what we know and say. We don't know if we don't know, but it's, you know, I don't really know the answer to that, but let me find out for you and I'll tell you tomorrow and then keep that promise. So be supportive. Provide knowledge that you have. If you don't have some knowledge, find it and bring it back. Compliment and reinforce behaviors whenever possible. Showing up on time, identifying if a client seems to be in a better mood, if they're more participatory in group, if they've stayed clean for an extended period of time, Anything you can find to complement and reward that supports recovery, do that. Try to compliment and reward every single client at every single meeting. Listen Rather than tell. More often than not, you know, clients can solve their own problems. They're smart people, they're just kind of stuck. So we want to listen to what they're saying and use Socratic questioning to, to get them to find their own answers. So if they're saying, you know, I've been feeling really fatigued and depressed and I might say, well, tell me about what's changed that triggered these feelings. And they'll tell me maybe they started taking a new medication. And I said, okay, so have you taken that medication before? They say no. And I said, okay. Have you talked to your doctor about the side effects that you think you might be experiencing? You know, we can go from there, but I'm not going to tell them, well, it sounds like this, this and this. So you need to do whatever. I'm going to walk them through my thinking process to help them see how I arrive at my conclusions. But I want them to do it. We want to gently persuade clients to do things with the understanding that the decision to change is theirs. You know, I can provide my 2 cents, what I think is going to be really helpful. But otherwise they may have to make the decision about whether they're going to do it. We want to continue to provide support throughout the recovery process and navigate the tension that we will experience between being empathetic and supportive and having to handle issues like minimization, evasion, dishonesty, and denial. Now TIP 35 treatment improvement protocol 35 from SAMHSA has an entire chapter on rolling with resistance. So I'm not going to go through that here, but they do give a lot of great examples for how to handle these things in a supportive, empathic way. We need to employ culturally appropriate methods, which means don't make assumptions about a client based on culture. And you're like, well, I thought you just said culturally appropriate. Knowing about a culture is important because it gives you a foundation from which to build. For example, when a five year old walks into my office, I make certain assumptions based on what I know in general about 5 year olds. But every 5 year old is different. This one could be gifted from for all I know. So I don't want to make assumptions necessarily about that five year old until I get to know him or her. But my knowledge of 5 year olds in general gives me a starting point so I can start to try to figure out things. Same thing about culture. If you meet somebody who's American, you know, you have some ideas about what they may believe, what they may do, what their you know all that kind of stuff. But we know that all Americans have very, very different points of view. So we can't make any broad assumptions about any cultural group culture. Cultural awareness just lets us have a foundation from which to start learning about a client in treatment. Some cultures may tend to somaticize symptoms, which means make them physical and expect the clinician to relieve these physical complaints. Some clients may be offended by too many probing or personal questions, especially early in treatment. And this, you know, older people can get very offended, as well as people from other ethnic cultures, etc. Different cultures have different views of the client's role in the family and, and its cultural significance. So, you know, we need to take into account who makes the decisions in the family and how does this person fit in this family unit. And different cultures have different perceptions of substance abuse, mental disorders and healing. So what causes them, why the person has them, whether they're bad or not, and how to address them. So we do need to be sensitive to, to that as well, which is why it's important when you first meet a client to say, tell me about the problem. What do you think caused it? What do you think might help fix it? Because we want to understand their worldview. We need to increase structure and support. Because free time is a trigger for substance cravings and a negative influence for many individuals with mental disorders. People with depression who have too much free time, or people with anxiety who have too much free time can get sick, stuck thinking about unhelpful thoughts and toiling over them. Not everybody needs to be going all the time. You know, you can watch a movie, you can, you know, go on a walk. There are a lot of things you can do. But it's important that people have some activities scheduled, a variety, you know, most of the time in order to avoid spinning around, going, I'm really bored, I don't know what to do. And then they start, their mind starts to wander and it can wander into unhelpful places. We need to help people develop strategies for managing free time, including structuring the day to have meaningful activities and avoiding activities that can be risky. If you're someone who is recovering from substance use, you know, going to a bar is probably going to be risky. So we want to make sure that they're avoiding those things. If you are somebody who is struggling with compulsive pornography viewing, being around an open wi fi could be a dangerous situation. So you want to plan for those things. Daily activities should also include opportunities for receiving support and encouragement from significant others. So Being in isolation can also be detrimental. Not everybody has a lot of support, like, tangible. Right here. People can get support on the phone, via the Internet, at meetings. There are a lot of different ways to make sure people are getting the support they need. Provide motivational enhancement. This approach involves accepting a client's level of motivation, whatever it is the only possible starting point for change. If they're not motivated, that's where you start. If they are motivated, okay, great, we're starting way ahead of the game. But that is the only possible starting point. We need to express empathy, recognizing that ambivalence is normal. People do things because there's a benefit. So if they were using drugs, all right, we need to understand why they were using drugs. What was the benefit to using drugs, and what are their apprehensions or their worries about change? For depression, that's a little harder to find the benefit for. But the ambivalence about change for a lot of people is that maybe they've had a period of remission before, and then they've had another depressive episode, and it was so oppressive that they're afraid that if they start feeling better again and then relapse, that they won't be able to tolerate it. So there are a lot of things that we need to look at and address. In increasing motivation, we need to develop discrepancy between present behavior and important personal goals and values. You know, this is what I talked about in tip 35, and that includes rolling with resistance. Don't argue for change. We're past the days of break them down and build them up. We want to recognize that resistance needs to be addressed, but not directly opposed and saying you're wrong or you're lying or you're contradicting yourself. We need to invite new perspectives about behaviors and situations and recognize that the client is the primary resource in finding answers and solutions. And if you don't get anything else from this slide, resistance is a signal to respond differently. It means what you're doing ain't working, so you need to back up and go, okay, if this client is resistant, then I'm missing something and I need to figure out what it is. Think about a kid that won't go to bed, and you think the child is just being resistant. They want to stay up and watch tv. Well, that could be it, but more like, you know, if you delve deeper, you might find out that the child's been having nightmares and thinks there's monsters under the bed. So what you were missing was the fact that the child hadn't told you about the monsters he thought were under his bed. So we do need to back up and go, okay, what is prompting this person to do this? Why is this behavior that they insist on continuing more rewarding than what I want them to do? And we want to support self efficacy. It's the client, not the counselor, that's responsible for choosing and carrying out change. We can provide them a menu of options. It's like going to a restaurant. We can provide them a menu, but they're the ones who have to order and then eat the meal. We need to design contingency management techniques and these work really well, but they're really hard to design super well. So you need to pick and choose. Contingency management principles for substance abuse treatment have been structured around four central principles. The clinician arranges for regular drug testing to ensure the client's use of the targeted substance is detected. The clinician provides positive reinforcement when abstinence is demonstrated. The clinician withholds the designated incentives when the substance is detected. And the clinician helps the client establish alternate healthier activities. Well, that's for substance abuse, if you use it for co occurring disorders, if you use it for mental health. We want to arrange for regular check ins about the client's behavior. What are they doing towards their treatment plan, what are they doing in terms of a recovery lifestyle? We want to provide positive reinforcement for adhering to their treatment plan. We want to withhold the designated incentives when the client has just not done anything that they were supposed to do on their treatment plan and help them establish alternate healthier activities. So again, it's really very much the same. Contingency management techniques are best applied to specific targeted behavior such as drug abstinence treatment plan compliance, clinic attendance, or attaining particular goals. Different reinforcers you can use include cash such as discounts off of their treatment sessions, vouchers for things. Sometimes, especially if you work at a nonprofit, you can get movie tickets and stuff, donated prizes, retail items and privileges. When I was working for the adolescent boys unit, they would earn points based on their behaviors and at the end of the week they would be able to cash those points in and they could go to the closet and there were, you know, there was junk food and you know, other things they could get that the boys found rewarding and they were able to choose what went into the, what went into the closet. Or they were able to choose privileges such as extra video game time. And this worked really well for that particular unit. Okay. When designing a contingency management program, choose A behavior, and it needs to be observable and measurable, specific, realistic and time limited. You know your smart goals. Choose a reinforcer and you can look at external reinforcers like privileges and tangible things like prizes. But also identify intangible rewards such as flexibility in their appointment times or the groups they come to, or increased freedom like more smoke breaks or passes to go off campus. If it's a residential facility, use behavioral principles for monitoring and reinforcement. That means you've got to figure out a way to monitor what's being done and what's not being done in an effective way and reward frequently. And you've got to choose your schedule of reinforcement that works best. Generally, initially a fixed ratio works best. So if they do this for every time they do something or every three times they do something, they get a reward. Eventually you can, you can change that reward schedule. Prepare a behavioral contract, being specific and considering alternate interpretations. You don't want people to have a way around it to try to get a reward when they don't do what they're supposed to. Implement the contract and ensure consistent application by devising methods in order to ensure that staff knows how to implement the contract and follow procedures and continually remind the client of behaviors and their consequences, their account balance, so to speak, and what's required to obtain a bonus. And we would do this a lot of times with the adolescent boys when they were in school, they had school at the facility, and if they weren't getting their work done or they were having a difficult day, the teacher would pull them aside and remind them that, you know, in order to earn their points for the day, they had to do X, Y and Z. Use cognitive behavioral techniques. Well, we're familiar with those, but what's the point? Well, cognitive behavioral assumes that substance abusers and people with co occurring disorders may be deficient in their ability to cope with interpersonal, social, emotional and personal problems. Now that sounds really ugly, but basically we're saying the person doesn't have effective skills to deal with life on life's terms. That's like trying to, you know, screw in a screw with a butter knife instead of a screwdriver. It doesn't work near as well. Or worse yet, trying to do it with your fingernail. Been there. I digress. In the absence of these skills, problems can be viewed as threatening, stressful, and potentially unsolvable. I've started watching the reboot of MacGyver lately and you know, this is kind of what it reminds me of in cognitive behavioral. You know, he runs into these weird Wacky problems. And he finds avant garde ways of approaching them and solving them. So cognitive behavioral enhances problem solving skills as well as reduces cognitive distortions like all or none thinking and personalization. And we also need to teach grounding and mindfulness to help people who get upset de escalate themselves. And you know, sometimes you call this distress tolerance or emotion regulation or whatever you want to call it. And mindfulness helps them be more aware of how they're feeling so they can address issues before it's a full blown crisis. And almost. Last but not least, relapse prevention techniques. We need to remember that relapse is a breakdown or setback in a person's attempt to change or modify any behavior. So it's going back to the old way. Whether it's quitting smoking or exercising, or, you know, just being happy, it's a setback. So if somebody who is experiences periodic major depressive episodes, asymptomatic, and they start having a major depressive episode, you can consider it a relapse because they've returned to a prior level of functioning. A key factor in preventing relapse is to understand that relapses are preceded by triggers or cues. They don't come from out of the blue people. We need to be cognizant. And this is where mindfulness comes in too. If you look at any relapse, look back six months or, you know, if they haven't been asymptomatic that long, look back to when they became asymptomatic and then follow it and see what changed. Did they start, you know, not eating well? Did they start not sleeping enough? Did they take on a new job? Did they start having fights with their significant other? What changed that indicated that they might be going back to old behaviors and old ways of thinking. Lapses are single episodes or brief returns to that old behavior, drug use, depression, whatever, and they're an expected part of overcoming problematic behaviors. It's not a signal of failure. You know, sometimes if, for example, somebody's struggling with depression, substances are easy to use an example. So I'm trying to stick with the mental health aspect of it. If somebody's recovering from depression and something happens, they may get depressed. But if they can experience that clinical depression, that, you know, oppressive depression for a day or a weekend as opposed to two weeks, okay, so that's positive movement. So let's see what, what led up to that depressive episode and what skills or tools do you need to prevent that from happening in the future? Every lapse is A learning opportunity. In relapse prevention, we explore and identify relapse warning signs. For example, stopping going to meetings or dropping out of counseling, or not contacting supportive people with whatever your relapse warning signs are and triggers. You know, sometimes it's a holiday, sometimes it's a time of day, sometimes at people, places, things. What are some of the most common triggers for that person for their substance use or their mood issues. Then we need to help them develop a broad repertoire of cognitive and behavioral coping strategies to handle high risk situations and relapse warning signs. And I always recommend that clients develop an emergency card that they keep with them. And you know, with the advent of mobile devices, a lot of times it's just on a notepad document on their mobile device. But when you're in a high risk situation or when they are, or when they're starting to have relapse warning signs, they're in a little bit of a crisis, so they're not thinking as clearly. An emergency card has all the emergency plans laid out ahead of time, so there's no thinking involved. It's following the steps. We want to increase their ability to make lifestyle changes to decrease vulnerabilities. And vulnerabilities are things that make, you, guess what, more vulnerable to stress, anxiety, depression, anger, substance use. So what things do it for your client? For me, lack of sleep is a huge vulnerability. If I don't get enough sleep, I am a great big old cranky pants and I tend to see the negative and tend to get irritable. It's just ugly. So vulnerabilities are things that clients do have the ability to prevent. It means shoring up whatever is going on in their life to make sure they're living as happily and healthfully as possible. We want to increase healthy pro social activities. It can be going to the library, it can be going on a nature walk. If the person is an introvert, it can be going to the gym. You know, I like to go to the gym where I'm around other positive, healthy people. Whatever it is for that person, encourage them to do more of it. Prepare for interrupting lapses so they don't end in a full blown relapse. You know, if somebody starts, has a lapse and they take a drink, for example, or they have a lapse and they're depressed for a day, okay? Remind them that that's a normal part of recovery and they have an emergency card. So and strategy that they can follow so they can prevent a full blown relapse. But if a full Blown relapse occurs. It's important to resume or continue relapse prevention skills in order to renew commitment to recovery. This is not the time to give up. This is the time to realize that there were some holes in our emergency plan that we need to shore up a little bit. Clients with co occurring disorders often have cognitive limitations, including difficulty concentrating. These limitations can be transient, like right after the detox period. During the detox period they can be persistent as in post acute withdrawal syndrome, which can last for up to a year where there are intermittent periods of symptoms. Or they can be permanent, such as if the person has schizophrenia. We need to be aware of these things. People who are just out of detox or have post acute withdrawal symptoms or even schizophrenia can learn any of these techniques. We just may need to break it down into smaller steps. You know, you don't give them all 15 cognitive distortions in one group and send them on their merry way to apply it. You may give them one and then practice it and do more rehearsal in group and then the next group talk about a different cognitive distortion. So you need more practice, more rehearsal, more repetition, just slow it down a little bit. And finally facilitate client prepared groups. 12 steps, you have dual recovery and double trouble. Those are your two kind of 12 step dual recovery groups, co occurring disorders, groups that people can attend and they are more open to to clients being on psychotropic medications and things like that. People who have co occurring disorders may also choose to go to 12 step meetings like AA or NA and mental health support groups. That's their choice. Or they may choose to go to mental health support groups or Smart recovery if they choose not to go to a 12 step. Smart Recovery again only addresses the addictive behaviors. But a lot of what people learn in Smart recovery are those cognitive behavioral tools that apply to both mental health and substance use. So in summary, to work with people with co occurring disorders, we need to develop a therapeutic alliance and engage them. It's important that we maintain a recovery perspective and address countertransference. We need to monitor their psychiatric symptoms and increase the level of structure and support that they have, provide motivational enhancement that is consistent with their specific stage of change. We can design contingency management techniques in order to enhance certain behaviors. We can use cognitive, behavioral and relapse prevention techniques for both mental health disorders and substance abuse and the way they interrelate. And we can use repetition and skills building to help people who have deficits in functioning, especially cognitive functioning, learn the skills that they need. Finally, it's important that we facilitate client participation in mutual self help groups because we can't be there all the time, nor should we be. That would be fostering a dependence. We want to increase them or encourage them to be independent in their environment of choice. Alrighty everybody, thank you for being with me for this one and I'll see you next Monday. All of us at All CEUS wish you great success on your exam. Once you're certified or licensed, please Remember to visit all CEUs for all of your continuing education needs. We offer unlimited CEUs for $59 for addiction and mental health counselors, social workers and marriage and family therapists. If you're still thinking about becoming an addiction counselor, all CEUs offers the training you need in three formats online multimedia, self study, self study plus live webinars or Face to Face weekend intensives which meet one weekend per month for 12 months. We can even present a training series at your facility. Just email supportlce.com go to allce.com acer that's allce.com acer to learn more.