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Substance Use Disorder Treatment for People With Co-Occurring Disorders: Updated 2020 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2020. (Treatment Improvement Protocol (TIP) Series, No. 42.)
This Treatment Improvement Protocol (TIP) update is intended to provide addiction counselors and other providers, supervisors, and administrators with the latest science in the screening, assessment, diagnosis, and management of co-occurring disorders (CODs). For purposes of this TIP, the term CODs refers to co-occurring substance use disorders (SUDs) and mental disorders. Clients with CODs have one or more disorders relating to the use of alcohol or other substances with misuse potential as well as one or more mental disorders. A diagnosis of CODs occurs when at least one disorder of each type can be established independently of the other and is not simply a cluster of symptoms resulting from the one disorder.
Many may think of the typical person with CODs as having a serious mental illness (SMI) combined with a severe SUD, such as schizophrenia combined with alcohol use disorder (AUD). However, counselors working in addiction agencies are more likely to see people with severe addiction combined with mild-to moderate-severity mental disorders. An example would be a person with AUD combined with attention deficit hyperactivity disorder (ADHD) or an anxiety disorder. Efforts to provide treatment that will meet the unique needs of people with CODs have gained momentum over the past two decades in both SUD treatment and mental health services settings.
An expert panel developed the TIP's content based on a review of the most up-to-date literature and on their extensive experience in the field of SUD treatment. Other professionals also generously contributed their time and commitment to this publication.
This TIP is organized to guide counselors and other addiction professionals sequentially through the primary components of proper identification and management of CODs. The TIP is divided into chapters so that readers can easily find the material they need. Following is a summary of the TIP's overall main points and summaries of each of the eight TIP chapters.
The primary focus of this TIP is co-occurring SUDs and mental disorders, not physical disorders. People with mental illness also frequently develop physical conditions that, like SUDs, can exacerbate or induce symptoms (e.g., HIV, hepatitis C virus, hypothyroidism). However, physical conditions are beyond the scope of this publication and are excluded.
People with SUDs are more likely than those without SUDs to have co-occurring mental disorders. Addiction counselors encounter clients with CODs as a rule, not an exception. Mental disorders likely to co-occur with addiction include depressive disorders, bipolar I disorder, posttraumatic stress disorder (PTSD), personality disorders (PDs), anxiety disorders, schizophrenia and other psychotic disorders, ADHD, and eating and feeding disorders.
Serious gaps exist between the treatment and service needs of people with CODs and the actual care they receive. Many factors contribute to the gap, such as lack of awareness about and training in CODs by addiction counselors, as well as workforce factors like labor shortages and professional burnout.
Failure to routinely screen clients receiving behavioral health services for mental disorders and SUDs creates a problematic domino effect. A lack of screening means a lack of assessment, which results in a lack of diagnosis, which leads to a lack of treatment, which then reduces a person's chances of achieving long-term recovery for either or both disorders. Counselors and other providers can prevent this cascade of negative events by understanding how and why to screen, how to perform a full assessment, and how to recognize diagnostic symptoms of mental disorders and SUDs.
CODs are treatable conditions, and a range of treatment modalities exists that can be implemented across numerous inpatient and outpatient settings. Counselors may need to adapt interventions based on the treatment setting as well as the unique needs and characteristics of clients, including their gender, race/ethnicity, life circumstance (e.g., homelessness, involvement in the criminal justice system), symptoms, functioning, stage of change, risk of suicidality, and trauma history.
People with CODs are at an elevated risk for self-harm, especially if they have a history of trauma. Counselors, other providers, supervisors, and administrators should make client safety a priority and ensure that providers have the necessary training to detect and respond to suicidal thoughts, gestures, and attempts in COD clientele.
Essential services for people with CODs are person centered, trauma informed, culturally responsive, recovery oriented, comprehensive, and continuously offered across all levels of care and disease course.
There is no “wrong door” by which people with CODs arrive at treatment. Counselors and programs should have a range of interventions and services in their “toolbox” with which they can help all clients.
Administrators and supervisors play a critical role in responding to workforce challenges, such as unmet training needs, low employee retention, staff burnout, and low competency in advanced COD management skills. Such workforce matters are directly tied to treatment availability and quality, so these challenges should be taken seriously and addressed actively by all COD treatment programs.
This TIP is divided into eight chapters designed to thoroughly cover all relevant aspects of screening, assessment, diagnosis, treatment, and programming.
This chapter provides a broad introduction to CODs and to SUD treatment for people with CODs. It serves as an outline of the main focus of this TIP. The intended audiences are addiction counselors and other SUD treatment professionals (e.g., psychologists, psychiatrists, licensed clinical social workers, licensed marriage and family therapists, psychiatric and mental health nurses [specialty practice registered nurses]), supervisors, and administrators.
Mental illness is highly comorbid in people with addiction and associated with low rates of treatment engagement, retention, and completion. CODs are linked to numerous negative health outcomes and life circumstances, like elevated risk of homelessness, trauma, and self-harm. To close treatment gaps and ensure that people with SUDs and mental disorders achieve long-lasting recovery, educating counselors, supervisors, and administrators about the prevalence and seriousness of these conditions is essential.
In Chapter 1, readers will learn about:
The appropriate terminology surrounding CODs and COD treatment approaches.
The numerous factors that led to the creation of this TIP update.
The need for this TIP, which addresses CODs and summarizes prevalence and treatment rates, trends in programming, and negative events associated with CODs (e.g., increased hospitalization).
The complicated and bidirectional relationship between mental disorders and SUDs that can make diagnosing and treating these conditions difficult.
This chapter reviews strategies and recommended guidelines for effective COD services. The intended audiences are counselors and other behavioral health service providers, supervisors, and administrators.
Service provision guidelines help safeguard the well-being of clients with CODs and ensure that they receive high-quality, evidence-based care. Counselors and other providers, supervisors, and administrators can take small but powerful steps to increase the likelihood that clients with CODs get the services they need, such as using person-centered approaches, providing comprehensive care, and integrating research into clinical services. These strategies can have a large impact in terms of generating positive treatment outcomes.
In Chapter 2, readers will learn that:
Essential services for people with CODs must be recovery oriented, culturally responsive, and inclusive of clients’ families or support system (including mutual-help and peer recovery supports).
Counselors should ensure that they are providing clients full access to treatments; routine screening and complete assessments; services tailored to clients’ symptoms and stage of change; and services that are integrated, comprehensive, and continuous across treatment settings and disease course.
Administrators and supervisors can increase the odds of clients achieving optimal recovery outcomes by ensuring that providers possess the appropriate basic, intermediate, and advanced competencies and have access to training opportunities—both of which are essential if counselors are to confidently and competently manage CODs.
Integration of evidence-based care into COD programming increases the chances of clients receiving effective therapies that improve their odds of lifelong recovery.
In addition to establishing essential services (e.g., screening and assessment, onsite prescribing, psychoeducation, mutual support), program developers and administrators should engage in ongoing assessment to ensure that their organization has the capacity to serve clients with CODs and is faithfully following service implementation guidelines.
This chapter describes the screening and full assessment process for identifying people with and at risk for mental illnesses and SUDs. The intended audiences are addiction counselors and other providers, supervisors, and administrators.
To reduce gaps in treatment access and provision, counselors must appropriately engage in timely, evidence-based screening and assessment. This multistep process is designed to help counselors thoroughly explore all areas of clients’ history, symptoms, functioning, readiness for treatment, and other service needs so that treatment decision making is fully informed and tailored to each individual's clinical situation. In short, without timely and effective screening and assessment, the chances of clients receiving appropriate care decrease significantly.
In Chapter 3, readers will learn that:
All SLID treatment clients should be screened at least annually for SUDs, mental disorders, risk of harm to self and others, functional impairment, and trauma.
Screening is an informal yet highly effective process of initially identifying people with CODs who may ultimately need formal treatment or other services.
A full biopsychosocial approach to assessment helps counselors thoroughly explore clients’ physical, substance use-related, psychiatric, social, educational/vocational, and family histories for indications of addiction, mental illness, or both.
Numerous screening and assessment measures are validated for use with people who have mental disorders and SUDs to help counselors make diagnostic determinations and guide decisions about referral for further evaluation (e.g., psychiatric, medical).
Assessment is more than just administering questionnaires; it includes exploring clients’ risk of harm to self and others, trauma history, strengths and supports, cultural needs, and readiness for change.
When performed correctly, a full assessment should help build rapport between the counselor and the client and foster shared decision making for treatment or other services.
This chapter will help readers learn the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013) diagnostic criteria for mental disorders that commonly occur alongside SUDs, as well as symptoms of substance-related disorders. The intended audiences are addiction counselors and other providers, supervisors, and administrators.
Not all addiction counselors are permitted to diagnose mental disorders (regulations vary by state). However, all addiction counselors and other providers should become familiar with the diagnostic criteria for mental illnesses that commonly co-occur with SUDs so that they can refer clients for a full psychiatric evaluation (if needed) and tailor treatment and services accordingly.
Someone with CODs will sometimes need treatment approaches that differ slightly from those for a person who has either an SUD or a mental disorder but not both. Counselors and other providers must understand how to recognize signs of highly comorbid mental illnesses, know how these disorders affect treatment decision making, and recognize the trauma history and risk of self-harm associated with these disorders. Equally important, clinicians should learn how to differentiate independent mental disorders from substance-induced mental disorders, as the latter are often treated differently than the former (if they require treatment at all, given that many substance-induced conditions remit once substance use has ended).
In Chapter 4, readers will learn that:
Mental disorders that most commonly co-occur with SUDs include major depressive disorder, persistent depressive disorder (dysthymia), bipolar I disorder, PTSD, borderline and antisocial PDs, schizophrenia and other psychotic disorders, generalized anxiety disorder, panic disorder, social anxiety disorder, ADHD, anorexia nervosa, bulimia nervosa, and binge eating disorder.
Although less common in the general population, all of these mental disorders are likely to be seen by counselors working in SUD treatment settings.
Counselors may need to treat SUDs in the presence of a mental disorder in slightly different ways than they would treat addiction without comorbid mental illness. The way in which treatment proceeds can vary depending on the mental illness.
Nearly all CODs carry an increased risk of suicide, and counselors are obligated to thoroughly assess and respond to a current report or history of self-harm.
Trauma is ubiquitous across CODs and needs to be managed using trauma-informed techniques.
Many mental disorder symptoms mimic symptoms of SUDs, and vice versa. Being able to differentiate between the two is a core competency.
Similarly, many mental disorders may appear in the context of substance intoxication or withdrawal. Treatment approaches for these substance-induced disorders can differ from the treatment of independent mental disorders, so counselors must recognize the difference between the two.
This chapter summarizes the importance of establishing a therapeutic alliance with clients who have CODs and discusses how providers can do so. The intended audiences are addiction counselors and other providers, supervisors, and administrators.
Good provider-client rapport can enhance treatment outcomes and completion and is a cornerstone of providing high-quality care. When working with clients who have CODs, counselors and other providers should be aware of clinical factors and concerns—like confidentiality matters, use of empathy, and cultural responsiveness—that can make the therapeutic relationship more successful and increase the chances that clients will achieve and maintain recovery.
For co-occurring mental disorders, like depression, anxiety disorders, PTSD, and SMIs, specific treatment strategies (e.g., selecting appropriate therapeutic interventions; structuring clinical sessions) can improve client adherence and outcomes. Counselors and other providers should learn these techniques and approaches before treating individuals with CODs so that they are prepared to best respond to clients’ needs and help establish good therapeutic alliance from the outset.
In Chapter 5, readers will learn that:
Rapport building is essential in helping clients achieve and sustain positive behavior change.
Working with people who have CODs can be challenging given clients’ feelings of mistrust or shame. CODs can be complex and lifelong, causing a range of difficulties for people living with them.
A successful therapeutic alliance is built on empathy and support and by providing services fully responsive to all clients’ needs.
Relapse prevention and skill building are critical components of comprehensive care.
Culturally sensitive techniques can help build rapport and trust between counselors and clients from various cultural, racial, and ethnic backgrounds.
For clients with depression, cognitive-behavioral techniques, behavioral activation, and medication evaluation are core services.
Clients with anxiety may need treatments tailored to their anxiety diagnosis, such as individual therapy for a client with social anxiety and fear of group settings.
Safety and trust are cornerstones of effective treatment for people with trauma and PTSD.
People with SMI may have cognitive limitations that undermine treatment participation and adherence and may need help with basic living needs (e.g., housing, employment).
This chapter discusses four populations with CODs who may be especially susceptible to treatment challenges and negative outcomes: people experiencing homelessness, people involved in the criminal justice system, women, and racial/ethnic minorities. The intended audiences are SUD counselors and other providers, supervisors, and administrators.
Although all people with CODs are vulnerable to treatment difficulties and poor outcomes because of the complex and chronic nature of their illnesses, certain COD populations are especially susceptible and may benefit from tailored services. Counselors and other providers need to be sensitive to specific treatment needs of such populations and make adjustments in their assessment, diagnosis, referral, and service provision accordingly.
In Chapter 6, readers will learn that:
CODs are highly prevalent in people who are experiencing homelessness, but several service models exist to help counselors address clients’ behavioral health concerns and their housing needs.
People involved in the criminal justice system are at risk for CODs both during incarceration and after release into the community.
Treatment of CODs among justice system-involved people is important because, if left untreated, CODs can increase their risk of recidivism, rearrest, and reincarceration.
Women are a vulnerable population because of the increased likelihood that they will face trauma, which heightens the occurrence of CODs, and pregnancy/child care-related factors, which can also exacerbate CODs or otherwise affect treatment provision (such as pharmacotherapy).
Although research suggests that COD treatment outcomes for men and women are generally equivalent, women may benefit from gender-specific services in order to stay engaged in (and thus benefit from) interventions.
Compared with U.S. Whites, people from racial/ethnic minorities face significantly greater mental health service and SUD treatment access barriers and are likelier to have negative treatment outcomes.
Counselors and other providers should learn how to provide culturally responsive assessments and treatments or other services to meet the unique needs facing clients of diverse racial/ethnic backgrounds who have CODs.
This chapter is an overview of treatment models and settings for clients with CODs. It will help counselors and administrators offer empirically supported care for this population. The intended audiences are counselors and other providers, supervisors, and administrators in addiction programs.
CODs are complex conditions, and clients can engage in services across a multitude of inpatient and outpatient settings. Counselors and other providers have at their disposal several empirically validated treatment approaches designed to address the full scope of needs of people with CODs, including services to reduce symptoms, increase abstinence, achieve stable housing, and help clients make meaningful connections with resources and networks of support in the community. Although not appropriate for all clients with CODs, pharmacotherapies are a treatment option that, for certain conditions like AUD and opioid use disorder (OUD), can not only improve functioning but also reduce mortality and morbidity. Counselors and other providers who do not prescribe medication for clients with CODs should nonetheless be aware of their uses, side effects, and interactions/warnings so that they can help monitor clients for safety and offer referrals for medication evaluation as needed.
In Chapter 7, readers will learn that:
COD treatment can be sequential, simultaneous (but in parallel), or concurrent (and integrated).
People with CODs face a multitude of individual, logistic, socioeconomic, cultural, organizational, systemic, and policy-related barriers to accessing and using SUD treatment and mental health services. Counselors and administrators play important roles in reducing these barriers and helping clients overcome such challenges.
Integrated care is recommended as a best practice for serving people with CODs.
Assertive community outreach and intensive case management are multidisciplinary approaches that can be easily adapted to integrated settings and thus offer clients comprehensive, continuous care. They can also be adapted to populations vulnerable to CODs and poor outcomes, like people without stable housing and those involved in the criminal justice system.
Mutual supports, including from peer recovery support specialists, are critical because they offer clients information and support from others with a lived experience with mental illness, SUDs, or both. Many COD-specific mutual-support programs are available, and counselors should keep referral information on hand so they can readily refer clients interested in these services.
Providers can offer COD services in many different settings, including therapeutic communities, outpatient addiction centers, residential treatment facilities, and acute medical care facilities.
Pharmacotherapy is often a core part of COD treatment, especially for people with depression, bipolar I disorder, anxiety, schizophrenia/psychotic disorders, AUD, or OUD. Counselors do not prescribe medication, but they should understand what medications their clients are likely to take and the side effects clients are likely to experience so they can offer proper psychoeducation, help monitor for unsafe side effects, and refer clients to prescribers for medication management as needed.
This chapter reviews major issues facing the mental health service and SUD treatment labor force and demonstrates how workforce matters can negatively affect clients with CODs. The intended audiences are supervisors and administrators in SUD treatment.
Projections about the behavioral health workforce suggest that serious gaps will only increase as the number of people entering and staying in the profession is outpaced by the number of people needing those professionals’ services. This trend will continue unless there are interventions to support the growing capacity and training needs of the field. These gaps have resulted in people with CODs having fewer opportunities to access high-quality, evidence-based care across a broad continuum of settings and services. Further, unmet training, education, and credentialing in CODs means that there is an insufficient number of counselors and supervisors who understand the treatment needs of this population and how best to manage their conditions. Ensuring better recruitment and retention of well-trained behavioral health professionals is paramount and will help broaden and strengthen the SLID treatment and mental health services systems.
In Chapter 8, readers will learn that:
This country has a major shortage of mental health and addiction professionals, and the shortage will only continue to grow unless the field uses strategies to increase the size of the workforce and retain current professionals.
Workforce shortages partly account for why people with CODs face challenges in accessing, engaging in, adhering to, and benefitting from services.
Recruitment, hiring, and retention techniques can help programs attract and keep the right candidates while reducing turnover.
Burnout is a major component of turnover and is prominent in these fields because of the complex and challenging nature of the client population.
Many professionals working with clients who have CODs feel uncomfortable or inadequately prepared to offer effective COD services, but better training and active clinical supervision can remedy this.
Supervisors and administrators must ensure that counselors are properly trained if good client outcomes are to be achieved. Numerous training resources are available to assist with this process.
Professional certification and credentialing give counselors and supervisors the necessary skills to provide effective COD services and convey a sense of staff competency and professionalism within an organization.
TIP ORGANIZATION BY KEY TOPIC AREAS OF INTEREST.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
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