Looking Below the Surface: An AMA Exploring Co-Occurring Disorders and Treatment Methods.

Gateway Foundation
Jul 9, 2018

Did you know many people walking into an addiction treatment center have an underlying mental illness? Nearly 40% of patients, to be exact.

SAMHSA defines co-occurring disorders as the coexistence of both a mental health and substance use disorder. For example, a person may have an opiate use disorder, and also have bipolar disorder.

Earlier this year, the Gateway Foundation became the first treatment center in Illinois to achieve the highest ranking for serving patients with co-occurring disorders, as rated by an independent agency. It’s called the Dual Diagnosis Enhanced (DDE) rating. Coming from the Dual Diagnosis Capability in Addiction Treatment index, the DDE rating is granted to programs serving those with co-occurring disorders in a fully integrated manner.

To us at Gateway, achieving DDE simply means we’re best equipped to serve the people who walk through our doors. But we want to extend this care and knowledge to more people. It’s our goal to provide treatment and service to anyone in need of help. And participating in an AMA will help us do just that.

My name is Gilbert Lichstein. I’m the Clinical Director for Gateway Foundation’s Chicago Independence and River North locations. Please feel free to Ask Me Anything about co-occurring disorders and substance-use disorders. I’m happy to help!

Gateway Foundation is the largest nonprofit treatment provider in the U.S., specializing in substance use disorders since 1968. Gateway's clinicians support over 6,000 people a day to successfully complete treatment by developing a personalized plan to treat the underlying causes of substance use disorder—not just their addiction to drugs or alcohol.

What is the Vibe of this AMA? What is AMA Vibe?

This AMA has finished, no more comments and questions can be posted and votes submitted to those. Check other similar AMAs here or host your own AMA!

Conversation (125)

In three easy steps and under a minute you could be hosting your own AMA. Join our passionate community of AMA hosts and schedule your own AMA today.

Let's get started!

When looking for treatment options for an individual with co-occurring disorders, what are the features that a program should offer?
Jul 15, 12:25PM EDT0

Hello, and thank you for the question.  On a basic level, we recommend a program that offers integrated, simultaneous care for both disorders.  We use a multidisciplinary approach to develop a comprehensive assessment and treatment plan in a cohesive manner.  When we talk about programs with the Dual Diagnosis Enhanced designation (DDE), we are talking about programs whose underlying structure and clinical model drive integrated care.

Two other characteristics I would look for are a reliance on evidence based practices, and a non-confrontational approach.  The treatments we include in our clinical model have been verified to work through scientific study, rather than anecdote.  We favor an eliciting approach that builds a client’s confidence, and helps them develop internal motivation to address a Substance Use Disorder.     

Jul 16, 3:23PM EDT0
What types of behavioral therapies does your treatment center offer?
Jul 15, 10:18AM EDT0

Hello, thanks for the question.  We use a number of behavioral therapies in our programs, and I’ll give an overview of some of those that feature prominently.  The Mindfulness Based Sobriety curriculum we use incorporates Marlatt’s Relapse Prevention model, which is a Cognitive-Behavioral model that helps clients build recovery skills and address high-risk situations.  We also use CBT approaches to address the mental health conditions that are present with co-occurring disorders. 

Motivational Interviewing (MI) is a technique we use in all programs to elicit motivation to change, and ideas about the best way to make a change for clients who are unsure that they want to stop using drugs or alcohol.  We also use Dialectical Behavioral Therapy in most of our programs to help clients develop skills for emotion regulation and impulse control. 

Jul 16, 3:40PM EDT0
What are the misconceptions surrounding co-occurring disorders and its treatments?
Jul 15, 6:39AM EDT0

Hello, thanks for the question. I think that the biggest misconception is that the prognosis for co-occurring disorders is somehow worse.  It’s important to never lose hope when dealing with a Substance Use Disorder.  When done in an integrated manner, treating co-occurring disorders can be very rewarding for the clinician, because gains made in one domain can lead to gains in other domains, leading to synergistic effects. 

Jul 16, 3:45PM EDT0

Hi There, how effective is your treating underlying causes of addiction and are your patients usually closely monitored? Are they placed on a supervised detox for treatment to be effective at all?

Sincerely,

Jul 14, 4:01PM EDT0

Hello, thank you for the question. The level of supervision in the program depends on the level of care the program offers.  Residential treatment is the highest level of care we offer, which includes significantly more monitoring than a recovery home or outpatient program.  The extent of the monitoring in Residential programs is less than what a client would experience in an inpatient hospitalization, so it’s important that our client’s medical and psychiatric conditions do not require emergency care.  We are able to manage a wide range of withdrawal symptoms at the Residential level of care.  As treatment progresses, clients are discharged to lower levels of care which provide more freedom to reintegrate back into their home lives. 

Jul 16, 3:51PM EDT0
Are there any options of treatment regarding family therapy and support for dual diagnosis patients?
Jul 14, 3:50AM EDT0

Hello, thank you for the question. Our residential programs incorporate weekly, evidenced-based programming for families.  This provides disease education, and information about what to expect.  When a client comes into treatment, we ask them if they wish to sign releases for their families to receive information about their treatment.  If so, we make every effort to include the input of the family as a source of support in the client’s treatment and discharge plans. We view the family as integral to the client’s well-being, and avoid non-scientific and pejorative descriptions of families such as “”co-dependent” and “enabling.”

Jul 16, 3:56PM EDT0
What are other treatment options for co-occurring disorders besides psychotherapy?
Jul 14, 2:29AM EDT0
What treatment strategies should you consider when you’re planning your recovery?
Jul 13, 11:10PM EDT0
Do you provide aftercare, including maintaining treatment regimens as required for the co-occurring disorders? How is your aftercare program like?
Jul 13, 5:11PM EDT0
What disadvantages do you see in the confrontational treatment approach?
Jul 13, 2:03AM EDT0

Hello, thanks for the question.   The confrontational approach can be problematic if it interferes with a person developing their own motivation to change, or if it undermines the person’s belief in themselves.  Self-efficacy is a term used to describe a person’s belief in their own ability to accomplish things they want to accomplish, and we know from academic studies that high perceived self-efficacy is a strong correlate to behavioral change.  Consequently it’s beneficial for a treatment provider to engage clients in activities that build self-efficacy, such as skill building exercises and interventions designed to enhance physical health and mental well-being.  Conversely, treatment providers risk diminishing a client’s self-efficacy when they engage them with a confrontational approach. 

For many people, when someone else tells you forcefully how or why to do something, that can provoke a paradoxical reaction where you formulate a desire not to do what they’re telling you to do.  Clients are the experts on themselves, and know which whys are most important to them, and which hows will work the best for them.  Rather than telling people the hows or whys, we elicit these using a technique that I describe in some of the other responses called Motivational Interviewing. 

Jul 13, 4:15PM EDT0
What specific skillset and organizational structure does the Gateway Center have to care for their patients?
Jul 13, 12:28AM EDT0

Hello, thanks for the question.  The use of evidence based practices is a bedrock principle of how we operate.  Our organizational structure is such that we have an intricate training apparatus to train staff in how to use the techniques present in our clinical model, and an integrated fidelity monitoring apparatus to ensure that these techniques are applied as they were designed.   We find that most providers say they use evidence based practices, but not many have systematic approaches to training and fidelity monitoring, which is very important.  Gateway has quality assurance bodies that meet regularly and incorporate the input from staff at sites throughout the company when developing clinical enhancements.   Gateway has a corporate medical director who oversees protocols for providing care throughout the organization.

Our skillset includes Motivational Interviewing for working with clients who are ambivalent about changing their behavior, and a curriculum called Mindfulness Based Sobriety that was developed at Gateway.   We are leaders in the implementation of Medication Assisted Treatment for managing cravings and withdrawals.  All staff are trained in trauma informed care, and all masters-level clinical staff complete a training in trauma focused CBT.  We also feature Dialectical Behavior Therapy (DBT) in our residential and outpatient programs.

Jul 13, 4:30PM EDT0
How do you preserve the mental health of your own staff so their own health won't suffer from the emotional drain of working with such difficult health issues?
Jul 12, 6:09PM EDT0

Thank you, this is a very important question.  I think it’s key for people who work in this field to keep successes in focus, and to always maintain hope.  As managers, we make an effort to highlight these successes and bring attention to them in team meetings.  Along those lines, it’s helpful to take a strength-based approach in conceptualizing what’s going on with clients.  When you see the person as a collection of strengths, rather than a list of problems, it’s a much more empowering interaction for both people involved.

A big part of this is avoiding a confrontational dynamic.  We encourage our staff to engage the clients in a collaborative process in which many of the answers come from the client.  It’s important for clinicians to develop and utilize their skills so they can maintain objective distance when needed.  Finally, it’s very important for clinicians to have active lives away from work, which includes engaging social activities and pastimes.    

Jul 13, 4:38PM EDT0
How did you go about developed your own clinical model with treatment techniques that are evidence-based?
Jul 12, 5:32PM EDT0

That’s a very interesting question.  Our clinical model is the product of a continuing and ongoing review of all of the evidence based practices for addiction treatment.  Phil Welches, one of the authors of the Mindfulness Based Sobriety curriculum we use, deserves a lot of the credit for establishing the foundations of our clinical model when he was at Gateway.  By design, it fits hand in glove with the DDCAT to support integrated care.  The ongoing development of the clinical model is supported by company-wide work groups that incorporate the input of our many knowledgeable Doctors, Nurses, Psychologists, Counselors, Social Workers, and Addiction Treatment Specialists to keep us at the forefront of the field.  We consult extensively with outside experts, trainers, and ratings agencies.  

We are partnering now with area universities in research studies to address client needs such as treatment for trauma.  The goal is to incorporate new evidence based practices that are effective and can be replicated in residential and outpatient treatment settings.  One thing that differentiates Gateway from other providers is our emphasis on training and fidelity monitoring.  We give clinicians the tools they need to provide the treatment that goes in to our clinical model. 

Jul 13, 4:58PM EDT0
Is it better to integrate both mental health and substance use disorders? Why or why not?
Jul 11, 7:03AM EDT0

Hello, and thank you for the question. Academic research and anecdotal observations both indicate strongly that integrated treatment for mental health and substance use disorders is the most effective option.  One reason this is true is that the disorders have an interactive course, which means that gains you make in treating one disorder can lead to gains in treating the other disorder, leading to synergistic effects.  The person experiencing a co-occurring disorder doesn’t want to treat one disorder after the other- they want treatment for both disorders, now.  Additionally, it’s important that from the perspective of the treatment team that one hand knows what the other hand is doing.  This is why Gateway utilizes an integrated multidisciplinary approach. 

Many of the techniques that one uses to treat a substance use disorder are also applicable to a mental health condition, and vice versa. For example, Mindfulness can help people address cravings and urges, and it can also help people address symptoms of depression and anxiety.  It used to be that clients were expected to address a mental health condition before they obtained treatment for a substance use disorder.  Then, people were expected to obtain treatment for the two disorders in simultaneous, but distinct settings.  Now, at providers like Gateway, people can experience truly integrated care, starting at the time of diagnosis, and continuing throughout the care continuum.  

Jul 11, 11:31AM EDT0
How effective are your treatments? How long do they take? What treatment options are available?
Jul 10, 10:49PM EDT0

Hello, and thank you for the question. We offer both residential and outpatient treatment options.  The length of treatment is based on how long the person meets ASAM criteria for that level of care, and it’s hard to provide specifics on how long treatment will take without knowing more about the specifics of a person’s situation.  We work to make treatment available to people close to home, in a manner that minimizes disruptions to their lives to the greatest extent possible.

We know from our data that the vast majority of people who participate in treatment with us would recommend it to a friend or loved one. We also know that the majority of our clients experience significant reductions in cravings, and substantial increases in their confidence that they can manage high risk situations.  Many of the statements of efficacy that other treatment providers provide are non-scientific and inflated because they engineer biases into their sampling methodology that influence the results.  We think it’s important to be transparent with people about the efficacy of care, and for this reason have pursued independent validation of our success rates, as well as university partnerships to test the efficacy of the methods we use as they are delivered in our settings.  This data will appear in our outreach materials in coming months.  

Jul 11, 11:43AM EDT0

DO you accept clients without insurance? DO you treat patients from acrossed the country?

Jul 10, 8:50PM EDT0

Hello, and thank you for the question. We think it’s important for people to have access to the best care, regardless of income, and regardless of where they live.  We are a non-profit that relies on a diverse funding stream, including options for people without insurance from across the country.  We focus tirelessly on enhancing care and expanding our capacity to get more people the treatment they need.  Our call center can discuss the specifics of a person’s situation, and point them to applicable treatment options. 

Jul 11, 11:49AM EDT0
Which treatment program should come first? The addiction recovery one or the mental health one?
Jul 10, 5:01PM EDT0

Hello, and thank you for the question! I am going to repost an answer I provided to a similar question.  Academic research and anecdotal observations both indicate strongly that integrated treatment for mental health and substance use disorders is the most effective option.  One reason this is true is that the disorders have an interactive course, which means that gains you make in treating one disorder can lead to gains in treating the other disorder, leading to synergistic effects.  The person experiencing a co-occurring disorder doesn’t want to treat one disorder after the other- they want treatment for both disorders, now.  Additionally, it’s important that from the perspective of the treatment team that one hand knows what the other hand is doing.  This is why Gateway utilizes an integrated multidisciplinary approach. 

Many of the techniques that one uses to treat a substance use disorder are also applicable to a mental health condition, and vice versa. For example, Mindfulness can help people address cravings and urges, and it can also help people address symptoms of depression and anxiety.  It used to be that clients were expected to address a mental health condition before they obtained treatment for a substance use disorder.  Then, people were expected to obtain treatment for the two disorders in simultaneous, but distinct settings.  Now, at providers like Gateway, people can experience truly integrated care, starting at the time of diagnosis, and continuing throughout the care continuum.  

Jul 11, 11:53AM EDT0
Are eating disorders considered a form of co-occurring disorder? Are there any cases of eating disorders associated to substance addiction?
Jul 10, 11:11AM EDT1

Hello, many people experience both a Substance Use Disorder and a co-occurring Eating Disorder. The relationship I would note between the two disorders is that Substance Use and unhealthy eating behaviors can both arise as ways to manage unpleasant feelings and stressors.  Additionally, once the person decides to make a change, the experience of managing these behaviors is also similar.  It’s important to address both simultaneously because the alternative is the person engaging in more in one type of behavior when they try to discontinue the other.  It’s not uncommon to see a dormant eating disorder flare up when the person addresses a substance use disorder, or vice-versa.  For the person experiencing an eating disorder, it’s important to be open about this with your treatment provider.  They can point you to an appropriate treatment environment.  

Jul 11, 12:02PM EDT0
Do you believe that treatments should adjust to the patient, rather than the opposite? Why or why not?
Jul 10, 6:22AM EDT1

Great question! Our perspective is that we give people a menu of options, and help them choose what will work best for them in their treatment plan.  We prefer an eliciting, rather than instilling, approach when it comes to discussing the reasons and ways people change.  What this means is that we will try to extract the reasons and ways to make a change from what the client says, rather than insert these ourselves.  This is because people are the best judges of what will work for them, and what they are ready to do.  There are many ways to effectively experience recovery. 

About half of our participants come to treatment knowing that they want to incorporate 12-step involvement in their recovery plan. For this reason, many of our staff are very experienced with and knowlegable about 12-steps themselves, and can guide clients through the meetings we have onsite.  On the other hand, many of our clients do not want to be involved with 12-steps, and for them we offer peer support alternatives like SMART Recovery and Refuge Recovery.  We don’t want someone to get disillusioned with treatment or to lose confidence because they think there is only one way to recover.  

Jul 11, 12:56PM EDT0

Great question! Our perspective is that we give people a menu of options, and help them choose what will work best for them in their treatment plan.  We prefer an eliciting, rather than instilling, approach when it comes to discussing the reasons and ways people change.  What this means is that we will try to extract the reasons and ways to make a change from what the client says, rather than insert these ourselves.  This is because people are the best judges of what will work for them, and what they are ready to do.  There are many ways to effectively experience recovery. 

About half of our participants come to treatment knowing that they want to incorporate 12-step involvement in their recovery plan. For this reason, many of our staff are very experienced with and knowlegable about 12-steps themselves, and can guide clients through the meetings we have onsite.  On the other hand, many of our clients do not want to be involved with 12-steps, and for them we offer peer support alternatives like SMART Recovery and Refuge Recovery.  We don’t want someone to get disillusioned with treatment or to lose confidence because they think there is only one way to recover.  

Jul 11, 12:56PM EDT0
Could a mental disorder be an underlying cause for substance abuse?
Jul 10, 5:34AM EDT0

Hello, it’s frequently the case that a mental health condition or traumatic experience is playing a significant role in driving a Substance Use Disorder. This is because people sometimes use drugs and alcohol to manage unpleasant emotions and experiences.  While this may work in the short term, the problem is it usually stops working, and distances the person from their long term values and goals.  One thing we do in treatment is help people get reacquainted with their values and goals, and move toward living a goal-directed life.  This requires using new techniques to manage mental health symptoms, which is why integrated treatment is important.

Jul 11, 1:01PM EDT0
How many people are affected with co-occurring disorders?
Jul 10, 2:21AM EDT0

Hello, and thanks for the question. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2014, 7.9 million adults in the United States experienced co-occurring disorders. 

Jul 11, 1:05PM EDT0