Working with Co-occuring Disorders in Residential Support Programs
Reprinted from "Concurrent Disorders" issue of Visions Journal, 2004, 2 (1), p. 42
lient access to appropriate support and treatment [may be] limited to the few programs and support groups that are staffed with trained professionals and designed to provide services to individuals with co-occurring disorders. Desperate clients who have been deinstitutionalized and living in the community, where ready access to drugs and alcohol has become more and more prolific, often turn to those individuals with whom they have the most contact – their ‘residential support’ counselors, who may be present in a number of housing settings.
Although the services of these programs may vary in intensity depending on the individual’s level of need, they often include supervision; counseling; life skills training; medication monitoring and education; transportation; housing assistance; health and safety education; prevocational, social and communications skills training; and coordination with all other necessary psychiatric and support services. Actively engaged in caring for these clients on a daily basis, these counselors are left with the overwhelming task of find ing solutions to the complex needs of the clients they serve in an environment that often seems stacked against them. Despite the political and economic factors that hinder their ability to take action, they have nonetheless been compelled to find new and low-cost approaches that have proven successful for their clients struggling with cooccurring substance-related and mental disorders.
One such approach that has proven to be successful for residential providers has been weekly psychoeducational groups, in which clients can learn about and discuss issues related to their co-existing disorders. At the St. Vincent DePaul Society of Waterbury’s mental health division, a communitybased mental health residential support program, they have integrated these groups into their model of care and have found them particularly effective in helping individuals with cooccurring disorders maintain their sobriety. After years of experience in facilitating such groups, they consider certain elements to be the key ingredients of their success including active listening, celebrating success, being flexible and non-judgmental and emphasizing a psychoeducation and relapse prevention approach. What follows focuses on the last two key elements of support.
psychoeducation It is essential that clients understand the link between their psychiatric treatment and their sobriety as well as their mental illness and their substance abuse. Education and support can help clients understand these fundamental concepts, which are so important in preventing relapse. Fortunately, residential counselors are often in the unique position to reinforce these connections on an almost daily basis. Clients with co-occurring disorders must recognize that their substance abuse may be an attempt to cope with their psychiatric symptoms, and that if they continue to drink or use drugs, they will have even less control over their psychiatric problems; for example, alcohol can worsen depression, and opiates or stimulants can increase auditory hallucinations, paranoia and delusional thinking.
Additionally, clients must understand that continued alcohol or drug abuse often results in medication non-compliance, which only exacerbates their psychiatric symptoms and that without medication they are more likely to spiral out of control. Part of educating clients about both problems must include the message that they deserve a better life, and that sobriety is the foundation or the best path they can take towards the improvement they deserve. After all, clients have been attempting to feel good without first being able to feel good about themselves. The ‘doublewhammy’ of substance abuse and psychosis has greatly diminished their sense of control and ability to make sound decisions. Ultimately, the harmful choices they have made have introduced even more chaos into their lives, and alienated them from many of the resources they could use to restore their independence and control. Through ongoing support and psychoeducation, clients are more likely to make the connections they require in order to improve their decisionmaking abilities, remain abstinent and maintain their medication regimen and psychiatric treatment compliance.
Incorporate relapse prevention in everday activities
Professionals such as residential counselors who work with clients with co-occurring disorders on a day-to-day basis, can often help them identify potential triggers or develop the coping mechanisms they require to avoid relapse. By identifying potentially stressful situations before they become critical, counselors can help clients either avoid stressors or cope with them on a daily basis. These relapse prevention plans should include not only the development of individualized strategies, but also hobbies, games, meditation and relaxation techniques, social events, the development of support networks, as well as diet and exercise routines which often have an immediate effect on the clients’ clarity of thought and decision making abilities. Such self directed activities help clients resist temptation, boost self-esteem, and develop the kind of associations that decrease the opportunities and the desire to drink or use drugs.
Overall, the techniques suggested throughout this article may not be appropriate for all providers or client populations. Ultimately, it is important to design a program that works – one that not only meets the needs of the clients, but also the structure of the organization. It is equally important to recognize that clients may feel more relaxed and receptive to services when they are in familiar territory or on their own ‘home turf.’ This is often the case for clients in mental health community-based residential programs, where services are available to them within the same apartment complex or group home in which they reside. As a result, clients do not feel obliged to ‘fit in’ to an artificial programmatic role, and providers find it easier to develop rapport, and work with those clients that are more prone to bouts of paranoia. Perhaps this ‘home court’ advantage should be considered when allocating funds to providers who serve this ever taxing and growing population.
About the Authors
Gary is a Director of Mental Health Services for the Saint Vincent DePaul Society of Waterbury, Connecticut and has worked in the addictions and mental health field for more than 14 years
Thoms heads a co-occurring disorders support team for the Center for Human Development in the Waterbury, Connecticut area and also facilitates a co-occurring disorders support program for the Saint Vincent DePaul Society
The following article was excerpted from: Beaulieu, G & Flanders, T. (2000). Uncovering the elements of success: Working with co-occurring disorders in residential support programs. International Journal of Psychosocial Rehabilitation, 5 11-17. To download the full article and model description, see www.psychosocial.com/volume5.html