INTEGRATED HIV-‐SUBSTANCE USE TREATMENT A Treatment

Transcription

INTEGRATED HIV-‐SUBSTANCE USE TREATMENT A Treatment Manual for Integrated HIV-‐Substance Use Therapy and Cross-‐Provider Communication in Infectious Disease Clinics Developed by the Carolina Alcohol and Drug Education Team (CADET) of: The Duke Infectious Diseases Clinic; The University of North Carolina Infectious Diseases Clinic; and The Lincoln Community Health Center Early Intervention Clinic The CADET team includes: Natasha Bowditch, LCSW, Amy Carmen, LCSW, Katie Cooper, LCSW, LCAS, Sandra Gomez, MSN, MPA, Amy Heine, MSN, FNP, Katie Jorgensen, P-‐LCSW, LCAS, Keith R. McAdam, LCSW, LCAS, Laura Musselwhite, LCSW, Randall Scott Pollard, LCSW, Rae Jean Proeschold-‐Bell, PhD, E. Byrd Quinlivan, MD, and Heidi Swygard, MD, MPH For more information, contact: Rae Jean Proeschold-‐Bell, PhD Duke Global Health Institute Duke Center for Health Policy and Inequalities Research 2812 Erwin Rd., Suite 403 Durham, NC 27705 919.613.5442 [email protected] Supported by the Substance Abuse and Mental Health Services Administration, HIV/TCE grants 6H79TI14386 and 6H79T1018825.
Integrated HIV-Substance Abuse Treatment
Table of Contents
1. Why integrated HIV-SA treatment?
2. Continuum of integrated care
3. Site descriptions
Background
Description of clinics
Clinic differences
4. Drawing on empirically supported treatment
Biopsychosocial-spiritual framework
Harm reduction
Stages of change
Motivational Enhancement Therapy
Cognitive Behavioral Therapy
5. Treatment structure
6. Modified Intensive Outpatient Treatment Overview
Provider description
Referral and screening
Individual therapy
Group therapy
Psychiatric care
Cultural considerations
Tying theory into individual and group therapy
7. Modifications to Intensive Outpatient Therapy
8. Session content
9. Sample session materials
Why integrated HIV-SA treatment?
Substance abuse is a common co-morbidity for persons with HIV. An estimated 19% of
patients with HIV also have co-occurring alcohol or drug dependence (Galvan, Burnam, & Bing,
2003). Mental health problems including diagnosable mental illness is also frequently
experienced by persons with HIV, and mental illness further co-occurs with HIV and substance
abuse (Galven, Burman, & Bing, 2003). Indeed, in a national sample of HIV positive men and
women, 13% were triply diagnosed with HIV, a mental illness and substance abuse (Galven, et
al., 2003). Although not all persons dually diagnosed with HIV and substance abuse also
experience mental illness, this integrated treatment attempts to attend to the treatment needs of
dually and triply diagnosed patients, and therefore much of this manual refers to triply
diagnosed individuals.
Compared to persons with HIV alone, triply diagnosed individuals are more likely to have
negative health outcomes, including HIV-related mortality, poor medical adherence, lower
quality of life and risky sexual behavior (Avants, Warburton, Hawkins, & Margolin, 2000; Bartlett,
2002; Kelly et al., 1993; Turner et al., 2001). In addition, those who are triply diagnosed have a
greater disease burden, making them more vulnerable to negative health consequences (Batki,
1990; Douaihy, Jou, Gorske, & Salloum, 2003). Indeed, the treatment needs of this vulnerable
population are highly complex and multifaceted. Evidence-based practices can inform treatment
for dually diagnosed individuals, but HIV-specific interventions are needed since an HIV
diagnosis contributes a host of additional physical, social, and psychological stressors that may
influence mental health and substance use treatment outcomes (Angelino & Treisman, 2001;
Douaihy, et al., 2003).
Due to the complex treatment needs of this population, we have developed a 12-month
Modified Intensive Outpatient Treatment (M-IOP). We call it “modified” intensive outpatient
treatment because its intensity is substantially less than typical intensive outpatient programs.
However, there can be patient benefits to a less intense and more flexible treatment. Briefly, the
model uses an integrated and biopsychosocial-spiritual framework, combined with cognitive
behavioral therapy (S Bouis et al., 2007). It combines evidenced-based practice for the dually
diagnosed with HIV-specific treatment across the behavioral and medical system of care (S.
Bouis et al., 2007). M-IOP is an integrated model in that it includes facilitating collaboration
between mental health/substance abuse providers and HIV medical providers, including colocation of medical care and behavioral health care.
The M-IOP model has been tested in two separate studies. From 1998-2002, it was
tested among 140 triply diagnosed patients at 4 sites and, based on patient interviews spaced
at 3 month intervals, demonstrated a decrease over time in psychiatric symptoms, hospital
admissions, and use of illicit substances and alcohol (K Whetten et al., 2006). In the second
study, from 2002-2008, the model was tested among dually diagnosed (HIV and substance use)
patients at 3 sites. Based on patient interviews spaced 6 months apart, the model
demonstrated decreases in alcohol and drug use (Proeschold-Bell, Heine, Pence, McAdam, &
Quinlivan, 2010). Decreases in alcohol use were seen at 6 months with additional improvement
at 12 months. Decreases in drug use were seen at 12 months only.
Continuum of Integrated Care
Integrated care can broadly be defined as the merging of behavioral health care services
with primary medical services in an effort to comprehensively treat the wide array of issues for
which patients seek help through primary care (Blount, 2003). Blount’s (2003) theoretical
classification of the degree and qualities of integration of behavioral health services in primary
care settings allows readers to conceptualize the M-IOP’s degree of integration both along a
continuum and in terms of key integration characteristics. The continuum of integrated care can
range from the program’s services being coordinated (delivered in different settings but with
information sharing between the two programs), to co-located (both services delivered at one
location), to integrated (merged medical and behavioral health care components in one
treatment plan for individual patients). The M-IOP model could be classified as integrated care
by “prearranged protocol” which is defined by Blount (2003) as the “regular use of screening
and outcome assessment being addressed, a standard set of protocols for addressing the
illness, a database to track the care of patients screened into the program, and a staff member
designated as managing the program under the direction of a cooperating group of providers.”
The next classification looks at whether the service is for a targeted or non-targeted
patient population. Programs that are targeted seek specific patient populations for their
program, while non-targeted programs have the goal of delivering service to any patient with an
identified need of behavioral health services within a primary care setting. The M-IOP model is
considered targeted because the focus of the project is to deliver evidence-based substance
abuse treatment to individuals living with HIV.
Blount further categorizes treatment modalities as being specified or unspecified.
Specified treatment uses a defined modality that is presented to all patients who are eligible.
This contrasts with unspecified treatment modalities which can be defined as a unique and
patient-specific modality determined by the analysis of each practicing clinician. The M-IOP
treatment modalities are considered unspecified since the M-IOP is designed to incorporate the
individual skills and therapeutic styles of the practicing clinician with the specific needs of each
client. Indeed, the M-IOP is an adaptable treatment design that meets the specific needs of
each client.
Integrated care is widely agreed upon as a necessity, as the majority of Americans today
receive their treatment for behavioral health conditions from primary care providers (Quirk et al.,
2000). Primary care providers are frequently the first to discover a patient’s behavioral health
condition, but are often not equipped with the knowledge or resources to effectively treat the
patient. Thus, working in collaboration with behavioral health professionals in an integrated
care context, where clients may receive mental health care at the same location as they receive
medical care, may offer better overall health outcomes for the client (Friedman, Sobel, Myers,
Caudill, & Benson, 1995). Outcomes of integrated treatment models include: improved medical
provider comfort in diagnosing mental health disorders; reduced stigma, and augmented followup with mental health services (Williams, Shore, & Meschan, 2006). Among integration studies
with the elderly, health outcomes such as improved depression remission, depression severity,
and symptom severity, and improved rates of engagement have been noted, even between
different demographic and organizational factors (Bartels et al., 2004); (Krahn et al., 2006).
Implementation of the M-IOP can be adapted across different levels of integrated care.
The M-IOP has been implemented at a fully integrated site, where care is co-located and
communication is comprehensive across all providers on the team, and at co-located sites
where care is co-located but less integrated in terms of communication and shared treatment
plans. Below are the descriptions of the sites in which the M-IOP has been implemented, plus
differences along the integration continuum (Lombard et al, 2009).
Site Descriptions
Background. To understand something of the differences in clinical settings where this
treatment model has been successfully applied, we will describe how services have been
provided previously and currently at our institutions. These three institutions are two large
teaching medical centers, one private (Duke Infectious Disease Clinic) and one state-run (UNC
Infectious Disease Clinic), and one community health center with a Ryan White-funded HIV
treatment clinic (Lincoln Community Health Center Early Intervention Clinic). The medical and
health centers are located in two small cities in adjacent counties. The history of these programs
began in 1997 and has continued to the present, evolving through a series of three federallyfunded grants, each building on the successes of the previous one.
The program began when, at the private medical center, a primary HIV treatment clinic and a
substance abuse treatment center formed a collaboration (coordinated) to enhance care for
patients triply diagnosed with HIV infection, a mental health disorder and a substance abuse
disorder. Initially, the relationship was one of mutual support and referrals. People meeting the
criteria of this triple diagnosis could be referred into the substance abuse treatment program
either internally from the HIV clinic or externally from other community institutions such as case
management agencies. Those clients not currently in medical care would, as part of their
treatment in the substance abuse program, be referred into medical care.
Eventually, with new funding, an expanded program was developed. The expansion was both
in the services provided at the original site and in the number of sites where services were
made available. At the original site, the large private medical center, two additional substance
abuse counselors were hired, for a total of three at this institution. Internally, the substance
abuse treatment program and the HIV treatment clinics moved towards a closer integration by
co-locating services when one of the three substance abuse counselors was placed in the HIV
treatment clinic. This provider had office space in the clinic, and shared clinic resources
including reception and waiting area space and staff. This co-location allowed informal contact
with medical and other mental health providers in the clinic. In addition, for a couple of years,
the substance abuse counselor attended weekly patient care meetings with clinic staff, but then
those meetings were discontinued. The system of medical record keeping did not permit the
sharing of clinical notes. The substance abuse program maintained its space in a separate
facility where group therapy sessions and some individual counseling were provided.
Externally, the expansion of these integrated HIV and substance abuse services occurred
through involving the other two institutions. At the large state teaching hospital, two substance
abuse counselors were hired by the HIV treatment clinic, were provided with office space and
shared facilities there, and were made part of treatment teams in the clinic. In addition to the
informal communication that was permitted by the co-location of services, regularly scheduled
meetings of treatment teams consisting of medical and behavioral health providers were held.
Furthermore, unlike at the private medical center, the sharing of clinical notes through an
electronic medical record system was possible. At the HIV clinic in the community health center,
part-time substance abuse services were provided by co-locating one of the three substance
abuse counselors from the private medical center in that clinic for several hours a week. As in
the other HIV clinics, space and other clinical facilities were shared, but clinical notes could not
be shared across medical and substance use disciplines.
An important tool for identifying patients with substance abuse problems and potential
candidates for the program is a short screener called the Substance Abuse and Mental Illness
Symptoms Screener (SAMISS) (K. Whetten et al., 2005). It consists of 20 questions and is
administered orally in about three minutes. The screener has been designed to be easily
administered by non-mental health professionals.
Throughout the history of these programs, it should be understood that staff, policies, and
procedures did not remain static. The programs in the three institutions needed to adjust and
adapt to the inevitable turnover in clinic staff, new developments in procedures, shifts in policies,
and other changes. Furthermore, each institution built on its experience to enhance its methods
of communicating about treatment needs and plans.
Currently, a third federal grant has permitted another expansion of substance abuse services for
people in treatment for HIV at these three sites. At the time this treatment manual was written
(2010), the situation on the projects is as explained below.
Description of Clinics. The M-IOP has been implemented in three different infectious disease
(ID) clinics and a substance abuse site. The infectious disease clinics are differentiated by
catchment area, treatment structure, delivery of care, and communication. Two of the ID clinic
sites are considered to offer co-located care on the integrated care spectrum. They are both
located within a small (population 225,000) urban setting. The third ID clinic is also located in a
small urban setting (population 54,492) but draws patients from all over the state; it is
considered to offer more fully integrated care on the integrated care spectrum. The Behavioral
Health Providers (BHPs) provide treatment to ID clinic patients with HIV and substance abuse.
Private –urban Hospital. This clinic provides care to 1,581 patients, mostly from rural and
semi-urban regions of the state. Patients entering the HIV clinic are screened for substance
abuse and see a BHP as part of regular protocol. This site has two BHPs, who currently have
office space inside the clinic. In addition, one of the BHPs works at the substance abuse
treatment site and is able to provide treatment to HIV-positive persons who do not receive HIV
treatment but who are referred by HIV case management organizations. Thus, those BHPs are
able to see people living with HIV/AIDS (PLWHA) who are not currently a patient at any ID clinic
and link them into medical care. This site is considered co-located. The patients in this urban
setting are generally able to use the city’s bus system to access services. Substance abuse
treatment has always been free due to federal grants.
Public –urban clinic. This site is an Early Intervention HIV Clinic operated by a
community health center and housed in the county health department. The clinic provides HIV
care for 350 PLWHA who have limited access to health insurance (53%, none; 37%, public
insurance). In 2005, each person was seen an average of 6.1 medical visits. Services are colocated in that the clinic houses one BHP, who sees patients based on referrals from community
based organizations and from the medical providers at the clinic. Group therapy is offered offsite, and is in collaboration with clients and BHPs at the private-urban hospital. Treatment is
financed by state and Ryan White funds. All new patients are screened for substance abuse.
Large public hospital. HIV-substance abuse treatment at this site can be considered
more fully integrated on the integrated care spectrum. This site houses 3 BHPs within the
infectious disease clinic. This clinic provided care to 1,325 PLWHA in 2005. The clinic provides
walk-in services in addition to scheduled appointments with primary providers. As the state-run
tertiary hospital and healthcare system, patients travel an average of 60 miles from rural areas
to access this clinic’s services. It enrolls patients from the local community as well as from the
surrounding rural counties. As such, the patient population is less cohesive than the co-located
urban sites because patients come from a larger catchment area and, due to transportation
barriers, are not able to come to the clinic for group or individual therapy as frequently. The
BHPs from this site note that the client population is ever-changing, and as such, service
delivery must accommodate for this larger and more fluid client population.
Clinic differences. There are distinct differences among the sites in communication,
coordination, and organizational structure. Understanding these differences can help one see
where each site falls along the integrated continuum. We describe below how the sites differ in
communication and coordination, as well as organizational structure. After the M-IOP has been
described, we will also take a look at how these different sites have adapted the program to
meet the treatment needs of their clients.
Communication and coordination. Clinic size, institutional medical record design and
integration structure influence communication between the medical and behavioral team
members. At the integrated public hospital site, the exchange of information among BHPs and
medical providers occurs through universal consenting procedures. Formal communication
occurs via team meetings and shared use of one electronic medical record (EMR) system. Joint
use of the EMR by all members of the treatment team is a core element in integrated service
delivery. At the co-located sites, the private-urban and public-urban sites, communication
occurs between individual providers, not in interdisciplinary team meetings. Unlike the fully
integrated site, there is not a universally accessible EMR available to all providers.
Communication occurs in informal settings, providers communicate to others primarily about
their areas of specialty (i.e., BHPs communicate about psychiatric, addiction, and social support
issues, and medical providers communicate about HIV disease status and associated medical
issues (Lombard, Proescholdbell, Cooper, Musselwhite, & Quinlivan, 2009).
Professional autonomy. The M-IOP can be adapted in settings where there is a different
authority structure. For instance, at the integrated public hospital site, there is a clear line of
authority throughout the treatment team. Providers have identified HIV medical care as the
priority service, thus substance abuse treatment is a core service available to patients to assist
them in engaging in and maintaining medical care. When attending their substance abuse
appointment, they are also provided with a medical check-in if they need medical care or are out
of compliance with their medical appointment schedule. Essentially, at this site, HIV medical
treatment takes priority.
At the co-located public and private-urban sites, authority is housed primarily in the psychiatric
department which employs one BHP, and medical providers provide limited input to behavioral
treatment. The BHPs have greater independence than the more integrated site, since their
services are seen as separate and coordinated with medical treatment but not subordinated to
medical treatment. At this site, the BHPs do not have to make the coordination of HIV medical
care the first priority, but could instead decide with the client where to place HIV in the priority
order of treating multiple morbidities. For example, if the patient is more concerned about his
substance use than his HIV treatment, the BHP and patient could begin work on an agreedupon initial goal of substance use reduction, and later discuss HIV treatment and its interaction
with substance use (Lombard, et al., 2009).
What has been shown above is that there are structural differences in the settings in which the
M-IOP has been implemented. The public-rural hospital contains: 1) universal screening of the
illness and tracking of those patients who screen positive; 2) shared protocols to address the
illness; and 3) a staff member designated to manage the program under the auspices of medical
and behavioral health providers. At this integrated site, substance use screening is universal for
every referred client, with referral and treatment protocols in place to address substance use
and HIV. Interdisciplinary team meetings and protocols allow for a coordinated treatment plan
(Lombard, et al., 2009).
In contrast, the co-located sites (the public and private urban clinics) include: 1) medical and
behavioral health services provided in the same office suite, sharing front desk staff and waiting
space; 2) communication between providers, not necessarily through formal means, but through
proximity with a referral process between medical and behavioral health providers; 3) BHPs
provide most of their individual sessions on-site, which fosters communication between the
medical provider and the BHP. In addition, the respective referral process is known to both the
medical and behavioral health specialists (Lombard, et al., 2009).
This integrated, multidimensional model of outpatient treatment can be implemented across
different settings. Despite differences in communication methods, catchment area, treatment
structure, and professional authority, the flexibility of the intervention allows for these different
sites to implement the M-IOP and achieve effectiveness (Lombard, et al., 2009; K Whetten, et
al., 2006). The flexibility of the intervention has much to do with the theoretical approach to the
problem of addiction. The next discussion highlights the different theoretical models of addiction
and evidenced-based clinical theories used by the BHPs.
Drawing on Empirically Supported Treatment
Biopsychosocial-spiritual Framework. The M-IOP approaches treatment of the triply
diagnosed through a biopsychosocial-spiritual model of understanding the client. In contrast to a
disease model, where substance abuse and HIV diagnosis are seen as problems within the
individual, a biopsychosocial-spiritual model sees substance abuse, HIV, and mental health as
complex challenges that require interventions across the biological, psychological, social, and
spiritual components of the individual. Indeed, triply diagnosed clients experience challenges
across all of these domains, negatively impacting their overall HIV medical care (Palmer,
Salcedo, Miller, Winiarski, & Arno, 2003).
Biological. Substance abuse/dependence occurs more frequently where there is a
genetic history. Children of alcoholic parents are at a higher risk of becoming substance
dependent than those without alcoholic parents (Chassin, Rogosch, & Barrera, 1991).
Substance abuse alters the brain’s chemistry by high-jacking reward pathways; the
resulting feeling of euphoria teaches the person to repeat behaviors that cause this
sensation. Over time, chronic substance abuse can alter the brain’s chemical systems
which may ultimately lead to impaired cognitive functioning.
Psychological. Individuals living with HIV and substance abuse problems often have
psychiatric disorders as well (Alvan, Burnam, & Bing, 2003). In addition, it is likely that
dually and triply diagnosed individuals have experienced physical or sexual trauma in
their lives (K Whetten, Reif, Whetten, & Murphy-McMillian, 2008). Essentially, individuals
who experience painful feelings associated with trauma and mental illness may use
substances to self-medicate (Kasten, 1999). Rather than actively addressing difficulties,
a pattern of avoidant coping develops and can reinforce helplessness and passivity.
Moreover, these maladaptive patterns of coping replace more adaptive cognitive and
behavioral skills. In our initial study ending in 2002, high rates of psychological comorbidities were found: depression, 58%; PTSD, 30%; panic disorder, 9%; antisocial
personality disorder, 35%; borderline personality disorder, 38%; and psychotic disorder,
21% (Kathryn Whetten et al., 2006).
Social. Persons living in neighborhoods with high numbers of drug users and social
disorganization are more likely to use drugs or have mental illness (Latkin & Curry,
2003). Recovery in unstable neighborhoods can be difficult as the luxury of a ‘safe’ and
supportive drug-free space does not exist. In addition, family and social problems create
significant barriers to HIV medication adherence (Palmer, et al., 2003). Without
meaningful activity and genuine social support, recovery can be nearly impossible.
Helping to increase social support can reduce the use of substances and keep
individuals in treatment (Dobkin, De Civita, Paraherakis, & Gill, 2001).
Spiritual. Separate, or as a part of religion, spirituality is the self-awareness that one is
part of something larger than one’s self. The extent to which one is involved in religious
or spiritual practices has been to shown to correlate with less risk behavior, such as
alcohol abuse (Koenig, George, Meador, Blazer, & Ford, 1994), and a more optimistic
life orientation, greater perceived social support, and lower levels of anxiety (Pardini,
Plante, Sherman, & Stump, 2000). Of course, correlation is not the same as causation.
Currently, the strongest evidence we have regarding specific religion-health pathways
lends support to the hypotheses that church attendance encourages a healthier lifestyle,
provides meaningful social roles, and offers the experience of positive emotions, thereby
leading to better health (Powell, Shahabi, & Thoresen, 2003). There is also support for
negative religious coping (e.g., “I feel God has abandoned me”) leading to worse health
outcomes (Powell, et al., 2003). Among studies with persons with HIV, some religious
practices, like church attendance and prayer, have been associated with medication
adherence among HIV positive individuals, while some spiritual beliefs, like HIV is a sin
or punishment, can negatively impact medication adherence (Parsons, Cruise,
Davenport, & Jones, 2006). Thus, by including attention to patients’ spirituality, this
treatment aims to strengthen patients’ health practices, involvement in meaningful social
roles, and the experience of positive emotions.
Harm Reduction. The treatment approach of the M-IOP includes this biopsychosocial-spiritual
framework and uses a harm reduction strategy. Harm reduction builds on the principles outlined
above. A harm reduction strategy focuses its efforts on reducing substance abuse-related harm;
it sees abstinence as sometimes the most certain way to protect against harm, but any move
toward reducing harm is seen as a positive step and worthy of support (Martlett, 1998).
Consistent with a motivational approach, described below, harm reduction starts “where the
client is.” The BHP and the client work together to develop a plan that may include abstinence
or a reduction of substance use, in the context of a larger clinical picture. That is, clients may
identify housing needs, relationship problems, or other problems that take priority over their
drug/alcohol use or HIV medication adherence. This allows the client to ‘buy into’ their
psychotherapy, developing trust between the client and the BHP. The BHP is then more
effective in addressing the way in which substance abuse interplays with other problem areas of
the client’s life, motivating the client to take steps to reduce or stop their problematic behavior
(Denning, 2000).
Stages of Change. The M-IOP utilizes the transtheoretical theory of behavioral change model
(J. Prochaska & DiClemente, 1982). This theory incorporates the biopsychosocial-spiritual
model outlined above. It assumes that there are varying stages of one’s readiness to change
behavior and interventions to facilitate this change need to start “where the client is” (J.
Prochaska & DiClemente, 1982). Applying the transtheoretical model to triply diagnosed
individuals involves assessing readiness for behavioral change for each present diagnosis (HIV,
substance abuse, and/or mental illness) and planning treatment objectives based on the stage
of behavior change for each diagnosis (Kathryn Whetten, et al., 2006). The BHP assists the
client through the change process by empowering the client to identify his or her problematic
behavior and their own unique path to accomplishing change by moving through the stages.
The stages of change are as follows:
Precontemplative. In this stage, individuals do not have any intention to change and are
unaware that their behavior is problematic. It is not the goal of the counselor to get the
patient to change. Rather, through empathy and open and reflective listening, the
counselor may be able to get the individual to start thinking about change (J. Prochaska,
DiClemente, & Norcross, 1992).
Contemplative. At this stage, individuals are aware a problem exists and they begin to
seriously consider making a change. People can stay at this stage for a very long time.
The role of the counselor is to acknowledge the difficulty in change, while providing a
foundation for hope. Doing this involves getting the individual to consider what the
individual has done to overcome difficult situations in the past. A discussion considering
the barriers to change and strategies to overcome these barriers is also helpful (J.
Prochaska, et al., 1992).
Preparation. In this stage, individuals have the intention to change their behavior and
begin to make small behavioral changes. However, individuals in this stage have not yet
reached the criterion for effective action, such as meeting one’s goal for decrease in
alcohol or drug use, or total abstinence (J. Prochaska, et al., 1992). The counselor offers
encouragement and helps the individual develop behavioral skills that can move them
into effective action.
Action. The action stage is where the individual has successfully modified their behavior,
experience, or environment to overcome their problem behavior for a period from one
day to six months (J. Prochaska, et al., 1992). This stage requires a considerable
amount of time and commitment for the individual. Thus, counselors should provide
encouragement and praise for positive behavior.
Maintenance. Individuals in the maintenance stage are working to prevent relapse. They
are sustaining abstinence from problematic behavior or achievements in that regard from
a period of six months to an indeterminate period of time. Individuals at this stage benefit
from encouragement and behavioral skill development. A discussion of relapse is helpful
so that the individual may identify successful strategies to prevent relapse from
happening again, if it occurs (J. O. Prochaska & DiClemente, 1986).
Relapse. It is common for clients to relapse into old behaviors when faced with triggers
and difficult circumstances. Often, when the individual uses alcohol or drugs after a
period of sobriety, relapsing can be seen as failure. Thus, it is important for the BHP to
normalize this experience and use it as an occasion to reflect on strategies to become
more effective in dealing with the circumstances that caused one to relapse. Indeed, it is
used as an opportunity to learn how to cope differently.
Motivational Enhancement Therapy. The BHP facilitates the movement across these stages
of change through the principles grounded in Miller’s (1995) Motivational Enhancement Therapy
(MET). MET is a client-centered approach that attempts to help the client overcome
ambivalence regarding their problematic behavior. MET begins with the assumption that
responsibility and capability for change lie within the client (Miller, 1995). The BHP aims to
create a set of conditions that develop the client’s own motivation and commitment to change by
utilizing the client’s intrinsic resources (Miller, 1995). Motivational Enhancement Therapy has
been rigorously tested and found to be effective in reducing problem behaviors, like frequency
of drug and alcohol usage, and increasing treatment adherence (Burke, Arkowitz, & Menchola,
2003; Hettema, Steele, & Miller, 2005). MET is grounded in the following core principles:
Express empathy. The foundation of MET is empathic communication. The BHP seeks
to communicate a deep level of respect for the client, including their freedom of choice
and self-direction (Miller, 1995). The BHP should employ reflective listening to
communicate an acceptance of where the client is in their life. The goal is to understand
the client’s situation from the client’s own perspective.
Develop discrepancy. MET helps to move the client through ambivalence by highlighting
the discrepancy between their stated goals and their current behavior. For example, the
BHP emphasizes the discrepancy between the client’s negative behavior, such as binge
drinking, with their stated values and goals of healthy living and better relationships.
This information can compel the client to enter into a discussion around options for
change in order to reduce perceived discrepancy (Miller, 1995). The BHP does not
impose external pressure based on their own goals for the client. Rather, change is
more likely to occur when the client is motivated by intrinsic goals and values as
opposed to external goals and values.
Avoid argumentation. MET involves challenging and confronting the client’s negative
thoughts and/or behaviors. However, it does not involve arguing or debating a value or a
perspective held by the client. Doing so may evoke resistance and put the client on the
defensive, and possibly reinforce the behavior that is trying to be changed (Sikkema,
Kochman, Berg, & Hansen, 2010). The BHP utilizes other strategies to assist the client
in recognizing the consequences of their problem behavior.
Roll with resistance. It is expected that there will be a certain level of resistance from the
client, and how the BHP responds to this resistance is an essential piece of the MET
approach. Resistance should not be directly challenged or confronted, but rather
redirected with the goal of shifting the client’s perspective. The BHP should invite the
client to consider other alternatives or new ways to think about the problem. Rolling with
resistance is also a time to return to empathic listening and re-visit discrepancies based
on the client’s values, thus potentially increasing the client’s intrinsic motivation
(Sikkema, et al., 2010). That is, instead of playing devil’s advocate or challenging the
client on their thoughts or behaviors, maintaining an empathetic rapport in the midst of
the client’s resistance allows space for the client to see the discrepancy between their
goals and behaviors. This can contribute to intrinsic motivation.
Support self-efficacy. Self-efficacy is the belief that one can accomplish or perform a
specific task. The BHP acts to support the self-efficacy of clients by instilling confidence
and helping the client develop a set of behavioral skills that will successfully lead to
change.
Cognitive Behavioral Theory. BHPs utilize Cognitive Behavioral Theory to augment and
support the effectiveness of individual and group therapy. Cognitive therapy was developed in
the early 1960’s by Aaron Beck. Cognitive Behavioral Therapy (CBT) is a synthesis of both
cognitive and behavioral models of treatment. From the behavioral model, one understands that
behavior impacts one’s thoughts and emotions. Thus, if you change the behavior that relates to
a phenomenon, you change your thoughts associated with the phenomenon. From the cognitive
model, one understands behavior as primarily impacted by our cognitive schemas or ways of
thinking. Our cognitive schema is constructed by life experiences and our biological
predispositions (Beck, 1995).
CBT assumes a triangular relationship between our behavior, thoughts, and emotions
with each item impacting the other. Essentially, negative thoughts lead to negative emotions
which lead to negative behaviors. The same pattern is true for positive thoughts. Thus, CBT
attempts to help the client identify negative or distorted thoughts and then challenge the validity
of those thoughts to effect a change in behavior. For example, if anger induces a client to drink,
then CBT will attempt to explore the circumstances that provoked the anger, the thoughts and
behavioral processes that lead from anger to drinking, as well as the events that occur after the
drinking (Longabaugh & Morgenstern, 1999). More specifically, CBT allows the client to ‘tell
their story’, provides education around automatic thoughts, beliefs, and emotions, and helps the
client develop the skills to identify and challenge negative thoughts. CBT attempts to enhance
coping skills to provide an alternative to problem behavior. These coping skills are used by the
patient to cope with triggers and other stressors to prevent relapse (Siqueland & CritsChristoph, 1999).
There is plenty of research backing the effectiveness of CBT for substance abusers.
Project MATCH, a longitudinal study on the effectiveness of three different psychosocial
interventions on alcohol and substance abuse, found CBT effective in reducing alcohol
consumption and alcohol-related negative consequences (Siqueland & Crits-Christoph, 1999).
Moreover, for the purposes of the M-IOP, CBT combined with Motivational Enhancement
Therapy has been shown to reduce drug use and promote HIV behavior change (Baker, Boggs,
& Lewin, 2001; Kalichman, Cherry, & Browne-Sperling, 1999). Indeed, for substance abusers
who are HIV positive, cognitive behavioral therapy combined with Motivational Enhancement
Therapy is thought to be a promising intervention for reducing substance use and increasing
medication adherence (Parsons, Rosof, Punzalan, & Di Maria, 2005).
TREATMENT STRUCTURE
Modified Intensive Outpatient Treatment Overview. The M-IOP is a twelve-month program
that includes individual and group therapy, enhanced communication and coordination between
medical and behavioral health providers, and access to psychiatric care if necessary. It is
designed to provide flexibly-delivered, high-impact services through individual and group
therapy. Group therapy generally lasts 90 minutes with therapists allotting time for education,
open discussion, or social and life skills development, with issues of HIV integrated throughout.
These open groups are optimal with a maximum of 12 members and two leaders. This model of
integrated care has been provided for the past four years. As described above, it has been
shown to relate to decreases in substance use in triply and dually diagnosed individuals.
Provider description. The key providers necessary for the implementation of the M-IOP are
Behavioral Health Providers (BHPs), medical providers, and psychiatrists. The BHPs are
master’s level licensed clinical social workers and/or licensed addiction specialists. The
medical providers are Infectious Disease medical providers (MDs, physician assistants,
nurse practitioners) located at the clinic. The psychiatrists have an MD and psychiatric
training and are also part of the coordinated team, or provide services at the same location
as the BHPs and medical providers.
Referral and screening. Clients are referred to the M-IOP program through: 1) screening
positive for substance use problems during routine clinic screening; 2) HIV medical
providers noting a substance use problem with a patient; and 3) by community-based
organizations.
1) Substance abuse/mental health screening
o When possible, all Infectious Disease Clinic patients are screened for
substance use annually using the Substance Abuse and Mental Illness
Symptoms Screener (SAMISS). The SAMISS has excellent sensitivity
(86%) and moderate specificity (75%) for identifying HIV patients with
active substance use disorders (Pence et al., 2005). In this project, the
administration of the screener has been handled in different ways. This
task has been handled by licensed clinical social workers, by medical
providers, and even by trained undergraduate student interns, but the
results are interpreted by professional substance abuse counselors or other
mental health providers. If there is a positive screen, the HIV-substance use
treatment program is discussed and referral to the BHP is made, if desired.
2) Medical provider referral
In some cases, a medical provider may be concerned about a patient’s
substance use and call the BHP into the exam room, or walk the patient to
the BHP’s office. We have found such personal hand-offs to be helpful in
transferring trust in the medical provider to trust in the BHP and in
increasing patient willingness to begin the program.
3) Community-based organization referral
Patients are also referred to the BHP by community providers. One of our
sites requires that the client become a patient at the ID clinic before starting
substance abuse treatment, and another site is willing to start with
substance abuse treatment and then link into medical care. Below outlines
the procedure:
Referral procedure:
o Providers obtain from the potential client the Substance Abuse/Mental
Health Screener and a signed Release of Information.
o Upon receipt of Screener information and signed Release of Information,
the BHPs verify eligibility (i.e., HIV+, using substances or afraid of
relapse, and for some sites, a patient at the ID clinic).
o The BHPs contact the potential client to schedule an appointment as
soon as possible. During this time, the purpose of treatment is reviewed
and barriers (e.g., transportation, anxiety, inconvenience, etc.) to
keeping appointments are addressed.
Individual therapy. At the beginning of treatment, each client is assigned to a clinical social
worker who is then responsible for assessing the client’s needs, engaging the client in
treatment, providing in-depth counseling, and working with other providers associated with the
client’s care plan. In doing so, the BHP can determine if the client needs additional treatment,
including psychiatric care (S Bouis, et al., 2007). In addition, the BHP may also need to fulfill a
case management role by linking the client with additional services or helping with applications
for disability or other support services. The frequency of individual sessions is determined by the
needs of the client. Sessions can range from once per month to twice a week (S Bouis, et al.,
2007).
Individual therapy is driven by the needs of the client. The initial meeting begins with an
introduction and education as to the roles of the BHP and other providers. The BHP attempts to
have a discussion around the goals of the client. However, it may be the case that the client is
not ready to have the discussion. The BHP utilizes the set of clinical skills and theories
described above (i.e., motivational interviewing, cognitive behavioral therapy, etc.) to develop
rapport and trust with the client, which usually allows for a discussion of goals. Often, clients do
not return to their individual therapy appointments. While BHPs often will follow-up with the
client, their unwillingness to participate is respected and understood within the stages of change
context.
The content of individual therapy is often determined by the client, and by what stage of
change the client is at. For instance, if the client is in the precontemplation stage, the BHP may
focus on providing information around HIV and/or drug use, or understanding mental health
treatment. As the therapeutic relationship develops and the client moves beyond the
precontemplative stage, the BHP may work with the client on developing coping skills for stress,
making healthy decisions, or understanding grief and loss. It is important to note that, as
mentioned above, the client’s stage of change may be fluid, and it is important to adapt
therapeutic skills to match the client’s readiness for change. Essentially, the BHP “starts where
the client is” and intentionally does not provide a rigid structure to the session. It is often the
case that the client’s current issues do not pertain to substance use or their HIV, and the BHP
utilizes the above skills to bring the conversation back to addiction. Over time, the BHP builds
rapport with the client and is able to utilize the clinical skills necessary to benefit the client.
If the BHP assesses that the client may benefit from group therapy, then they are
referred. However, this is a determination made by the client and BHP together. The client may
be more comfortable in an individual setting, or it may be the case the client is more comfortable
in a group setting. Some clients may not be appropriate for group therapy, for example, if they
have mental health problems that would make them particularly disruptive in group. However,
clients are usually referred to group therapy.
Group therapy. Although many clients benefit from individual therapy alone, the most
effective element of the M-IOP for most clients is group therapy. The BHPs who have
implemented the M-IOP have found group to be a very powerful way for clients to share
with others and to find acceptance, support, and suggestions. The essential role of the
group is to provide a space for triply and dually diagnosed individuals to be authentic, find
hope and belonging, and reduce the isolation that is commonly experienced among
multiply diagnosed individuals. Through the group process, participants develop close
relationships with each other and may even be instrumental in re-engaging members who
have dropped out.
The content and structure of group can vary based on the needs of the client
population, but in general, group meetings are one and a half hours long and have open
sharing, education and activities. Participants develop their own group rules, such as
tolerating and respecting that others are at different stages in their addiction. Honesty is
expected from everyone. While the group structure can change based on the needs of the
client population, there are general segments of group that seem to maximize
participation. These segments are outlined below (minutes are approximate):
o
o
o
o
Introduce new members (5 minutes), by each person giving first name (or
what they want to be called) and a short personal statement. Examples of
short personal statements include “a personal strength”; “3 things you
wouldn’t mind others knowing about you”; and “one positive change you
noticed in yourself this week.”
Review norms (10 minutes). It is important that members develop these
norms at the beginning. We have found that they will “own” and reinforce
the norms. Members take turns choosing a norm and explaining what it
means to them. All members agree to adhere to the norms. Take time to
process any difficulty.
Briefly cover any group business such as upcoming events or other general
information (5 minutes).
Psychoeducational presentation or open discussion (40 minutes for either)
o
o
o
Psychoeducational presentation (40 minutes). Clinicians, group
members, or guests (with prior group member agreement to protect
confidentiality) present. These activities should be active and
engage clients.
Ex:
 Substance abuse: disease process, relapse prevention,
identifying and resisting urges to use, etc.
 Emotional/mental: stress management, depression and
anxiety, relaxation strategies, anger management, selfesteem
 Physical: exercise, medication adherence strategies
 Skills: social skills, distress tolerance, time management,
organization, assertiveness
Open discussion: (40 minutes). Group members choose topics, which may
not be related to recent psychoeducational topics. It is recommended that
this activity begin with members stating whether they need “group time.”
The session may be facilitated by a clinician, a peer leader or group
member. It is important to balance contributions so dominant members
practice listening and controlling their urge to talk and quieter members
practice speaking up and taking a stand.
o
o
o
Lunch: 20 minutes (Note that not all of our sites have had the funds to
provide lunch). This segment is intended not only to provide needed
sustenance but also as a culturally important activity. Additionally, it serves
as “decompression” and a bridge to “reentering” the world and allows
clients to practice social skills.
o Food is provided by the program.
o Lunch is “hosted” by a group member who begins with a prayer or
blessing.
o Members serve themselves and return to the group to eat “family
style.”
Session end:
o Distribute bus passes if needed
o Schedule individual appointments as needed, etc.
o Serenity prayer or other closing ritual
Optional raffle: Session may include a raffle which can be “positioned” in
the schedule wherever needed. For example, to reinforce arriving on time,
conduct the raffle at the beginning of session. Or alternatively, to reinforce
attending through the entire session: give members arriving within first 10
minutes of group 2 tickets and thereafter 1 ticket. But conduct the drawing
at the very end of the session, prior to departing.
It should be noted that this is only a basic skeleton of what group looks like. Group members at
all sites come to group at a different stage or readiness for change. Also, different sites have
different delivery and protocol structures. The public and private urban clinic offer two groups a
week, with one dedicated to psychoeducation and the other to open discussion. When planning
for a psychoeducation group, this manual can help the BHP determine the key information, key
questions, and key resources for each topic. For a psychoeducation group, the BHP may select
a topic that best matches the needs of the group. During an open discussion group, the BHP
may pick up on themes like anger, poor decision-making, poor understanding of HIV, or the
medical consequences of non-adherence to medication. The BHP may intuit these themes as
an opportunity to provide psychoeducation, or, for example, an opportunity to help the group
explore ways to manage stress or anger. Much like individual therapy, the BHPs “start where
the client is”, and facilitate group based on the needs identified within the group. Consequently,
the minutes provided above are approximate, and the overall structure is implemented with
flexibility in order to accommodate current participant needs.
Psychiatric care. It is often the case that triply and dually diagnosed clients may benefit from
psychopharmacology. BHPs make this determination based on the severity of addiction or
mental illness, as well as past experiences with medication. Some questions that are
considered when thinking about referring a client to psychiatry are: Has the client used
behavioral health medication in the past? What was their experience like? To what extent are
they willing to use medication? Indeed, the decision to refer to a psychiatrist is made on a case
by case basis, with close collaboration with the client and the appropriate medical provider.
In the private-urban and public-urban settings in which the M-IOP was implemented, a
psychiatrist was on staff and accepted referrals from the BHP. The public-rural clinic refers
clients out to the Local Management Entity (LME) or other community based organizations,
which facilitates access to psychiatric care. It is also the case that while the two urban clinics
have part-time psychiatrists on staff, BHPs will refer clients to community-based services
depending on the specific needs of the client. Clients are seen every 4-6 weeks, depending on
the severity of the client’s condition.
Financing the medication differs across sites. At the public-urban clinic, most patients
are enrolled in the Ryan White AIDS Drugs Assistance Program, and are automatically enrolled
in Medicare Part D. This helps pay for psychotropic medication, yet clients face co-payments
that they are unable to afford. If clients cannot pay out of pocket, then the clinic pays for the
medication. Similarly, at the private-urban clinic, Medicaid and the Patient Assistance program
help finance psychotropic medication. At the public-urban clinic, a program called Charity Care
pays out-of-pocket costs for the uninsured. Many clients are also enrolled in Medicare D.
If a client is seeing a psychiatrist, regular communication between the psychiatrist, BHP,
and medical provider would ideally occur. At our different sites, this communication has
occurred through electronic medical records, interdisciplinary team meetings, handwritten notes
in charts, and verbal communication.
Cultural considerations. Cultural considerations are fundamentally important within the individual
and group settings. In the individual setting, sensitivity to different cultural, ethnic, religious, and
sexual backgrounds of the client is fundamental to the effectiveness of treatment. It is also
important to recognize the BHP’s own cultural background and potential biases. An employed
White male is not privy to the experiences and understandings of an unemployed homeless
African American woman. BHPs adhere to an ethnographic approach that attempts to capture
the norms the client ascribes to. This allows the client to tell their story, which better illustrates
their own values, beliefs, and worldview. This information is essential to building rapport and
trust with the client in the individual setting.
In addition, taking into account the cultural backgrounds of clients in the group setting is
necessary. For instance, some clients come from strong Christian evangelical backgrounds and
find their Christian faith as essential to their recovery. On the other hand, others experience
Christianity as the reason why they are rejected or ostracized from their family. Other examples
of cultural differences include beliefs around sexual orientation and differences in spirituality and
religiosity. Establishing group norms and rules that facilitate a safe and culturally sensitive
space for people from varied cultural backgrounds to participate in group is important.
Tying theory into individual and group therapy. As noted above, this treatment is undergirded by
cognitive behavior therapy, motivational enhancement therapy, and stages of change theory.
These three theories are quite complementary and are in no way mutually exclusive. It is
possible to use all three at once. For instance, a BHP may have assessed a client to be in the
Preparation stage of the Stages of Change. The BHP may work with the client using
motivational enhancement therapy to develop discrepancy between the client’s current drinking
and ideal life vision of strong relationships. In the same session, to help advance the client into
the action stage, the BHP may use cognitive behavioral therapy techniques to have the client
test alcohol-reducing behaviors (e.g., go on a walk instead of to the bar) and write down the
thoughts and feelings they have when trying this out.
BHPs draw on these theories throughout individual and group therapy. Stages of
Change theory is used more in individual than group therapy because the theory works by
noting the stage of an individual. However, cognitive behavioral techniques are used
throughout group and individual therapy, as are motivational enhancement techniques. For
example, even during group therapy a BHP would avoid argumentation and roll with resistance
if an individual in group is expressing resistance to treatment.
Modifications to Intensive Outpatient Therapy
As explained above, the complex needs of the triply and dually diagnosed populations
call for a flexible treatment modality that meets the client’s bio-psycho-social needs. To this end,
individual and group treatments can be modified based on the needs of the clinic. For example,
the private-urban clinic group sessions are offered twice a week, and while that is now true of
the more fully integrated public hospital, for many years this site offered group therapy only
once a week. Groups at each site follow a similar framework. However, each site modifies group
content and frequency based on the population needs.
At the private-urban and public-urban clinics, the first group of the week is an open
discussion that focuses on the issues patients present on that particular day. There are
introductions, overview of group rules, check-in and assessment, group discussion, and closing.
The second group of the week is a more structured psycho-educational experience with a
scheduled speaker following a brief check-in. Lunch and support for transportation are provided
both days. The average group size is about 12, and is composed of more men than women.
The clients that come to group are mostly from the local community and feature a strong identity
and cohesiveness. Individuals are able to mentor, model, and both give and receive support
and information in group sessions.
At the large public-rural clinic, group sessions are offered twice a week on-site at the
clinic conference room. Two of the social workers rotate the responsibility of group leader. The
format is similar to the urban clinics; however, members are less cohesive and group is less
structured to accommodate for the group’s diversity of stages of treatment and recovery. While
clients at the urban clinics have access to public transportation, many clients at this rural public
hospital do not have transportation to group or individual sessions. BHPs at this site offer
individual therapy over the telephone to accommodate for transportation barriers.
These adaptations reflect the programmatic flexibility necessary for the treatment of this
population. One barrier to treatment is the rigidity of traditional treatment models which are
often abstinence-based. Few patients identify total abstinence as a goal, but, for us, maintaining
the patient in care is a primary goal; therefore, this M-IOP approach begins where the patient is
in their stage of change, whether that is abstinence or not. Substance abuse is a chronic
disease impacting function throughout life. Clients and counselors collaboratively develop a
treatment plan based on the client’s vulnerabilities, strengths, and goals. Treatment plans are
dynamic, changing according to patient needs. Some patients receive only individual therapy,
while others participate in group therapy and/or receive psychiatric treatment. Treatment plans
are specific, goal directed, and measurable; goals are mutually agreed upon and incremental to
maximize success. Goals may include quitting one problematic substance while continuing
another or reducing the frequency and quantity of all substances. Goals may be work-related,
family or peer group-focused, or medically driven. Clients’ presenting complaints may diverge
from a programmatic goal of abstinence; patients may focus on psychiatric or medical
symptoms or social instability. The initial treatment focus is to fulfill the most urgent needs
identified. Stabilization through individual counseling or psychiatric medications may be needed
before addressing substance abuse, though they are not prerequisites to participation in care.
Session Content
For those interested in implementing this treatment, we have collated a set of materials,
included here, that we have used in both group and individual sessions. There is not a particular
order in which to cover topics. Instead, the BHPs determine what topics are of interest to current
group members or, for individual therapy, to individuals. Alternatively, sometimes BHPs
determine that there are certain skills that individuals or group members would benefit from. For
example, the need for improved anger management skills became evident for one ongoing
group. The BHPs raised the issue in group, noting that there are ways to develop anger
management skills. Following these suggestions from the BHPs, group members began asking
for training on anger management, which led to a multi-week module.
With this client-centered approach, not all clients will receive the same education and
skills training. The point, rather, is for clients to receive the education and skills training that will
most help them reduce substance use and attend to their HIV. That said, because the ultimate
goal is integrated substance use-HIV treatment and improvements in the two areas, it is likely
that all clients will receive education on the inter-relationships between HIV and substance use.
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infected persons. Journal of General Internal Medicine, 16, 625-‐633. Whetten, K., Reif, S., Ostermann, J., Pence, B., Swartz, M., Whetten, R., . . . Eron, J. (2006). Improving health outcomes among individuals with HIV, mental illness, and substance use disorders in the southeast. AIDS Care, 18, S18-‐S26. Whetten, K., Reif, S., Swartz, M., Stevens, R., Ostermann, J., Hanisch, L., & Eron, J. J., Jr. (2005). A brief mental health and substance abuse screener for persons with HIV. AIDS Patient Care STDS, 19(2), 89-‐99. Whetten, K., Reif, S., Whetten, R., & Murphy-‐McMillian, L. (2008). Trauma, mental health, distrust, and stigma among HIV-‐positive persons: Implications for effective care. Psychosomatic Medicine, 70, 531-‐538. Whetten, K., Rief, S., Ostermann, J., Pence, B. W., Swartz, M., Whetten, R., . . . Eron, J. (2006). Improving health outcomes among individuals with HIV, mental illness, and substance use disorders in the Southeast. AIDS Care, 18(S1), S18-‐S26. Williams, J., Shore, S., & Meschan, J. (2006). Co-‐location of mental health professionals in primary care settings: Three North Carolina models. Clinical Pediatrics, 45, 537-‐543. TABLE OF CONTENTS FOR THERAPY SESSION CONTENT
SCREENING AND ASSESSMENT
•
•
Screening and Assessment
Treatment Planning
PHYSICAL CONCERNS
•
•
•
•
•
•
•
•
•
•
•
•
HIV 101
Coping with HIV
Drugs 101/Substance Abuse
Negative Consequences of Drug Use
Basics of Recovery with Multiple Diagnosis
Cross Addiction/ Multiple Substance Abuse
Decision-making Balance
Medication Adherence
Handling Medical Side Effects
Nutrition and HIV / Multiple Diagnosis
Safer Sex/Risky Behavior
Understanding Mental Health and Mental Health Treatment
TRIGGERS
•
•
•
Identifying Physical and Emotional Triggers
Coping with Cravings
Stress
EMOTIONAL ISSUES AND COMMUNICATION
•
•
•
•
•
•
•
Healthy Relationships
Self-Esteem
Disclosure of HIV/Substance Abuse Status
Confidentiality
Grief/Loss
Anger Management
Trust/Honesty/Denial
RESOURCES
•
•
•
Identification of Community Resources
Coping with Financial Stress
System Navigation
SCREENING
Goal: To identify alcohol/drug abuse and indications of mental illness in patients
attending Infectious Diseases Clinic. The SAMHSA screening tool targets the collection
of information about current status and previous treatment and helps to determine if the
patient needs referral for treatment.
Key questions:
Using the SAMHSA screening tool identify areas of physical, mental and emotional
concern, explore patient attitudes toward diagnosis and treatment and inventory patient
resources and sources of support.
Key information:
•
•
•
•
•
•
Alcohol/drug use is often a way people cope with stress. There are other healthy ways to
cope and they can be learned.
Seeking treatment is the first step towards recovery.
There is good treatment available for substance abuse and mental illness.
Dispelling the myths and stigma involved: taking psychiatric medication and seeking
treatment does not mean a person is “crazy.”
If untreated, mental illness and substance abuse make it difficult to adhere to a
medication regimen.
Resources and treatment are available through individual and group therapy.
Accompanying documents: SAMHSA Substance Abuse and Mental Health screening tool
ASSESSMENT
•
Goal: Obtain a comprehensive assessment of the patient and functioning in multiple
aspects of his/her life in order to determine services needed. The assessment gathers
information in the following areas:
Key questions:
• Substance Abuse/Dependence
• Mental Health
• Family History
• Legal History
• Educational History
• Employment and Vocational History
• Military History
• Spiritual History and Cultural Influences
• Psychosocial History
Key information:
N/A
Accompanying documents: UNC School of Medicine Alcohol and Substance Abuse
Program: Psychosocial History
Brief Assessment of Substance Use and Mental Illness
12/5/07
Revised
UNC/Duke Infectious Diseases Clinics
Name _____________________________________________________ Date of Visit
- Gender
M
F
T
Phone Number (
) ________________________
Date of Birth
Alternate Phone (
) ______________________________
Street Address: ______________________________________________________________
City, Zip Code:
______________________________________________________________________
Case Manager Name: _______________________
Agency__________________________________
County:____________________ ID Clinic: ____________ Provider:
__________________________
INTERVIEWER: “I will be asking you some questions regarding substance abuse and mental
health issues. Because of the type of questions I will be asking you, they may cause you some
embarrassment. You may refuse any question or stop the questions at any time. Depending on
your answers, you may be eligible for treatment services and/or a research study." [ ] Patient
gave verbal consent to administer the screener
SA Screener
1. Do you currently drink alcohol? [ ] Yes [ ] No
If no: Did you ever drink? [ ] Yes [ ] No If no, skip to 5a.
If yes: When was the last time you drank? ( ) within the last 2 weeks ( ) 2-4
weeks
to 5a.
( ) 1-3 months ( ) 3-6 months ( ) 6-12 months If greater than one year, skip
2. In the last year, how often did you have a drink containing alcohol? (Alcoholic drinks include
one beer, one glass of wine, one mixed drink of hard liquor, or one wine cooler. Each of these
counts as one drink, unless they have double shots, which would equal two drinks.)
less
4
[]
4 or more times a week
1
[]
Monthly or
3
[]
2-3 times a week
0
[]
Never
2
[]
2-4 times a month
3. In the last year, how many drinks did you have on a typical day when you were drinking?
5
[]
10 or more
2
[]
3 or 4
4
[]
7 to 9
1
[]
1 or 2
3
[]
5 or 6
0
[]
Never
4. In the last year, how often did you have four or more drinks on one occasion?
4
[]
Daily or almost daily
3
[]
Weekly
2
[]
Monthly
1
[]
Less than monthly
0
[]
Never
5a. In the last year, how often did you use non-prescription drugs to get high or to change the
way you feel?
4
[]
3
[]
Weekly
2
[]
Monthly
1
[]
Less than monthly
0
[]
Never
5b. Which non-prescription drugs did you use? Please list all used weekly or more often.
0 [ ] Marijuana
1 [ ] Crack
2 [ ] Cocaine
3[]
Heroin
4 [ ] Other (specify)
_____________________________________________________
6a. In the last year, have you taken prescription pain medication?
[ ] No [ ] Yes
6b. If yes: In the last year, have you taken more than the doctor prescribed?
[ ] No [ ] Yes
7. In the last year, how often did you use drugs prescribed to you or to someone else to get high
or change the way you feel?
4
[]
1
[]
Less than monthly
3
[]
Weekly
2
[]
Monthly
0
[]
8. In the last year, how often did you drink or use drugs more than you meant to?
Never
4
[]
3
[]
Weekly
2
[]
Monthly
1
[]
Less than monthly
0
[]
Never
9. How often did you feel you wanted or needed to cut down on your drinking or drug use in the
last year, and not been able to?
4
[ ] Daily or almost daily
1
[]
Less than monthly
3
[]
Weekly
2
[]
Monthly
0
[]
Never
10. Have you ever had a problem (i.e. job/school, relationships, DUI ) with drugs, legal or
illegal? 0 [ ] No 1 [ ] Yes
MH Screener
11. To your knowledge, have you ever been diagnosed with a mental health disorder? [ ] No [ ]
Yes
Specify diagnosis if known
_______________________________________________________________
12. In the last year, did you ever take medication/antidepressants for depression or nerve
problems?
[ ] No
[ ] Yes
13. In the last year, was there ever a time when you felt sad, down, or depressed for 2 weeks or
more in a row?
[ ] No
[ ] Yes
14. In the last year, did you ever have a period lasting 1 month or longer when most of the time
you felt worried and anxious?
[
] No
[ ] Yes
15. In the last year, did you have a spell or an attack when all of a sudden you felt frightened,
anxious, or very uneasy when most people would not be afraid or anxious?
[ ] No
[ ] Yes
16. At anytime in your life, when you were not using drugs or alcohol, did you ever see or hear
things that other people did not?
[
] No
[ ] Yes
17a. At anytime in your life, have you experienced or witnessed a traumatic event(s) such as
physical or sexual abuse, domestic violence, street violence, or accident?
[ ] No
[ ] Yes
17b. If yes: In the last year, have you been troubled by flashbacks, nightmares, or thoughts of
the
trauma?
[ ] No
[ ] Yes
18. In the last three months, have you experienced any event(s) or received information that was
so
upsetting it affected how you cope with everyday life?
[ ] No
[ ] Yes
Mental Health History
19. Have you ever seen a mental health or substance abuse professional for problems with
emotions, nerves, or mental health?… [ ] No
[ ] Yes
[ ] Yes………In the last year? [ ] No
drugs or alcohol?……………………..[ ] No
[ ] Yes
20. Have you ever stayed overnight in a hospital or treatment center because of problems with
emotions, nerves, or mental health?….[ ] No
[ ] Yes
drugs or alcohol?……………………. [ ] No
[ ] Yes
21. Has anyone ever expressed concern about your…
emotions, nerves, or mental health?… [ ] No
[ ] Yes
drug or alcohol use…………………...[ ] No
[ ] Yes
Relationship to you:
CLINICIAN: In your judgment, is further substance abuse evaluation indicated?
[ ] Yes
[ ] No
In your judgment, is further mental health evaluation indicated?
[ ] No [ ] Yes
Pt declines referral. [ ]
_______________________________________________________________
Referral made? [ ] No [ ] Yes
__________________________________________________________
In your judgment, does the patient have signs of a HISTORY OF substance abuse? [ ] No [ ]
Yes
In your judgment, does the patient have signs of a HISTORY OF mental illness?
Yes
Clinician’s signature: __________________________________________
[ ] No [ ]
TREATMENT PLANNING
Goal: To identify problem areas of the patient’s life and to develop a specific plan to
address those issues that pose difficulty and require specific attention and focus.
Treatment planning can be specifically targeted in the following areas:
Substance Abuse/Dependence
Medical/Physical Diagnosis
Mental Health Diagnosis
Psychosocial Issues
Housing
Other (Employment, Relationships etc.)
Key questions:
What aspects of your life do you feel need improvement?
What changes would you like to see take place?
What are you willing to do to undertake these changes?
What tools or resources do you think would help support these changes?
Key information:
Each person has a right to live a healthy, productive life.
The quality of a person’s life is his/her responsibility.
Both healthy and unhealthy choices have consequences.
Accompanying documents: CADET Individual Treatment Plan
HIV 101
Goal : Patients will develop a basic understanding of HIV including common terminology,
physical indicators and diagnosis, transmission, testing and risk behaviors. This topic will be
discussed in a revolving, on-going fashion in both individual and group therapy sessions.
Patients need to understand how HIV is affecting their body and what they can do to keep
themselves as healthy as possible.
Key questions:
•
•
•
•
•
•
•
•
What is a CD4 count?
What is a Viral Load?
What is resistance?
What is adherence?
What are some behaviors and circumstances that positively and negatively affect CD4
and viral load?
What is the difference between an HIV and AIDS diagnosis?
What is super-infection and how can you avoid it?
How is HIV transmitted and what are the levels of risk with certain behaviors?
Key information:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
HIV is a chronic disease, not a death sentence
Analogy: CD4 cells as fighter cells (Army) against the virus – optimum for as many
soldiers as possible to engage in battle
Definition of Viral Load: amount of virus in the bloodstream, and treatment goal is for
that number to fall <48 (considered undetectable)
Undetectable does not mean a patient is cured but that the virus is laying low
and not replicating or destroying the immune system
HIV Transmission risk is always present but lower with an undetectable viral load.
Condoms should always be worn because of the risk of super infection
(contracting/transmitting multiple strains of HIV)
Resistance can happen even with perfect adherence (fidelity to one’s regimen)
but also may happens when ART’s are being taking as prescribed or drugs/etoh are
involved
AIDS diagnosis is given when CD4 count is 200 or below and patient has experienced
one opportunistic infection
Even when CD4 count goes above 200, person retains an AIDS
diagnosis: patient is more susceptible to infections as their immune
system is weaker
Levels of risk that accompany certain behaviors (anal, vaginal, and oral sex; IVDU;
mother-to child, breast milk)
Accompanying materials:
1.
2.
3.
4.
HIV 101: The Basics
What You and the People You Care About Need to Know About HIV/AIDS
HIV and its Treatment: What You Should Know
Web directory
sdsd
COPING WITH HIV
Goal: To provide information and emotional support to patients diagnosed with HIV. HIV
diagnosis is a life-changing event and patients will often go through the stages of grief before
coming to an acceptance of this diagnosis.
Key questions:
• When were you diagnosed with HIV? What were the circumstances? How did you
respond?
• What support systems do you have in place to help you live with this? To whom have
you disclosed?
• What do you know about HIV?
Key Information:
•
•
•
•
Living with any stigmatized diagnosis is difficult. You have at least three.
You still have control over your life and health. The more you know, the more control
you have.
You need at least one person (friend of family member) to know that you have HIV so
that you can talk through stressful events.
You are not alone.
Accompanying Materials:
•
•
Coping diary handout
Action Plan for the Holidays handout
Drugs 101/Substance Abuse
Goal: Patients will possess a general knowledge of the different classes of drugs and how
they impact the body and behavior. It is important for patients to understand the indicators
and effects of both tolerance and withdrawal. It is also important for patients to understand
how these drugs affect the course of their HIV and their adherence to medication.
Key questions:
• what are the different classes of drugs?
• how do drugs affect the brain and behavior?
• what is the effect of drugs/alcohol on HIV?
• what is the difference between abuse and dependence?
• what is a tolerance?
• what is withdrawal and what are the levels of risk and consequences associated with
withdrawal from specific drugs?
Key information:
• difference between opiates, depressants, stimulants, and hallucinogens
• brief overview of neurotransmitter, how they are depleted by drug use and the possible
result of long-lasting depression
• drug use can affect HIV by interfering with adherence, causing resistance and
• increasing the likelihood of infections. It can also make HIV medications more or less
potent, depending on which medications people are on and which drugs they are using.
• DSM diagnosis of abuse and dependence
• Definition of tolerance and describing how it occurs
• Definition of withdrawal and discussion of withdrawal symptoms (flu like feelings,
sweats, diarrhea, insomnia etc.)
• Identification of types of withdrawal that are life threatening
• (benzodiazepines and etoh)
Negative consequences of drug use
Substance abuse jeopardy
Substance abuse self-evaluation handout
Addiction and Recovery Road Map handout
Negative Consequences of Drug Use
Key Questions:
•
How has your life changed as a result of your drug and/or alcohol use?
•
How has your health changed as a result of your drug and/or alcohol use?
•
Did you contract HIV as a direct result of drug and/or alcohol use? For example, were
you an intravenous drug user and contracted HIV via sharing needles. Or, were you
addicted to drugs and/or alcohol and traded sex for drugs and contracted HIV during this
process?
•
How have your relationships changed as a result of your drug and/or alcohol use?
•
Have you been incarcerated because of drugs and/or alcohol?
•
Have drugs and/or alcohol hindered your progress in areas of life such as your education
or employment?
•
Do you regret your involvement with drug and/or alcohol?
•
Have members of your family become involved in drugs and/or alcohol as a result of
your involvement?
•
What consequence was most important to you that made you want to stop using drugs
and/or alcohol?
Key Information:
•
Drug and/or alcohol use/abuse, especially alcohol, can be passed down from generation
to generation in a family both socially and genetically.
•
Addiction affects the family of the addict just as much, if not more, than it affects the
addict himself.
•
The negative consequences of drug and/or alcohol abuse are present well after an addict
or alcohol is in recovery.
Many of the negative consequences of drug and/or alcohol abuse are irreversible. For example:
HIV, end stage renal disease, chronic hepatitis, changes in brain function, irreparable familial
relationships, fetal alcohol syndrome, human capital (education, employability, etc).
Many of the intangible consequences of drug and/or alcohol abuse are the hardest to repair such
as broken trust, lack of bonding due to parent being absent in child(ren)’s life, continued cycle of
poverty due to lack of or underemployment, poor healthcare due to lack of financial resources
and insurance, etc.
Basics of Recovery with Multiple Diagnoses
Goal: Patients are coping every day with being triply diagnosed. Many have unhealthy ways
of coping that may have formerly been protective, such as drug use in the face of trauma.
New coping mechanisms will be identified and worked into the recovery plan and old,
negative ways of coping will hopefully be extinguished.
Key questions:
•
•
•
•
•
How did you cope at first with your HIV diagnosis? How are you coping now?
What are your coping skills?
What are healthy versus unhealthy ways of coping?
Has your substance use served as a coping mechanism and if so, how?
How do you cope with your mental health disorder?
Key information:
•
•
•
•
Some coping mechanisms that once worked can stop working (this often happens
with substance abuse when people use to cope with things like abuse/trauma)
Everyone copes differently, but there are some common ways of coping that you
can learn and practice on a daily basis
Keeping a coping diary can help you monitor your thoughts, feelings, and coping
strategies, and can chart how you are doing with your goals
It is important to remember that you can get through this and that you are a person
who deserves self-respect and respect from others
“To achieve your dreams remember your ABC’s” handout
Primary Elements of Recovery handout
How are you doing? Packet
Defenses Against Change in Recovery handout
All Purpose Coping Plan handout
Exhibit 9: All-Purpose Coping Plan
Remember that running into problems, even crises, is part of life and cannot always
be avoided, but having a major problem is a time to be particularly careful about
relapse.
If I run into a high-risk situation:
1. I will leave or change the situation.
Safe places I can go:
2. I will put off the decision to use for 15 minutes. I'll remember that my cravings usually go
away in ___ minutes and I've dealt with cravings successfully in the past.
3. I'll distract myself with something I like to do.
Good distractors:
4. I'll call my list of emergency numbers:
Name:
Name:
Name:
5. I'll remind myself of my successes to this point:
6. I'll challenge my thoughts about using with positive thoughts:
Source: Adapted from Jaffee et al. 1988.
Cross Addiction/Multiple Substance Abuse
Goal: Patients will discuss their behavior and attitudes about the use of other substances and
receive facts and information about the affect of this use on treatment and recovery.
Key Questions:
•
Are you currently ingesting any mood altering substances?
•
Have you found that you have increased the use of a different substance since you have
been clean of your previous substance of abuse?
•
Do you feel it is OK to drink or use other substances that you never had an issue with
abusing in the past?
•
Do you feel recovery involves abstinence from all substances?
•
Do you know people who are in recovery from one particular substance, but have been
able to use other substances recreationally without becoming addicted?
•
Do you feel you would be able to continue to use substances without spiraling out of
control and becoming fully dependent and/or addicted?
•
Have you used prescription medications that were not prescribed to you?
•
Are you currently on any prescription pain medications?
•
Do you take prescription or over the counter sleep aids?
•
If prescribed pain and/or sleep aids, do you only take the prescribed dosages?
•
Do you feel as if you would be able to stop taking the pain and/or sleep medication if
they were no longer being prescribed to you?
Key Information:
•
Cross addiction is a very serious phenomenon that occurs when someone in recovery or
in active addiction begins to use other drugs and mood altering substances and then
become addicted to those substances in addition to their primary substance or substances
of abuse.
•
Many addicts, both in recovery and active addiction, make the mistake of substituting a
new substance for their substance of abuse believing that they only have “problems with
addiction” to their substance of abuse and that they can “handle” using other substances
recreationally.
•
For many addicts, even smoking cigarettes could be dangerous as they can trigger the
urge to begin to use other substances. This is especially true if cigarette smoking was
done in conjunction with drug and or alcohol abuse when the person was in active
addiction.
•
Medical providers have to be especially careful when prescribing pain medications and/or
sleep aids to persons in recovery or active addiction. This is why it is especially important
for medical providers and/or medical social workers/addictions specialists to do a
thorough mental health and substance abuse evaluations on all patients prior to
prescribing controlled substances and substances that are highly addictive.
•
There are some people who can handle drinking a beer occasionally and social drinking
post active addiction or while in recovery from alcoholism, but this is not a safe gamble
to take in your individual situation. This should be looked at as the EXCEPTION and not
the rule.
Decision-Making Balance
Goal: Patients will examine the ambivalence surrounding behavior change, personally evaluate
the pros and cons of engaging in behaviors with negative impact and the losses involved in
positive life style changes.
Key questions:
•
What are your attitudes about using another drug besides the drug of choice/substance
you are addicted to?
•
What are the specific and general pros and cons of substituting one drug/substance for
another?
•
What are the pros and cons of continuing in certain habits and relationships?
Key information:
•
•
Potential consequences of making change or continuing their current use or behavior.
Decision balance involved in considering future events or opportunities.
Decision Balance Worksheet
Out of the Frying Pan and Into the Fire handout
Ten Most Common Dangers handout
Alcoholism: Progression and Recovery handout
The Ten Most Common Dangers
1. Being in the presence of drugs, drug users, or places where you used to “cop” drugs or get
high.
2. Negative feelings, particularly anger, sadness, depression, loneliness, guilt, fear, and anxiety.
3. Positive feelings that make you want to celebrate.
4. Boredom.
5. Getting high on any drug, including alcohol.
6. Physical pain.
7. Listening to drug use stories and dwelling on getting high.
8. Suddenly having a lot of cash or expecting a check.
9. Using prescription drugs that can get you high, even if you use them properly.
10. Believing that you are finally cured and no longer addicted, that is, that none of the above
situations nor anything else stimulate you to crave drugs and that, therefore, it’s safe for you to
get high occasionally.
Medication Adherence
Goal: Adherence to HIV treatment is vital to long-term survival. The medications are far less
forgiving of missed doses than the typical. Adherence to your psychiatric meds is essential to
battling addiction. Patients who are in active addiction usually do not adhere to their medication
regimen and even when patients are in the recovery process and not in active addiction it is often
difficult for them to learn to take their medicine as prescribed because their lives have been so
chaotic. It is as important to assess the patient's readiness for change in regard to taking medicine
as it was to assess his//her readiness for change to engage in substance abuse treatment.
Key Questions:
•
•
•
•
•
•
•
•
Do you take your medications as prescribed? What prevents you from doing that?
Do you understand the consequences of repeatedly missing doses?
Do you understand the importance of adhering to a medication regimen?
How do drugs and/or alcohol affect your ability to take your medications?
What are the (physical, financial, social) barriers to the patient’s ability to adhere to
his/her medication regimen?
Does the patient have to hide medicine so that no one finds it because no one knows
his/her HIV status?
Are you having negative side-effects to the medicine, such as nausea, diarrhea, or night
sweats?
Are you able to swallow large pills or do they need liquid medication?
Key Information:
•
•
•
•
•
•
•
•
Missing doses leads to viral resistance. Resistance to multiple classes of HIV meds can
make it extremely difficult for you to stay healthy.
Being drunk or high will impair your ability to take your meds.
Common strategies to help them remember to take their meds.
There are a limited number of medication regimens and each time you "blow" a
regimen by not taking it correctly and becoming resistant, there is one fewer medication
options available to you.
CD4 counts, viral loads, and how they are affected by taking medication as prescribed.
Educate the patient about the importance of informing the nurse or medical provider
about side effects and the hazards of stopping the medication on his/her own.
Ask the patient what he/she thinks would help them be able to adhere to the medication
regimen.
What is Treatment Adherence? handout Handling Medical Side Effects Goal: Patients will receive facts and information about their medication and treatment program, possible side effects, how to cope with them and when to seek medical advice. Key questions: •
•
•
•
•
•
•
•
•
•
•
Are you currently on an ART regimen? Have you experienced any negative side effects from your medications? Have you or do you use drugs while on your ART regimen? Have you spoken with your ID medical provider about any changes you’ve noticed since being on medications? Have you been taking your medications as prescribed each and every day? Are there side effects that you used to experience that you no longer experience? Was there anything in particular that you did that helped you through these side effects until they subsided? Have you used drugs and/or alcohol as a result of trying to cope with side effects of your medications? Have you found that your drug and/or alcohol use has helped to ease or worsen the side effects of your HIV medications? Have you had to stop your regimen due to side effects? What are some positive best practices that you have used to deal with side effects of your medications? Have you been able to talk with others (who are on or have been on the same medications ) to get support for dealing with side effects? Key information: •
•
•
•
•
All medications have side effects whether they are HIV or non-‐HIV medications. Many of the side effects of HIV medications will subside once your body has adjusted to the medication. The adjustment period can be difficult and it is important to get the necessary support during this time. There are some side effects that, if left unmonitored, can be dangerous, so it is very important to monitor changes in your body and let your provider know immediately of any of these changes. It is equally important to be open and honest with your ID provider about drug and/or alcohol use. Your provider needs to know if the drugs and/or alcohol use are a contributing factor in the exacerbation of the side effects that you are experiencing. No two patients are alike. While it is important to have social support from others living with HIV/AIDS who have also experienced side effects to medications, keep in mind that each person’s disease is different. How the disease and the medications act can vary according to the individual. One person might experience the whole list of possible side effects for a particular medication •
•
while another person might not experience any side effects. It is important to seek reliable information about your personal condition. Nutrition plays a big role in how the body reacts to certain medications. Talk to your provider about what role nutrition plays in your particular regimen and ask him/her if there are dietary suggestions for dealing with side effects. If you receive other medical care outside of the healthcare network that your ID provider operates within, it is importation to make your ID provider aware of any other medical conditions and/or medications that you are taking in addition to your HIV medications. There may be interactions between your HIV meds and other medications that should be avoided and there may be some medications that exacerbate the possible side effects of your HIV medications. Nutrition and HIV Goal: Good nutrition can have a significant impact on the overall health and well-‐being of patients in recovery and treatment. Patients will learn the basics of good nutrition and specific foods to include and avoid at this critical time. Key questions: What is your typical diet? How does your diagnosis affect your appetite and food choices? Are you able to shop and prepare nutritious foods? Do you have enough money for food? Key information: Basics of healthy nutrition and diet How good nutrition affects HIV Supplements Accompanying Materials: Nutrition and HIV handout Safer Sex/Risky Behaviors Goal: Patient will be able to identify specific practices and behaviors that present physical risk and safe alternatives. Key questions: -‐
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Using principles of Motivational Interviewing/Motivational Enhancement Therapy investigate and address patient’s reluctance and ambivalence regarding risky behaviors. Key information: Provide most current information and statistics on dangers of risky behaviors. Clinician must be knowledgeable of cultural norms and beliefs Use principles of CBT to address patient’s assumptions Pros and cons of problematic behaviors, being careful to understand and address issues specific to patient’s situation. Understanding Mental Health and Mental Health Treatment Goal: Patient will understand the relationship between his/her different diagnoses and the implications for treatment and care. Key questions: •
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What are your thoughts, beliefs and ideas about individuals with a mental health diagnosis? What do you know about treatment for specific diagnoses? How does substance abuse affect a person with a mental health diagnosis? Key information: •
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Connection between mental health, addiction and HIV, especially as regards negative consequences of untreated mental illness (e.g. adherence to medications and psychotherapeutic treatment) Physiological connection between drug abuse and long-‐term psychological and physiological complications. Explanation of diagnosis to patient and address common misconceptions (e.g. depressed does not equal “crazy”) Additional notes: Clinician must be knowledgeable of cultural norms and beliefs around mental illness and treatment. Use principles of CBT to address patient’s assumptions. Clinician should have basic understanding of psychotropic drugs and their side effects and interactions with HIV medicines. Use principles of Motivational Interviewing/Motivational Enhancement Therapy to address reluctance and ambivalence as regard psychotherapy and pharmacotherapy. TRIGGERS •
Identifying Physical and Emotional Triggers •
Coping with Cravings •
Stress Identifying Triggers Goal: Triggers exist everywhere and can lead to relapse if not actively resisted and dealt with effectively. They can be external (being around dealers) or internal (feeling lonely). Goal is for patients to identify their personal triggers and what coping mechanisms they can employ to not relapse. Key questions: •
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what are your personal triggers (i.e. cash, being in neighborhoods where you have used, feeling lonely etc.) what coping mechanisms or plans can you put into place to reduce triggers and your urge to use? Key information: •
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triggers can be thoughts, feelings, actions, people, places, or things goal is to figure out how to avoid or how to cope with the trigger(s) Accompanying materials: Check list of symptoms of relapse handout Recognizing relapse triggers handout Identifying internal triggers handout Internal trigger questionnaire Internal trigger Chart Identifying external cues and triggers handout External trigger questionnaire External trigger Chart Signs of tension and anxiety handout A Checklist of Symptoms Leading To Relapse
The time to prevent a relapse is long before the irrational thinking has reached the final
insanity of taking the first drink, pill or fix. The following is a list of common symptoms
leading to a possible relapse - or what the 12 Step programs commonly call "stinking
thinking."
1. EXHAUSTION: Allowing yourself to become overly tired or in poor health. Many
chemically dependent people are also prone to work addictions. Perhaps they are in a
hurry to make up for lost time or overworking to compensate for feelings of guilt or
personal inadequacy? Good health and enough rest are essential to recovery. If you feel
physically well, you are more apt to have a healthy and optimistic mental outlook (think
well). If you feel physically poor or fatigued, your thinking is more likely to deteriorate
toward becoming negative. A pessimistic attitude may follow and if you feel badly
enough, you might begin thinking that a drink couldn't make it any worse or that it
could help you return to a positive frame of mind.
2. DISHONESTY/DENIAL: This begins with a pattern of unnecessary little lies
and deceits with fellow workers, friends and family. Then what follow are important lies
to yourself. This is called rationalizing, making excuses for not doing what you do not
want to do, or for doing what you know you should not do. Small deceits sow the seeds
for major dishonesty.
3. IMPATIENCE: Things are not happening fast enough. Or others are not doing
what they should or what you want them to. Impatience involves having a hard time
tolerating frustration and delayed gratification; wanting everything “yesterday.” Give
yourself the time you need for you to get well and for things in your life to change as a
result.
4. ARGUMENTATIVENESS: Arguing small and ridiculous points of view
("argumentativeness") indicates a need to always be right. "Why don't you be
reasonable and agree with me?" Are you looking for an excuse, a reason, or permission
to take a drink or a drug? Rather than arguing with others, try considering others’
differing points of view. Consider the importance of learning an attitude of acceptance
of your addiction and of the value of tools of recovery.
5. DEPRESSION: Unreasonable and unaccountable melancholy and despair may
occur from time to time as a natural part of getting well from a chemical dependency.
Periods of depression are times when risk of relapse is very high. Deal with your
negative feelings by talking about them. There are different kinds of depression. Some
are part of the recovery process. All need to be talked out. Lingering and severe
depression may need to be checked out by a professional familiar both with depression
and the recovery process.
6. FRUSTRATION: You may feel frustration with people as well, because things may
not be going your way. Remember everything is not going to be just the way you want
it. You must develop new coping skills and outlets to cope with frustration.
7. SELF-PITY: "Why do these things happen to me?" "Why must I be an addict?"
"Nobody appreciates all that I am doing." In other words, "Poor me, poor me, pour me
a drink!" Self-pity is a breeding ground for negative and low self-esteem. Everyone
has their issues and problems, some more, some less - but focusing on feeling sorry for
yourself is not going to improve your life.
8. COCKINESS/OVERCONFIDENCE: This dangerous attitude of "I've got this
problem licked. I no longer fear addiction!" may lead to entering drinking/drugging
situations to prove to others that you don’t have a problem. Do this often enough and it
will wear down your defenses against relapse. Don't test your recovery. You may lose
9. COMPLACENCY: One may become complacent and have thoughts of "Drinking
was the farthest thing from my mind." Not drinking was no longer a conscious thought
either! It is dangerous to let up on discipline because everything is going well. A little
fear and constant awareness of one's thoughts, feelings, and vulnerabilities are good
things to develop. More relapses occur when things are going well than when things are
going badly.
10. EXPECTING TOO MUCH FROM OTHERS: "I've changed; why hasn't everyone
else" It's a plus if others do change, but change or not, the business of recovery is your
business. They may not trust you yet or may be looking for more evidence of your
improved physical and mental health. Be prepared to deal with disappointment in your
expectations of others. Expecting others to change their lifestyle just because you have
will set you up for a lot of frustration & other negative feelings.
11. LETTING UP ON DISCIPLINES: Don’t let up on the daily structure within your
day. Whether it includes prayer, meditation, daily inventory, exercise, and/or AA/NA
attendance, keep with it! Letting up on these things can stem from complacency or
boredom with your program of recovery. You cannot afford to be bored with your
recovery. The cost of relapse is always too great.
12. USE OF MOOD ALTERING CHEMICALS: You may feel the need to ease things by
taking a prescription or over-the-counter drug prescribed by your doctor. You may
never have had a problem with other chemicals, but be careful as taking medication can
be a subtle way to have a relapse. The reverse of this is true for drug dependent
persons who start to drink. Remember, once addicted to one substance the potential to
become quickly addicted to another definitely exists. So, if you and your doctor decide
together that perhaps trying a medication may help with your mood, that’s fine, but be
careful and choose wisely. Stay in good communication with your physician regarding
the effects of the medication and by all means, stay away from using addictive or
commonly abused medications (i.e.: Vicoden , Klonopin , Percocet , Valium ).
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13. WANTING TOO MUCH: Do not set goals you cannot reach with normal effort. Do
not expect too much. It's always great when good things happen that you were not
expecting. You will get what you are entitled to, as long as you do your best, but
maybe not as soon as you think you should. "Happiness is not having what you want,
but wanting what you have."
14. FORGETTING GRATITUDE: You may be looking negatively on your life,
concentrating on problems that still are not totally corrected. It is important to
remember where you started from and how much better life is now.
15. "IT CAN'T HAPPEN TO ME": This kind of thinking is very dangerous. Almost
anything can happen to you and is all the more likely to happen if you become careless
with your recovery. Remember that alcoholism is a progressive disease and you will be
in even worse shape if you relapse.
16. OMNISCIENCE: This is an attitude that results from a combination of many of
the above: you now have all the answers for yourself and others.* No one can tell you
anything. You ignore suggestions or advice from others. If such is the case, relapse is
imminent unless drastic changes take place. ("Omniscience' is derived from two Latin
words: "Omnia Scit," meaning: "He knows it all.")
In addition to the above, ask yourself:
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Do I have a recovery Plan?
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Am I carefully following that plan?
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Have I let up on any part of that plan?
Identifying Internal Triggers Stimulant cues can include certain feelings and emotions that can trigger drug hunger. Below are
lists of emotions, feelings, and circumstances. Check those items that, in the past, have been
associated with your stimulant use. Within each list, circle the item that you think may be the
internal trigger with which you may struggle the most.
"Negative" Feelings •
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Feeling afraid
Feeling anxious
Feeling guilty
Feeling irritated
Feeling
overconfident
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Feeling angry
Feeling criticized
Feeling hateful
Feeling jealous
Feeling overwhelmed
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Feeling ashamed
Feeling depressed
Feeling inadequate
Feeling left out
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"Normal" Feelings •
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Feeling bored
Feeling insecure
Feeling nervous
Feeling sad
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Feeling
embarrassed
Feeling lonely
Feeling
pressured
Feeling tired
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Feeling frustrated
Feeling neglected
Feeling relaxed
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"Positive" Feelings Feel like celebrating
Feeling excited
Feeling happy
Feeling passionate
Feeling strong
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How do you feel immediately before using stimulants?
Typically, how do you want to feel immediately before using stimulants?
In the past few days, what were you feeling when you either used or wanted to use
stimulants?
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Feeling confident
Feeling exhausted
Feeling "normal"
Feeling sexually aroused
________________
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Identifying External Cues and Triggers Stimulant cues are those things in your life that remind you of stimulant use and can trigger drug
hunger. Below are lists of people, places, events, objects, and activities. Check those items
around which or whom you have frequently used stimulants. Within each list, circle the item that
you think is most strongly associated with your stimulant use.
People •
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Drug dealers
Employer
Dates
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Friends
Family members
Neighbors
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Coworkers
Spouse/lover
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Places •
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Neighborhoods
Hotels
Certain freeway exit
School
Friend's home
Worksite
Bathrooms
Downtown
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Bars and clubs
Concerts
Stash storage place
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Parties
Before work
Going out
After sex
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Events •
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Meeting new people
Payday
During work
Before sex
Anniversaries
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Group meetings
Calls from creditors
After work
During sex
Holidays
Objects •
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Paraphernalia
Movies
Credit cards
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Magazine
Television
ATM machines
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Pornography
Cash
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Behaviors and Activities •
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Listening to certain music
Going out to dance or eat
When hanging out with friends
When driving
After paying bills
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Before or during a date
When home alone
When dancing
After an argument
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Coping with Cravings Goal: Cravings are a normal but disturbing part of the recovery process. They can be very intense but typically do not last more than a few minutes. Those few minutes are crucial and can determine whether a patient chooses to use or not. Goal is for patients to identify high-‐risk situations when and where cravings are most likely to occur and what can be done to counteract them. Key questions: •
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are there certain times or instances when you tend to experience cravings? how long do they typically last? what are some things you can do when experiencing a craving so you don’t use? Key information: •
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cravings are a common and normal (and problematic) part of recovery Cravings typically do not last more than a few minutes but can feel very overwhelming Cravings can be physical and/or psychological Accompanying materials: Relapse Prevention Workbook Some Principles of Deactivation of Craving handout Deactivation of Craving: A Case to Consider handout Warning Signs of Relapse (I) handout Warning Signs of Relapse (II) handout Difference between Urge and Craving handout Coping with Urges and Cravings handout Interventions for Urges/Cravings handout Relapse Cycle handout DE-ADDICTION TO CRAVING
A Case to Consider: “Frank”
I’m confused and upset. I shot some dope the other day. Don’t ask me why
because I don’t know why. I mean I know I did it--but I didn’t want it to happen,
The day started off great. It was a holiday and I didn’t have to go to work and I
was really in a good mood. So I just walked downtown thinking I might do some
shopping. Then I ran into this guy I used to hang with. Actually he came up to
me and we shot the breeze for a quick second but I left before drugs were even
mentioned. After I walked away I thought about this place where I used to buy
some pretty sharp clothes and it wasn’t too far away--so I headed over there.
All I wanted were some shirts or sweaters I’d look good in. To get to the store I
had to pass near where I would sometimes cop. Believe me, I had no intention of
getting drugs and for all I knew the dealer didn’t even live around there anymore.
But I really started thinking about the old days as I got closer to that apartment.
And then I felt an urge. I wasn’t going to do it--I just had the want. That’s when
these two other guys I used to know--users, but nice guys--saw me and asked me
was I looking for something. I said, “Not really.” I didn’t want to say I wasn’t using
drugs because if that was true I’d have no reason to be standing on that corner.
It was a real weak feeling. Then one of the guys took out a joint and we smoked
it. (Actually I had a little pot at a party recently) I can’t even think about what
happened next. But a half-hour later they had my money and I had shot a bag. I
got high, but I felt disgusted. It was sickening.
Now you’re not going to anything, will you? My parents think everything’s great
because of my job and apartment and all that. And I have this straight girl friend.
She doesn’t even know about the past. I sort of want to tell my cousin--the one
who used to take pills and drink--since he’s been clean for years and helped me
out. But what could he say to me that I don’t already know? I know I shouldn’t
have been there and I already feel terrible. Maybe I’ll never be strong.
Questions:
I. Did Frank “choose” to get high? Why or why not?
2. What should he do now? If he’s being honest and determined, what else does
he need?
3. What can be learned from the incident?
Relapse Warning Signs
1. Apprehension about well being.
2. Denial
3. Adamant commitment to staying clean.
4. Compulsive attempts to impose staying clean on others.
5. Defensiveness
6. Compulsive behavior
7. Impulsive behavior
8. Tendencies toward loneliness
9. Tunnel vision
10. Minor depression
11. Loss of constructive planning
12. Plans begin to fail
13. Idle daydreaming and wishful thinking.
14. Feeling that nothing can be solved.
15. Immature wish to be happy.
16. Periods of confusion
17. Irritation with friends
18. Easily angered
19. Irregular eating habits
20. Listlessness
21. Irregular sleeping habits
22. Progressive loss of daily structure
23. Periods of deep depression
24. Irregular attendance at meetings
25. Development of an "I don't care" attitude.
26. Open rejection of help
27. Dissatisfaction with life
28. Feelings of powerlessness and hopelessness
29. Self-pity
30. Thoughts of social using
31. Conscious lying
32. Complete loss of self-confidence
33. Unreasonable resentments
34. Discontinuing all treatment
35. Overwhelming loneliness, frustration, anger and tension
36. Start of "controlled" using
37. Loss of control
Stress
What is Stress?
What is Stress?
Stress is the "wear and tear" our bodies experience as we adjust to our continually changing
environment; it has physical and emotional effects on us and can create positive or negative
feelings. As a positive influence, stress can help compel us to action; it can result in a new
awareness and an exciting new perspective. As a negative influence, it can result in feelings of
distrust, rejection, anger, and depression, which in turn can lead to health problems such as
headaches, upset stomach, rashes, insomnia, ulcers, high blood pressure, heart disease, and
stroke. With the death of a loved one, the birth of a child, a job promotion, or a new relationship,
we experience stress as we re-adjust our lives. In so adjusting to different circumstances, stress
will help or hinder us depending on how we react to it.
Stressful Situations in Early Recovery
Giving up old acquaintances, developing healthy sober friendships
Addressing old or new challenges for the first time without a
chemical filter
Communicating with your family on issues you previously avoided
Experiencing intense feelings, and often mood swings, without being
able to numb them
Responses to Stress
Physiological
Increased heart rate Diarrhea
Elevated blood pressure Nausea and/or vomiting
Tightness of chest Sleep disturbance
Difficulty in breathing Anorexia
Sweaty palms Sneezing
Trembling or twitching Constant state of fatigue
Tightness of neck or back muscles Accident proneness
Headache Susceptibility to minor illness
Urinary frequency Slumped posture
Bruxism (grinding of the teeth), TMJ
Emotional
Irritability Diminished initiative
Angry outbursts Tendency to cry
Feeling of worthlessness Sobbing without tears
Depression Reduction of personal involvement
Suspiciousness with others
Jealousy Tendency to blame others
Restlessness Critical of self and others
Anxiousness Self-depreciating
Withdrawal Lack of interest
Intellectual
Forgetfulness Lack of attention to details
Preoccupation Past oriented rather than present or
Rumination future oriented
Mathematical and grammatical errors Reduction in creativity
Errors in judging distance Diminished productivity
Blocking Diminished fantasy life
Lack of concentration Reduction in interest
How Can I Manage Stress Better?
Identifying unrelieved stress and being aware of its effect on our lives is not sufficient for
reducing its harmful effects. Just as there are many sources of stress, there are many
possibilities for its management. However, all require effort toward change: changing
the source of stress and/or changing your reaction to it. How do you proceed?
1. Become aware of your stressors and your emotional and physical reactions.
Notice your distress. Don’t ignore it. Don’t gloss over your problems.
Determine what events distress you. What are you telling yourself about meaning of these
events?
Determine how your body responds to the stress. Do you become nervous or physically
upset? If so, in what specific ways?
2. Recognize what you can change.
Can you change your stressors by avoiding or eliminating them completely?
Can you reduce their intensity (manage them over a period of time instead of on a daily
or weekly basis)?
Can you shorten your exposure to stress (take a break, leave the physical premises)?
Can you devote the time and energy necessary to making a change (goal setting, time
management techniques, and delayed gratification strategies may be helpful here)?
3. Reduce the intensity of your emotional reactions to stress.
The stress reaction is triggered by your perception of danger…physical danger and/or
emotional danger. Are you viewing your stressors in exaggerated terms and/or taking a
difficult situation and making it a disaster?
Are you expecting to please everyone?
Are you overreacting and viewing things as absolutely critical and urgent? Do you feel
you must always prevail in every situation?
Work at adopting more moderate views; try to see the stress as something you can cope
with rather than something that overpowers you.
Try to temper your excess emotions. Put the situation in perspective. Do not labor on the
negative aspects and the “what if’s.”
4. Learn to moderate your physical reactions to stress.
Slow, deep breathing will bring your heart rate and respiration back to normal.
Relaxation techniques can reduce muscle tension. Electronic biofeedback can help you
gain voluntary control over such things as muscle tension, heart rate, and blood pressure.
Medications, when prescribed by a physician, can help in the short term in moderating
your physical reactions. However, they alone are not the answer. Learning to moderate
these reactions on your own is a preferable long-term solution.
5. Build your physical reserves.
Exercise for cardiovascular fitness three to four times a week (moderate, prolonged
rythmic exercise is best, such as walking, swimming, cycling, or jogging).
Eat well-balanced, nutritious meals.
Maintain your ideal weight.
Avoid nicotine, excessive caffeine, and other stimulants.
Mix leisure with work. Take breaks and get away when you can.
Get enough sleep. Be as consistent with your sleep schedule as possible.
6. Maintain your emotional reserves.
Develop some mutually supportive friendships/relationships.
Pursue realistic goals which are meaningful to you, rather than goals others have for you
that you do not share.
Expect some frustrations, failures, and sorrows.
Always be kind and gentle with yourself–be a friend to yourself.
Healthy Relationships Goal: Relationships can be a crucial and supportive element in the recovery process and/or act as a barrier and impediment. Patients need to be able to differentiate between healthy and unhealthy relationships and how best to seek out and maintain the healthy ones. It is important for patients to understand that romantic relationships early in recovery can be detrimental and why it is important to resist the development of a romantic relationship with another group member. Patients will learn the cycle of esteem and will work on developing their self-‐esteem. Key questions: •
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Who are the important people in your life? What role does your family of origin play in your life now? Are the people in your life positive or negative influences? Who knows about your HIV and addiction? How does that affect those relationships? What differentiates healthy from unhealthy relationships? Why are relationships important? How would you describe the strongest relationships in your life? Have you ever been in an abusive relationship as an adult? Have you found it difficult to work with medical and/or social service providers? How often, if ever, do you find yourself in physical or extreme verbal altercations? Do you ever feel isolated or abandoned? How would you describe your relationships with your family of origin? How can relationships change with drug use? How can you maintain your own identity/recovery in a relationship? What happens when both people in the relationship use? What if only one person uses? What are the problems with having a relationship with someone in group? What is important to know when one person is HIV positive and one is negative (serodiscordant relationships)? Key information: •
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Healthy relationships are impossible when drug/etoh use is involved One person being clean does not make the relationship any healthier (concept of enabling) Why there is the 12-‐step rule of no relationships for the first year clean Reasons why group relationships are not encouraged (interferes with purpose of group, can influence one’s recovery and their support net work, can result in one or both people leaving the group if the relationship disintegrates Positives and negatives of childhood remain throughout life, but don’t have to be remain negative forces Wise decisions aren’t always easy when it comes to friends and family. Violence and addiction are generationally cyclical. Patients must be aware and prepared to break the cycle. The clinic and CADET staff are available to assist. • The people with whom we choose to interact play a huge role in the ability to be healthy and sober. • HIV relationships are physically healthy as long as condoms are used. Important for partner to have been informed of HIV status, understand HIV and the attendant risks. •
Accompanying Materials: Healthy Relationships handout The Body: Serodiscordant Relationship handout RELATIONSHIPS
Being in a healthy relationships means…
1. Respecting individuality, embracing differences, and allowing each person to “be
themselves”
2. Discussing things, allowing for differences of opinion, and compromising equally.
3. Expressing and listening to each other’s feelings, needs, and desires.
4. Trusting and being honest with yourself and each other.
5. Resolving conflicts in a rational, peaceful, and mutually agreed upon way.
Other Characteristics of a Healthy Relationship
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Each person has individual rights
Open communication
Trust
Mutual respect for opinions
Equality in decision making
Shared respect for each other’s values
Respect for each person’s sexual boundaries
Willingness to honestly discuss problems
Willingness to tell your partner what you need or want
Honesty
Always using a nonviolent approach to resolving conflict
Understanding that conflict and anger are okay
Taking responsibility for yourself
Accepting the fact that everyone makes mistakes
Owning your own mistakes
Commitment
Joy and playfulness
Direct, kind, and clear communication is the most effective way to communicate
with your partner. We can minimize conflict by learning to express our needs, wants,
hopes, and desires clearly and caringly. We can also listen to other people and hear
what they have to say. Respecting them as well as ourselves is part of this process.
Examples:
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“I want this, but what do you want?”
“How can we work this out?”
“I care about what you need. I want to solve this.”
Results:
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You often get your needs met.
You build and maintain the relationship.
Your partner respects you.
You work towards peace in the relationship.
Signs of an Unhealthy Relationship
A climate of negativity within the relationship; a disproportionate number of negative
comments about each other vs. positive comments about the relationship. E.g. “we
never have any fun,” vs. “we laugh a lot.” Constant negativity can be emotionally
draining.
Allowing hurtful behavior from one another. A high tolerance for bad behavior in the
beginning of a relationship may lead to trouble down the road.
Conflict escalates from the get-go with one partner making a critical or contemptuous
remark in a confrontational tone. Blaming and exploding cause more harm than good…
as can avoiding or burying the conflict. E.g. “give it to me now…,” or “I don’t care, it
doesn’t matter to me…”
Seek help early. If you and your partner are experiencing problems in your
relationship, consider seeking help from others instead of living with the unhappiness
for too long. The UCTC offers both individual and couples counseling, and often has
groups running that focus on establishing healthy relationships.
Serodiscordant Relationships From Canadian AIDS Treatment Information Exchange March 2004
"Serodiscordant couples raise the thorniest set of issues, because they must face major concerns
about both transmission and care-giving."
What Is a Serodiscordant Relationship?
A serodiscordant couple is made up of one person who is HIV negative and one who is HIV
positive.
The term serodiscordant originates from the word "seroconversion", which is the medical term for becoming HIV positive, and the word "discordant", which means "at odds". Some people don't like the term serodiscordant and may use other terms to describe their
relationship. Some of these terms are:
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magnetic sero-‐divergent inter-‐viral positive-‐negative mixed sero-‐status mixed status. The challenges that you may experience while in a serodiscordant relationship may not have
much to do with how you or your partner got infected with HIV. The challenges are based on the
fact that HIV is present in your relationship.
"Accept the reality that your serostatus is 'opposite' and talk about what a positive and
negative identity mean to you. Neither experience is more legitimate. Both deserve
respect."
Things You or Your Partner May Be Worried About ...
•
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•
•
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•
rejection or abandonment losing your partner infecting your partner or being infected practising safer sex health issues and illness following treatment plans (treatment adherence) effects of treatment or illness on body image and energy levels loss of sex drive or sexual desire caregiving responsibilities family planning or financial planning for the future •
disclosure and privacy issues in talking to others about your relationship and HIV status. Communication Is the Key ...
Relationships of any kind need good communication strategies in order to stay healthy.
All couples face conflict and compromise -- issues about sex, household chores, financial
matters, and family dynamics are common. Because of HIV, serodiscordant couples face added
fears and anxieties. For example, worries about transmitting the infection to the HIV-negative
partner can lead to sexual problems and emotional withdrawal. And body changes like
lipodystrophy (fat redistribution, which is a side effect of medication) can result in depression
and cause the HIV-positive partner to feel less attractive.
Communication is the key to resolving conflict, reducing stress and keeping your relationship
strong.
Try to be open about your feelings with your partner. Talk about:
•
•
•
•
your feelings of grief, anger or fear your concerns about providing care in times of illness what sexual practices you feel comfortable with your needs in terms of support and information. Ask questions about anything you don't understand.
Just like other couples, those who are dealing with HIV need to respect each other's decisions,
and validate each other's feelings.
You may find it helpful to seek professional support for the issues that you and your partner have
the most difficulty working out.
"Many members of mixed-status couples avoid discussing their mutual HIV-related
concerns in order to 'protect' their partner from these potentially troubling thoughts and
feelings."
Points of Discussion for Serodiscordant Couples ...
Silence and secrecy in any relationship can be disastrous. In serodiscordant relationships, not
discussing things can lead to risky behaviours and greater anxiety. As difficult as it may be, it is
important to discuss very personal issues. By exploring difficult and painful topics, you take
away their power to interfere in your relationship.
Emotional health. Talk about your fears of illness and loss. Discuss the feelings you have about grief and death, and explore your ideas about "survivor guilt" (the guilt one may feel about being the HIV-‐
negative partner). Identify areas where you feel the need for more support or information. Sex talk. Discuss your worries about infecting your partner or being infected by your partner.
Decide together what precautions and risks you are willing to take in your sexual relationship.
Talk about your likes and dislikes, and identify your concerns about body image, sexual drive
and desire.
Medical treatments. Be open about your feelings around treatment issues such as compliance,
side effects, and drug trials. Get the information you need and respect the decisions that are made
about what treatment options are right for the HIV-positive partner.
Caregiving. Talk about the stress that the HIV-negative partner may feel about becoming the
caregiver for the HIV-positive partner. Discuss the concerns that the HIV-positive partner may
have about getting sick and needing care.
Family planning. Make decisions about family matters together. If you want to have children,
talk about the possibilities of transmission (to partner or to child). Discuss the pros and cons of
options such as alternative insemination and adoption. If you already have children, discuss the
potential of one partner being a single parent if serious illness or death occurs.
Future planning. Explore any differing attitudes about financial issues. Discuss concerns about
saving for the future versus desires to spend in the short term. As hard as it may be, it is
important to talk about end-of-life preparation for both partners, including difficult subjects like
palliative care, power of attorney, and funeral arrangement preferences.
"If either person does not want to engage in an activity, that person has the final say."
Disclosure. Talk about issues related to disclosing HIV status to others outside the relationship.
Discuss the possibilities of not disclosing in order to protect your privacy and avoid
discrimination, while examining the option of disclosure in order to gain support and reduce
isolation. Keep in mind that, except for emergency situations, the HIV-positive person is
ultimately the only person who can decide when, how and with whom the information is shared.
Negotiating Safer Sex in Serodiscordant Relationships ...
Together, you can work out strategies by staying away from blame, shame, anger, and guilt.
Try these strategies for negotiating safer sex:
•
Listen to each other -‐-‐ both partners must have a say in what activities you are going to engage in. •
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•
•
•
Seek clarification if you don't know which behaviours are risky for transmission and which are safer. Become familiar with the options you have when choosing condoms or dental dams. Know that HIV transmission isn't the only risk: be aware of and protect each other from other illnesses and sexually transmitted infections. Communicate your fears -‐-‐ talk about your concerns. Share your ideas for creative alternatives for sex play. Establish guidelines with each other that you can both accept. These guidelines should not only be about the protection of the HIV-‐negative partner; they need to include strategies for addressing desirability and gratification too. Getting on With Living ...
Serodiscordant couples, like all couples with special challenges, need to look for ways to live as
normal a life as possible. Of course, what is "normal" for one couple might not feel right for
another. Remember that you are a unique couple, and that you love each other. Together, you can
use your love and attraction to your advantage and enjoy a healthy relationship.
Some community health or AIDS service organizations provide services for people living with
and affected by HIV/AIDS, and may offer support for serodiscordant couples.
Self-‐Esteem Goal: How people feel about themselves effects their choices about relationships, behavior and health. Patients will gain an understanding of how this issue impacts their life-‐style, their addiction, treatment and recovery, and learn strategies to make positive changes in their lives. Key Questions: •
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How does your opinion of yourself affect the way you present yourself and how you are treated? How does it affect your behavior and choices? What are the basic rights of all human beings? How can you improve your emotional well-‐being? Key Information: •
•
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Cycle of self-‐esteem and positive and negative behavior. Strategies for self-‐care and to promote the development of positive self-‐esteem. Understanding of basic rights in relationships and how to set limits in relationships. Accompanying Materials: -‐
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Developing Self-‐Respect handout Rights handout Affirmations handout Cycle of Esteem Ten Things You Can Do To Enhance Your Emotional Well-‐Being Developing Self-‐Esteem Personal Bill of Rights I HAVE A RIGHT ...
1. I HAVE A RIGHT ... to all the good times that I have longed for all these years and didn't get.
2. I HAVE A RIGHT ... to joy in this life, right here, right now - not just a momentary rush of
euphoria but something more substantive and sustaining.
3. I HAVE A RIGHT ... to relax and have fun in a non-alcoholic, non-abusive and in a nondestructive way and to feel FREE.
4. I HAVE A RIGHT ... to actively pursue people, places, and situations that will help me in
achieving a good life for myself.
5. I HAVE A RIGHT ... to say no whenever I feel something is not safe or I am not ready or
doesn`t feel right.
6. I HAVE A RIGHT ... to not participate in either the active or passive "crazy-making"
behaviours of parents, of siblings, partner and of all others.
7. I HAVE A RIGHT ... to take calculated risks, be creative and to experiment with new
strategies.
8. I HAVE A RIGHT ...to change my tune, my strategy, and my funny equations.
9. I HAVE A RIGHT ... to "mess up", to make mistakes, to "blow it", to disappoint myself and to
fall short of the mark.
10. I HAVE A RIGHT ... to leave the company of people who deliberately or inadvertently put
me down, lay a guilt trip on me, manipulate or humiliate me, including my alcoholic parent,
abusive parent, my non-alcoholic parent, my non-abusive parent, partner or any other member of
my family or anyone else.
11. I HAVE A RIGHT... to put an end to conversations with people who make me feel put down
and humiliated.
12. I HAVE A RIGHT ... to all my feelings. They belong to me.
13. I HAVE A RIGHT ...to trust my feelings, my beliefs, judgement, my hunches, my intuition.
14. I HAVE A RIGHT ...to develop myself as a whole person emotionally, spiritually, mentally,
physically and psychologically in the ways I find appropriate.
15. I HAVE A RIGHT ...to express all my feelings in a non-destructive way and at a safe time
and place.
16. I HAVE A RIGHT ... to as much time as I need to experiment with this new information and
these new ideas and to initiate changes in my life as I see fit.
17. I HAVE A RIGHT ...to a mentally healthy, sane way of existence, though it may or will
deviate in part, or all, from my parents' and/or partners` or others prescribed philosophy of life.
18. I HAVE A RIGHT ...to my sexuality - to be heterosexual, homosexual, bisexual or
transsexual and carve out my place in this world.
19. I HAVE A RIGHT ... to follow any of the above rights, to live my life the way I want to with
respect for others, and not wait until my alcoholic/abusive parent/partner/other gets well, gets
happy, seeks help, or admits there is/was a problem.
20. I HAVE A RIGHT ...to be HERE and to be ME
Ten Things You Can Do to Enhance Your Emotional Well-Being
By J. Buzz von Ornsteiner, Ph.D.
2005
1. Build a strong, supportive, trusting relationship with an
HIV/AIDS doctor. You should be able to freely discuss everything
and anything and, if needed, to challenge your doctor's advice.
2. Develop consistent contact with a health care case manager who
can help to make the rocky road to benefits and services easier for
you. One mold does not fit all, so try to find a case manager that you
trust, even if you have to switch to a new one.
3. Join an HIV/AIDS support group. Find out if they use an ongoing,
drop-in format or if they are time-limited and require pre-enrollment.
Also find out about the training and qualifications of the group
leaders.
4. Get a therapist, preferably a good licensed psychologist or certified
social worker. Remember anyone can state they are a "therapist";
request more information about their background and experience.
Keep looking until your instincts tell you that you have found a good
match.
5. Attend workshops or other HIV/AIDS events so that you can find
out as much as you can about HIV/AIDS. You must be the expert on this disease and be
on top of any new developments and programs.
6. Stay informed about your HIV/AIDS medications by seeking out information from
any and all sources, including people, Web sites, and periodicals. The more you know
about the medication you are taking and its potential side effects, the more you know
what to expect about your emotions and mental well-being.
7. Address any substance use issues you may have by looking into substance use
programs and groups. Consider working towards being clean and sober.
8. Exercise regularly and maintain good nutrition because the mind and the body are
closely linked, and physical health enhances mental health.
9. Work if you can for income but also work for the structure and well being that
employment can provide. Everyone can benefit from structure, and we all need to feel we
are productive members of this world.
10. Seek a sense of belonging outside of HIV/AIDS such as by starting a hobby, traveling
and exploring, getting a pet, starting or finishing school, or volunteering. The bottom line
is to keep your stress low; keeping your stress low will help you to keep your immune
system high.
Disclosure of HIV/Substance Abuse Status Goal: Patient will be able to anticipate consequences and make an informed decision about the choice to disclose. Patient will receive support and information following disclosure. Key questions: • Have you disclosed your HIV and/or SA status to anyone (other than this group)? • What are your concerns about disclosure? • How do you view yourself in terms of your HIV status and/or Substance Abuse? • What are the opinions of those in your community about persons living with HIV/AIDS and/or about substance abusers? • Do you feel your safety would be in jeopardy if your status were disclosed? • If you have disclosed, did it turn out the way you expected? Did you receive the reaction(s) you were expecting? • If you have disclosed, what made it easier or harder to make the disclosure? • Why did you choose the person (people) that you chose to disclose to? • Did or do you feel better after having disclosed your HIV and/or SA status? • What are some of the pros and cons of disclosure? • Which status was easier to disclose: SA or HIV? • How long after your diagnosis did you disclose? • Have you found it easier to disclose the longer you have lived with HIV and/or Substance Abuse? • Have you been “outed” by someone who you trusted with knowledge of your status? • Have you had people question your status (HIV and/or SA)? How did you react? • How do you handle intimacy in terms of disclosing your HIV status? Key information: • Disclosure is a very personal matter and for some patients it requires careful consideration and planning • Disclosure should not be forced upon anyone, except in situations where it is mandated by legal statutes (i.e., intimate partners, public health concerns (exposure), etc.) • Disclosure support groups can be very helpful when one is considering the ramifications of disclosure. Consulting with one’s medical provider and/or case manager can also be helpful when considering when and how to disclose one’s status. • Often it is helpful to discuss one’s substance abuse in conjunction with disclosure about HIV status. In many cases they are directly related to one another. Accompanying information: •
•
The Body: Telling Others You’re HIV Positive Successful Health Strategies: Disclosing Your HIV Status packet Additional Notes: •
Clinician must express empathy and elicit specific information around reluctance or ambivalence •
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Clinician should be knowledgeable on subject of appropriate legal issues &/or able to refer for further information. Use principles of CBT to address patient’s assumptions In-‐depth discussion of pros and cons, being careful to understand and address issues specific to patient’s situation. Use principles of Motivational Interviewing/Motivational Enhancement therapy to address reluctance and ambivalence around disclosure Understand and address how stigma of HIV status affects substance use and mental health. Telling Others You're HIV Positive March 31, 2011
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What Are the Issues? General Guidelines Special Situations Getting Help What Are the Issues?
When you test positive for HIV, it can be difficult to know who to tell about it, and how to tell
them.
Telling others can be good because:
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You can get love and support to help you deal with your health. You can keep your close friends and loved ones informed about issues that are important to you. You don't have to hide your HIV status. You can get the most appropriate health care. You can reduce the chances of transmitting the disease to others. In many states, you can be found guilty of a felony for not telling a sexual partner you are HIV-‐
positive before having intimate contact. Telling others may be bad because:
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Others may find it hard to accept your health status. Some people might discriminate against you because of your HIV. You may be rejected in social or dating situations. You don't have to tell everybody. Take your time to decide who to tell and how you will
approach them. Be sure you're ready. Remember, once you tell someone, they won't forget you
are HIV-positive.
General Guidelines
Here are some things to think about when you're considering telling someone that you're HIVpositive:
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Know why you want to tell them. What do you want from them? •
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Anticipate their reaction. What's the best you can hope for? The worst you might have to deal with? Prepare by informing yourself about HIV disease. You may want to leave articles or a hotline phone number for the person you tell. Get support. Talk it over with someone you trust, and come up with a plan. Accept the reaction. You can't control how others will deal with your news. Special Situations
People You May Have Exposed to HIV It can be very difficult to disclose your status to sexual partners or people you shared needles
with. However, it is very important that they know so they can decide to get tested and, if they
test positive, get the health care they need. The Department of Health can tell people you might
have exposed, without using your name.
Employers You may want to tell your employer if your HIV illness or treatments interfere with your job
performance. Get a letter from your doctor that explains what you need to do for your health
(taking medications, rest periods, etc.). Talk with your boss or personnel director. Tell them you
want to continue working, and what changes may be needed in your schedule or workload. Make
sure they understand if you want to keep your HIV status confidential.
People with disabilities are protected from job discrimination under the Americans with
Disabilities Act (ADA). As long as you can do the essential functions of your job, your employer
can not legally discriminate against you because of your HIV status. When you apply for a new
job, employers are not allowed to ask about your health or any disabilities. They can only legally
ask if you have any condition that would interfere with essential job functions.
Family Members It can be difficult to decide whether to tell your parents, children, or other relatives that you are
HIV-positive. Many people fear that their relatives will be hurt or angry. Others feel that not
telling relatives will weaken their relationships and may keep them from getting the emotional
support and love that they want. It can be very stressful to keep an important secret from people
you are close to.
Family members may want to know how you were exposed to HIV. Decide if or how you will
answer questions about how you got infected.
Your relatives may appreciate knowing that you are getting good health care, that you are taking
care of yourself, and about your support network.
Health Care Providers It's your decision whether or not to tell a health care provider that you have HIV. If your
providers, including dentists, know you have HIV, they should be able to give you more
appropriate health care. All providers should protect themselves from diseases carried in patients'
blood. If providers are likely to come in contact with your blood, you can remind them to put
gloves on.
Social Contacts Dating can be very threatening for people with HIV. Fear of rejection keeps many people from
talking about their HIV status. Remember, every situation is different and you don't have to tell
everybody. If you aren't going to be in a situation where HIV could be transmitted, there's no
need to tell. Sooner or later in a relationship, it will be important to talk about your HIV status.
The longer you wait, the more difficult it gets.
An HIV-‐Positive Child's School It is best to have good communication about your child's HIV status. Meet with the principal and
discuss the school's policy and attitude on HIV. Meet with the nurse and your child's teacher. Be
sure to talk about your child's legal right to confidentiality.
Getting Help
You can get help with telling others about your HIV status from the counselors at the HIV
anonymous test sites, or your HIV case manager.
Confidentiality Goal: It is important that patients feel they have a safe environment where they can be honest and open in discussing concerns surrounding their HIV status, mental health issues and chemical dependency. Patients will understand 1) the importance of confidentiality for themselves and others, 2) their rights regarding confidentiality and sharing of information and 3) respect group norms and guidelines about privacy and disclosure. Key Questions: -‐
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What is your definition and understanding of confidentiality? Why is it important? How does confidentiality build affect trust in a treatment setting? Has your confidentiality ever been broken? When? Why? How did it affect you? Do you know about the laws that protect your privacy and confidentiality? What action can you take if your confidentiality is violated? Key Information: -‐
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Patients will understand the definition and importance of confidentiality. Patients will understand federal and state regulations for confidentiality regarding HIV, substance abuse and mental health treatment services. Patients will understand how information is shared within the same agency or organization. Patients will understand how information is shared between different agencies, organizations, providers and case managers. Patients will understand the exceptions to confidentiality. Patients will understand the guidelines and rules for confidentiality for group and individual therapy. Patients will understand their rights and recourse available in the event of a breach of confidentiality. Grief and Loss The grief and loss of a loved one or of something of value are important issues for those in HIV/Substance Abuse/ Mental Health treatment and have the potential to influence relapse or progress in treatment. The loss of a group member impacts each member of the group and the group process. Goal: Patients will enhance their understanding of grief as a process, how it can lead to relapse, and learn healthy ways to cope and support themselves and others. Key Questions: •
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How is grief defined? What does grief mean to the patient/each member of the group? What has been your personal experience(s) with grief? What is the relationship between grief/loss and HIV? Between grief/loss and substance abuse? How have you felt supported during a time of grieving and loss? Key Information: •
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Explanation of Kubler-‐Ross model and timeline of the 5 stages of grief and how to identify where one is in the process. Why it is important to honor feelings of grief and loss. How to avoid relapse during a period of grieving. Strategies, resources and support available during this time that promote healthy coping and avoidance of risky behaviors and relapse. Accompanying materials: -‐
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About Grief handout What You Can Expect on the Journey of Grief handout Tasks of Grief handout Healthy Coping Skills for Dealing with Grief/Loss and Avoiding Relapse handout Dimensions of Grief handout Grief and the Grieving Process handout Normal Grief Reactions handout Kubler-‐Ross Model of grief handout Healthy Coping Skills for Grief and Loss Having healthy alternatives is one of the most effective factors in maintaining abstinence from addiction and other compulsive behaviors, and that is true in this area as in others. Some healthy coping skills for grief and loss, which can reduce the risk of relapse, include the following: • Build, maintain, and rely on a support system: Both within a recovery program such as Alcoholics Anonymous and in other situations, it is vital to find people who are supportive, who will listen to and spend time with someone who is suffering, and to turn to them when one has the kind of painful feelings that led to drinking, drugs, or other excesses. For some of us, our habit has been to isolate ourselves, and it may take deliberate and uncomfortable effort to go to others. It is especially helpful to join with others feeling the same loss for mutual support. • Understand and accept the grieving process: Learn about the information in this presentation, and understand that feeling as if you are falling apart or going crazy is normal and not a sign that you aren’t handling the situation adequately. • Remind yourself that the pain is temporary: As people often say, “This, too, shall pass.” It does not lessen the hurt in the present to remember this. However, a dangerous aspect of depression is the feeling that life will always be sad and painful, and this can lead to despair. Remembering how past pains healed can be a source of hope and strength. • Slow down: When we are grieving, we don’t function as well in any area of life. We are less effective at work, more prone to problems in relationships, more likely to get physically sick, and more accident-‐prone. It is important not to expect as much of ourselves as we normally would. • Concentrate on basics: We may tend to neglect self-‐care in times of grief. It is important at these times to make sure we eat properly, get enough rest, and get regular exercise of some kind. Failure to do these things makes us vulnerable to stress and depression even under normal conditions. In a time of loss this failure can set us up for relapse. • Turn to spiritual sources of support: Whether through participation in an organized religion or a private relationship with a personal higher power, faith and reliance on something larger than oneself for support can be a literal lifesaver. In circumstances of loss, the application of some of the tools and principles of 12-‐Step recovery programs can be as useful to cope with grief as to avoid relapse. Anger Management Goal: Anger is a common and normal emotion but can lead to relapse if not monitored and dealt with appropriately. Patients will be able to identify circumstances, feelings and interactions that make them angry and how they can deal with them without resorting to violence or substance abuse. Best-‐practice module is used in the therapeutic process over a series of weeks to help patients understand and deal with anger. Key questions: -‐is anger normal? -‐what are the different ways to cope with anger? -‐why is anger important in recovery? Key information: -‐anger is normal and expected -‐how you react can strongly influence the outcome -‐anger is something everyone deals with, but is a very hard emotion to “sit with” in recovery as it often triggers cravings or a relapse Accompanying materials: -‐Anger handout (Emily Dickinson) -‐HALT handout -‐Anger group exercise -‐Anger management module Trust/Honesty/Denial Denial is a defense mechanism used for emotional protection from something perceived to be threatening to the patient and can also be defined as a refusal to accept a situation or information. Denial is a primary symptom of addiction and in substance abuse, and may also be a reaction to a diagnosis of HIV. In these situations denial presents a barrier to seeking and receiving treatment and working toward recovery. Building trust and honesty with patients is essential to both the individual therapeutic and group process. Honesty allows patients to meaningfully discuss and receive support and treatment for concerns surrounding HIV status, addiction, mental health and other daily stressors. Goal: Patients will enhance their awareness and understanding of denial as it relates to HIV, addiction and recovery. Patients will understand how trust and honesty promote recovery and treatment and allow for necessary support during treatment and recovery. Key questions: •
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What is denial? Why would someone stay in denial? How can denial effect addiction, treatment and recovery? What is the importance of honesty in regards to HIV/addiction and recovery? Key information: •
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Different forms of denial How denial effects HIV status/treatment/addiction/recovery/relationships Fear of being honest and how to overcome it Benefits of trust and honesty Strategies for facing fears of honesty Accompanying Materials: •
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Denial handout Defense Mechanisms handout Stages of Change handout Resistance and Personal Protection handout Identification of Community Resources Goal: Patients will be able to identify agencies, faith-‐based organizations and other community resources that may be able to provide support and services. Key questions: -‐
Are you aware of the agencies in your community where you can get assistance and/or social support for HIV/AIDS and/or substance abuse? -‐ Are you involved with a local church or faith based organization that offers support for persons living with HIV/AIDS and/or those in recovery or trying to gain recovery from substance abuse? -‐ Do you feel comfortable seeking help in your local community? Why or why not? -‐ What services are available in your area? -‐ What services would you like to see available in your area? -‐ Are you able to travel to neighboring communities to seek and gain the support that is lacking in your local community? (Issues of confidentiality play a huge role in people seeking out resources for HIV/AIDS support and substance abuse services. This is especially true in rural areas where many people know each other and are afraid of people learning for their HIV and/or substance abuse status.) Key information: -‐
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It may be difficult to find adequate support for persons living with HIV/AIDS in smaller communities due to the perceived lack of need and the lack of adequate funding for such agencies. Substance abuse supports and resources are usually more readily available in larger cities and more densely populated areas. List of agencies, faith-‐based organizations and community resources (with contact persons and information) for specific issues and needs Coping with Financial Stress Goal: The negative relationship between financial hardship and stress, addiction and incidence of disease is well-‐documented. It also has further implications for the ability to seek and access care, maintain adherence to medication and treatment and a healthy lifestyle. Key questions: •
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Do you have adequate, safe housing? Is your rent reasonable, relative to your income? Do you have enough food? Are there needs that you have that you have not found resources to meet? Do you have heat in the winter? Do you have refrigeration for food and medications? Are you able to access transportation when needed? Are you able to access medical care as needed? Key information: •
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Resources to assist with housing, food, utilities and information to address restrictions and qualifications. Everyone deserves adequate, safe housing and enough food. No one will be denied HIV or addictions care at our medical center. Social workers are available to help navigate those systems. Experiencing the inequities in our society can be a trigger for many people with addiction problems. It is important to have a plan for coping with both these triggers. Avoiding the people, places and situations that promote addiction and making positive change is much harder with limited resources. It is important to factor this into a sobriety and treatment plan. System Navigation Goal: Many patients require the assistance provided by social service agencies. These institutions often impose rules and requirements that make obtaining the services and assistance a lengthy and difficult process. These difficulties are multiplied for individuals with addiction, medical and/or mental illness issues and often become another barrier to successful treatment. The goal of this unit is to help patients identify the needs that they have and which programs might be helpful in addressing those needs, and how to complete the necessary processes and requirements in order to receive assistance. Key questions: What needs do you have that aren’t currently being adequately met? What issues are causing you the most stress at this time? What services are you receiving at this time? Are they actually meeting your needs? What programs have you unsuccessfully attempted to access? Are there members of your immediate family who have unmet needs? •
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Key information: •
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Assistance in prioritizing needs and seeking help appropriately. Ways that others have learned to navigate these programs. Support while experiencing frustration and delays in obtaining services. Information about various programs and the accompanying processes and requirements.

INTEGRATED HIV-‐SUBSTANCE USE TREATMENT A Treatment

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