Multimedia
The Road to Recovery 2006 Ask the Expert Series
Ask
the Expert: |
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Topic: |
At the Crossroads: Examining the Intersection of Care for Persons With Mental and Substance-Use Conditions |
When: |
September 2006 |
Sponsor: |
CSAT |
Below are the answers to your questions about topics covered in the September 2006 Road to Recovery Webcast for our expert, Mark Segal.
To view the Webcast, visit http://www.recoverymonth.gov/2006/multimedia/w.aspx?ID=483.
Ask the Expert Transcript
Question: Should children of a person in active
addiction visit/see them regardless of their current condition or
situation?
Mr. Segal: My short answer would be no. As a
parent, your primary responsibility is to your children and not to
your spouse, or girlfriend/boyfriend. Children often are perceptive
and understand that something is "wrong" with Mommy or
Daddy. The instability inherent with a person in active addiction
outweighs the possible benefits to the children by having visits
in most cases. In this questioner's situation, she reported that
her children are well adjusted and the father has little interest
in actually seeing them, which is even more indicative that visits
are not essential to the children's well being.
Sometimes the significant other of an addict hope that an addicts
involvement with there children will motivate them to quit using
drugs or in the very least allow them (significant other) to maintain
contact with the addict. It is very hard emotionally to love and
care about someone who is self destructive. For some people, it
is even more hard to begin letting go of the unhealthy relationship.
If this is the case, I would recommend initiating individual therapy
to explore and resolve possible internal conflicts that the significant
other may be experiencing. I would also recommend AL-ANON, a self
help group for family and Friends of addicts. They meet to help
each other learn how to cope with an addicts behavior, set healthy
boundaries for themselves and be mutually supported when doing
so.
When an addict is in the recovery process and has built a foundation
for themselves, at some point visits with children can be a healthy
experience by all parties.
Question: Please reference a good screening instrument
for adolescents.
Mr. Segal: I would like to begin answering this
question by letting you know my bias. I believe a well trained clinician
doing a complete bio/psych/addiction/social assessment that includes
a detailed mental status evaluation would produce the most accurate
assessment. The oral interview skills by a clinician using open ended
questions is a true art, which is part of the problem. Not all clinicians
have equal interviewing skills, so results may vary. A standardized
test/assessment will produce easily replicated results no matter
the interviewer.
My organization uses the POSIT (pre-assessment) and the Addiction
Severity Index. The Gain Q can also be helpful.
Question: Can cooperation exist between the mental
health fields and the addiction Fields, and if so, what would they
look like?
Mr. Segal: My short answer is yes, cooperation
can exist. Traditionally, mental health and addiction have been separated
by having different government agencies that regulate treatment and
funding , as well as health insurance companies that require a primary
diagnosis that will send the patient into one system or the other.
We now know that mental illnesses and addiction effect one another
and to treat one in preference to the other often leaves the patient
a risk for relapse or psychiatric deterioration.
Some states have eliminated separate Mental Health and Addiction
regulatory/funding agencies and combined them into a Behavioral
Health agency. This reduces systems that are incompatible in dealing
with one another. My state of Maryland still uses two separate
systems; one grant based (addiction) and one insurance fee-for
service (mental health). Not only can it be challenging for the
consumer to get both his/her addiction and mental health needs
met simultaneously, it can be hard on the providers. A consequence
of having two separate systems is in creating clinicians that perhaps
do not have the expertise to deal with both sets of problems, as
there primary experience and training is geared towards one set
of problems.
Ideally, a consumer would be referred to have an assessment and
in that process a determination and implementation of the appropriate
type of care could be implemented. The referral could be made from
any source; school, family physician, social service, police/courts,
self, etc... If a client has both a severe mental illness and addiction
they might be referred to a residential treatment that provides
integrated co-occurring treatment. Both illnesses are treated simultaneously.
The client has one therapist that is qualified to treat both issues
simultaneously. The facility I am the clinical director of is such
a facility. We have our own psychiatrist, Nurse and all groups
address both mental health and addiction problems. The therapist
have 1/2 the case load that the state of Maryland will allow (8
instead of 15). As such, this treatment is in the short run more
expensive then traditional treatments. In the long run it saves
money by having less arrests, jailing, emergency room visits etc...
If a client has a less severe mental illness or addiction, they
may benefit from parallel treatment. Instead of one provider comprehensively
treating both issues, they may have separate providers. An example:
If a client is employed, has cocaine addiction, has a healthy support
system and suffers from depression, they may be referred to an
Intensive Outpatient Addiction program, as well as a psychiatrist/therapist
for depression management.
Question: How can religious institutions play
a part in the recovery process?
Mr. Segal: Spirituality can be very important
to people attempting to become sober. The 12-step community encourages
addicts to learn to turn over anxieties and problems that they have
no control over to there "Higher Power" which may or may
not be G-d. Often when addicts worry about problems, they will go
use drugs to relieve the anxiety or depression, even though they
are often aware that the relief is temporary and may carry significant
consequences.
Religious Institutions can provide a since of community and belonging,
both of which can be vital in the recovery process. Often an addict
feels alone and cut off from everyone. Perhaps their families and
friends have literally cut off contact because of past behaviors.
A welcoming community that is often found within our religious
institutions are sometimes one of the few supports a person in
early recovery may have.
Also, places of worship have been very generous in allowing their
buildings to be used by the 12-step communities.
Question: How long is it necessary is it for
a young adult to stay in-patient after heroin, meth-amphetamine or
cocaine addictions?
Mr. Segal: Short answer: it depends. Sometimes
no inpatient treatment at all may be indicated. The first step is
to have an accurate assessment done by a qualified individual. Often
this will include a medical exam to insure that no life threatening
issues are present (heart defect as an example) and a toxicology
screen can also be important to rule-out that a drug such as a benzodiazapine
is being used, which may be life threatening if stopped abruptly
and therefore require detoxification.
Some insurance policies and some government agencies provide funding
for detoxification only if there is medical necessity which may
be defined as a withdrawal of a substance that can be life threatening.
The two most common drugs that may produce life threatening withdrawal
are alcohol and benzodiazipines, both of which may produce severe
seizures if the person meets the criteria for physical dependence.
Please note that the mere use of alcohol or benzodiazapines do
not necessitate physical withdrawal. The three drugs mentioned
in this question; heroin, meth-amphetamine, and cocaine are not
typically life-threatening when the drug is ceased. They are more
likely to cause death during the use of the substance. Withdrawal
from these three drugs can be uncomfortable and will often result
in the addict going out to use their drug of choice again to eliminate
their discomfort. In-patient detox can make the withdrawal more
tolerable.
After the initial detox period has concluded (about 3 days for
heroin) a determination of the level of care and length of stay
for that treatment is made. The determination is very individualistic
and should be based upon severity of drug dependence or abuse,
past recovery experience (example: 2 years sobriety after 1 outpatient
treatment episode), employment status, living situations, presence
of mental illness, criminality, among other factors.
Often the decision is made based upon what is available and not
always the clinical indication. The reality is that government
funding sources have limited resources and would like to treat
as many people as possible, so they fund programs for specific
length of stays (short). There is evidence that out patient programs
of at least 16 weeks work very well for those that meet that criteria,
that 28 day programs work well for that target population and longer
stay of at least 210 days work well for those that meet the clinical
criteria. However access to treatment is not always based upon
need. If a client can only get into a 28 day program, even though
they may need a longer stay, then they enter the 28 day program.
I could post many studies that would indicate x number of days
is needed for various severities of addictions, but then again,
other studies would indicate otherwise.
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