This document discusses concurrent disorders and harm reduction. It provides an overview of concurrent disorders, their prevalence and outcomes. It discusses barriers and gaps in treatment, including fragmented systems and lack of coordination. The philosophy and principles of harm reduction are outlined as an integral approach for supporting those with concurrent disorders. Recommendations include integrated services, varied components, staff qualities, education, and community development. Research on harm reduction and concurrent disorders is important to better understand these populations and improve care.

1. HARM REDUCTION &
CONCURRENT DISORDERS
POSSIBILITIES FOR CHANGE
Stephanie Baker, MSW, RSW
Guelph Wellington Drug Strategy
Harm Reduction Forum
March 20th, 2013

2. OVERVIEW
• Importance & Relevance
• Barriers & Gaps
• Harm Reduction & CD
• CD Philosophy/Treatment
• Recommendations

3. IMPORTANCE & RELEVANCE
PREVALENCE AND OUTCOMES

4. CONCURRENT DISORDERS
Substance Concurrent Mental
Use Disorders Health
Disorders Disorders

5. LIFE TIME PREVALENCE OF SUBSTANCE USE
DISORDER FOR EACH MENTAL HEALTH
DISORDER
• Major Depression 27%
• Any Anxiety Disorder 24%
• BPD 23%
• Schizophrenia 47%
• Bipolar Disorder 56%
• PTSD 30-75%
• Eating Disorder 23-55%
(Skinner, 2005)

6. CONCURRENT DISORDERS ARE
IMPORTANT BECAUSE…
• Poorer treatment outcomes than if person has
either a MH disorder or a SA disorder alone
• Concurrent disorders affect many areas of a
person’s life
• Individuals with concurrent disorders are in
almost every treatment setting – they are the
“expectation, NOT the exception”

7. RISKS ASSOCIATED WITH CD
• Suicide
• Relapse
• Violence
• Prostitution
• Victimization
• Re-hospitalization
• Financial problems
• Loss of family/friends
• Treatment non-compliance
• Poor response to medication
• Housing instability/homelessness
• Medical problems (e.g. HIV, Hepatitis, STD, etc.)
• Criminal involvement/legal problems/incarceration

8. RELATIONSHIP BETWEEN SA & MH
COMMON ELEMENTS
• Both SA and MH can be chronic and recurring,
requiring immediate interventions and ongoing
support
• SA and MH problems may be triggered by the
same factors
• MH problems may influence the development of
SA problems and SA problems may influence the
development of MH problems
• Outcome of treatment for MH disorders is
negatively affected by SA and vice versa

9. BARRIERS & GAPS
CHALLENGES TO IMPLEMENTING BEST PRACTICE

10. TREATMENT BARRIERS
1.Structural Barriers: make it difficult for people with
concurrent disorders to access appropriate treatment
2.Personal Barriers: characteristics of the person that
prevents her/him from initiating or continuing with
treatment for a concurrent disorder issue
(Mueser et al., 2003)

11. SYSTEMIC GAPS
• Present system of care in Canada is fragmented and compartmentalized
• People accessing either system are often struggling with both issues
• Individuals are frequently treated for only one of their co-occurring
disorders
• Few CD research studies considered harm reduction effects, most
emphasize abstinence-related outcomes
• Most CD programs studied have been unsuccessful in bringing about
substance use reductions
• Important need for research to assess the effects of harm-reduction
programming on health improvements for individuals living with CD
(CCSA, 2009; O’Campo et al., 2009 )

12. OUTCOMES OF BARRIERS/GAPS
• Dissonance in philosophical perspectives regarding
the “primary problem”
• Lack of coordination amongst service providers
• Inappropriate service provision
• Increased feelings of stigma
• Poorer treatment outcomes

13. HARM REDUCTION & CD
HR IS INTEGRAL TO SUPPORTING
INDIVIDUALS & FAMILIES LIVING WITH CD

14. WHAT IS HARM REDUCTION?
•A philosophical approach applied in practice
•Often understood broadly - can encompass many
variations of policies and programs
•Intention is to support people in reducing negative
consequences of use by moderating intake/switching to
less harmful modes of use (e.g. methadone or needle
exchange programs)
•A health-centered approach - implicitly and explicitly
acknowledges the social determinants of health

15. FOCUS OF HARM REDUCTION
• A non-judgmental response
• Offers a direct point of contact
• Focuses on achievable improvements that can reduce
adverse health and safety consequences
• Emphasizes measurable health, social, and economic
outcomes as well as cost effectiveness of interventions
• A best practice treatment recommendation, particularly for
people with severe and persistent MI

16. PRINCIPLES OF HARM REDUCTION
•Pragmatic
•Respectful
•Prioritizes goals
•Maximizes intervention options
(James, 2007)

17. PHILOSOPHY OF HARM REDUCTION
• Respects people and their abilities
• Recognizes the ‘Stages of Change'
• Removes barriers to accessing programs and
services
(James, 2007)

18. HARM REDUCTION MODEL
(RNAO, 2009)

19. CHALLENGES WITH
HARM REDUCTION
1) Community resistance
2) The need to work with highly marginalized groups
3) Ensuring appropriate knowledge and training
4) Adequate resources to initiate and maintain initiatives
(James, 2007)

20. CD TREATMENT
CD PHILOSOPHY IS HARM REDUCTION

21. QUADRANT MODEL
High
Severity
Specialized INTEGRATED
Addiction
Primary Care Specialized
Mental Health
Low High
Severity Severity
(Skinner, 2005)

22. CD TREATMENT PHILOSOPHY
• Integrated treatment approach
• Promotes flexibility of goal choice
• Importance of working as a team
• Works with the person where s/he is at
• Offers individualized treatment planning

23. CD TREATMENT PHILOSOPHY
• No “wrong door”
• Motivational enhancement
• Goal of continued engagement
• Involves concerned significant others
• Minimization of treatment-related stress
• Offers flexible hours, duration, and location

24. STAGES OF CHANGE/MOTIVATIONAL TREATMENT
Stage of Change Characteristics Stage of Tasks and Outcome
Treatment Motivational
Strategies
Pre- ~ Not thinking about Pre- ~ Outreach to ~ Person has no
Contemplation change engagement establish contact with contact with mental
~ Feeling of no the person health or substance
control ~ Listen reflectively use worker
~ Denial: does not ~ Affirm
believe it applies to
self
~ Believes
consequences are
not serious ~ Give practical help ~ Person has
Engagement for person’s assigned worker but
immediate concerns no regular contact
~ Model open,
honest
communication
~ Express empathy
(Connors et al., 2001; Mueser et al., 2003)

25. STAGES OF CHANGE/MOTIVATIONAL TREATMENT
Stage of Change Characteristics Stage of Tasks and Outcome
Treatment Motivational
Strategies
Contemplation ~ Weighing benefits Early Planning/ ~ Align with person’s ~ Person has
and costs of struggle (MH & SU) regular contact but
behaviour Persuasion no reduction in
~ Explore person’s
~ Proposed change substance use
goals
~ Support person’s
desire to change
Preparation ~ Experimenting Late Planning/ ~ Explore person’s ~ Person discusses
with small changes concerns (MH & SU) substance use in
Persuasion regular contact, and
~ Develop
discrepancies shows reduction in
between the person’s use for at least 30
goals and current days
behaviour
~ Identify options to
help the person
decide on a course of
action
~ Plan social supports
(Connors et al., 2001; Mueser et al., 2003)

26. STAGES OF CHANGE/MOTIVATIONAL TREATMENT
Stage of Change Characteristics Stage of Tasks and Outcome
Treatment Motivational
Strategies
Action ~ Taking a definitive Early Active ~ Start action plan ~ Person is
action to change Treatment ~ Elicit change talk engaged in
~ Reward progress treatment with the
~ Use slips as learning goal of abstinence
opportunities or reduction,
~ Involve social supports though s/he may
~ Develop specific action
still be using
steps to work on target substances
behaviours
~ Encourage self-efficacy
Late Active ~ Continue to elicit change ~ Person is
talk engaged, and has
Treatment
~ Review/reinforce actions achieved clear
that are producing behaviour goals for changing
change his/her substance
~ Review and identify new use for less than
goals as person continues six months
with change
~ Emphasize health
alternatives
~ Identify examples of self-
efficacy
~ Nurture and sustain
(Connors et al., 2001; Mueser et al., 2003)

27. STAGES OF CHANGE/MOTIVATIONAL TREATMENT
Stage of Change Characteristics Stage of Tasks and Outcome
Treatment Motivational
Strategies
Maintenance ~ Maintaining new Relapse ~ Keep focus on the ~ Person is
behaviour over time Prevention person’s goals engaged and has
~ Reinforce link between achieved clear
change behaviour and goals for changing
accomplishment of his or her
person’s goals substance use for
at least six months
~ Identify continuing high-
risk situations (occasional lapses
may occur)
~ Develop relapse
prevention plans
~ Reinforce self-efficacy
Relapse ~ Experiencing ~ Focus on the ~ Person discusses
normal part of successful part of the substance use in
process of change plan regular contact,
~ Usually feels ~ Promote problem- and shows
demoralized solving reduction in use for
~ Encourage/assist the at least 30 days
person to re-engage their
efforts in the change
process
(Connors et al., 2001; Mueser et al., 2003)

28. RECOMMENDATIONS
CONSIDERATIONS FOR IMPROVED SUPPORT

29. WHY RESEARCH FOR HARM
REDUCTION & CD IS IMPORTANT
• People with CD have been excluded from mainstream
psychiatric/addiction research and scientific trials
• Results in CD not being well understood
• Care provided may be inappropriate
• Interdisciplinary research is needed to contribute to a
comprehensive understanding
(CCSA, 2009)

30. SUCCESSFUL PROGRAMS
• Client choice
• Positive interpersonal relationships
• Proactive multidisciplinary teams
• Housing provision
• Instrumental supports
• Flexible program policies
(O’Campo et al., 2009)

31. RECOMMENDATIONS
1) Integration of harm reduction mental health service
2) Varied service components
3) Staff qualities
4) Education and information
5) Community development
(Altenberg et al., 2003)

32. REFERENCES
Altenberg, J., Balian, R., Lunansky, L., Magee, W., & Welsh, S. (2003). Falling through the cracks: An evaluation of the
need for integrated mental health services and harm reduction services, Toronto, ON: Wellesley Central Health
Corporation.
Becker, M., Fortin, S., Nepinak, D., Noel, L., & Stopkewich, L. (Directors). (2012). Here at Home [Interactive Website].
Toronto, ON: National Film Board of Canada.
Canadian Centre on Substance abuse. (2009). Substance abuse in Canada: concurrent disorders. Ottawa, ON:
Canadian Centre on Substance Abuse.
Connors, G., J., Donovan, D., M., & DiClemente, C., C. (2001). Substance abuse treatment and the stages of change:
Selecting and planning interventions. New York, NY: The Guilford Press.
James, D. (2007). Harm Reduction: Policy Background Paper. Alberta Alcohol and Drug Abuse Commission. Alberta, CA:
Alberta Health Services.
Mueser, K., Noordsy, D., Drake, R., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice.
New York, NY: The Guildford Press.
O’Campo, P., Kirst, M., Schaefer-McDaniel, N., Firestone, M., Scott, A., & McShane, K. (2009). Community- based services
for homeless adults experiencing concurrent mental health and substance use disorders: A realist approach to
synthesizing evidence, Journal of Urban Health, 86(6), 965-989.
Registered Nurses’ Association of Ontario. (2009) Supporting Clients on Methadone Maintenance Treatment. Toronto,
Ontario. Registered Nurses’ Association of Ontario.
Skinner, W. J. (2005). Treating concurrent disorders: A guide for counselors. Toronto, ON: Centre for Addiction and Mental

33. Stephanie Baker, MSW, RSW
Email: stephbaker1@gmail.com