With the high occurance of dual diagnosis (mental health diagnosis and substance use disorder), CooperRiis uses a integrated approach in order to address both conditions simultaniously. This approach is multidiciplinary as well as holistic; we address the biopsychosocial and spiritual aspects for our residents. Working towards true recovery is optimal, not just abstinence. This integrated approach has proven to be more effective through research, as treating these conditions separately often leads to relapse.

1. Integrated Dual Recovery
CooperRiis QMHP
August 9, 2017

2. What is
Integrated Dual Recovery?

3. Dual Diagnosis &
Dual Recovery
• Most often refers to having both a
Substance Use Disorder and Mental Health
diagnoses. Literally having two diagnoses at the same
time.
• DD designation is needed because the treatments
have evolved differently and have historically been
provided in separate programs, by differently trained
staff, and with minimal collaboration.
• Those seeking treatment have often been misdiagnosed
due to this separation.

4. Statistics on Dual Diagnosis
• About a 1/3 of all people experiencing mental health issues
and about 1/2 of people living with severe mental health
issues also experience substance abuse.
• About a 1/3 of all those who abuse alcohol and more than
1/2 of all those who abuse drugs report experiencing a mental
illness.
• Men are more likely to develop a co-occurring disorder than
women.
• Individuals of lower socioeconomic status, military veterans,
and people with more general medical illnesses are at higher
risk. (NAMI)

5. How are Mental Health Disorders
and Substance Use Disorders
Related?

6. What does it mean to be
“Integrated”?
• Recognition of the need to treat both the mental
health and the addiction issues simultaneously
• Multidisciplinary approach
• Holistic approach – addressing the
biopsychosocialspiritual aspects

7. BIOPSYCHOSOCIALSPIRITUAL
MODEL

8. TYPES OF ADDICTION
• Addiction
related to
the specific
impact of a
substance
• Addiction
related to
an action
Substance Process
• Physical damages are clearer
and quicker
• Tolerance and withdrawal are
more severe.
• Examples:
gambling, TV, internet, video
games, exercise, sex/porn,
shopping/spending $

9. DSM V Substance Use Disorder
Criteria
• 11 different criteria for SUD
• Substance use is considered on a continuum of
severity
• Mild – 2-3 criteria
• Moderate – 4-5 criteria
• Severe – 6 or more criteria

10. SUD Criteria
1. Taking the substance in larger
amounts or for longer than the
you meant to
2. Wanting to cut down or stop
using the substance but not
managing to
3. Spending a lot of time getting,
using, or recovering from use
of the substance
4. Cravings and urges to use the
substance
5. Not managing to do what you
should at work, home or
school, because of substance
use
6. Continuing to use, even when
it causes problems in
7. Giving up important social,
occupational or recreational
activities because of substance
use
8. Using substances again and
again, even when it puts you in
danger
9. Continuing to use, even when
you know you have a physical
or psychological problem that
could have been caused or
made worse by the substance
10. Needing more of the substance
to get the effect you want
(tolerance)
11. Development of withdrawal
symptoms, which can be
relieved by taking more of the
substance

11. Biological Component of Addiction
• Thanks to recent neuro-imaging technology
(MRI, PET, etc), researchers now understand
that addiction is a chronic disease that
changes both brain structure and function.
•Cardiovascular disease
damages the heart, diabetes
impairs the pancreas,
addiction hijacks the brain.

12. Brain areas affected by drug abuse include:
•The brain registers all pleasures in
the same way, whether they
originate with a psychoactive drug,
a monetary reward, a sexual
encounter, or a satisfying meal.
•The release of the
neurotransmitter dopamine in the
nucleus accumbens produces
feelings of pleasure.
•The relationship between
dopamine and pleasure in this area
is often referred to as the
pleasure center.
Pleasure Center

13. .
•All drugs of abuse, from nicotine to heroin, cause a particularly
powerful surge of dopamine in the nucleus accumbens.

14. So, what happens to your Brain
if you keep taking drugs?
• Eventually the brain adjusts to the overwhelming surges in
dopamine (and other neurotransmitters) by producing less
dopamine or reducing receptors. As a result, normal dopamine’s
impact can become abnormally decreased, reducing one’s ability
to experience any pleasure.
• Eventually, a substance abuser will feel flat, lifeless, depressed,
and unable to enjoy things that were previously pleasurable
(relationships, hobbies, previously enjoyed activities).
• Repeated substance use is needed to bring dopamine function
back up to normal.
• Larger amounts of the drug will be needed to produce the
familiar dopamine high—an effect known as tolerance.

15. Reward Center
•The hippocampus and the
amygdala store information
about environmental cues
associated with the desired
substance, so that it can be
located again.
•These memories help
create a conditioned
response — intense craving
— whenever the person
encounters those
environmental cues.

16. •The Brain’s Reward Center has an important role in
sustaining life because it links activities needed for human
survival (such as eating and sex), by connecting motivation
and memory with pleasure and reward.
•Repeated exposure to an addictive substance or behavior
causes these parts of the brain to communicate in a way that
couples liking something with wanting it, and eventually
into needing it (intense craving ).

17. HTTP://WWW.SC.DOE.GOV/ACCOMPLISHMENTS_AWARDS/DECADESDISCOVERY/94.HTML_
THE NORMAL IMAGES IN THE BOTTOM ROW COME FROM NON-ADDICTS;
THE ABNORMAL IMAGES IN THE TOP ROW COME FROM PATIENTS WITH
ADDICTION DISORDERS.
PET BRAIN SCANS REVEAL CHEMICAL DIFFERENCES IN THE BRAIN
BETWEEN ADDICTS AND NON-ADDICTS.

18. Psychological Component
• Emotions and beliefs are intertwined with addiction
and mental health. Anxiety, loneliness, guilt, and helplessness
are examples of emotions often related to the use of
substances.
• Negative beliefs about one self (i.e. “I am no good”),
others (i.e. “People aren’t to be trusted”), and the world
(i.e. “Life is hopeless”) often proceed or accompany
addiction.
• It is a misconception that individuals abuse substances
just to get high. People abuse substances to alter
negative emotional states. Positive Intention behind all
use.

19. “Positive Intents” of Addictions
• What was the original function or purpose of
the behavior?
• What unmet needs does it indicate?
• What ways can you develop skills and
resources to meet those needs in
healthy ways moving forward?

20. Toxic Shame vs. Guilt (Brene Brown)
• Shame – Focus on Self (“I am a mistake.”)
• Guilt – Focus on Behavior (“I made a mistake.”)
• Shame is highly correlated with addiction,
depression, suicide, and eating disorders. Guilt
inversely correlated with these things.
• What causes shame to grow?
• Secrecy, silence, and judgment
• What stops the shame spiral?
• Talk to yourself like you talk to someone you love.
• Reach out to someone you trust.
• Tell your story.

21. Trauma/Neglect & Addiction
• As the number of Adverse Childhood Experiences
increases, so does the risk for alcoholism, illicit drug use,
smoking, depression, and suicide attempts.

22. Social Component
Social interactions are an essential part of our lives and
are highly impacted by substance use and addiction.
• Substances and addictive behaviors become strongly
associated with many social activities, and with
abstinence, social interaction will often be a struggle.
Once sober, substance abuser may feel a high degree
of fear, anxiety, boredom, isolation…
• One’s environment, family, friends…can become a
conditioned stimuli that triggers craving.

23. Spiritual Component
When in active addiction one often describes
feeling a spiritual void - including a loss of values,
morals, connectedness, and peace.
• Recovery from addictions can involve a spiritual
journey in becoming more whole as a person. A
person in recovery has the opportunity to identify their
values, integrate core aspects of their identity, and live
congruently.

24. Stages of Change
(Visitor, Browser, Shopper – Scott Miller)

25. ABSTINENCE OR RECOVERY?
• Abstinence is:
– Not using or
engaging in the
pattern
– Abstinence alone is
the “white
knuckling” approach
• Recovery is:
– Thriving
– Healthy social
relationships
– Addressing mental health
issues and underlying
causes of addiction
– Accomplishing “positive
intents” in healthy ways
– Learning how to be
motivated by your
recovery

26. Impact of Recovery on the Brain
These images of the dopamine transporter show the brain's
remarkable potential to recover, at least partially, after a long
abstinence from drugs - in this case, methamphetamine.

27. Why is “Integrated Dual Recovery”
Important?
• Integrated treatment is consistently more
effective per research
• Recognition of the relationship can help to
plan continued support
• Treating one without the other usually leads
to relapse of both (to relapse on one is to
relapse on the other)
• To increase understanding that, while related,
there is no evidence that one causes the other
• To be aware of the risks of returning to use,
primarily activation of symptoms

28. Seven Domains of Recovery at
CooperRiis
• 1) Social/Community/Connectedness
• 2) Spirituality
• 3) Purpose/Productivity/Fulfillment
• 4) Empowerment/Independence
• 5) Emotional and Psychological Health
• 6) Physical Wellness
• 7) Intellectual/Learning/Creativity

29. What we offer at CooperRiis….
• Psychopharmacology
• Individual therapy and addictions counseling
• Weekly Dual Diagnosis Support Group (run by residents)
• Weekly Dual Diagnosis Psychoeducation & Process Support
Group (run by therapists)
• Weekly Addiction Education Group, including nicotine cessation
• AA group meets weekly on campus at the farm
• Regular and random drug & alcohol screening
• Staff supported outings
• Relapse prevention and sobriety resources
• Assessing severity of addiction
• Appropriate referral based on American Society of Addiction
Medicine (ASAM)

30. Integrated Treatment Approach
Focusing on the Whole Person
• Safe, Healing Environment with Minimal Triggers
• Milieu Therapy within a Supportive Community
• Community Work & Service Program
• Anti-inflammatory Mediterranean Plant-Based Diet
• Integrative Health Director & Personal Trainer
• Massage Therapist and Acupuncturist
• Yoga and Mindfulness
• Art Therapy
• Therapeutic Drumming
• Recreation and Fun

31. Recovery Groups
• 12-Step groups (AA/NA) (Spiritual)
• 1. We admitted we were powerless over alcohol—that our lives had become
unmanageable.
• 2. Came to believe that a Power greater than ourselves could restore us to sanity.
• 3. Made a decision to turn our will and our lives over to the care of God as we understood
Him.
• 4. Made a searching and fearless moral inventory of ourselves.
• 5. Admitted to God, to ourselves, and to another human being the exact nature of our
wrongs.
• 6. Were entirely ready to have God remove all these defects of character.
• 7. Humbly asked Him to remove our shortcomings.
• 8. Made a list of all persons we had harmed, and became willing to make amends to them
all.
• 9. Made direct amends to such people wherever possible, except when to do so would
injure them or others.
• 10. Continued to take personal inventory and when we were wrong promptly admitted it.
• 11. Sought through prayer and meditation to improve our conscious contact with God as
we understood Him, praying only for knowledge of His will for us and the power to carry
that out.
• 12. Having had a spiritual awakening as the result of these steps, we tried to carry this
message to alcoholics, and to practice these principles in all our affairs.

32. Recovery Groups
• Celebrate Recovery (Christian)
• 12 step Christ-centered program that uses biblical scripture
references
• 8 Recovery Principles Based on the Beatitudes:
– Realize I’m Not God - Admit powerlessness and unmanageable life
– Earnestly believe that God exists, that I matter to Him and that He has
the power to help me recover.
– Consciously choose to commit all my life and will to Christ’s care and
control.
– Openly examine and confess my faults to myself, to God, and to
someone I trust.
– Voluntarily submit to any and all changes God wants to make in my life
and humbly ask Him to remove my character defects.
– Evaluate all my relationships - Offer forgiveness and make amends
when possible.
– Reserve a daily time with God for self-examination, Bible reading, prayer
– Yield myself to God and be used to bring this Good News to others

33. Recovery Groups
• Refuge Recovery (Mindfulness-Based/Buddhist)
• Four Truths of Refuge Recovery:
– 1. Addiction creates suffering
2. The cause of addiction is repetitive craving.
3. Recovery is possible.
4. The path to recovery is available.
• Eight Fold Path:
– 1. Understanding 5. Livelihood/Service
– 2. Intention 6. Effort
– 3. Communication/Community 7. Mindfulness/Meditations
– 4. Action 8. Concentration/Meditations

34. Recovery Groups
• Dual Diagnosis Anonymous (12 steps program)
• Smart Recovery Groups (non-spiritual)
• Offers tools and techniques for:
– 1: Building and Maintaining Motivation
2: Coping with Urges
3: Managing Thoughts, Feelings and Behaviors
4: Living a Balanced Life

35. WHAT CAN I DO AS A FAMILY MEMBER?
• Offer support and encouragement for treatment
• Take care of yourself – you cannot give more than you have
• Don’t use alcohol or other drugs around your recovering family member
• Lapse Vs. Relapse – Relapse is a part of Recovery
• Abstinence Violation Effect
– “I had one cigarette, I might as well buy a pack.”
• Set limits for yourself, emotionally and financially
• Be aware that it does sometimes take multiple episodes of treatment to
establish long term recovery
• Ask for help from your own support system as well as treatment
providers and support groups.
• Arm yourself with education
• Don’t drop the subject – keep the conversation open, so that a lapse
might be shared
• HANG IN THERE!

37. REFERENCES AND RESOURCES
• Bram, Matt. Integrated Dual Recovery Workbook, 2015
• American Legacy Foundation - http://www.americanlegacy.org/
• Centers for Disease Control – http://www.cdc.gov
• Cohen, W., & Inaba, D., (2007) Uppers, Downers, and All Arounders
• Greenfield, S., Weiss, R., & Tohen, M. (1995, June). Substance abuse and the
chronically mentally ill: A description of dual diagnosis treatment services in a psychiatric
hospital. Community Mental Health Journal, 31(3), 265-277. Retrieved April 16,
2009, doi:10.1007/BF02188753
• National Institutes for Drug Abuse – http://www.nida.nih.gov/
• National Alliance for the Mentally Ill - www.nami.org/
• National Alliance for Tobacco Cessation - https://www.thenatc.org/Default.aspx
• Powledge, Tabitha M. , Addiction and the brain. www.bioscience.oxfordjournals.org/
• Substance Abuse and Mental Health Services Administration - www.samhsa.gov/
• Quit Smart Smoking Cessation - http://www.quitsmart.com/