Co-occurring Disorders / Dual Diagnosis

What are the stages of change?

The stages of change come from something called the transtheoretical model. It sort of simplifies progression towards. The stages include:

• Precontemplation

• Contemplation

• Determination

• Action

• Relapse

• Maintenance

These stages are there to help professionals and also the individuals in change, understand where they are and how to treat based on their readiness. For example, someone who is in contemplation won’t be ready to take a deep dive to address unresolved childhood trauma. Whereas, someone who is in action will be turned off with treatment that is too slow or gentle.

There are different therapeutic approaches for each stage.

Now it’s important to know that not everyone goes through a linear progression. Meaning some people will teeter back and forth between stages for quite some time before moving ahead.

What makes co-occurring disorders a bit trickier is that individuals can be on one stage for their mental health and another stage for their substance use. For example, someone who struggles with diagnosed depression and a substance use disorder - drug of choice opioids, may be in action stages for their substance use disorder but in pre-contemplation for their depression. This means they may be in rehab or actively engaging in a drug treatment program but have undiagnosed depression or refusing to believe the diagnosis. We see the opposite though happen quite frequently. A lot of mental health professionals will be treating someone with, let’s say bipolar disorder and overtime, digging into their daily habits find out the person is also struggling with substances. Yet, they are in complete denial that their substance use has anything to do with their treatment progress for bipolar disorder. When this happens, the mental health professional must be patient and willing to adjust their approach as their client works through each stage.

Now that you know what the 5 stages of change are and how that impacts co-occurring disorders, I’d like to dig a little deeper into each stage. In this lecture we’re going to focus on pre-contemplation.

So remember earlier when we talked about the chicken or the egg theory? This stage, the precontemplation stage is where something happens before anyone even knows it’s happening and when digging a little deeper, most people can somewhat figure out what came first - their mental health struggles or their addiction.

For some, this stage may start in childhood. Perhaps it starts with trauma or growing up in unideal situations. Children who experience a tough childhood tend to look for ways to feel better. This could be anything from drugs and alcohol to gambling, sex, shopping, social media, or just avoiding homelife altogether. An outsider looking in, may look at a situation like and see clearly there’s trouble ahead whereas the person who is going through experience doesn’t see anything to be a problem. They may not even feel as though their struggles are impacting their mental health and definitely don’t see getting involved with dangerous activities as a problem and in fact they may see it as a benefit as they feel better about their whole situation.

Pre-contemplation doesn’t always start in childhood though, it can happen at any point in life. And precontemplation doesn’t always start with mental health struggles either. For example, a 32 year old, very normal life, gets into a car accident, breaks their back, is prescribed opiates. Pre-contemplation is the part where they run out of opiates earlier than expected, beg the doctor to get an early refill. Of course there’s no problem right? They broke their back and their doctor is prescribing the medication. Everything that is happening is perfectly legal and they deserve the medication after everything they went through.

The medication reduces anxiety and post traumatic stress symptoms that were caused by the car accident.

There are all types of scenarios but what’s important to know is that most people, while in pre-contemplation, will not change their behavior because they don’t see it as a problem. They haven’t been negatively impacted yet so trying to get someone to see things clearly is a lot harder in this stage, most of the time nearly impossible. And if approached about their situation they often are defensive and combative as truly in their mind it’s not an issue.

Now there’s no time limit on any of the stages so it’s not surprising that this stage can last a while and it’s tough for family and friends to see the writing on the wall and feel helpless but until the person reaches the next stage, contemplation, there isn’t much anyone can do accept sit back. The person struggling with either grows out of precontemplation naturally or they will move to contemplation. And that’s what we’ll talk about in the next lecture.

Welcome back. So moving along, we’re now going to talk about the contemplation stage. So the contemplation stage is where the person who is struggling with drugs or alcohol starts to acknowledge that there may be a problem. They notice the little signs that possibly other people have noticed. They are thinking in the back of their mind that they should cut back or even quit. They may say things to themselves or even other people like once they get through a certain part of their life they will quit.

For example, perhaps someone has a massive project going on at work and to relieve stress they start drinking heavily when they get home. Then they start to notice that their work performance hasn’t been great so they may think to themselves, once this project is over I’ll just go back to how it was.

The example I gave in the last lecture, the guy with the opiate prescription addiction. In this stage they may say something like I’m going to start weaning myself off once I get the results of my scan next month.

When it comes to mental health, in contemplation the person struggling may even start to notice that their mental health is suffering. So they may start to research therapists in their area or call their insurance company to see what mental health care coverage they can get.

During contemplation, the person struggling knows that they want to cut back or quit in the future but now may not be the best time. They start to acknowledge though there is a problem and understand that if they don’t cut back or quit things may get worse.

This stage may last a while but it could also last as little as a few hours.

For example, someone with an alcohol addiction may drive while drinking, not thinking they are doing anything wrong and then suddenly they get pulled over and arrested for a DUI. During that arrest they suddenly realize they have a problem and then right to determination - meaning they are ready to quit and get help now. On the flip side, some people stay in contemplation for years. You may even know someone like this. The person who is saying yes I know I need help and I know I need to quit but I’m doing it on my own time, when I’m ready, and years later it’s the same story.

Remember, the stages are fluid so it’s possible as well for people to flip between precontemplation and contemplation. So for example, someone admitting they have a problem, need to get help, maybe even stop drugs and alcohol for a few days, then go back to their old ways saying they are better now and can control things.

After contemplation is determination so I’ll see you in the next lecture when we talk about that.

Determination is the next stage and this is the stage where someone is acknowledging their behavior, knowing they must change in order for things to get better and actively making plans. This is the stage where someone might choose a specific quit day or make phone calls for detox or rehab.

This is the stage too where someone may start to make the correlation between their mental health and their substance use and may start to look for counseling or therapy. Some even have a counselor or therapist and in determination they will start to open up with their mental health professional about their drug use. Up until this stage, most people aren’t truthful about their substance use which makes treating their mental health difficult. If a mental health professional doesn’t know about their patient’s drug or alcohol use they cannot address both at the same time.

Again, like any stage, a person’s path isn’t always linear so sometimes people acknowledge their behavior, make plans to quit and before they can get to action they go back to contemplation. This is where some might start to question themselves - will this even work? Do I have what it takes? And negative self talk combined with shame and embarrassment can take a person back to contemplation, meaning “I know I have a problem but I just don’t have it in me to change.” or even back to pre-contemplation - where someone might say, “I never had a problem, I don’t know why I thought I did. I’m fine.”

There are a lot of variables and each person’s path will greatly vary. Better case scenarios are those who have the support and tools they need to move from determination to action. But not everyone will have that and if there are barriers, then that can halt progress or cause someone to regress. For example, let’s say someone made it all the way to determination. They know they have to change and they want to but they can’t afford professional help, they have a family to care for, they have work that they can’t quit or maybe they don’t have work which results in not having the money for help. Maybe they have a social circle that feels impossible to distance from or toxic family or friend relationships. Of all the stages, going from determination to action is often the most challenging. So let’s now talk about what action is.

Welcome back. So taking action. This is the stage where someone says they are going to change, take all the right steps to get there and actually follow through. This is the stage, where someone will set a quit date, the date will come and they are motivated and ready to continue on with their plan to quit.

But taking action is a bit more complicated than what it seems on the surface. For those who don’t understand addiction very much, might look on the outside and say oh wow they are sober now and that’s it - everything is fixed. But it’s usually not that easy.

Action isn’t just about quitting drugs or alcohol it’s about following through with a behavior change. This is the stage where a person sets up and follows through with processes. This usually falls in some form of treatment. Treatment looks different for everyone - whether it’s in person or online, 12 step meetings, counseling, therapy, etc. but it’s taking charge and following a plan.

During the action stage, a person will start to understand their knowledge or healthy behavior and the positive impacts it can make on their life. It’s also the stage where they come to an actualization or realization that having a healthy life is something they actually want rather than something that just happens.

When it comes to co-occurring disorders, during action, a person must be working on their mental health at the same time as their substance use so in this stage, ideally, a person would be talking to a professional who specialises in co-occurring disorders or at a minimum be talking to someone who specialises in their mental health and also someone who specialises in substance use.

During this stage, a person generally achieves some sort of social and self liberation. This means that a person who is taking action understands cognitively that society supports their healthy change and at the same time they are understanding and supportive of themselves knowing that they can achieve the goals they have set for themselves.

During the action stage though, no one should be letting down their guard when it comes to their mental health or substance use. When a person gets too comfortable and stops working towards their recovery, a relapse is likely to happen.

So most of the time when thinking about addiction, most people believe that relapse is inevitable. If you were looking at numbers and statistics, you might just reach that conclusion but there’s so much more that goes into it.

After we talk about the stages of change we will then talk about the biopsychosocial model which is basically saying that in order to have a successful recovery, a person needs to be healthy physically, mentally and socially. It’s also incredibly crucial that a person who struggles with a co-occurring disorder to receive help at the same time.

So what are some reasons people relapse? A lot of it comes down to properly planning and support. It doesn’t matter how committed someone is to quitting, if they aren’t prepared for the intensity of detox or triggers, no amount of willpower can help them through if they are caught off guard.

Thinking about the bio psycho social model, if one area of a person’s life isn’t in order, the odds immediately are stacked against them.

Let’s say someone is struggling with a physical problem, chronic pain for example, and they prepare and get everything set up. Overtime, the physical pain starts to take its toll and no amount of doing all things right can make the pain go away. So of course, they will look for ways to feel better as in their mind, what’s the point of quitting if I feel worse physically?

Same thing for mental health and this is where treating co-occurring disorders is crucial to the success of one’s recovery. If someone only focuses on substance use, goes through detox and takes action but feels horrible mentally, such as suffering from depression or anxiety, it’s inevitable that at some point their thought process will start to turn to again. What's the point of quitting if I feel worse mentally?

And then there’s the social side of things - social includes family, friends, and professional relationships. If someone is in constant contact with toxic people in their life or in a toxi work situation, at some point substances will tempt them as they will be looking for ways to mask their social situation, ways to deal with things as sometimes that’s easier when using a substance than it is going about it all sober.

Now when someone relapses does that mean they will go all the way to pre-contemplation? For some yes but not necessarily everyone and even if they do, the stages are often quite short. For example, someone may have relapsed after a year of being sober when their ex-dealer sees them at the store, they then leave town, go on a 3 day binge. During those three days they may have gone from precontemplation, contemplation and determination. Whereas, before those three stages took years. Some people go from relapse right back to maintenance, it all really depends on the situation.

So that brings me back to the point of relapse being inevitable. Statistically speaking maybe but it doesn’t have to be. For it not to be though it takes a village, it takes proper planning, proper support, some luck and a lot of determination.

So the very final stage is maintenance. Maintenance is the stage that people who have achieved a full recovery, fall into. Now there is some debate about whether or not there is another stage after this one which is called termination but most people agree that most people will be in maintenance forever.

That is not to say that a person in recovery has to have a lifelong focus on everything recovery related. For some people, that is the only way for them. You know - those people who have been sober and in AA for 20 years. And if that works, great. But most people don’t want to have that hanging over them for their entire lives and want to be able to just have a normal life that doesn’t involve substances. But the real question is, is that even possible?

Well, yes. It is and it can happen in the maintenance stage.

In early maintenance, a person should continue to work on their recovery but at the same time work on integrating themselves back into society. They should be working on having healthy relationships, healthy thought processes and removing unhealthy behaviors even if they aren’t associated with drugs or alcohol. When it comes to co-occurring disorders in this stage, someone is receiving the right mental health care, perhaps they are on the right medication that works for them or received enough therapy to now be in full recovery.

During this stage, if a person wants to make sure they stay in this stage for life, they will know that they have to keep doing the things that work and be very self aware to know that if their behavior or thought processes start to change they need to be more conscious of what is happening so they ensure they don’t have a relapse. Sometimes people bounce between maintenance and action. So maybe they were a little lax and noticed a change and started therapy again.

As the maintenance stage progresses it’s generally okay for a person to know they can relax a bit. If they are strong in their recovery they will have all the tools and knowledge they will need to support them for life. This means, a person can do anything a normal person can do without feeling like it will turn into a relapse. They are confident being present with the substances they were once struggling with won’t cause them to go backwards.

To progress through the stages of change, people apply cognitive, affective, and evaluative processes. Ten processes of change have been identified with some processes being more relevant to a specific stage of change than other processes. These processes result in strategies that help people make and maintain change.

Welcome to our next section. In this section, I’m going to be talking about the bio-psycho-social model of health. I am the owner of Live Rehab.com and the Sobriety Success Program incorporates this model of health.

The bio psycho model of health is a model that interconnects biology, psychology and sociology as a way of treatment. This means that during treatment, there must be a focus on all three: the physical health, psychological health and social circles. If one of these is out of whack then the chances of a full recovery will be slim.

For example, if someone is in treatment and doing well with their co-occurring disorder - meaning their are focusing on their mental health and substance use disorder but they are neglecting their physical health, such as eating junk food, not sleeping well, and not getting any physical activity, their progress will be slow and will likely never achieve their full potential. Or if someone is engaged in treatment yet they are surrounded by toxic people in their life; once they are out of treatment, their chances of success are slim.

So let’s take a deeper dive into some of these categories. We’ll start with physical health. See you in the next lecture.

Okay so let’s talk about the biological side of the bio psycho model. So when someone is in treatment for a co-occurring disorder, they should also be working towards having a healthier body. This includes taking care of any medical conditions, eating healthy, and having good fitness and sleep.

When a person first starts their treatment, I always recommend that they make a doctor’s visit to get a checkup including blood work. It’s important to know if there are any major medical needs that need to be addressed such as high blood pressure or cholesterol, and can also pin point quick fixes such as being low on a certain vitamin or mineral. Oftentimes, people with co-occurring disorders neglect their physical health so it’s important to help them get on track towards living a healthier life.

Treatment should include things like eating healthy and this can be set up by them following some sort of healthy eating plan or them taking charge in reducing junk food, sugar and adding more whole foods, grains, fruits and vegetables into their diet. Having a healthy diet can also help with mood, mental health and can help with triggers and cravings.

In addition to nutrition, it’s also important to focus on fitness. Now most people, new to treatment, will be starting from probably having minimal fitness so you would never expect someone to go from a starting point to running a 5k in two weeks. It needs to be a gradual plan that incorporates fitness. Fitness doesn’t have to be daunting so it should not be something the individual finds boring or uninteresting. Not everyone wants to go work out in a gym. Some people prefer things like hiking, swimming or riding their bike. It’s important to figure out what motivates the individual and what they can find joy in. Otherwise, burnout generally comes after about 1-2 weeks.

And the last part of it is ensuring proper sleep. When someone is struggling with either their mental health or a substance use disorder, having sleep issues generally is part of that so when it comes to co-occurring disorders it’s a double whammy. The sleep thing generally works itself out with a bit of effort and time but sometimes people develop sleep disorders which do need to be addressed by a doctor. Lack of proper sleep definitely halts the recovery process so it's important to tackle sleep early on.

Alright so now that we’ve talked about the physical body let’s move on to talk about the psychological part.

Okay so moving on now to the psychological part of the biopsycho social model of health. This part of the model has everything to do with how the brain processes information and how the mind reacts. This can range from the mood to personality and is rooted in behavior. Mental health should always be treated at the same time as any physical disease and that’s especially true for co-occurring disorders. Other things that coincide would be religion and spirituality and how a person can learn behavior changes such as how to live with intention; meaning how to think critically about situations and act accordingly.

So mental health can be a lot of different things but it’s a huge focus when it comes to co-occurring disorders because that’s exactly what a co-occurring disorder is. So treating one’s mental health is crucial for recovery. Other things to think about when it comes to psychology is a person’s past and present way of thinking.

Changing thought patterns isn’t easy but it’s the only way a person can change their behaviors. It always starts with thought processes. So this is where mental health professionals come into play. Mental health professionals are specialized in all sorts of areas so depending on what a person needs, a mental health professional such as a psychologist, therapist or counselor should be able to help.

Welcome back. Okay so we’ve talked about the biological and psychological part of addiction which focuses on the individual person who struggles with addiction but what about other people?

The people in a person’s life can make a huge difference in how a person succeeds in their recovery.

For example, if someone is in recovery for depression and alcohol and lives with someone who is degrading, unsupportive of their recovery, and drinks around them constantly it won’t matter how much that person has focused on their physical health or psychological health, the torment of their living conditions will not allow them to move forward in a positive direction. Another example would someone who is in recovery from cocaine and anxiety. If they live next to their old drug dealer and haven’t cut ties, yet the drug dealer is constantly messaging them, pressuring them to buy, that’s not going to help their addiction or their anxiety. So lots of things come into play when thinking about the social part of someone’s life.

We all have family, friends, professional relationships; schoolmates, work colleagues, and acquaintances.

So when someone is in recovery for a co-occurring disorder, all of these factors must be included and part of a recovery plan.

Welcome back. So now I want to tell you about the Sobriety Success Method. I created the Sobriety Success Method to help people who struggle with addiction get sober from home. A huge part of the Sobriety Success Method is also helping people recognize and identify whether or not they have a co-occurring disorder. So here’s how the Sobriety Success Method works.

It’s broken down into four parts and all four parts must be worked on at the same time.

The four parts are: Physical Health, Psychological Health, Social Health and Addiction focused topics. Each part is broken down into three categories.

Physical health includes nutrition, fitness and sleep

Psychological health includes mental health, spirituality and how to live intentionally

Social health includes family, friends and professional relationships

And the additional addiction focused topics are how to set a quit date, taking inventory and triggers

In my program; the sobriety success method, I walk my students through step by step on how to address each individual category. For example, nutrition; I help my students set up unique individualized nutrition plans, teach them what foods are best when fighting an addiction, how to meal plan and how to grocery shop.

When I talk to my students about their mental health I have a huge focus on helping them learn about co-occurring disorders and part of the Sobriety Success Method is encouraging my students to get a mental health evaluation from a mental health professional if they feel they have any underlying or undiagnosed mental health disorder or if they already have a diagnosed mental health disorder, we talk about how to start or continue treatment for that while including the Sobriety Success Method into their treatment plan.

Welcome to our next section. In this section we’re going to talk about how trauma changes the brain and then we’ll get into abstinence versus harm reduction. So let’s start with trauma.

A lot of people who struggle with co-occurring disorders have dealt with traumatic experiences and it’s important to uncover this as the treatment approach would be different than with someone who does not have past trauma. Trauma actually changes the brain. Trauma affects three part of the brain: the amygdala, the hippocampus and prefrontal cortex and all three of these are responsible for how the body manages stress.

A lot of people with past traumatic experiences or PTSD use drugs and alcohol to numb the mind. You see when someone is reminded of a past traumatic experience the amygdala goes into overdrive meaning they will feel the same way they felt when experiencing the traumatic experience firsthand. The hippocampus has reduced activity so it’s impossible for the brain to know if the experience is in the past or the currently happening now.

When someone thinks about a past traumatic experience their prefrontal cortex becomes suppressed so they are not able to control their fear so they become reactive

So when someone is using alcohol or drugs to suppress those memories it’s unfair to ask them to stop using immediately. Again, it’s a process that will take time.

If a person is in treatment for PTSD or anxiety due to past trauma, working through the past trauma is what is going to help them be more confident in reducing their drug or alcohol use.

They will have to have the tools necessary to deal with the traumatic thoughts as they come so that they don’t have to resort to drugs or alcohol.

If someone is using drugs or alcohol constantly to suppress their thoughts then the first step might be to reduce the drugs or alcohol so that they can start to feel those memories again and use the tools they receive in therapy to work through them.

The good news is that the brain can be rewired; this is called neuro plasticity but in order for that to happen the individual needs to be able to not use drugs or alcohol. It’s a delicate balance and the timing must be right but for the best outcome, eventually, anyone who struggles with past trauma and addiction will need to quit drugs and alcohol for the right therapy to work properly.

Okay so with all this being said, if someone has a mental health disorder that they are being treated for and they also struggle with drugs and alcohol, how do you get them on board with recognizing that their addiction could also be a problem? Well remember when we talked about the stages of change?

• Pre-contemplation

• Contemplation

• Determination

• Action

• Relapse

• Maintenance

• When someone isn’t ready to change, there’s nothing anyone can do or say that will suddenly make them listen or be ready and that’s okay. It’s all part of the process. When someone enters the contemplation stage they may be thinking about how their addiction is affecting their life but until they reach determination they won’t be ready. So what is the best approach for those who just aren’t ready? Of course, long term, ideally someone is going to completely abstain from drugs and alcohol and treat their mental health but that’s not always realistic.

When someone isn’t ready to change, the best approach is harm reduction.

Harm reduction is exactly how it sounds.

Reducing the chance of harm.

In harder drugs like heroin or crack cocaine, a harm reduction approach would be supplying users with free needles so they don’t spread disease like hepatitis or HIV and programs like these have shown to be successful.

Contrary to what many people think, it doesn’t encourage them to keep going. In fact, by getting people used to the routine of going to get free needles they will also, at the same time, be given information about how to get into recovery and overtime, most of these users enter into a drug treatment program eventually. So let’s say for example someone is struggling with depression and in treatment for that but also heavily drinks every weekend, yet they are in denial that drinking has anything to do with their depression and they don’t want to quit drinking. Instead of making a plan for them to completely quit or telling them that they have an addiction and need to go to AA, it’s best to approach this gradually and talk about ways to reduce harm. If their weekend binges involve destructive behavior then focus on how they can help themselves stay safe: for example, giving someone their car keys once they start drinking, making sure they know who to call if they get into trouble or danger, things like that. Another way is to start to talk about the physical health and dangers of binge drinking. One of the first things I try to do is encourage my students to get a medical health check up. It’s a way to make sure their liver, kidneys, and so on are okay and if there are problems we can focus on that. For example I was working with someone who had a fatty liver but in denial that it was caused from alcohol even though they were a daily drinker. So we would talk about things they could do to help their liver and little by little we would have small conversations about reducing their alcohol intake. But it was a long process that eventually did lead to abstinence. But had I started out with an abstinence based approach, they would have immediately shut down. And this is why it’s so important to understand the stages of change and how a person can be guided but should never be pushed into the next stage. It really does have to come from within.

Okay so there may be times when abstinence may be the best approach and that’s if using drugs or alcohol puts their life in immediate danger. For example, I was working with someone who struggled with schizophrenia but also was addicted to meth. Every time they were high on meth they would try to hurt or kill someone else or themselves. It also reacted negatively to their antipsychotic medication they were on. For their own safety and others we focused heavily on why they should never ever use methamphetamine for any reason.

It’s important though to analyse each situation and leave any biases at the door. For example, someone who has been using heroin for 30 years and still in the contemplation stage would not respond well to someone pushing abstinence immediately even if their behavior appears to be reckless and dangerous it’s best to start with harm reduction and approach the situation slowly until they reach determination.