Don’t allow preconceptions about addiction interfere with learning about what the client really needs
Know diagnostic criteria
Don’t assume that there is one correct treatment approach
Empathy and hope are the most valuable components

Stage specific motivational enhancements
Express empathy
Develop discrepancy
Roll with resistance
Support self-efficacy
Use contingency management techniques to target specific behaviors
Use cognitive-behavioral techniques
Visual aids
Role playing/practice
Outline sessions with specific behavioral objectives
Techniques cont…
Use relapse prevention techniques
Daily inventory
Recovery group participation
Coping skills training
Medication adherence
Skill building to address functional deficits
Express concern about the client’s substance use, or the client’s mood
State non-judgmentally that substance use (or mood, anxiety, self-destructiveness) is a problem
Agree to disagree about the severity of the issues
Consider a trial of abstinence to clarify the issues
Suggest bringing a family member to an appointment
Explore the client’s perception of the problems
Emphasize the importance of seeing the client again; that you will try to help
For involuntary clients, develop mutually acceptable goals

Elicit positive and negative aspects of substance use or psychological symptoms
Ask about positive and negative aspects of past periods of abstinence and remission
Summarize the client’s comments
Make explicit discrepancies between values and actions
Consider a trial of abstinence and/or psychological evaluation
Acknowledge the significance of the decision to seek treatment
Support self-efficacy
Help the client decide on appropriate, achievable action for each issue
Caution that the road ahead is tough
Explain that relapse should not disrupt the client–clinician relationship
Be a source of encouragement and support
Remember that the client may be in different stages of readiness for change regarding different issues
Acknowledge the uncomfortable aspects of withdrawal and/or psychological symptoms
Reinforce the importance of remaining in recovery from both problems
Anticipate and address difficulties
Recognize the client’s struggle with either or both problems
Support the client’s resolve
Reiterate that relapse or psychological symptoms should not disrupt the counseling relationship
Explore what can be learned from the relapse
Express concern about the relapse
Emphasize the positive aspect of the effort to seek care
Support the client’s self-efficacy
Older adults are at highest risk for combined mood disorder and substance problems
Worry or obsessive thoughts about multiple things
Sleep disruption
Activity & What to do
Differentiate among the following:
anxiety and mood disorders
commonplace expressions of anxiety and depression (What do your clients say?)
anxiety and depression associated with more serious mental or physical illness
medical conditions and medication side effects
substance-induced changes
Start low, go slow
Combine addiction counseling with medication and mental health treatment
Schism—two worlds
What looks like resistance or denial may in reality be negative symptoms of schizophrenia.
An accurate understanding of the role of addiction in the client’s illness requires a multiple-contacts, longitudinal assessment.
Clients with COD involving psychosis have a higher risk for self-destructive and violent behaviors, homelessness, victimization, poor nutrition and poverty.
Stacy (8 failed treatments)
Tommy (Voices)
Andre—(Group Home)
What to do
Know the signs and symptoms of the disorder
Work closely with a psychiatrist or mental health professional
Expect crises associated with the mental disorder
Assist the client in linking with social services, housing, vocational services
Monitor medication and promote medication adherence
Provide frequent breaks and shorter sessions or meetings

What to do cont…
Employ structure and support
Present material in simple, concrete terms with examples and use multimedia
Encourage participation in social clubs
Teach the client skills for detecting early signs of relapse for both mental illness and addiction
Involve family in psychoeducational groups
Monitor clients for signs of relapse and a return of psychotic symptoms

Co-occurring disorders are the rule not the exception
Mental health issues, especially trauma and eating disorders, may not be revealed during the initial assessment
Be alert for “substitute” addictions
Adequate treatment must address the person as a whole