Comorbidity Guideline PDF
Comorbidity Guideline PDF
Comorbidity Guideline PDF
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SECOND EDITION
SECOND EDITION
Christina Marel
Christina Marel
Katherine L Mills
Katherine L Mills
Rosemary Kingston
Rosemary Kingston
Kevin Gournay
Kevin Gournay
Mark Deady
Mark Deady
Frances Kay-Lambkin
Frances Kay-Lambkin
Amanda Baker
Amanda Baker
Maree Teesson
Maree Teesson
Guidelines on the
management of co-
occurring alcohol and
other drug and mental
health conditions in alcohol
and other drug treatment
settings
NHMRC Centre of Research Excellence in Mental Health and Substance Use
Sydney, Australia
Christina Marel, Katherine L Mills, Rosemary Kingston, Kevin Gournay, Mark Deady, Frances Kay-
Lambkin, Amanda Baker, Maree Teesson
© Centre of Research Excellence in Mental Health and Substance Use at NDARC (National Drug and
Alcohol Research Centre) at UNSW Australia (The University of New South Wales) 2016.
This work is copyright. You may download, display, print and reproduce this material in unaltered form only
(retaining this notice) for your professional, non-commercial use or use within your organisation. All other
rights are reserved. Requests and enquiries concerning use and reproduction should be addressed to the
Information Manager, National Drug and Alcohol Research Centre, University of New South Wales, Sydney,
NSW 2052, Australia.
ISBN 978-0-7334-3609-3
Disclaimer
These Guidelines were funded by the Australian Government and developed by NDARC to support health
services and AOD (alcohol and/or other drug) treatment service workers to more accurately identify and
manage the needs of comorbid clients. These Guidelines do not claim to reflect all considerations. As with
all guidelines, recommendations may not be appropriate for use in all circumstances. These Guidelines
should only be followed subject to the AOD worker’s judgement in each individual case.
Whilst the Guidelines are considered to be true and correct at the date of publication, changes in
circumstances after the time of publication may impact on the accuracy of the Guidelines. While the
Guidelines have been prepared and presented with all due care, UNSW Australia does not warrant or
represent that the Guidelines are entirely free from error or omission. They are made available on the
understanding that UNSW Australia and its employees and agents shall have no liability (including liability
by reason of negligence) to the users for any loss, damage, cost or expense incurred or arising by reason
of using or relying on the Guidelines.
Links to a selection of available Internet Sites and resources are identified. Links to other Internet Sites that
are not under the control of NDARC at UNSW Australia are provided for information purposes only. Care
has been taken in providing these links as suitable reference resources. It is the responsibility of users to
make their own investigations, decisions and enquiries about any information retrieved from other Internet
Sites. The provision and inclusion of these links do not imply any endorsement, non-endorsement, support
or commercial gain by UNSW Australia.
While the Guidelines were prepared after an extensive review of the literature, review by an expert
advisory committee and broad consultation, the authors do not bear any clinical responsibility for actions
undertaken on the basis of this information.
The suggested citation for this document is: Marel C, Mills KL, Kingston R, Gournay K, Deady M, Kay-
Lambkin F, Baker A, Teesson M (2016). Guidelines on the management of co-occurring alcohol and other
drug and mental health conditions in alcohol and other drug treatment settings (2nd edition). Sydney,
Australia: Centre of Research Excellence in Mental Health and Substance Use, National Drug and Alcohol
Research Centre, University of New South Wales.
The updating of these Guidelines through the National Drug and Alcohol Research Centre at the University
of New South Wales was supported by funding from the Australian Government Department of Health.
Acknowledgements
We would like to express our sincere gratitude to the members of the Expert Panel (see p.iii), Discussion
Forum, key-stakeholders, and all other individuals who have made contributions to this important
document. Specifically, we would like to acknowledge and thank Melinda Beckwith, Rob Chase, Ruth
Collins, Angela Corry, Gary Croton, Marie Coughlan, Neil Frazer, Deb Gleeson, Penny Glover, Sukalpa
Goldflam, Rosemary Hambledon, Paul Harvey, Naomi Henderson, Bronwyn Hendry, Kate Hewett, Breanne
Hobden, Kah-Seong Loke, Danny McCulloch, Jane Moreton, Hoa Nguyen, Marcus Pastorelli, Brendan Pont,
Michael Quaass, Greg Robertson, Melanie Schofield, Jessica Smedley, Amanda Street, Elizabeth Stubbs,
Michelle Taylor, Deb Tipper, Gerard Tracey, Sharon Tuffin, Frankie Valvasori, and Barry White.
We would also like to thank Cath Chapman, Sharlene Kaye, Mary Kumvaj, Mark Mulgrew, Suzanne
Nielsen, Joanne Ross, Lexine Stapinski, and Matt Sunderland for providing invaluable advice, support, and
comment.
Our sincere thanks also go to the Australian Government Department of Health for funding the update and
revision of these Guidelines.
Finally, we would like to acknowledge previous work that has influenced the development of these
Guidelines; in particular:
Australian Department of Health and Ageing. (2007). Alcohol treatment guidelines for Indigenous
Australians. Canberra, Australia: Australian Government Department of Health and Ageing.
Baker, A., Kay-Lambkin, F., Lee, N. K., Claire, M., & Jenner, L. (2003). A brief cognitive behavioural intervention
for regular amphetamine users. Canberra, Australia: Australian Government Department of Health and
Ageing.
Baker, A. & Velleman, R. (2007). Clinical handbook of co-existing mental health and drug and alcohol
problems. New York, NY: Routledge.
Croton, G. (2007). Screening for and assessment of co-occurring substance use and mental health
disorders by alcohol and other drug and mental health services. Wangaratta, Australia: Victorian Dual
Diagnosis Initiative Advisory Group.
Deady, M. (2009). A review of screening, assessment and outcome measures for drug and alcohol settings.
Strawberry Hills, Australia: Network of Alcohol and other Drug Agencies.
Jenner, L. & Lee, N. (2008). Treatment approaches to users of methamphetamine: A practical guide for front
line workers. Canberra, Australia: Australian Government Department of Health and Ageing.
Lee, N., Jenner, L. Kay-Lambkin, F., Hall, K., Dann, F., Roeg, S., et al. (2007). PsyCheck: Responding to mental
health issues within alcohol and drug treatment. Canberra, Australia: Commonwealth of Australia.
Marsh, A., Dale, A., & Willis, L. (2007). A counsellor’s guide to working with alcohol and drug users (2nd
edition). Perth, Australia: Drug and Alcohol Office.
Marsh, A., O’Toole, S., Dale, A., Willis, L., & Helfgott, S. (2013). Counselling guidelines: Alcohol and other drug
issues (3rd Edition). Perth, Australia: Western Australia Drug and Alcohol Office.
Acknowledgements i
NSW Department of Health. (2007). Mental health reference resource for drug and alcohol workers.
Sydney, Australia: NSW Department of Health.
NSW Department of Health. (2008). NSW Health drug and alcohol psychosocial interventions: Professional
practice guidelines. Sydney, Australia: NSW Department of Health.
Teesson, M., Degenhardt, L., Hall, W., & Proudfoot, H. (2012) Addictions: Clinical psychology module (2nd
edition). East Sussex, UK: Psychology Press.
Teesson, M. & Proudfoot, H. (2003). Comorbid mental disorders and substance use disorders: Epidemiology,
prevention and treatment. Canberra, Australia: Australian Government Department of Health and Ageing.
ii Acknowledgements
Expert panel
Prof Steve Allsop National Drug Research Institute
Ms Jennifer Holmes Drug and Alcohol Nurses Australasia; Medically Supervised Injecting Centre
A/Prof Nicole Lee National Centre for Education and Training on Addiction
Ms Leonie Manns Consumer Advocate; Co-chair of Executive Advisory Board, NHMRC Centre
of Research Excellence in Mental Health and Substance Use
Contents iv
Contents
Discharge planning 96 Treating bipolar disorders 125
B5: Approaches to comorbidity 97 Summary 128
Models of care 97 Depression 130
Approaches to comorbidity 99 Clinical presentation 130
Psychological approaches 99 Managing depressive symptoms 130
Pharmacological approaches 102 Treating depressive disorders 131
Self-help groups 105 Summary 138
E-health interventions 105 Anxiety 140
Physical activity 105 Clinical presentation 140
Complementary and alternative Managing symptoms of anxiety, panic,
therapies 106 or agitation 140
B6: Managing and treating specific Treating anxiety disorders 141
disorders 107
Generalised anxiety disorder (GAD) 142
Attention defecit/hyperactivity
disorder (ADHD) 110 Panic disorder 143
Treating psychotic spectrum disorders 118 Trauma and post traumatic stress
disorder (PTSD) 154
Summary 121
Clinical presentation 154
Bipolar disorders 123
Managing trauma-related symptoms 154
Clinical presentation 123
Treating PTSD 156
Managing symptoms of bipolar 123
Summary 160
v Contents
Contents
Eating disorders (ED) 162 B7: Worker self-care 185
Clinical presentation 162 Holistic self-care: AOD workers 186
Symptoms of ED 162 Burnout 186
Anorexia nervosa 162 Secondary traumatic stress 187
Bulimia nervosa 163 Clinical supervision 188
Binge eating disorder 164 Part C: Specific population groups 189
Managing ED 164 Indigenous Australians 189
Treating ED 165 Culturally and linguistically diverse
groups 193
Treating anorexia nervosa 165
Gay, lesbian, bisexual, transgendered
Treating bulimia nervosa 167 and intersex individuals 195
Treating binge eating disorder 169 Rural/remote communities 196
Summary 171 Homeless persons 197
Personality disorders 173 Women 199
Clinical presentation 173 Men 199
Managing symptoms of personality Coerced clients 200
disorders 173
Young people 201
Treating personality disorders 174
Older people 202
Borderline personality disorder (BPD) 174
Appendices (See page vii) 205
Antisocial personality disorder
(ASPD) 176 Worksheets (See page viii) 262
Summary 177 References 276
Confusion or disorientation 179
Cognitive impairment 179
Grief and loss 180
Aggressive, angry, or violent behaviour 181
Concluding remarks 184
Contents vi
Appendices
Appendix A: Other guidelines 205 Appendix T: Cognitive behavioural
techniques 255
Appendix B: Other useful resources 208
Cognitive restructuring 255
Appendix C: Research and information
organisations 214 Structured problem solving 257
Appendix D: DSM-5 and ICD-10 Goal setting 257
classification cross-reference 216
Pleasure and mastery events
Appendix E: Motiviational interviewing 218 scheduling 258
Appendix F: Mental state examination 229 Appendix U: Anxiety management
techniques 259
Appendix G: Integrated Motivational
Assessment Tool (IMAT) 231 Progressive muscle relaxation 259
Appendix H: Additional screening tools 232 Controlled or abdominal breathing 260
Appendix I: CANSAS-P 234 Calming response 260
Appendix J: Kessler psychological Visualisation and imagery 260
distress scale (K10) 236
Grounding 261
Appendix K: The PsyCheck Screening
Tool 237
Appendix L: Depression Anxiety Stress
Scale (DASS 21) 241
Appendix M: The Primary Care PTSD
Screen (PC-PTSD) 243
Appendix N: Trauma Screening
Questionnaire (TSQ) 244
Appendix O: Psychosis Screener (PS) 245
Appendix P: Indigenous Risk Impact
Screener (IRIS) 246
Appendix Q: Adult ADHD Self Report
Scale (ASRS) 247
Appendix R: Suicide risk screener scorer
and interpretation 251
Appendix S: Referral pro forma 253
Appendices vii
Worksheets
Identifying negative thoughts 262
Cognitive restructuring 263
Structured problem-solving worksheet 265
Goal setting worksheet 266
Pleasure and mastery worksheet 268
Progressive muscle relaxation 270
Controlled abdominal breathing 271
Visualisation and imagery 272
Food and activity diary 273
Common reactions to trauma 274
Common reactions to grief and loss 275
Worksheets viii
Abbreviations
ADHD Attention-Deficit/Hyperactivity Disorder K10 Kessler Psychological Distress Scale
BMI Body Mass Index NaSSA Noradrenaline and specific serotonergic agent
BPD Borderline Personality Disorder NDARC National Drug and Alcohol Research Centre
CAN Camberwell Assessment of Need NHMRC National Health and Medical Research Council
DASS Depression Anxiety Stress Scale PC-PTSD Primary Care PTSD Screen
ERP Exposure and Response Prevention SNRI Serotonin and Noradrenaline Reuptake Inhibitor
GLBTI Gay, Lesbian, Bisexual, Transgender, Intersex SSRI Selective Serotonin Reuptake Inhibitors
Abbreviations ix
Glossary
The following terms are used throughout this document and are defined here for ease of reference.
Alcohol and/or other The presence of an AOD use disorder as defined by the DSM-5. This term
drug (AOD) use disorders is used interchangeably with ‘substance use disorders’, and includes the
use of alcohol; benzodiazepines; cannabis; methamphetamines, cocaine,
and other stimulants; hallucinogens; heroin and other opioids; inhalants;
and tobacco.
AOD workers All those who work in AOD treatment settings in a clinical capacity. This
includes, but is not limited to, nurses, medical practitioners, psychiatrists,
psychologists, counsellors, social workers, and other AOD workers.
AOD treatment settings Specialised services that are specifically designed for the treatment of
AOD problems and include, but are not limited to, facilities providing
inpatient or outpatient detoxification, residential rehabilitation,
substitution therapies (e.g., methadone or buprenorphine for opiate
dependence), and outpatient counselling services. These services may
be in the government or non-government sector.
Comorbidity Use of the term ‘comorbidity’ in these Guidelines refers to the co-
occurrence of one or more AOD use disorders with one or more mental
health conditions. The terms ‘comorbid’ and ‘co-occurring’ are used
interchangeably throughout this document.
Mental health disorders Refers to the presence of a mental health disorder (other than AOD use
disorders) as defined by the DSM-5.
Mental health conditions Refers to those with a diagnosable mental health disorder as well as
those who display symptoms of disorders while not meeting criteria for a
diagnosis of a disorder.
Glossary x
In a nutshell...
These Guidelines aim to provide alcohol and other drug (AOD) workers with evidence-based information
to assist with the management of co-occurring, or comorbid, AOD and mental health conditions. They
represent an update and revision of the first edition of these Guidelines published in 2009.
Population estimates indicate that more than one-third of individuals with an AOD use disorder have at
least one comorbid mental health disorder; however, the rate is even higher among those in AOD treatment
programs. Additionally, there are a large number of people who present to AOD treatment who display
symptoms of disorders while not meeting criteria for a diagnosis of a disorder.
The high prevalence of comorbidity means that AOD workers are frequently faced with the need to
manage complex psychiatric symptoms that may interfere with their ability to treat clients’ AOD use.
Furthermore, clients with comorbid mental health conditions often have a variety of other medical, family,
and social problems (e.g., housing, employment, welfare, legal problems). As such, it is important that AOD
workers adopt a holistic approach to the management and treatment of comorbidity that is based on
treating the person, not the illness (see Chapter B1).
The first step in responding to comorbidity is being able to identify the person’s needs (see Chapters B2
and B3). Despite high rates of comorbidity among clients of AOD services, it is not unusual for comorbid
mental health conditions to go unnoticed. This is mostly because AOD workers are not routinely looking
for them. It is a recommendation of these Guidelines that all clients of AOD treatment services should be
screened and assessed for comorbidity as part of routine clinical care.
Once identified, symptoms of mental health conditions may be effectively managed while the person is
undergoing AOD treatment (see Chapters B5 and B6). The goal of management is to allow AOD treatment
to continue without mental health symptoms disrupting the treatment process, and to retain clients
in treatment who might otherwise discontinue such treatment. Comorbidity is not an insurmountable
barrier to treating people with AOD use disorders. Indeed, research has shown that clients with comorbid
mental health conditions can benefit just as much as those without comorbid conditions from usual AOD
treatment.
Some clients with comorbidity may require additional treatment for their mental health problems (see
Chapter B6). Some interventions have been designed for the treatment of specific comorbidities; however,
these interventions generally have not been well researched. Where there is an absence of specific
research on comorbid disorders, it is recommended that best practice is to use the most effective
treatments for each disorder. Both psychosocial and pharmacological interventions have been found to
have some benefit in the treatment of many comorbidities. Consideration should also be given to the use
of e-health interventions, physical activity, and complementary and alternative therapies, as an adjunct to
traditional treatments.
In addition to mental health services, AOD workers may need to engage with a range of other services to
meet clients’ needs, including housing, employment, education, training, community, justice, and other
support services. A broad, multifaceted, and co-ordinated approach is needed in order to address all of
these issues effectively, and it is important that AOD services and workers develop links with a range of
local services (see Chapter B4).
In a nutshell... xi
About these
guidelines
Key Points
• The purpose of these Guidelines is to provide AOD workers with
up-to-date, evidence-based information on the management of
comorbid mental health conditions in AOD treatment settings.
• All AOD workers should be ‘comorbidity informed’ – that is,
knowledgeable about the symptoms of the common mental health
conditions that clients present with and how to manage these
symptoms.
• The Guidelines are not a policy directive and are not intended to
replace or take precedence over local policies and procedures.
• The Guidelines should be used in conjunction with existing
guidelines and discipline-specific practice standards.
• The Guidelines do not provide formal recommendations, but rather
guidance for AOD workers when working with clients who have
comorbid mental health conditions.
• The Guidelines are based on the best available evidence and draw
upon the experience and knowledge of clinicians, researchers,
consumers, and carers.
Rationale
In 2007, the Australian Government Department of Health and Ageing funded the National Drug and
Alcohol Research Centre (NDARC) to develop ‘Guidelines on the management of co-occurring alcohol and
other drug and mental health conditions in alcohol and other drug treatment settings’ (hereafter referred to
as the Guidelines) [1]. The development of these Guidelines was funded as part of the National Comorbidity
Initiative in order to improve the capacity of AOD workers to respond to comorbidity.
While the Guidelines have proved to be an extremely successful clinical resource, the scientific evidence
regarding the management and treatment of comorbid disorders has grown considerably since they were
first published. Consequently, the Australian Government Department of Health funded the NHMRC Centre
of Research Excellence in Mental Health and Substance Use, NDARC, to update and revise the Guidelines
to bring them up to date with the most current evidence. The purpose of this chapter is to describe the
aims, scope, and development of the revised Guidelines.
Guideline aims
These Guidelines aim to provide AOD workers with up-to-date, evidence-based information on the
management of comorbid mental health conditions in AOD treatment settings. They are based on the best
available evidence and draw upon the experience and knowledge of clinicians, researchers, consumers,
and carers. The intended outcome of the Guidelines is increased knowledge and awareness of comorbid
mental health conditions in AOD treatment settings, improved confidence and skills of AOD workers,
and increased uptake of evidence-based care. By increasing the capacity of AOD workers to respond to
comorbidity, it is anticipated that the outcomes for people with comorbid mental health conditions will be
improved.
These Guidelines are not a policy directive and are not intended to replace or take precedence over local
policies and procedures. The Guidelines are not formal recommendations, but instead provide guidance for
AOD workers when working with clients who have comorbid mental health conditions. The Guidelines are
not a substitute for training; rather, they should be used in conjunction with appropriate comorbidity training
and supervision. Workers should use their experience and expertise in applying recommendations into
routine clinical practice.
Intended audience
The Guidelines have been designed primarily for AOD workers. When referring to AOD workers, we are
referring to all those who work in AOD treatment settings in a clinical capacity. This includes nurses,
medical practitioners, psychiatrists, psychologists, counsellors, social workers, and other AOD workers.
AOD treatment settings are those specialised services that are specifically designed for the treatment of
AOD problems and include, but are not limited to, facilities providing inpatient or outpatient detoxification,
residential rehabilitation, substitution therapies (e.g., methadone or buprenorphine for opiate dependence),
and outpatient counselling services. These services may be in the government or non-government sector.
Although these Guidelines focus on AOD workers, a range of other health professionals may find them
useful. However, it should be noted that comorbidity is not homogenous, and different patterns of
comorbidity are seen across different health services [3]. For example, AOD treatment services are most
likely to see comorbid mood, anxiety, and personality disorders; mental health services, on the other hand,
are more likely to see individuals with schizophrenia and bipolar disorder comorbid with AOD use disorders
[4].
Given these differences in AOD workers’ roles, education, training, and experience, it is not expected that
all AOD workers will be able to address comorbid conditions to the same extent. Each AOD worker should
use these Guidelines within the context of his/her role and scope of practice. At a minimum, however, it
is suggested that all AOD workers should be ‘comorbidity informed’. That is, all AOD workers should be
knowledgeable about the symptoms of the common mental health conditions that clients present with
(see Chapter A4) and how to manage these symptoms (see Chapter B6). The provision of opportunities for
continuing professional development for AOD staff in the area of comorbidity should be a high priority for
AOD services.
All AOD workers should refer to the standards and competencies relevant to their own professions; for
example, those specified by the Australian Psychological Society, the Royal Australian and New Zealand
College of Psychiatrists, the Australian Medical Association, the Nursing Board, the Australian Association
of Social Workers, the Australian Counselling Association, and Volunteering Australia. In addition, the
National Practice Standards for the Mental Health Services [6] provide practice standards for services and
professionals who work with people who have mental health conditions.
Development
The current Guidelines represent an update, revision, and expansion of the original Guidelines [1], and
are based on comprehensive reviews of the best available evidence. The revision process also involved
consultation between academic experts in the field of mental health and substance use, consumer groups
and clinicians, and as such, the current Guidelines reflect the collective experience of an expert panel of
academic researchers, clinicians, consumers and carers (see p.iii). In addition to reviewing, synthesising, and
updating the evidence to date, feedback on the original Guidelines was obtained from key-stakeholders,
and areas for improvement identified.
Both clinical and scientific knowledge about what treatment modalities may help those with comorbidity
has been included, and as such, a variety of psychotherapies and pharmacotherapies are discussed. We
have also included discussion of physical activity, some complementary and alternative therapies, as well
as e-health interventions. The clinical evidence for the efficacy of these interventions varies greatly, and
it is critical to note that although there may be limited scientific evidence to recommend a treatment as
best practice, that does not necessarily mean that the treatment is ineffective. That is, the quality of some
studies evaluating some interventions is not as rigorous as others, and does not provide adequate support
or evidence for clinical guidance.
Mental health
Environmental
factors Wellbeing Physical health
Social factors
Although the fundamental approach to the development of the revised Guidelines was the same as
that used for the first edition, there were minor changes. The multidisciplinary panel of experts was
supplemented by an additional discussion forum, membership of which was comprised of stakeholders
who wished to contribute to the revision process.
The structure of the revised Guidelines has significantly changed from the first edition, and is formatted in
four parts:
• Part A addresses the nature and extent of comorbidity, and discusses why it is important for AOD
services to respond. Information regarding the prevalence, guiding principles, and classification of
disorders are contained in Part A.
• Part B contains information regarding responding to comorbidity, including holistic health care,
identifying comorbidity, risk assessments, care coordination, approaches to comorbidity, managing and
treating specific disorders, and worker self-care.
• Part C addresses specific population groups.
• Useful resources, techniques, and worksheets are contained in the appendices.
It should be noted that although the first edition of the Guidelines had separate chapters for information
regarding managing and treating comorbidity, the revised edition has combined these into one cohesive
section (see Chapter B6), which addresses specific disorders. In addition, the revised edition has included
discussion of comorbid attention-deficit/hyperactivity disorder (ADHD) as well as feeding and eating
disorders (ED).
The diagnostic criteria for mental health disorders are defined in internationally accepted diagnostic
manuals. Research settings most commonly use the Diagnostic and Statistical Manual of Mental
Disorders (DSM), published by the American Psychiatric Association. Although the fifth version of this
manual (DSM-5) was in use during the development of these guidelines, the large majority of studies
included in the literature reviews relied on DSM-IV-TR criteria for mental disorders. As such, we refer
to both DSM-IV-TR and DSM-5 criteria where appropriate. The other major classification system is the
International Classification of Diseases (ICD), with the current version being ICD-10. ICD-11 is currently under
development. Although widely used in clinical practice in many parts of the world, ICD is rarely used in the
type of research studies included for review. Nevertheless, ICD is referred to in these guidelines where
appropriate.
Case studies
A series of case studies have been included to highlight some of the presenting issues that are
experienced by AOD clients with comorbid mental health conditions and demonstrate some examples of
pathways through treatment.
These Guidelines are based on the evidence currently available. As new and emerging treatments will
likely contribute to a strong evidence base which should be included in future revisions, it is recommended
that the Guidelines be updated every five years.
important?
What is
Part A:
A1
A1: What is
Section
Heading
comorbidity?
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aspe quas experit re et ulpa.
A1: What is
comorbidity?
Key Points
• Although other types of ‘comorbidity’ exist, the use of the term in
this document refers to the co-occurrence of an AOD use disorder
with any other mental health condition.
• In this document, we use the term comorbid ‘mental health
disorder’ when referring to those who have a diagnosable mental
health disorder, as defined by the DSM.
• When using the term ‘mental health condition’, we are referring
to both those who have a diagnosable disorder as well as those
who display symptoms of disorders while not meeting criteria for a
diagnosis of a disorder.
• There are a number of possible explanations as to why two or
more disorders may co-occur. It is most likely, however, that
the relationship between comorbid conditions is one of mutual
influence.
Use of the term ‘comorbidity’ in these Guidelines refers to the co-occurrence of one or more AOD use
disorders with one or more mental health conditions. This phenomenon is often referred to as ‘dual
diagnosis’; however, this term is often misleading, as many clients present with a range of co-occurring
conditions of varying severity [8]. It should be noted that there are other types of comorbidity. For example,
a person may have co-occurring AOD use disorders (i.e., more than one AOD use disorder). Indeed, one of
the most common and often overlooked comorbidities in AOD clients is tobacco use (discussed in Chapter
B1) [9-12]. Other conditions that are often found to co-occur with AOD use disorders are physical health
conditions (e.g., cirrhosis, hepatitis, heart disease, diabetes), intellectual and learning disabilities, cognitive
impairment, and chronic pain [13-20]. While there are a number of different types of comorbidity, these
Guidelines focus on the co-occurrence of AOD use disorders and mental health conditions.
To be classified as having a mental health disorder, a person must meet a number of diagnostic criteria
(see Chapter A4 for a discussion of the classification of mental health disorders). There are, however, a
In this document we use the term comorbid ‘mental health disorder’ when referring to those who have a
diagnosable mental health disorder, as defined by the DSM [23, 24]. When using the term ‘mental health
condition’, we are referring to both those who have a diagnosable disorder as well as those who display
symptoms of disorders while not meeting criteria for a diagnosis of a disorder.
In some cases where there is comorbidity, the AOD use disorder occurs as a consequence of repeated
AOD use to relieve or cope with mental health symptoms. This is often described as the ‘self‐-medication
hypothesis’, in that substances are used in an attempt to medicate mental health symptoms [25-28]. In
these circumstances, mental health conditions may become more apparent after the AOD use has ceased.
Certain mental health conditions may also impair a person’s ability to make sound judgements regarding
his/her AOD use. For example, individuals with some personality characteristics or cognitive impairment
may have difficulty identifying social cues about appropriate use. This may lead the person to use in greater
quantities or with greater frequency, increasing the likelihood of developing an AOD use disorder.
Alternatively, AOD intoxication and withdrawal can induce a variety of mental health symptoms and
disorders, such as depression, bipolar, anxiety, obsessive-compulsive, and psychotic disorders (see
Chapter A4 for a discussion of substance-induced disorders). For example, alcohol use and withdrawal
can induce symptoms of depression or anxiety [29-31]; manic symptoms can be induced by intoxication
with stimulants, steroids, or hallucinogens; and psychotic symptoms can be induced by withdrawal
from alcohol, or intoxication with amphetamines, cocaine, cannabis, lysergic acid diethylamide (LSD), or
phenylcyclohexylpiperidine (PCP) [32, 33]. Other disorders that may result from AOD use include substance-
induced neurocognitive disorder, sexual dysfunction, and sleep disorder [24]. In the majority of cases,
these effects subside and eventually disappear with abstinence [34-36]. For some, however, symptoms
may continue even after they have stopped drinking or using drugs. Regardless of whether the comorbid
disorder is classified as independent or substance-induced, it may be associated with poorer treatment
outcomes [37].
An indirect causal relationship is said to exist if one condition has an effect upon an intermediary factor
that, in turn, increases the likelihood of developing the second condition [38]. For example, research has
shown that the presence of early onset AOD use reduces the likelihood of completing high school, entering
tertiary education, and completing tertiary education [39, 40]. This poor level of education may lead to later
life difficulties (e.g., unemployment) that may lead to other problems, such as depression [38]. Similarly, the
reverse is possible, whereby a depressive disorder may lead to difficulties in completing study and work
commitments, which may in turn lead to difficulties finding employment, increasing the risk of AOD misuse
[41-43].
Common factors
The co-occurrence of two conditions may also come about due to the presence of shared biological,
psychological, social, or environmental risk factors. That is, the factors that increase the risk of one
condition may also increase the risk for another [38, 44-47]. For example, both AOD and mental health
conditions have been associated with lower socioeconomic status, cognitive impairment, the presence of
conduct disorder in childhood and antisocial personality disorder (ASPD). It is also possible that a genetic
vulnerability to one disorder may increase the risk of developing another disorder [47-49].
Mental health
AOD use
condition
Mental health
AOD use
condition
Establishing the order of onset of conditions can be useful in understanding the relationship between
conditions. It is important to note, however, that once comorbid conditions have been established it is most
likely that the relationship between them is one of mutual influence rather than there being a clear causal
pathway [32, 52] (see Figure 3). Regardless of how the comorbidity came about, both conditions may serve
to maintain or exacerbate the other. For example, a person may engage in AOD use to reduce symptoms of
anxiety; however, research suggests that repeated use may lead to increased anxiety [53]. It is also possible
that the relationship between disorders may change over time [52, 54]. For example, depression may trigger
alcohol use on some occasions, while it may be the result of alcohol use on others [55]. Irrespective of what
order comorbid conditions have developed, the strategies used to manage these conditions are the same.
Mental health
symptoms
AOD use
Temporary relief
from mental health
symptoms
Return/worsening
of mental health
Increased AOD use
symptoms. Increased
tolerance to AOD
Return/worsening
of mental health
Increased AOD use
symptoms. Increased
tolerance to AOD
Temporary relief
from mental health
symptoms
A2
Goes here
comorbidity
and why is it of
Ipsandi te nus, omnime corat verum
nam vitecup tatem. Nam quaero ea
concern?
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eosapid itaturi tatendi tasperrum que
est laborum rest, esecte nis rem sit
aspe quas experit re et ulpa.
A2: How
common is
comorbidity
and why is it of
concern?
Key Points
• Mental health disorders are common among clients of AOD
services.
• The most common comorbid mental health disorders are anxiety,
depression, PTSD, and personality disorders.
• In addition to those with mental health disorders, there are a
number of people who present to AOD treatment who display
symptoms of disorders while not meeting criteria for a diagnosis of
a disorder.
• Although people with comorbid mental health conditions may
have more complex profiles, they have been found to benefit as
much from traditional AOD treatment methods as those without
comorbid mental health conditions.
Figure 4: Prevalence (%) of single and comorbid DSM-IV affective, anxiety and
substance use disorders amongst Australian males (left) and females (right) in the
past year
Males Females
Substance Substance
Anxiety 1.3 Use Anxiety 0.8 Use
6.7 4.3 12.6 1.7
0.9 0.6
0.6 0.2
2.0 3.9
Affective Affective
1.9 2.5
A variety of mental health disorders have been found to co-occur in clients of Australian AOD services.
Studies that have undertaken comprehensive assessments of mental health disorders indicate that
between 50–76% of Australian clients meet diagnostic criteria for at least one comorbid mental disorder
[65-67]. At least one in three have multiple comorbidities [65, 66, 68]. The proportion of clients who have a
mental disorder documented in their medical records, however, ranges from 42–52% [68-71], indicating that
a number of cases likely go unrecognised.
Affective disorders
Anxiety disorders
As in the general population, the most frequently seen disorders among people seeking AOD treatment are
anxiety disorders (45–70%), most commonly GAD [65, 66, 72, 73]; depression (26–60%) [65-67, 70, 73-76],
PTSD (27–51%) [65, 67, 74, 76]; and personality disorders, in particular, borderline personality disorder (BPD)
(37–66%) [76] and ASPD (61–72%) [72, 76]. Although less common, studies have also found elevated rates
of bipolar disorders (4–10%) [65, 67]; psychotic disorders (2–10%) [65, 68-71]; obsessive-compulsive disorder
(OCD) (1–10%) [65, 67]; ADHD (6%) [70]; and ED (2–9%) [68, 69].
A recent Australian study found that 82% of those in current residential rehabilitation had experienced an
anxiety disorder in their lifetime (70% were experiencing a current anxiety disorder), and just over 79% had
experienced depression in their lifetime (55% were experiencing current depression) [73]. Similarly, rates of
trauma exposure and PTSD have been shown to be extremely high across a number of settings [74, 77, 78].
It should be borne in mind that the prevalence of mental health disorders may vary between substances.
Little research has been conducted comparing the rates of mental health disorders across different types
of AOD use disorders; however, there is some evidence to suggest that co-occurring disorders are higher
among those who use stimulants and opioids [64]. For example, the prevalence of PTSD is much higher
among individuals with opioid, sedative, or amphetamine use disorders compared to those with alcohol or
cannabis use disorders [79].
The number of potential combinations of disorders and symptoms is infinite. Furthermore, as mentioned
in Chapter A1, there are a large number of people who present to AOD treatment who display symptoms
of disorders while not meeting criteria for a diagnosis of a disorder [80]. Individuals who display a number
of symptoms of a disorder but do not meet criteria for a diagnosis are sometimes referred to as having
Poorer
social and
occupational
Poorer Greater drug
functioning
physical health use severity
Harms
Increased stress
on relationships
associated Increased risk
(including family with of self-harm
and suicide
and friends)
comorbidity
comorbidity
ipsam quidem aut audandelique apisit
eosapid itaturi tatendi tasperrum que
est laborum rest, esecte nis rem sit
aspe quas experit re et ulpa.
A3
A3: Guiding
principles of
working with
clients with
comorbidity
Key Points
• When working with clients l Conduct ongoing monitoring of
with comorbid mental health symptoms and assessment of
conditions, it is recommended client outcomes.
that AOD services and AOD l Adopt a holistic approach.
workers take the following
l Adopt a client-centred
principles into consideration:
approach.
l First, do no harm.
l Emphasise the collaborative
l Work within your capacity. nature of treatment.
l Engage in ongoing professional l Have realistic expectations.
development.
l Express confidence in the
l Recognise that the effectiveness of the treatment
management of comorbidity program.
is part of AOD workers’ core
l Adopt a non-judgemental
business.
attitude.
l Provide equity of access to
l Adopt a non-confrontational
care.
approach to treatment.
l Adopt a ‘no wrong door’ policy.
l Involve families and carers in
l Recognise that comorbidity is treatment.
common and that all clients
l Consult and collaborate with
should be routinely screened
other health care providers.
for comorbid conditions.
l Ensure continuity of care.
First, do no harm
The principle ‘first, do no harm’ is not unique to comorbidity; it underscores the provision of all health care.
AOD workers must consider the risks and benefits of potential actions and avoid those that may result in
harm to the client.
In line with the principle above, each AOD worker should work within his/her capacity to address comorbid
conditions. As mentioned in Part A, AOD workers differ with regard to their roles, education, training, and
experience. It is not expected that all AOD workers will be able to address comorbid conditions to the same
extent. It is essential that appropriate supervision be provided to those working with comorbid clients,
particularly for those who are less experienced in mental health.
All AOD workers should be knowledgeable about the symptoms of the common mental health conditions
that clients present with and how to manage these symptoms. Where AOD workers do not have these
skills, professional development should be provided to bring them to a level of confident and competent
performance. The provision of opportunities for continuing professional development for AOD staff should
be a high priority for AOD services. AOD workers should seek out, and actively engage in, comorbidity-
specific training. It is important that professional development in this area be ongoing, as it is an evolving
area of research with many studies currently underway. AOD workers are encouraged to update their
knowledge by accessing new research and training opportunities, and new clinical guidelines as they
emerge (Appendix C provides a list of research organisations).
Recognise that the management of comorbidity is part of AOD workers’ core business
AOD treatment services and AOD workers need to recognise that working with comorbidity is part of their
core business. Indeed, managing comorbidity is the core business of all health care providers.
Cases have been documented where clients of AOD services have received prejudicial treatment or were
refused entry to treatment due to the presence of comorbid disorders [96]. All clients, regardless of their
mental health status, are morally and legally entitled to equal access to the highest quality of care [97].
In line with the above principles, AOD services (and all other health services) should adopt a ‘no wrong
door’ policy. No client should be turned away from treatment; rather, it is necessary to establish where the
client will receive the most appropriate care. When a person presents at a facility that is not equipped to
provide a particular type of service, he/she should be guided to appropriate facilities (using active referral
methods discussed in Chapter B4), with follow-up by staff to ensure that he/she receives appropriate care
[94, 98]. In this way, every door in the health care system should provide access to the services needed.
Guidance about which sector of the health care system should have primary responsibility for comorbid
presentations is provided in Figure 6. It should be noted, however, that it can be difficult to discern
Primarily responsible for people severely Primarily responsible for people severely disabled
disabled by current substance use and adversely by current mental health problems and adversely
affected by mental health problems. affected by substance use.
Shared responsibility for people severely Primarily responsible for people with mild to
disabled by both substance use and mental moderate AOD and/or mental health conditions
health disorders. The client should be treated by but with access to specialist AOD and mental
the service that best meets his/her needs. health services as required.
Recognise that comorbidity is common and that all clients should be routinely
screened for comorbid conditions
Despite the fact that comorbid mental health conditions are common among people with AOD use
disorders, they are often overlooked in AOD treatment settings [100]. This is mostly because AOD workers
are not routinely looking for them. As part of routine clinical care, all clients should be screened for
comorbidity. Chapter B2 discusses how to screen and assess for comorbidity.
Assessing mental health is a process, not a one-off event. It is important to monitor a person’s mental
health symptoms throughout treatment as they may change over time. For example, a person may present
with symptoms of anxiety and depression upon treatment entry; however, these symptoms may subside
with abstinence. Alternatively, a person may enter treatment with no mental health symptoms, but such
symptoms may develop after a period of reduced use or abstinence.
Clients should also be provided with feedback regarding changes in their mental health. It is often difficult
for clients to detect subtle changes over time. Evidence of a reduction in psychiatric symptoms may help
to maintain their motivation. On the other hand, evidence that there has been no change or that their
psychiatric symptoms have worsened may help them understand why they have been using substances
and alert them to the need to address these issues.
The development of a trusting therapeutic alliance with the client is essential to engaging the client in
the treatment process [101, 102]. Engaging clients in treatment can be difficult, particularly clients with
personality or psychotic disorders. This may be due to a history of poor relationships with AOD and
other health professionals; a bias towards suspiciousness or paranoid interpretation of relationships; or a
chaotic lifestyle, making appointment scheduling and engaging in structured work more difficult [103]. The
following strategies may assist in engaging the client in treatment [99]:
The primary goal of AOD treatment services is to address clients’ AOD use. In order to do so effectively,
AOD workers must take into account the broad range of issues that clients present with, including their
mental health. When considering comorbidity, one cannot look at the person’s AOD use and mental health
alone. Clients with comorbid conditions often have a variety of other medical, family, and social problems
(e.g., housing, employment, welfare, and legal problems). These problems may be contributing to the
client’s AOD and mental health conditions, or they may be the product of his/her AOD and mental health
conditions. Clients also need to be viewed in light of their age, gender, sexual orientation, culture, ethnicity,
spirituality, socioeconomic status, and cognitive abilities.
AOD workers are specialists in their field. It important to acknowledge, however, that it is the client who
is the expert on him/herself. It is important that AOD workers listen to what clients want to achieve from
treatment. This will assist in developing the treatment plan and identifying other services that may need to
be engaged.
In terms of clients’ AOD use, the goal of abstinence is usually favoured, particularly for those whose mental
health conditions are exacerbated by AOD use. Abstinence is also preferred for those with more severe
mental disorders (or cognitive impairment) because even low level substance use may be problematic
for these individuals [54]. Those taking medications for mental health conditions (e.g., antipsychotics,
antidepressants, mood stabilisers) may also find that they become intoxicated even with low levels of
AOD use due the interaction between the drugs. Although abstinence is favoured, it is recognised that
many people with comorbid conditions prefer a goal of moderation. In order to successfully engage with
the client, AOD workers should accommodate a range of treatment goals and adopt a harm reduction
approach [104].
Clients with comorbid conditions often feel that they have very little control over their lives. It is important
that they understand that you will be working together throughout treatment, to help them re-establish a
sense of control.
It is important that AOD workers have realistic expectations regarding the course of treatment and
outcomes to be expected of clients with comorbidity. It is commonly believed that clients with comorbid
mental health conditions are more difficult to treat, require more intensive treatments, and have poorer
treatment outcomes. However, comorbidity is not an insurmountable barrier to treating people with AOD
use disorders. As discussed in Chapter A2, research has shown that clients with comorbid mental health
conditions can benefit just as much as those without comorbid conditions from usual AOD treatment [66,
94, 95, 105].
As mentioned above, positive outcomes can be achieved in clients with comorbid conditions. AOD workers’
confidence in the treatment will increase clients’ confidence that the treatment they are entering can help
them.
Clients with comorbid problems have often been subjected to stigmatisation and discrimination in relation
to their AOD use (particularly those who use illicit drugs) and their mental health condition. People with
mental health disorders have traditionally been viewed by society as violent, brain damaged, intellectually
disabled, unimportant, untrustworthy, or worthless. As a result, clients with comorbidity will often feel
too ashamed or embarrassed to tell people about it, even health professionals [97]. It is important that
clients with comorbid conditions do not feel that AOD workers have the same negative attitudes towards
them. AOD and other health professionals should view and treat people with comorbidity with the same
respectful care that would be extended to someone with any other health condition. Just as people with an
AOD use disorder should not be thought of or referred to as an ‘addict’, a person with schizophrenia should
not be referred to or thought of as ‘schizophrenic’. The mental health condition does not define the person;
rather, it is one aspect of the person.
Sustained emotional distress can worsen a number of mental health conditions and a highly demanding
or confrontational treatment approach may be harmful to those with mental health conditions [54].
Emotional distress may be triggered by criticism, rejection, or an inability to deal with task demands [106].
It is recommended instead that a non-confrontational approach, such as a motivational enhancement
approach, be taken with clients with comorbidity. Motivational interviewing (MI) techniques are described in
Appendix E.
With the client’s consent, AOD workers should involve the client’s family and carers where possible and
appropriate. Families and carers should be involved as much as possible in decisions regarding treatment
and discharge planning, as they will often need to facilitate the client’s access to other services. With the
client’s consent, family members/carers should be provided with regular feedback so that they know
their views and feelings are valued. It is important to clarify with clients specifically what information they
consent to being shared with their families or carers. Families and carers should also be informed of
services available to them in the form of advocacy and support groups.
Two useful resources are available, and may have relevant information for families, friends, carers, and
friends:
• Tools for change: A new way of working with families and carers, developed by the Network of Alcohol
and Drug Agencies, available as part of the Families and Carers Toolkit [107]. http://www.nada.org.au/
resources/nadapublications/resourcestoolkits/familycarertoolkit/
• Guidelines to consumer participation in NSW drug and alcohol services, developed by the NSW
Ministry of Health [108]. http://www0.health.nsw.gov.au/policies/gl/2015/pdf/GL2015_006.pdf
AOD clients present with diverse issues that cannot possibly be addressed by one health professional
or service alone. A broad, multifaceted, and multidisciplinary approach is needed in order to address all
of these issues effectively [97, 109]. It is important that AOD services and AOD workers develop links with
local services and engage them in clients’ treatment. Such services include mental and community health
practitioners, as well as housing, employment, and welfare services. General practitioners (GPs) in particular
play an important role in delivering care to people with comorbidity, as they are often their first and most
consistent point of contact [110, 111]. Ideally, case management and treatment should be shared by health
care providers/services, and there should be good communication and sharing of information between
these professionals.
People with comorbid conditions often have difficulty navigating their way through the services required
to address all of their needs. It is crucial that systems be established that ease clients’ transitions between
services to prevent them from ‘falling through the gaps’ between services [98]. Chapter B4 discusses
methods that may be used to refer clients to other services.
A4
A4:
Classification
of disorders
Key Points
• Disorders represent particular combinations of signs and
symptoms that are grouped together to form criteria. A certain
number of criteria need to be met within a certain timeframe for a
person to be diagnosed as having a disorder.
• Not all AOD workers are able to formally diagnose the presence
or absence of mental health disorders. Diagnoses of mental health
disorders should only be made by suitably qualified and trained
health professionals.
• It is nonetheless useful for all AOD workers to be aware of the
characteristics of disorders so that they are able to describe and
elicit information about mental health symptoms when undertaking
screening and assessment, and to inform treatment planning.
• It is important that clients suspected of having a comorbid
mental health condition undergo a medical assessment as many
symptoms of mental health disorders mimic those of physical
disorders.
This chapter provides a brief overview of the mental disorders most commonly seen among clients of
AOD treatment settings. Not all AOD workers are able to formally diagnose the presence or absence of
mental health disorders. Diagnoses of mental health disorders should only be made by suitably qualified
and trained health professionals (e.g., registered or clinical psychologists, and psychiatrists). It would be
unethical for non-trained workers to use diagnostic labels in clinical notes, or to inform the client that they
have a diagnosis, unless they have received written confirmation from a suitably qualified professional.
Disorders represent particular combinations of signs and symptoms that are grouped together to form
criteria. A certain number of criteria need to be met within a certain timeframe for a person to be diagnosed
as having a disorder. There are two main classification systems used to diagnose mental health disorders:
• The Diagnostic and Statistical Manual of Mental Disorders, currently in its fifth edition (DSM-5) [24].
• The International Classification of Diseases, currently in its 10th revision (ICD-10) [112].
These systems are similar; however, there are a number of important differences. The disorder descriptions
outlined in this chapter are based on those provided by the most recent diagnostic manual available, the
DSM-5, which was released in May 2013 [24]. AOD workers are encouraged to familiarise themselves with
the DSM-5, in particular its uses, limitations and recommendations regarding differential diagnosis (i.e.,
determining which symptoms are attributable to which disorder).
It is important to note that substantial revisions to diagnostic and classification criteria have been made for
many mental disorders, and the disorder descriptions may vary greatly from those in the previous edition
(DSM-IV-TR [23]). In an effort to help navigate the major revisions, the primary changes between the DSM-
IV-TR and the DSM-5 disorder classification are explained. As many AOD workers may also use ICD codings,
we have cross-referenced the DSM-5 disorders described here with the corresponding ICD-10 codes in
Appendix D.
In these Guidelines we focus on 10 categories of disorder that are most commonly seen among people
with AOD use disorders:
There are, however, a number of other disorder types that individuals with AOD use disorders may
experience. These include somatoform disorders, sleep disorders, and adjustment disorders. For further
information on these disorders readers are referred to the DSM-5 [24].
It is also important to note that many symptoms of mental health disorders mimic those of physical
disorders. For example, heart palpitations may be related to anxiety, or they may be a symptom of a heart
condition. Similarly, depressed mood may be a symptom of major depressive disorder, or it may be a
symptom of hypothyroidism. For this reason, it is important that clients suspected of having a comorbid
Inattention:
Case study A: What does comorbid ADHD and AOD use look like?
Ali’s story
Ali, a 23-year-old unemployed man who was living with his parents, presented to the local AOD
service. His presentation followed an arrest and fine for possession of a small amount of speed.
Ali said that he had only come to the appointment to get his parents ‘off his back’, and although he
agreed to an assessment, he said he would probably not come back.
Ali’s AOD use dated back to his mid-teens, and he described using both speed and cannabis. He
admitted that some of his drug use was funded by borrowing money from friends and family and,
on occasion, stealing money from his parents. Ali said that when he first started using speed, he felt
‘inner calmness’, but as he increased the quantity and frequency of use, his life became increasingly
chaotic. However, he found that smoking a joint had helped him calm down and sleep.
During the assessment, Ali described being brought up in a loving family home, but he encountered
a number of problems at school. All of Ali’s teachers agreed that he was brighter than most of his
classmates, but his school reports often mentioned that he had difficulty paying attention to detail,
was inattentive in class, and forgot to bring in school materials or homework. During the assessment
Ali was noticeably fidgeting and often answered a question before the AOD worker had finished
asking the question.
Key points:
Individuals with AOD use disorders may display symptoms of psychosis that are due to either intoxication or
withdrawal from substances. However, if the person experiences psychotic episodes even when they are
not intoxicated or withdrawing, it is possible that they may have one of the disorders described in Table 4.
These are severely disabling mental health disorders. Psychotic symptoms may also present in people with
major depressive disorder or bipolar I disorder, or from a medical condition. A case study example of how
comorbid psychosis and AOD use disorder may present is illustrated in Box 2.
Delusions
Delusions are false beliefs that usually involve a misinterpretation of perceptions or experiences. For
example, people who experience delusions may feel that someone is out to get them, that they have
special powers, or that passages from the newspaper have special meaning for them. Delusions may
be either bizarre or non-bizarre.
• Bizarre delusions are those that are clearly implausible, not understandable, and not derived
from ordinary life experiences (e.g., the belief that one’s internal organs have been removed and
replaced with someone else’s by a stranger without leaving any wounds or scars).
• Non-bizarre delusions are those which involve situations that could conceivably occur in real life
(e.g., being followed, poisoned, or deceived by one’s partner).
Hallucinations
Hallucinations are false perceptions such as seeing, hearing, smelling, sensing, or tasting things that
others cannot. These are vivid and clear, with the impact of regular perceptions, and are not under
voluntary control. It is important to note that the classification of an experience as either a delusion or
a hallucination is dependent upon culture. That is, the experience must be one that most members of
that culture would deem a misrepresentation of reality.
Disorganised Speech
Disorganised speech involves difficulty with communication, through difficulty keeping track of
conversations, switching between unrelated topics, or incoherent words or sentences.
Grossly disorganised or abnormal behaviour may be evident in several ways, ranging from inappropriate
behaviour or silliness, to unpredictable agitation. There may be problems with goal-directed behaviour
interfering with usual daily activities, or difficulty maintaining hygiene. Catatonic behaviour, which is
a decreased reactivity to the environment (sometimes to the extreme of complete unawareness,
maintaining a rigid or inappropriate posture, or complete lack of verbal or motor response) may be
present, which can include purposeless and excessive motor activity.
Negative symptoms
Negative symptoms account for much of the morbidity associated with schizophrenia, but are less
prominent in other psychotic disorders. These include:
• Schizophrenia.
• Schizophreniform disorder.
• Schizoaffective disorder.
• Brief psychotic disorder.
• Delusional disorder.
Disorder Symptoms
Schizophrenia Schizophrenia is one of the most common and disabling of the psychotic
disorders. It affects a person’s ability to think, feel, and act. To be diagnosed
with schizophrenia, two or more of the following symptoms must have
been continuing for a period of at least six months:
• Delusions.
• Hallucinations.
• Disorganised speech.
• Grossly disorganised or catatonic behaviour.
• Negative symptoms (diminished emotional expression or avolition).
Case study B: What does comorbid psychosis and AOD use look
like? Nick’s story
Nick, a 24-year-old, had been a client of community mental health services since his late teens. His
case manager, who was becoming increasingly concerned about Nick’s AOD use, contacted the local
AOD service requesting an assessment. Nick reluctantly agreed to an assessment and consented to
his case manager providing the AOD service with some background information.
Nick was first referred to community mental health services after being discharged from an inpatient
psychiatric unit to which he had been admitted after experiencing an acute psychotic episode. Nick
remained in the unit for four months. During his admission, Nick was treated with major tranquillising
medications and discharged on a regime that included a depot injection every two weeks. Following
discharge, he went home to his parents’ house. He was withdrawn, spending all of his time in his
bedroom, wearing headphones and playing music almost all the time, to ‘block out the voices’. Nick
became convinced that messages from another planet were being transmitted via the family’s
television set, and he subsequently smashed every electrical appliance in the house that he could
find, ‘to stop messages being sent to him’. The community mental health team organised some
rehabilitative activities, and encouraged him to ‘get out more’.
Unbeknownst to any of the professionals caring for him at the time, Nick had been introduced
to stimulant medication by another patient while in hospital, and continued to use following his
discharge. Over time, Nick continued to display features of his psychosis and remained fixed in the
belief that he was receiving communications from other planets – these communications coming
from multiple sources, including the electricity supply. He also continued to hear voices, most of
which were making complimentary comments about him; however, occasionally the voices accused
him of various wrongdoings.
Nick was compliant with appointments for his depot injection, as he knew that if he wasn’t he would
be compelled to do so by hospital admission. He was prescribed other oral medication for both his
psychosis and mood, but his compliance with the regime of oral medication was very poor. By the
time Nick was assessed by the AOD service, his substance use was far more extensive than his case
manager had realised. He was smoking cannabis daily, occasionally sniffing solvents, binge drinking
once or twice a week, and using cocaine whenever he could afford to do so. Although Nick had
never injected drugs, he had smoked heroin and, over time, had ‘tried every drug under the sun’. The
community mental health team had referred him to the AOD service on a number of occasions, but
Nick failed to attend any of the appointments made for him. On this particular occasion, the AOD
worker agreed to come to the community mental health service to meet with Nick during one of his
other regularly scheduled appointments to facilitate the process.
It became apparent during the assessment that Nick’s decline in mental health and escalating
substance use had been precipitated by the death of both parents a short time apart. For a while,
Nick remained in the family home until it became uninhabitable because of the appalling standards
of hygiene. He began to spend time away from home, spending the summer months ‘sleeping under
the stars’ or in hostels for the homeless.
Key points:
There are three types of mood disturbance episodes (see Figure 7, Table 7):
Manic Episode
Hypomanic Episode
In a major depressive episode, some of the following symptoms are experienced nearly every day for at
least two weeks:
Manic episode
During a manic episode, the person experiences an abnormally or persistently elevated, expansive,
or irritable mood and increased goal-directed activity or energy for at least one week. The episode is
characterised by the person experiencing some of the following symptoms:
• Inflated self-esteem.
• Decreased need for sleep.
• Increased talkativeness or racing thoughts.
• Distractibility.
• Agitation or increase in goal directed activity (e.g., at work or socially).
• Excessive involvement in pleasurable activities that have a high potential for painful consequences
(e.g., buying sprees, sexual indiscretions, dangerous driving).
Hypomanic episode
A hypomanic episode is the same as a manic episode, but is less severe. A hypomanic episode need
only last four days and does not require the episode to be severe enough to cause impairment in social
or occupational functioning.
Mania Depression
Energy Levels Increased energy, increase in activity Loss of energy, decrease in activity
and/or goal directed activities. May and interest in activities.
spend more money.
Changes in sleep Decreased need for sleep without Disrupted sleep patterns, with trouble
pattern feeling tired. falling or staying asleep, waking too
early, sleeping too much.
Thoughts and Feeling good, high or exhilarated. May Feeling down, low, empty, hopeless,
feelings think they are chosen, special, gifted, worthless. Think they are useless, a
entitled. Increased libido. Increased burden, and the cause of their own
thinking, disorganised, flood of ideas. problems. Decreased libido. Impaired
thinking, concentration, decision
making.
Speech and Pressured speech, maybe without Speech can be slowed, with few ideas.
sensations enough time to convey all of the ideas, Dulled perception and sensation, but
inappropriate. Heightened perception in some cases some senses can be
and sensation. May have underlying heightened (e.g., taste and smell).
agitation in severe cases
Delusions, In severe cases of mania, there may In severe cases of depression, there
hallucinations be grandiose delusions (e.g., may think can be nihilistic delusions (e.g., may
they are God, or they are a superhero think their body is decaying).
sent to save the world).
• Bipolar I disorder.
• Bipolar II disorder.
• Cyclothymic disorder.
A case study example of how comorbid bipolar and AOD use disorder may present is illustrated in Box 3.
Disorder Symptoms
Bipolar I disorder Bipolar I is characterised by one or more manic episodes, which can be
preceded or followed by hypomanic or major depressive episodes.
Cyclothymic Cyclothymic disorder is characterised by chronic (at least two years), fluctuating
disorder disturbances in mood involving numerous periods of hypomanic and depressive
symptoms. The symptoms do not meet the criteria for a manic or major
depressive episode.
Box 3: Case study C: What does comorbid bipolar and AOD use look like? Layla’s story
Case study C: What does comorbid bipolar and AOD use look like?
Layla’s story
Layla is a 30-year-old woman who was referred to the AOD service by her psychiatrist. Layla has been
referred to AOD services many times. On one previous occasion she attended for an assessment but
failed to return for any further appointments.
Layla grew up in a country town in what she described as a very happy family; she is the third of six
siblings. Layla described herself as always being ‘the life of the party’. She performed well at school,
enjoyed many interests and activities, and had a wide circle of friends.
Before going to university, Layla rarely drank alcohol and had never been around people who used any
drugs. However, after moving to the city to attend university, she discovered that she enjoyed a mixture
of methamphetamines, which helped her ‘to party through the night’, and cannabis, which calmed her
down.
This pattern continued for the duration of Layla’s years at university and, instead of being a star student,
she was only able to scrape through her exams. She presented to student psychological services on
several occasions requesting support in her applications for extensions and exemptions for several
assignments, describing her depressive episodes to them. She did not, however, reveal any details of
her substance use, or periods of feeling high when she had excessive amounts of physical and mental
energy.
Following university, Layla found an office job back in her country town and promised herself that she
would not engage in any more AOD use.
Several months later, Layla became more active, pursuing a wide range of social activities and became
increasingly distractible and irritable at work. She also began spending excessively on her credit card.
Several people close to her suggested that she see her doctor for some form of medical assessment,
however, Layla was reluctant see anyone and said she felt ‘on top of the world’.
Finally, to please her mother, Layla went to her GP who quickly recognised that she was experiencing a
manic episode and arranged for her to see a psychiatrist as a priority. The psychiatrist diagnosed Layla
with bipolar disorder. Despite having enormous credit card bills, loss of weight and complaints from all
of her friends that she was intolerable to be around, Layla refused to accept that there was anything
wrong. Layla would not accept any medication and stormed out of the psychiatrist’s consulting room.
Later that day, Layla was arrested in the town centre, having consumed a large amount of alcohol and
behaved in a sexually disinhibited way in a supermarket. She was admitted to hospital and prescribed
benzodiazepines.
After about a week, Layla’s mood had settled and she was prescribed a mood stabilising drug. Layla
was discharged to the care of her psychiatrist, and over three to four weeks she became well enough
to return to work. Several months later, Layla became depressed and, recognising this, went back to
see the psychiatrist who prescribed an antidepressant medication in addition to her mood stabilising
medication, and reduced her benzodiazepines.
At this point, Layla remembered how methamphetamines had lifted her mood and, for the first time
since her university days, she began taking methamphetamines on a daily basis and smoking cannabis
in the evenings to help her to sleep. Over the following years, Layla had three significant episodes of
mood disturbance – two manic and one depressive. Layla had been able to work intermittently, but it
was only because her employer was a family friend that she was able to keep her job.
During the last episode, it became clear that Layla’s compliance with her medication regime had been
poor. Layla was told on numerous occasions that she ‘needed to take the medications as prescribed
for the rest of her life’, and that the doctors and nurses ‘knew best’, and she should follow their advice.
There were no attempts made to enter into any detailed discussion about the nature and dose of
medication, which led Layla to feel a growing distance between herself and the health professionals
involved.
Key points:
• What are the primary concerns for Layla?
• Where to from here?
Depressive disorders are distinct from feeling unhappy or sad (which is commonly referred to as
‘depression’) in that they involve more severe and persistent symptoms. Depressive disorders are often
long-lasting, recurring illnesses. Individuals with depressive disorders feel depressed, sad, hopeless,
discouraged, or ‘down in the dumps’ almost all the time. They also experience other symptoms including
sleep disturbances (including difficulty getting to sleep, frequent waking during the night, being unable to
A case study example of how comorbid depression and AOD use disorder may present is illustrated in Box
4.
Disorder Symptoms
• Depressed mood.
• Loss of interest or enjoyment in activities.
• Change in weight and appetite.
• Sleeping problems (difficulty getting to sleep, frequent waking during the
night, being unable to wake in the morning or sleeping too much).
• Fatigue.
• Feelings of worthlessness or inappropriate guilt.
• Difficulty concentrating.
• Recurrent suicidal thoughts, attempts, or plans.
A person may have a single episode or they may have recurrent episodes over
his/her lifetime. The duration of depressive episodes may range from weeks to
years.
Disorder Symptoms
Box 4: Case study D: What does comorbid depression and AOD use look like? Jack’s
story
Case study D: What does comorbid depression and AOD use look
like? Jack’s story
Jack, a 51-year-old man, contacted his local AOD service at the recommendation of his psychologist.
Jack had been smoking cannabis every evening with his wife since leaving university 30 years ago.
He had also been drinking increasing amounts of alcohol. Until recently, Jack estimated that he was
drinking six to eight bottles of beer and half a bottle of wine every evening. In addition, Jack drank
several gin and tonics each weekend. Despite this being Jack’s first contact with an AOD service, he had
been a consumer of mental health services for many years.
Since his early 20s, Jack has had five separate occasions where he has felt incredibly low. The
episodes have increased in intensity, and the last two involved suicidal thoughts. Due to the increasing
severity of the episodes, Jack has needed to take a significant amount of sick leave from his work as
an accountant, and it was three months before he could return to work after the last episode. He has
worked for the same company for the past 10 years.
Jack has seen a number of psychiatrists but, due to staff turnover, he has seen three separate
consultants, all of whom have taken a comprehensive history. In the first four episodes, Jack was
managed without the need for inpatient care and received medication, which was monitored by his GP.
However, at the onset of the last episode, Jack’s presentation was so severe that he agreed to go into a
local psychiatric unit. His suicidal ideation was high and he was having trouble controlling the thoughts.
Jack had also made a plan and had the means with which to kill himself.
In addition to pharmacotherapy, Jack was referred for psychotherapy for the first time. Although
psychotherapy had previously been mentioned as potentially being part of his treatment, in practice,
there appears to have been an almost complete reliance on the use of medication. However, whilst an
inpatient, Jack started seeing a psychologist who he continued to see weekly as an outpatient following
his discharge. It was during one of these sessions that Jack first revealed details of his substance use.
When the psychologist asked whether he had disclosed this information to any health professional
before, Jack replied that no-one had ever asked him about any illicit substance use, and said this was
because he ‘always turned up for sessions in a suit and tie and presented as a pillar of the community’.
Jack said that when he had been previously questioned about his alcohol intake, he would say, ‘I’m just
a social drinker’ and no further questions were asked regarding the nature and quantity of his drinking.
Key points:
• What are the primary concerns for Jack?
• Where to from here?
People with anxiety disorders often experience intense feelings of fear and anxiety. Fear is an emotional
response that refers to real or perceived imminent threat, and anxiety is the anticipation of future threat.
Although fear and anxiety overlap, they are associated with differing autonomic responses. Fear is
associated with a flight or fight response, thoughts of immediate danger, and escape. Anxiety is more
commonly associated with muscle tension, hypervigilance in preparation for danger, and avoidance.
Feelings of panic are also common among people with anxiety disorders.
Panic attacks are not a specific disorder, but rather a symptom that is common amongst many of the
anxiety disorders. The symptoms of a panic attack are outlined in Table 9, although not all panic attacks
include all symptoms. Panic attacks can be terrifying. As many of the symptoms of a panic attack mirror
those of a heart attack, many people who experience them (particularly for the first time) have a genuine
fear that they are going to die. Given the overlap in symptoms (e.g., shortness of breath, chest pain and
tightness, numbness and tingling sensations), it is important that a person displaying these symptoms be
referred to a medical practitioner.
Anxiety disorders differ from one another in the types of objects or situations that induce fear, anxiety or
avoidance, and duration. There are a number of different types of anxiety disorders (see Table 10):
A case study example of how comorbid anxiety and AOD use disorder may present is illustrated in Box 5. It
should be noted that OCD, PTSD, and acute stress disorder were categorised as anxiety disorders in DSM-
IV-TR, but have been moved in the DSM-5 to other sections described later in this chapter.
Disorder Symptoms
Generalised GAD is marked by excessive anxiety or worry for at least six months, which a
anxiety disorder person feels more often than not. The worry or anxiety is difficult to control and
(GAD) is associated with at least three of the following:
• Restlessness or edginess.
• Being easily fatigued.
• Difficulty concentrating.
• Irritability.
• Muscle tension.
• Difficulty either falling or staying asleep.
Panic disorder Panic disorder involves the experiencing of unexpected panic attacks
followed by at least one month of persistent concern or worry about having
another attack, and the implications of having another attack. As a result the
person changes his/her behaviour in relation to the attacks. Panic disorder is
sometimes accompanied by agoraphobia.
Disorder Symptoms
Agoraphobia Agoraphobia involves marked fear or anxiety about two or more of the
following, for at least six months:
The person avoids these situations because anxiety about being in places or
situations from which escape might be difficult or embarrassing, or in which
help may not be available, in the event of a panic attack. The person avoids
these places or situations, or if such situations are endured there is considerable
distress or anxiety, or the need for a companion.
Social anxiety SAD (formerly known as social phobia) is characterised by excessive anxiety or
disorder (SAD) worry about one or more social situations for at least six months, where their
actions may be analysed by others, such as meeting new people, or eating,
drinking, performing, or speaking in public. The person fears he/she will be
negatively evaluated, humiliated, embarrassed, or rejected. The social situations
almost always provoke the same feelings of distress or anxiety, and are avoided
or endured with intense fear or anxiety, which is disproportionate to the actual
threat posed by the situation. Fearing embarrassment, humiliation, or rejection is
not necessarily unusual, but a person with SAD will fear the situation to the point
where their avoidance or anxiety causes significant distress, and interferes with
their ability to function.
Case study E: What does comorbid anxiety and AOD use look like?
Alina’s story
Alina, a 33-year-old medical secretary, was referred to a clinical psychologist by her GP for treatment of
her panic attacks, which were of increasing severity. The panic attacks had caused her to begin avoiding
a range of social activities and she had begun having days off work because she was unable to face the
crowded bus that she needed to take from her home to her workplace just five kilometres away.
On assessment, Alina told the psychologist of her upbringing, her schooling and family life. After school,
Alina attended a secretarial course and then began work as a medical secretary. She had been in her
current job in a hospital for six years. Alina’s background history appeared unremarkable and it seemed
that her family life, schooling, and upbringing had been happy and fulfilling. She said that she had
always been a bit nervous, although this had never really stopped her from doing anything. Alina told
the psychologist that she’d had two significant relationships, the most recent of which had lasted for
four years, ending six months ago. It appeared as though the breakup had been very upsetting to her.
There was no evidence of abuse or domestic or family violence.
The psychologist asked about any drug use and Alina said very firmly that she had never taken any
illegal drugs and seemed upset that the psychologist might have thought that this was a problem for
her. The psychologist asked about Alina’s alcohol use and she said that this was social. When asked
about quantities, Alina said that she drank three or four times a week, either a couple of beers or two to
three glasses of wine. The psychologist asked her to keep a diary.
The next week, Alina broke down in tears saying that she had been unable to complete her diary as
things were much worse. At this point, she revealed that she had not been truthful about her alcohol
intake and felt very ashamed about her dishonesty. She said that for many years she needed a nightcap
to help her sleep and, although she rarely got drunk, she felt an increasing need to drink every day after
work. Although this was usually in the company of her friends and workmates, since the breakdown
of her relationship, Alina’s drinking had become more solitary and she had begun drinking increasing
amounts of alcohol. After drinking her nightly bottle of wine (or more), she often woke up the next
morning in a state of anxiety and then began to experience periods of panic. She had lost weight over
recent months, her appetite had greatly reduced, and she had often woken in the morning unable to
remember what she had done the night before.
Alina appeared very relieved that she had been able to tell someone exactly what was happening. Her
psychologist suggested they contact her GP to discuss various treatment options.
Key points:
• What are the primary concerns for Alina?
• Where to from here?
OCD is characterised by the presence of compulsions or obsessions (see Table 11). It is distinct from feeling
a need for neatness, cleanliness, or order (which is sometimes referred to as ‘obsessive-compulsive’ or
‘OCD’). OCD is often long-lasting and debilitating with people feeling compelled to prevent disasters
befalling loved ones or alleviate anxiety by performing rituals which cause significant distress.
Obsessions are recurring, persisting thoughts, urges, or images that are intrusive or unwanted. Examples of
obsessions include persistent fears of contamination, thinking that he/she is to blame for something, or an
overwhelming need to do things perfectly. Compulsions are repetitive mental or physical acts that a person
feels driven to perform, in response to an obsession or rules that must be applied. Examples of compulsive
behaviours include the need to repeatedly wash one’s hands due to the fear of contamination, check that
things have been done (e.g., whether doors or windows have been locked, appliances switched off), or
avoid certain objects and situations (e.g., holes in the road, cracks or lines in the pavement). A case study
example of how comorbid OCD and AOD use disorder may present is illustrated in Box 6.
OCD is characterised by the presence of time-consuming (at least one hour per day) obsessions
or compulsions (or both), which are performed in order to prevent or reduce anxiety or distress, or
prevent a dreaded situation. However, the behaviours are not realistically connected with what they
are designed to prevent, or are excessive (for example, symmetrically ordering items so as to prevent
harm coming to a loved one). The behaviours or mental acts cause significant distress and, as the
performance of these rituals is time-consuming, they can significantly interfere with the person’s social
and occupational functioning.
Box 6: Case study F: What does comorbid OCD and AOD use look like? Jenny’s story
Case study F: What does comorbid OCD and AOD use look like?
Jenny’s story
Jenny is a 31-year-old self-employed jewellery designer, who lives at home with her parents. She was
brought by ambulance to the emergency department of her local hospital after vomiting large amounts
of blood. Jenny was diagnosed with alcoholic gastritis (stomach inflammation and erosion due to
alcohol intake), received a blood transfusion and was kept in hospital for several days. While she was in
hospital, she was visited by an AOD consult liaison nurse.
Jenny broke down in tears and told the nurse that her GP had prescribed her some Xanax to help her
manage her obsessive thoughts and panic attacks. She said that since her early 20s she had been
unable to stop herself ritualistically cleaning and checking. She had also been plagued by obsessive
ruminations that she might harm other people, or that she might perpetrate sexual abuse on children.
These thoughts had led to Jenny avoiding public places as much as possible, and made her highly
anxious around children.
Jenny told the liaison that although her GP had referred her to a psychologist, she had been unable to
travel to the appointment because of her anxiety and avoidance. She had also been consumed with
irrational and obsessional fears that she might somehow harm the psychologist during the consultation,
and went back to see her GP. Over the next several years, Jenny began experiencing panic attacks, for
which her GP continued to prescribe Xanax.
Although Jenny’s GP had told her the Xanax was for short-term use, due to the severity of the panic
attacks, her GP increased the dose. Jenny told the liaison nurse that she found taking Xanax in the
evening and at night helped her to sleep and temporarily suppressed her obsessive thoughts. However,
eventually her GP refused to prescribe Jenny any more Xanax, and suggested a program of tapering the
medication down before discontinuing. Jenny told the liaison nurse that she was not able to follow this
program, and had found a regular supply of Xanax through the internet, although this often left her with
hangover-type symptoms. These were compounded by the fact that Jenny had begun to supplement
Xanax with increasing amounts of alcohol, and was drinking a bottle of wine daily.
Up until her hospitalisation, Jenny had been conducting her business from home, but her use of
benzodiazepines and alcohol had made her feel tired for most of the day, and she had problems
fulfilling orders, eventually losing a number of clients. Although her distressing ruminations had been
somewhat supressed by her use of benzodiazepines and alcohol, they gradually began to lose their
effectiveness and Jenny became increasingly anxious.
Key points:
• What are the primary concerns for Jenny?
• Where to from here?
Reactions following exposure to a traumatic event are varied, and can include anxiety or fear-based
symptoms, aggression or anger-based symptoms, or dissociative symptoms. Although emotional and
behavioural disturbances following a traumatic event are to be expected, for some people the reaction
to the event can result in prolonged and significant distress, as well as impaired social and occupational
functioning.
These disorders were previously classified as anxiety disorders in DSM-IV-TR, but have formed their own
category in the DSM-5, which also includes other stressor-related disorders. It should be noted that the
DSM-5 does not require a person to have experienced a sense of fear, helplessness, or horror at the time
of the traumatic event, in order to meet criteria for either of these disorders, as was the case in DSM-IV-TR.
The structure of the criteria has also changed (there are now four symptom clusters instead of three) and
three new symptoms have been added. A summary of the DSM-5 criteria are provided in Table 12; however,
readers are encouraged to refer to DSM-5 for a more detailed explanation of the changes made between
editions. A case study example of how comorbid PTSD and AOD use disorder may present is illustrated in
Box 7.
Disorder Symptoms
Post traumatic PTSD is a disorder that may develop after a person has experienced a traumatic
stress disorder event during which the individual perceived his/her own (or someone else’s) life
(PTSD) or physical integrity to be at risk.
Following the event, for at least one month, the person experiences some of the
following symptoms:
These symptoms may begin immediately after the traumatic event, or they may
appear days, weeks, months, or years after the trauma occurred.
Acute stress Acute stress disorder is similar to PTSD but lasts for less than one month
disorder following exposure to a traumatic event.
Case study G: What does comorbid PTSD and AOD use look like?
Emily’s story
Emily is a 42-year-old woman, presenting to her local AOD service for her tenth admission for inpatient
detoxification from heroin, alcohol, and cannabis. Emily has been using heroin since she was 17 years
old. Although heroin has always been her main drug of concern, Emily also drinks heavily and smokes
cannabis daily, particularly on days when she cannot obtain heroin. She occasionally used stimulant
drugs but didn’t particularly like the effect.
In addition to her nine previous attempts at inpatient detoxification, Emily has been on a methadone
program on three occasions. The first time, she stayed on methadone for 10 years before being
imprisoned for her involvement in a break and enter. Emily stayed clean for the duration of her sentence,
but returned to use soon after she was released. Emily had also tried going cold turkey, and detoxing by
herself numerous times, with the help of non-prescribed benzodiazepines and buprenorphine - none of
which were successful. Her longest period of abstinence since she started using was two years after the
birth of her first child, who is now 16 years old. Emily has four children, ranging in age from 4–16 years,
all of whom are in foster care. Emily relies on the disability support pension to pay the rent towards her
Department of Housing flat, which she shares with her current boyfriend. She has never been able to
hold down a job for more than a few weeks.
Emily is highly motivated to stop using all drugs so that she may have more contact with her children
and hopefully one day have them returned to her custody. Emily was coping with withdrawal relatively
well until one night when a male client accidently walked into her room when trying to find the
bathroom. Emily was awoken by the feeling that someone was watching her and could hear heavy
breathing. His shadowed appearance in the half-light caused her to become hysterical and she lashed
out violently. Staff quickly arrived and calmed Emily and the male client who was swearing at her and
calling her a ‘crazy bitch’. Emily was given a sedative to help her sleep and permitted to sleep with the
lights on that evening.
The following morning, the incident was reported during staff handover. The psychologist starting her
shift identified seeing Emily as a priority. The psychologist told Emily that she had heard about what
happened last night and asked whether she was okay. Emily was still a little shaken but said that she
was okay now, she was just startled and overreacted. She explained that it had reminded her of a time
when one of her previous boyfriends had come into their bedroom one night and started beating her.
The psychologist asked whether she was hurt at the time, to which Emily replied that she required
surgery for internal injuries and was hospitalised. Emily appeared reluctant to talk about it. She said
that she tried not to think about it and avoided any possibility of running into him. Despite her efforts
to forget about it, she often had bad dreams, trouble sleeping, and had to take large amounts of
benzodiazepines to sleep.
After talking with Emily, the psychologist made a time to talk with her some more later in the day. During
this session, the psychologist asked more questions about how Emily felt after she was beaten and how
this had affected her. The psychologist was mindful of reassuring Emily that she did nothing to deserve
being treated this way, and her reactions were completely normal. Emily was shaking as she described
the incident in more detail, and later confided that she was also raped during this attack – something
that she had not previously told anyone.
Key points:
• What are the primary concerns for Emily?
• Where to from here?
A case study example of how comorbid ED and AOD use disorder may present is illustrated in Box 8.
Disorder Symptoms
Maintained body weight is below minimally normal for age, sex, development,
and physical health.
Disorder Symptoms
Bulimia nervosa Bulimia nervosa is characterised by three essential features, which must occur
on average at least once a week for three months:
People with bulimia nervosa are typically ashamed of their eating problems and
attempt to hide their symptoms, and may be within a normal weight range.
Binge eating The predominant feature of binge eating disorder is recurrent episodes of binge
disorder eating that occur at least once a week for three months. The episodes of binge
eating are accompanied by a sense of lack of control, where the person feels
that once they have started eating, they are unable to stop, and cause significant
distress to the person.
Box 8: Case study H: What does comorbid ED and AOD use look like? Charlotte’s story
Charlotte was not planning on following up the referral and attending the AOD service, but her mother
found her referral and forced her to go, accompanying her to the appointment. She had also been
concerned about Charlotte, as she noticed that Charlotte had been increasingly jittery, agitated, and
irritable, often snapping at her for no reason.
On assessment, Charlotte was uncommunicative, slumped in her chair and answered questions
monosyllabically. Charlotte’s mother attempted to fill in the gaps. When the AOD worker continued the
assessment privately, Charlotte told her to ‘butt out’, and mind her own business. When the AOD worker
asked about Charlotte’s use of Valium, she told her that she needed it to help her to calm down and
sleep. The AOD worker noted that Charlotte was visibly jittery, was bouncing her legs, and fidgeting.
When asked about her noticeable agitation, Charlotte admitted that she had been taking stimulants
every day, which she said were to help with her university work.
The AOD worker conducted some MI, and Charlotte agreed to come back and talk to the AOD worker.
Key points:
• What are the primary concerns for Charlotte?
• Where to next?
There is a wide range of personality disorders (see Table 14). All of them involve pervasive patterns of
thinking and behaving, which means that the patterns exist in every area of a person’s life (i.e., work, study,
home, leisure, and so on). The most significant feature of personality disorders is their negative effect
on personal relationships. A person with an untreated personality disorder often has difficulty forming
long-term, meaningful, and rewarding relationships with others. Individuals with a personality disorder
are generally not upset by their own thoughts and behaviours, but may become distressed by the
consequences of their behaviours [115].
AOD use disorders may cause fluctuating symptoms that mimic the symptoms of personality disorders
(e.g., impulsivity, dysphoria, aggressiveness and self-destructiveness, relationship problems, work
dysfunction, engaging in illegal activity, and dysregulated emotions and behaviour) making it difficult to
determine whether a person has a personality disorder.
• Cluster A: Individuals with these personality disorders often appear to be odd or eccentric. They
have significant impairment but infrequently seek out help. Cluster A includes paranoid, schizoid, and
schizotypal personality disorders.
• Cluster B: Individuals with these personality disorders tend to be dramatic, emotional, and erratic.
Generally they experience significant impairment and they are of considerable concern to health care
providers. Of all the personality disorders, people with Cluster B disorders are the ones that most
commonly present to services. Cluster B includes antisocial, borderline, histrionic, and narcissistic
personality disorders.
• Cluster C: Individuals with these personality disorders tend to be anxious and fearful and are generally
less impaired than those with Cluster B personality disorders. Cluster C includes avoidant, dependent,
and obsessive-compulsive personality disorders.
Among those with AOD use disorders, two Cluster B personality disorders, ASPD and BPD, are most
prevalent and tend to impact most upon treatment [116-118]. These are discussed in turn.
CLUSTER A
Paranoid personality disorder is characterised by a pattern of distrust and suspiciousness such that
others’ motives are interpreted as malevolent.
CLUSTER B
Antisocial personality disorder (APSD) is characterised by a pattern of disregard for and violation of
the rights of others. Individuals with this personality disorder are typically aggressive, unlawful and
impulsive.
CLUSTER C
The main feature of ASPD (previously known as ‘psychopathy’ or ‘sociopathy’) is a pattern of complete
disregard for the rights of others. Deceit and manipulation are central features of this disorder. ASPD begins
in childhood or early adulthood and continues into adulthood. For a diagnosis of ASPD to be made, the
individual must be at least 18 years old, and have had a history of some symptoms of ‘conduct disorder’
before age 15. The behaviours characteristic of conduct disorder fall into the following characteristics:
aggression to people and animals, destruction of property, deceitfulness or theft, and serious violation of
rules. This pattern of antisocial behaviour then continues into adulthood.
• Failure to conform to social norms with respect to lawful behaviour. Individuals with ASPD may
repeatedly be involved in actions that are grounds for arrest (e.g., destroying property, harassing
others, stealing, or pursuing illegal occupations). They tend to have disregard for the wishes, rights, and
feelings of others.
• Being deceptive and manipulative in order to gain personal profit or pleasure (e.g., to obtain money, sex,
or power). Individuals with ASPD may repeatedly lie or con others.
• Reckless disregard for their own or other’s safety (e.g., recurrent speeding, driving while intoxicated,
multiple accidents, or high-risk sex).
• A tendency for impulsive behaviour due to a failure to plan ahead. Decisions may be made on the spur
of the moment, without forethought, and without consideration of the consequences for themselves or
others. This may lead to sudden changes of jobs, residences, or relationships.
• Irritability and aggression; repeated involvement in physical fights or assaults.
• Consistent and extreme irresponsibility. Behaviour that is indicative of this may include irresponsible
work behaviour; for example, long periods of unemployment despite several job opportunities,
abandonment of jobs without a plan for getting another, or repeated unexplained absences from work.
Financial irresponsibility may include acts such as defaulting on debts and failing to provide child
support.
• The absence of remorse for the consequences of their actions. Individuals with ASPD tend to provide
superficial excuses for having hurt, mistreated, or stolen from someone. They may blame the victims
of their actions for being foolish, helpless, or deserving their fate. They generally fail to correct their
wrongdoings, or to apologise or show remorse for their behaviour.
A case study example of how comorbid ASPD and AOD use disorder may present is illustrated in Box 9.
BPD is marked by persistent patterns of instability in relationships, mood, and self-image. BPD is also
characterised by marked impulsivity, particularly in relation to behaviours that are self-damaging. The main
characteristics of BPD include:
• Extreme efforts to avoid rejection or abandonment (these threats of rejection may be real or imagined).
• A pattern of unstable and intense relationships, whereby the person alternates between idealising a
person and completely devaluing him/her.
• Unstable self-image or sense of self (e.g., the individual may suddenly change his/her goals or values
in life, jobs or career aspirations, sexual identity, friends).
• Impulsivity, particularly in relation to behaviours that are self-damaging (e.g., spending money
irresponsibly, binge eating, substance abuse, unsafe sex, and reckless driving).
• Recurrent suicidal behaviour, gestures, threats, or self-mutilating behaviour (e.g., cutting or burning) are
also common.
• Unstable mood (e.g., intense dysphoria, irritability, or anger usually lasting only a few hours).
• Chronic feelings of emptiness.
• Inappropriate intense anger or difficulty controlling anger.
• Transient, stress-related paranoid thoughts or severe dissociative symptoms (i.e., where the person
temporarily loses touch with where he/she is in time and/or space).
Case Study I: What does comorbid ASPD and AOD use look like?
Luke’s story
Luke is a 28-year-old man who was referred into AOD treatment from his local court as part of a
diversionary program. Luke was assessed on the day of his court appearance, where he was to face
charges for burglary. Luke was assigned to AOD treatment through the referral program, and his
burglary charges adjourned pending his involvement in the program. Luke had a history of heroin
use dating back at least 10 years. He had been on methadone a number of times in the past, but his
compliance was always short lived.
Luke had an abusive stepfather and at times, experienced abuse from his mother. He spent some time
in foster care before being returned to his mother when he was around 10 years old. Luke began sniffing
solvents and smoking cannabis, frequently wagged school before leaving school early (during year 9),
and worked casually on building sites. He joined a boxing club and later indicated that he would often
look for people to fight on nights out, and that he enjoyed inflicting injury on others. He told his therapist
that he often acted impulsively, destroying public property, and getting into fights.
Over the past 10 years, Luke had been in two long-term relationships, both with women who also used
heroin. During these relationships, Luke was sometimes violent towards his partner, but showed little
remorse. Following the breakup of his latest relationship, Luke had been sleeping in shelters and ‘couch
surfing’ at friends’ houses. He continued to have sporadic part-time work in the building industry but
much of his income was derived from shoplifting and opportunistic theft of mobile phones, wallets, and
so on
Key points:
• Whatare the primary concerns for Luke?
• Where to from here?
Symptoms of mood, anxiety, and psychotic disorders may all be induced as a result of AOD use or
withdrawal. For example, alcohol use and withdrawal can induce symptoms of depression or anxiety [29];
manic symptoms can be induced by intoxication with stimulants, steroids, or hallucinogens; and psychotic
symptoms can be induced by withdrawal from alcohol, or intoxication with amphetamines, cocaine,
cannabis, LSD, or PCP [32]. Other disorders that may result from AOD use include substance-induced
delirium, amnestic disorder, dementia, sexual dysfunction, and sleep disorder.
Visual hallucinations are generally more common in substance withdrawal and intoxication than in primary
psychotic disorders [121]. Stimulant intoxication, in particular, is more commonly associated with tactile
hallucinations, where the patient experiences a physical sensation that they interpret as having bugs under
the skin. These are often referred to as ‘ice bugs’ or ‘cocaine bugs’. Tactile hallucinations can also occur in
alcohol withdrawal; however, auditory and visual hallucinations are more common [121].
Those with stimulant psychosis will sometimes be more agitated, hostile, energetic and physically strong,
more challenging to contain in a safe environment, and more difficult to calm with sedating or psychiatric
medication, than people with psychosis not related to the use of stimulants [122, 123]. Other features that
differentiate substance-induced psychosis from schizophrenia include higher likelihood of polysubstance
dependence, a forensic history, ASPD, trauma history, and a lack of negative and cognitive symptoms with
a return to normal inter-episode functioning during periods of abstinence [122]. A case study example of
how substance-induced psychosis may present is illustrated in Box 10.
Box 10: Case study J: What does substance-induced psychosis look like? James’ story
Over the next hour, James’s behaviour became increasingly erratic: he began to believe that the
symbols in his new tattoo had hidden meaning and power, that it was trying to control him, and that the
tattoo artist was having an affair with his girlfriend. When they arrived back at their hotel, James went
through his girlfriend’s bags and searched her phone, looking for evidence of her affair. He threatened
to kill himself and attempted to jump out of the window. His girlfriend managed to calm James down
and convinced him to go to sleep, believing that the episode would resolve and he would sleep it off.
James had been smoking cannabis on and off from the age of 18, daily for the past five years. He
maintained that he had not used any other illicit substances, and rarely drank alcohol. In the past year,
James has been hospitalised twice for symptoms of mania and once for suicidal ideation. He was
prescribed lithium, and had been functioning well for the past three months. His father had a bipolar
disorder and his paternal grandfather committed suicide.
After two days of hospitalisation, James realised that his tattoo did not have any hidden messages or
power over him, and his girlfriend wasn’t cheating on him. The following day, he recognised that his
paranoia was the result of cannabis intoxication, and was discharged with an appointment to see his
psychiatrist.
Key points:
• Symptoms of psychosis emerged within hours of AOD use, which were followed by suicidal and
homicidal ideation. Following AOD withdrawal, the psychotic symptoms dissipated within a few
days, and James regained insight into the situation.
• This pattern of symptoms corresponds with DSM-5 substance-induced psychotic disorder, which
requires delusions or hallucinations that develop during or soon after substance intoxication or
withdrawal. The fact that James’s symptoms resolved within three days further supports a cannabis-
induced psychotic disorder – this would not be the case for an independent psychotic disorder.
It is essential to consider the whole person and accept that one approach is not necessarily going to work
for all clients. Different clients present with unique psychological and sociodemographic backgrounds
and it is important to take these factors into consideration when responding to comorbidity. It is also
critical to remember that the process of assessments, screenings, monitoring, cooperation, collaboration,
and partnerships are indeed processes, which should be ongoing throughout all stages of management
and treatment. Figure 8 illustrates a pathway through care model, highlighting the continuing stages of
reassessment, monitoring, and client involvement.
B: Responding to comorbidity 51
Figure 8: Pathway through care model
Screening and
assessment (see
B2), including risk
assessment (B3)
Consider the addition of
an adjunctive therapy, Involvement of other
(i.e., psychological or agencies and/or
pharmacological, as services to deliver
appropriate) (see B5 & coordinated care to
B6) the client (see B7)
If no
Reassess/monitor:
With the client, consider In partnership with
Is there an adequate the addition of e-health
response to the client, consider
interventions, physical
treatment? activity, complementary evidence-based
and alternative therapies, if treatments (see B5 &
appropriate (see B5) B6)
If Yes
Consider increasing
Reassess/monitor:
the intensity If no
of therapy (i.e., Is there an adequate
psychological or response to
pharmacological, as treatment?
appropriate)
If yes, consider
continuation of therapy
and relapse prevention
(see B4)
52 B: Responding to comorbidity
B1
B1: Holistic
Section
Heading
health care
Goes here
Ipsandi te nus, omnime corat verum
nam vitecup tatem. Nam quaero ea
ipsam quidem aut audandelique apisit
eosapid itaturi tatendi tasperrum que
est laborum rest, esecte nis rem sit
aspe quas experit re et ulpa.
B1: Holistic
health care
Key Points
• People with comorbid AOD and mental health conditions are at
increased risk of physical health problems, with higher mortality
rates than the general population.
• Those with comorbidity are at particular risk of developing CVD,
due to high rates of smoking, overweight and obesity, diabetes,
poor diet, physical inactivity, high alcohol consumption, and the use
of some antipsychotic medications.
• Recent research has highlighted the need for interventions that
focus on overall wellbeing, including reducing smoking, improving
dietary habits, increasing physical activity, and sleep patterns.
• Crucial to this approach is the inclusion of multiple service
providers who reflect the complex needs of clients, and are able to
deliver the right care, to the right person, at the right time.
The co-occurrence of poor physical and mental health has been well documented in recent years, with
greater attention paid to the role that mental health plays in increasing vulnerability to physical disability
and poorer outcomes [126-130]. Consumers of mental health services have more than double the mortality
rate than the general population [126], especially due to CVD [131].
Risk factors for CVD are prominent among people with AOD and mental health conditions [132]. These
include high rates of smoking [133-135], overweight and obesity [136-138], diabetes [127], poor diet [131,
139, 140], physical inactivity [141-143], excessive alcohol consumption [144], and use of some antipsychotic
medication [130].
Furthermore, these risk factors also place individuals at risk for metabolic syndrome. Metabolic syndrome
is the presence of three or more of the following risk factors [145]:
One third of Australians are currently diagnosed with metabolic syndrome [146], which has been found
to be directly affected by sleep, physical activity, and dietary behaviours [147, 148]. Research has found
that people with mental health disorders (e.g., schizophrenia, bipolar disorder, depression, PTSD, BPD)
should be considered a high-risk group for metabolic syndrome and associated morbidity and mortality,
particularly those prescribed antipsychotics [149-152].
• Smoking.
• Diet.
• Physical activity.
• Sleep.
Smoking
Smoking rates among those attending AOD treatment are substantial, ranging between 74-98% [157].
People with AOD and mental health conditions also smoke substantially more cigarettes per day, and
are more likely to be nicotine dependent, than the general population [158]. Despite tobacco accounting
for the highest rate of mortality among people with AOD and mental health conditions, the focus of
treatment has primarily centred on substances other than tobacco [159]. This reluctance to address
smoking by AOD workers may be due to the belief that doing so might exacerbate other AOD use [155],
and increase psychiatric symptoms and aggression [160, 161]. However, this view is not supported by the
evidence, which indicates no adverse outcomes on symptoms of psychosis [162]. On the contrary, smoking
cessation is associated with improvements in depression [163]. Two recent Cochrane reviews have been
conducted to examine the evidence pertaining to the treatment of nicotine dependence in schizophrenia
[164] and depression [165]. The findings indicate that rates of smoking abstinence were increased by the
use of bupropion among people with schizophrenia, without threat to their mental health [164], and by
the inclusion of a psychosocial mood management component to standard smoking cessation treatment
among those with current and past depression [165].
Nicotine is known to interact with the metabolism of some medications and drugs. Changes in how some
medications are metabolised (particularly clozapine and olanzapine) can occur following the cessation of
smoking or nicotine replacement therapy (NRT) [166, 167]. If AOD clients are withdrawing from nicotine, they
NRT can be used to minimise the physiological symptoms of nicotine withdrawal, and is available in
patches, gum, inhalers, lozenges, and microtabs [169]. NRT is not recommended without a clinical
assessment, or as first line of treatment for AOD clients who [168]:
Clinicians managing clients on NRT should regularly monitor clients’ withdrawal so as to tailor the NRT
dose, and address triggers, cravings, and stress through accompanying psychosocial interventions.
There have been several trials of healthy lifestyles interventions among people with mental health
disorders, all of which have included a smoking component. Baker and colleagues [170] conducted a pilot
trial to reduce CVD risk in 43 people with acute psychotic disorder, using MI with cognitive behavioural
therapy (CBT), accompanied with NRT. The study found significant reductions in CVD risk and smoking, and
participants indicated high levels of satisfaction with the program.
More recently, Baker and colleagues [171] provided up to 24-weeks supply of NRT to smokers with stable
psychotic disorder. This was accompanied by feedback provided to each participant on their smoking
and levels of dependence, and a case formulation developed with participants, focusing on individual risk
factors for CVD and unhealthy behaviours, utilising a MI approach and CBT approaches. The study found
that both NRT plus a telephone based intervention for smoking cessation (focused on monitoring smoking
and discussing CVD risk factors) and NRT plus an intensive face-to-face Healthy Lifestyles intervention
were effective in reducing smoking among people with severe mental health disorders.
Kelly and colleagues [153] are currently conducting the first study to address multiple CVD risk factors
within an AOD treatment setting, which will include health-focused psychoeducation, goal setting,
monitoring, MI, and CBT to help clients reduce smoking, increase fruit and vegetable intake, and increase
levels of physical activity.
Despite evidence to suggest that smoking can be effectively addressed in clients of AOD and mental
health services, there have been inconsistencies with the implementation of smoking interventions in AOD
agencies. A greater number of AOD staff smoke in comparison to the general population, and sometimes
smoke with clients in order to promote a therapeutic relationship [172]. Negative attitudes among treatment
staff have been acknowledged as potential barriers to effectively targeting nicotine dependence [173], with
staff who smoke themselves less likely to initiate smoking cessation among clients, and be less successful
when they do [174-176].
Diet
Clients of AOD treatment services tend to have poor dietary habits, electing to eat nutrient-poor, energy-
dense food, often to excess [143]. It is common for those accessing AOD treatment to report unhealthy
eating patterns, weight gain, and obesity, which suggests that energy-dense diets are sometimes used
to substitute AOD during recovery [136, 177]. Programs targeting the preparation of nutritional food can
produce lasting weight loss among people with mental health conditions [178], and AOD workers can assist
by encouraging adherence to Australian dietary guidelines (see Figure 9). Specifically, clients should be
encouraged to [171]:
Fruit
Lean meats, Milk,
poultry, fish, yoghurt,
eggs, tofu, cheese,
nuts, seeds, reduced fat
beans
Eat most Bread, cereals, rice, pasta, flour, fruit, 60% of budget
vegetables, baked beans, lentils
Eat moderately Lean meat, chicken, fish, eggs, nuts, 30% of budget
milk, cheese, yoghurt
Source: Western Australian Network of Alcohol and other Drug Agencies [181], Foodcents [180].
Physical activity has shown to be inversely related to smoking status (i.e., non-smokers are more physically
active than smokers) [182], number of cigarettes smoked, and nicotine dependence, and recent evidence
suggests that exercise may be an effective complementary intervention to smoking cessation strategies
[182, 188, 202, 203, 206-211]. Physical activity improves cardiovascular, pulmonary, and immune functioning,
which can in turn assist with the prevention of chronic disease [134]. Smoking cessation is more successful
for those who exercise during their attempts to quit smoking [203, 206, 209], and exercise can assist with
the prevention of relapse [206, 209]. Physical activity can also alleviate symptoms of smoking withdrawal,
such as irritability, depression, restlessness, and stress [182, 188, 202, 206-208, 210, 211].
Research suggests that although people with AOD use disorders may be interested in increasing their
levels of physical activity [212], it is unclear how frequently those in AOD treatment regularly engage in
moderate to vigorous levels of exercise, with few treatment programs incorporating dedicated time for
exercise [185, 213-215]. Although treatments for AOD use are focused on addressing behavioural patterns, it
is up to the person to avoid automatic behaviours (e.g., drinking or using other drugs) when they are faced
with a craving or desire to drink or use [185]. Particular social settings, activities, or times of day associated
with AOD use can become environmental cues, which can increase the risk of relapse [216, 217]. Rather
than using AOD when cravings or urges to use arise, engaging in an immediately rewarding, accessible,
sustainable, and safe behaviour, such as exercise and physical activity, can reduce the likelihood of relapse
[185]. Regular exercise is also often associated with other positive behaviours, such as healthy diet and
sleep patterns [218, 219], and overall feelings of wellbeing, vitality, high energy, and motivation to maintain
healthy lifestyle practices [220]. A systematic review of the literature examining the effects of exercise-
based interventions for AOD use on recovery, physical fitness, and psychological health found that exercise
is a potentially promising accompanying treatment for AOD use, with reductions in AOD use, improvements
in depression, anxiety, and stress, as well as significant fitness improvements in the exercise groups [186].
Despite this, the ideal dose (i.e., type of exercise, duration, and intensity) of exercise to maximise the effects
of potential health and psychological benefits is not clear, and is still the subject of research. Evidence
to date suggests that the ideal dose varies considerably between people, and depends on individual
preferences, as well as baseline physical fitness levels [221]. However, given that many people with AOD
use are fairly inactive, an initial program of light to moderate intensity exercise is likely to be more beneficial
than vigorous exercise, which may also assist with program adherence and retention [203, 212, 222].
Supervised physical activity may be useful, to ensure information about safe exercise (e.g., importance of
warm-up, cool-down, and stretching) and exercise intensity are provided (e.g., using heart-rate monitors)
[185]. Encouraging the pursuit of home-based exercise is likely to be important for clients to establish
and maintain exercise levels after the conclusion of the activity program, and integrating exercise into
psychotherapy may enhance treatment outcomes [185].
Research has also highlighted the importance of physical activity and exercise among comorbid
populations. Anxiety and depression have been associated with AOD relapse and treatment retention,
particularly in the early stages of recovery [187, 231, 232]. A study examining the effects of an 8-week
structured exercise program (treadmill and weight training) on depression and anxiety symptoms
among newly abstinent methamphetamine users in treatment found that those in the exercise group
had significantly greater reductions in depression and anxiety symptoms than the control group (health
education sessions) [233]. Further, a dose effect was found, whereby those who had attended more
exercise sessions during the 8-week program illustrated greater reductions in depression and anxiety
compared to those who had attended fewer sessions [233]. These findings support the important role of
physical exercise in improving mood symptoms among comorbid AOD populations.
There are six physical activity and sedentary behaviour guidelines for adults, outlined in Table 16.
Table 16: Physical activity and sedentary behaviour guidelines for adults
Physical activity and sedentary behaviour guidelines for adults (aged 18–64 years)
• Any physical activity is better than none. If there is currently none, start with a small amount and
gradually build up to the recommended amount.
• Be active most days, and preferably all days, of the week.
• Accumulate 150–300 minutes (2 ½–5 hours) of moderate intensity physical activity (i.e., out of
breath but can still say a few words) or 75–150 minutes (1 ¼–2 ½ hours) of vigorous intensity
physical activity (i.e., out of breath, difficulty talking), or a combination of both, each week.
• Incorporate muscle strengthening exercises each week.
• Minimise the amount of time spent in prolonged sitting.
• Break up long periods of sitting as often as possible.
Despite the overwhelming evidence of poor physical health among those with mental health conditions,
relatively few workers address the physical health of their clients as part of their practice [235]. This may
in part be due to clinicians questioning whether health and wellness are achievable goals for people with
mental health conditions, due to perceived lack of motivation, lifestyle challenges, and the side effects and
complications of many medications (e.g., weight gain, glucose and lipid abnormalities, and cardiac side-
effects) [130, 131, 235]. Although some research suggests that clients may prefer to make simultaneous
behavioural changes [236, 237], clinicians may feel ill-prepared to manage the physical health of clients,
particularly with standard screening tools and assessments not addressing the importance of health
screening in mental health patients [235]. AOD workers may find the food and physical activity diary located
in the Worksheets section of these Guidelines useful.
Better understood are the poor health outcomes associated with insufficient sleep duration. The quality and
duration of sleep has been linked to chronic disease, with insufficient sleep associated with higher body
mass [250], weight gain [251, 252], obesity [253], diabetes [254], CVD [255] and premature mortality [256].
Recent research suggests that the ideal amount of sleep varies with age. For adults aged between 18–64
years, the recommended duration of daily sleep is between seven and nine hours [257]. The increased risk
of chronic diseases, obesity, diabetes, hypertension, and CVD, however, is associated with both too little
(i.e., less than 6 hours) and too much sleep (i.e., more than 9 hours) [255, 258].
The American Academy of Sleep Medicine recommends the healthy sleep habits outlined in Table 17:
Sleeping tips
• Maintain a regular sleeping schedule, on weekdays and weekends (i.e., go to bed around the same
time each night, and wake at the same time each morning).
• Ensure at least seven hours sleep.
• Do not go to bed unless tired.
• Get out of bed if not asleep within 20 minutes.
• Practise relaxing bedtime rituals (e.g., mindfulness, meditation, relation exercises).
• Only use the bed for sleep and sex.
• Ensure the bedroom is calm and relaxing, and maintain a cool, comfortable temperature.
• Limit exposure to bright lights before bedtime.
• Do not eat large meals before bedtime. If hungry, have a light, healthy snack.
• Exercise regularly.
• Avoid caffeine in the late afternoon and evening.
• Avoid alcohol before bedtime.
• Reduce fluid intake before bedtime.
From an AOD worker’s perspective, it should be remembered that physical and mental health are
fundamentally entwined. As such, be prepared to take steps to manage clients’ physical and mental health:
consult with clients and assist with strategies to reduce smoking; assist with the planning of healthy meals
incorporating fruits and vegetables; encourage clients to become more physically active; and recommend
healthy and regular sleep patterns. A case study example of the interrelatedness of physical and mental
health is provided in Box 11.
Box 11: Case study K: Managing comorbid physical, mental, and AOD use disorders:
Sarah’s story
The pattern of Sarah’s psychosis has been unpredictable. While she had some periods of stability, her
auditory hallucinations, paranoid ideas, and mood fluctuations have recently become more frequent.
Although Sarah had a number of admissions to inpatient psychiatric units in her early 20s, since that
time she has been managed within the community mental health care services. However, Sarah’s recent
lifestyle has been chaotic, and she has moved across the city several times. As such, Sarah has been
under the care of several different community mental health services, with no single clinician knowing
her well. Due to her frequent moves, Sarah has also been under the care of several different GPs.
Sarah presented to the emergency department of an inner city hospital because of injuries suffered
during an argument with another resident in the hostel where she was staying. Her injuries were
relatively minor, but the doctor and nurse who assessed her noted that she had high blood pressure
and that she was overweight (with a body mass index (BMI) of 32). It was also noted that Sarah had a
cough, which she attributed to her smoking 20 cigarettes a day. When asked about her blood pressure,
Sarah told the doctor that her GP had prescribed her medication, but she had not taken it, and had not
attended any follow-up appointments. This information was brought to the attention of the community
mental health service who were caring for Sarah. At the first opportunity, her current community mental
health nurse made an assessment not only of her mental state and AOD use, but also attempted to
gather as much information as possible about Sarah’s physical health.
Over many years Sarah had been prescribed various antipsychotic medications and mood stabilisers
and it became clear that she had put on a great deal of weight. Despite her long-term use of
antipsychotic medication and high BMI, Sarah could not recall having been tested for type II diabetes,
or undergoing routine blood glucose measurement. More generally, the GP also noted that Sarah had
not previously received routine blood tests to cover matters such as liver function, thyroid function, and
haemoglobin (for anaemia), nor had she ever had any cervical smears, although she had been offered
these.
Key points:
• What are the primary concerns for Sarah?
• Where to from here?
B2
Goes here
Ipsandi te nus, omnime corat verum
nam vitecup tatem. Nam quaero ea
ipsam quidem aut audandelique apisit
eosapid itaturi tatendi tasperrum que
est laborum rest, esecte nis rem sit
aspe quas experit re et ulpa.
B2:
Identifying
comorbidity
Key Points
• Given the high rates of co-occurring mental health conditions
among clients of AOD treatment services, it is essential that routine
screening and assessment be undertaken for these conditions as
part of case formulation.
• Screening and assessment set the scene for the future client-
worker relationship and need to be conducted in a friendly and
empathic manner.
• It is important to consider a range of aspects in the process of
case formulation, not only AOD and mental health issues (e.g.,
sociocultural factors, motivation, living situation, and medical and
personal history).
• Full assessment should ideally occur subsequent to a period
of abstinence, or at least when not withdrawing or intoxicated.
Multiple assessments should be conducted throughout a person’s
treatment as symptoms may change over time.
• It is important to provide assessment feedback to the client in a
positive, easily understood manner.
Despite high rates of mental health conditions among clients of AOD services, it is not unusual for
these comorbid conditions to go unnoticed by AOD workers [100, 260]. This is mostly because they
are not routinely looking for these conditions. Many of the signs and symptoms of common mental
health conditions (e.g., depression) are not immediately obvious or visible, and may be overlooked if not
specifically asked about. As mentioned in Chapter A3, all clients should be screened and assessed for
Assessing and identifying the client’s needs is the first step. It is important to recognise whatever needs
the client may have as they will undoubtedly impact upon AOD treatment. Early diagnosis and treatment
of mental health disorders can improve treatment outcomes [261-263]. Identification does not necessarily
mean that the AOD worker has to personally treat the difficulty the client is experiencing; however,
they do need to consider the impact of these difficulties, manage them accordingly, and engage other
services where necessary. It is often difficult to determine which symptoms are attributable to which
disorders. Once symptoms are identified, more specialised assessment may be required by mental health
providers, psychologists, or psychiatrists to determine whether the person has a diagnosable disorder
(care coordination is discussed further in Chapter B4). It is equally important that other issues identified
(e.g., problems involving employment, housing, medical care) are dealt with appropriately, which may also
require consultation with other services.
Case formulation
Case formulation involves the gathering of information regarding factors that may be relevant to treatment
planning, and formulating a hypothesis as to how these factors fit together to form the current presentation
of the client’s symptoms [264, 265]. The primary goal of AOD treatment services is to address clients’ AOD
use. However, in order to do so effectively, AOD workers must take into account the broad range of issues
that clients present with. As discussed in Chapter A2, clients of AOD treatment services, and those with
comorbid conditions in particular, often have a variety of other medical, family, and social problems (e.g.,
housing, employment, welfare, or legal problems). These problems may be the product of the client’s AOD
and mental health conditions, or they may be contributing to the client’s AOD and mental health conditions,
or both. According to stress-vulnerability models (e.g., Zubin and Spring [266]), the likelihood of developing
a mental health condition is influenced by the interaction of these biological, psychological, and social
factors. These factors also affect a person’s ability to recover from these symptoms and the potential for
relapse.
After developing a case formulation, the AOD worker should be aware of:
• What problems exist, how they developed, and how they are maintained.
• All aspects of the client’s presentation, current situation, and the interaction between these different
factors and problems.
This information is the first step to devising (and later revising) the client’s treatment plan. There is no
standardised approach to case formulation [267], but it is crucial that a range of different dimensions be
considered, including history of present illness, AOD use history (amount and frequency, presence of
disorder), physical/medical conditions, mental state, psychiatric history, trauma history, suicidal or violent
thoughts, readiness to change, family history, criminal history, and social and cultural issues. Consideration
also needs to be given to the client’s age, sex, sexual orientation, ethnicity, spirituality, socioeconomic
status, and cognitive abilities.
Given the high rates of co-occurring mental health conditions among clients of AOD treatment services,
it is essential that routine screening and assessment be undertaken for these conditions as part of case
formulation. Screening is the initial step in the process of identifying possible cases of co-occurring mental
health conditions [268]. This process is not diagnostic (i.e., it cannot establish whether a disorder actually
exists); rather, it identifies the presence of symptoms that may indicate the presence of a disorder. Thus,
screening helps to identify individuals whose mental health requires further investigation by a professional
trained and qualified in diagnosing mental health disorders (e.g., registered or clinical psychologists, or
psychiatrists).
Diagnostic assessment should ideally occur subsequent to a period of abstinence [270, 271], or at least
when the person is not intoxicated or withdrawing. While the length of this period is not well established, a
stabilisation period of between two to four weeks is recommended [272]. A lengthier period of abstinence
is recommended for longer-acting drugs, such as methadone and diazepam, before a diagnosis can be
made with any confidence, whereas shorter-acting drugs such as cocaine and alcohol require a shorter
period of abstinence [270]. If symptoms persist after this period, they can be viewed as independent
rather than AOD-induced. In practice, however, such a period of abstinence is rarely afforded in AOD
treatment settings and, therefore, to avoid possible misdiagnosis, it has been recommended that multiple
assessments be conducted over time [80, 94, 273]. This process allows the AOD worker to formulate a
hypothesis concerning the client’s individual case and to constantly modify this formulation, allowing for
greater accuracy and flexibility in assessment.
Screening forms the first part of the assessment process. Unlike screening, assessment is a process rather
than a one-off event, which involves the ongoing monitoring of clients’ mental health symptoms. Ongoing
assessment is important because clients’ mental health symptoms may change throughout treatment.
For example, a person may present with symptoms of anxiety and/or depression upon treatment entry;
however, these symptoms may subside with abstinence. Alternatively, a person may enter treatment with
no mental health symptoms, but symptoms may develop after a period of reduced use or abstinence,
particularly if the person has been using substances to self-medicate these symptoms.
Groth-Marnat [274] suggests that a combination of both informal and standardised assessment techniques
is the best way to develop a case formulation. Figure 10 depicts how these techniques work together. In
addition to these assessments, with the client’s consent, it may be useful to talk with family members,
friends, or carers; they can provide invaluable information regarding the client’s condition which the client
may not recognise or may not want to divulge (see Chapter A3) [275].
Treatment
Discharge
Intake
Note: Figure 10 illustrates the need for assessment to be repeated throughout treatment, from intake
through to discharge, to inform the ongoing revision of a person’s treatment plan.
• Mental state.
• Source of referral and current health care providers.
• Presenting issues.
• AOD use history.
• Current situation.
• Personal, medical, and family history.
• Trauma history.
• Psychiatric history.
• Risk assessment.
• Criminal history.
• Strengths and weaknesses.
• Readiness for change.
Mental state
A crucial component of the assessment process is the evaluation of the client’s mental state and
presentation. An assessment of mental state should include:
• Appearance.
• Behaviour.
• Speech and language.
• Mood and affect.
• Thought content.
• Perception.
• Cognition.
• Insight and judgement.
The type of information sought in each of the above domains is outlined in Table 18. It should be noted
that all of the aforementioned factors may be affected by intoxication or withdrawal from substances. The
mental state examination should not consist of a series of direct questions, but rather should be based
on an overall evaluation of the client during the assessment (or preferably a number of assessments). A
record of the mental state examination should be completed after (rather than during) conversations with
the client. In addition to noting unusual or abnormal client behaviours, it is also good practice to record
normal behaviours (e.g., no speech disturbances noted, no unusual thought content noted) [276]. Appendix
F presents a form which may be useful in guiding note-taking for the mental state examination.
Appearance
Behaviour
Bizarre/odd/unpredictable actions.
Uncooperative or withdrawn.
Over familiar/inappropriate/seductive.
Incoherent/illogical thinking (word salad: communication is disorganised and senseless and the main
ideas cannot be understood).
Derailment (unrelated, unconnected, or loosely connected ideas; shifting from one subject to another).
Thought blocking (abrupt interruption to flow of thinking so that thoughts are completely absent for a
few seconds or irretrievable).
How does the client describe his/her emotional state (i.e., mood)?
What do you observe about the client’s emotional state (i.e., affect)?
Irritable, hostile.
Inappropriate – inconsistent with content (e.g., laughs when talking about mother’s death).
Thought content
Does the client believe that his/her thoughts are being broadcast to others or that someone/thing is
disrupting or inserting his/her own thoughts?
Perception
Does the client report auditory, visual, olfactory, or somatic hallucinations? Illusions?
Any other perceptual disturbances, such as derealisation (feeling one is separated from the outside
world), depersonalisation (feeling separated from one’s own personal physicality), heightened/dulled
perception?
Cognition
Level of consciousness
Is the client’s concentration impaired? (Can he/she count from 100 or say the months of the year
backwards?)
Orientation
The day of the week, the date, the month, and the year?
Memory
What he/she was doing around this time last year? (Remote)
Are they able to recall recent events (memory and simple tasks; e.g., calculation)?
How aware is the client of what others consider to be his/her current difficulty?
Adapted from NSW Department of Health [277] and Marsh et al. [276].
In addition to identifying the source of referral, it is important to identify all health care providers currently
involved in the person’s care (e.g., counsellors, psychiatrists, prescribers, GP, probation/community
offender service officers, case workers, social workers). Consistent with a coordinated approach to client
care, with the client’s permission the AOD worker should liaise with these providers regarding the person’s
treatment to ensure care coordination and continuity of care (see Chapter B4).
Presenting issues
Ascertain what the client perceives to be his/her biggest issues and the reasons why he/she is
in treatment. This is usually broader than the AOD issue (e.g., psychological, social, health, legal,
accommodation, financial).
Enquire also about the use of any non-traditional or new psychoactive substances (substances produced
to mimic the effects of illegal drugs), which may be referred to by a range of names including legal highs,
herbal highs, research chemicals, analogues, and synthetics (more information can be found through the
Drug Trends monitoring program [279, 280]).
It can be useful to ask the client to describe a normal day, in order to try to help the client evaluate the
ways in which his/her AOD use affects his/her health, relationships, legality, and livelihood (e.g., finances,
work). The typical day situation is explained in greater detail in Appendix E on MI.
Current situation
Enquire about the client’s current accommodation, living arrangements, children, family and friends, social
and other support networks, significant relationships, physical health, study, work commitments, legal, and
financial issues.
• Family context (including family history of AOD use and mental health disorders).
• Child and adolescent experiences.
• School experiences (e.g., academic performance, social experiences, bullying).
• Traumatic experiences.
• Work history.
• Leisure pursuits and personal interests.
• Financial and housing information.
• Sexual/marital adjustment.
• Legal issues and illegal behaviour.
• Medical history (including current and past medications, psychiatric medication).
• Current and past pharmacological/psychological treatment.
Trauma history
It is important to identify whether the client has experienced any traumatic events in his/her life [276, 281,
282]. As described in Chapter A4, traumatic events do not refer to any event that the person has found
upsetting. Rather, they are events where the individual perceived his/her own (or someone else’s) life or
physical integrity to be at risk. The trauma may be a one-off event or it may have occurred over a period of
time [24].
A history of trauma exposure may be integrally linked with the person’s current AOD use; a number of
people with AOD use disorders who have experienced trauma describe their use as an attempt to self-
medicate the thoughts and feelings they have had since the trauma. The presence of a trauma history also
indicates that further investigation is required to determine whether the person may have symptoms of
PTSD (described in Chapter A4).
While identification of past trauma is important, questioning needs to be sensitive and should not be
pursued if the client does not wish to discuss it. In some circumstances, it may be better to raise the
issue of trauma several weeks after the initial assessment interview, once the client feels safer and has
developed a therapeutic relationship with the AOD worker [276]. Before conducting trauma assessments,
workers should seek training and supervision in dealing with trauma responses. Some AOD workers may
be reluctant to discuss trauma with their clients due to events that have happened in their own lives.
These workers should seek assistance from their colleagues and should not be forced to conduct trauma
assessments if they are not comfortable doing so.
• Seek the client’s permission to ask him/her about exposure to traumatic events, and advise the client
that he/she does not have to talk about these experiences or provide any detail if he/she does not
want to. Clearly communicate the reasons for asking about past trauma. It may not be readily apparent
to the client that his/her current situation may be related to his/her past [281]. For example, clearly
explaining to the client that the questions relating to trauma will help contextualise his/her drug
use, which will also help gain a better understanding of the interplay between AOD use and trauma
symptoms [276]. Ensure that the client has the opportunity to say if they feel uncomfortable.
When broaching the subject of trauma, ask the client if he/she has ever experienced any traumatic events
such as witnessing or experiencing: car accidents or other types of accidents, natural disasters, war, adult/
childhood physical or sexual assault, having been threatened. Reliable reporting of events is best obtained
by asking about specific event types. Under-reporting of exposure tends to occur when people are asked
only broad questions such as ‘Have you ever experienced a traumatic event?’ [287]. Standardised screening
tools such as the Traumatic Life Events Questionnaire (TLEQ) and Trauma History Questionnaire (THQ)
described in Appendix H may be used to assess for a history of trauma exposure. Some clients find it easier
to complete a self-report screener than to say aloud to the assessor that they have, for example, been
raped [282], and research suggests that verbal disclosure of trauma via interview evokes more distress than
completing written questionnaires [286]. However, such screeners should always be completed with an
AOD worker present and should never be given to the client to complete at home.
It is important to understand that clients may be uncomfortable answering questions relating to past
trauma because of the personal nature of such questions. Client discomfort may also be associated with
distrust of others in general (or of service providers in particular), a history of having their boundaries
violated, or fear that the information could be used against them [281].
During the trauma assessment it is essential that the AOD worker questioning the client does not ‘dig’
for information that is not forthcoming, as this may result in destabilisation [282]. For those who have
experienced interpersonal trauma in particular, such pressure from an authority figure may imitate the
interpersonal dynamics that were evident in an abusive relationship and exacerbate trauma symptoms.
There is an inherent power imbalance in the helper–helped relationship and AOD workers must do their
best to reduce this inequity [281]. Trauma and AOD use are both characterised by the loss of control and
it is important that a sense of control be re-established. The following are some additional guidelines on
discussing traumatic experiences with clients [288]. Further information regarding the management of
trauma symptoms is provided in Chapter B6.
• Create a safe, welcoming environment. Let clients know what to expect and avoid surprises.
Sometimes clients who have experienced trauma may be physically and mentally ‘on guard’, so use
slow, calm movements, and a gentle tone of voice, and don’t encroach on their personal space.
• Adopt a non-judgemental attitude. People who have experienced trauma often feel a great deal of
shame and guilt either in relation to the trauma itself or how they reacted to the trauma. Sometimes
clients may have experienced stigmatisation from others due to their trauma experiences, mental
health, and/or AOD use. The client needs to feel that the AOD worker does not consider them in a
negative way (e.g., weak, immoral). It is important not to judge how the person reacted during or after
the trauma. It is easy to judge people harshly with the benefit of hindsight, but even if they did make a
mistake in judgement, they did not deserve to suffer.
• Display a comfortable attitude if the client describes their trauma experience. Some clients will
have had experiences that people do not want to hear about, especially the gruesome or horrific
details. They need to know that they can tell you anything.
• Normalise the client’s response to the trauma and validate their experiences. Many people who
have experienced trauma (especially those with PTSD) feel that they are ‘going crazy’ because
of the feelings they may have had since the trauma (e.g., re-experiencing the event, avoidance,
hypervigilance). Just hearing from a professional that the reactions they are experiencing are common
helps to normalise their experience, and also alleviate possible shame or guilt about not recovering
sooner. Normalisation and validation are discussed in further detail in Chapter B6.
Psychiatric history
Enquire as to whether the client has any current mental health symptoms (such as depression, anxiety,
psychosis), whether he/she has experienced these in the past, whether he/she has ever been diagnosed
with a mental health disorder, and whether he/she has ever received any treatment. If the client has
experienced mental health symptoms or has been diagnosed with a mental health disorder, ask about the
timing and context of these symptoms:
• When did the symptoms start (did they start prior to AOD use)?
• Do they only occur when the person is intoxicated or withdrawing?
• Have the symptoms continued even after a period of abstinence (approximately one month)?
• Do the symptoms change when the client stops using substances (i.e., do they get better or worse, or
stay the same)?
• Is there a family history of the particular mental health condition?
• What kind of treatment did the person have? Did it work well?
If symptoms arise only in the context of intoxication or withdrawal, it is likely that they are substance
induced [289], and will resolve with a period of abstinence without the need for any direct intervention
[35, 119, 290]. It is nonetheless important for these symptoms to be managed to prevent the client from
relapsing in the early stages (see Chapter B5). The duration of abstinence may vary depending on
substances used; however, most should start to see considerable improvement over a period of one month
[270, 291].
If the mental health symptoms started prior to the onset of AOD use, symptoms persist even during periods
of abstinence, or there is a family history of the particular mental health condition, the client may have a
mental health condition that is independent of his/her AOD use.
Criminal history
Enquire about past and present criminal behaviour, arrest history, any impending court cases or
outstanding warrants.
The stages of change model is also relevant in assessing motivation to receive treatment for comorbid
mental health conditions. Just because a person has presented for treatment for his/her AOD use, does not
necessarily mean that he/she has the same readiness to receive mental health treatment. For example, just
because the client is willing to consider reducing AOD use, this does not automatically mean that he/she
is also ready to deal with the trauma-related symptoms they experience due to abuse suffered as a child.
Appendix G provides a useful matrix for assessing motivation for both AOD and mental health treatment.
Although we include the stages of change model, it is important to note that this model has been subject
to some criticism. Some researchers and clinicians have questioned the divide between stages, the
distinction between stages, and the focus on conscious decision making (rather than the involvement of
other factors, such as unconscious motivations) [293-295].
Maintenance Changes are consolidated and Reinforce positives and assist with
maintained. lapses.
Self-help groups.
Provide relapse prevention
techniques.
Emphasise client alertness.
Work towards longer-term goals.
Groth-Marnat [274] suggests that when conducting standardised assessment, it is important to:
• Provide the client with the reasons for assessment and the purpose of each instrument.
• Explain that it is a standard procedure.
• Explain how standardised assessment can be useful in helping clients achieve their goals (e.g., by
providing an objective measure).
• Provide appropriate and timely feedback of the results of the assessment.
Standardised assessment should be completed upon entry into and exit from treatment, as well as at
follow-up [94, 300]. Test results can provide useful clinical information (for both the client and AOD worker)
on the client’s case and an evaluation of how effective treatment has been. A variety of different tools are
used, some of which are empirically established instruments, whilst others are purpose-built, internally
designed tools with increased practicality and utility but unknown validity and reliability [267]. Some helpful
screening tools have been included in Appendices I–R.
Standardised tools cover a range of areas that may be relevant to AOD services. The Camberwell
Assessment of Need (CAN) is one of the most widely used needs assessment and treatment outcome
tool [301] and has evidence to support its use among people with mental health conditions. It has also
been validated for use in Australian populations [302], and can be used in clinical practice without staff
training. The CAN assesses need in 22 domains, including accommodation, food, self-care, capacity to
look after the home, daytime activities, physical health, psychotic symptoms, mental health and treatment,
psychological distress, risk to self and others, AOD use, social relationships, child care, education, transport,
budgeting, and benefits [303]. Several versions of the CAN exist, including:
The CANSAS-P has been recommended as the preferred needs assessment measure for client
completion [302], and is available in Appendix I. Further information about each version can be obtained
through the CAN webpage: www.researchintorecovery.com/CAN.
There are also a wide range of standardised tools that can be used to screen and assess specifically for co-
occurring mental health conditions. Here we provide an overview of some of these tools, with focus given
to those that require minimal training to use and are freely available. A range of additional screening tools
are described in Appendix H. It should be noted that some of these tools require specialist training, or else
mislabelling, misinterpretation, or inappropriate use may occur [274]. Some tools are copyright protected
and need to be purchased, and/or require the user to have specific qualifications. The requirements of
each tool described here (and in Appendix H) are explained accordingly. It is important that workers are
aware of what they are and are not trained to use, and seek training where required. Readers are also
referred to Deady’s [301] comprehensive review of screening tools for use in AOD settings. This document
is available online at www.nada.org.au.
It should be noted that following the release of the DSM-5, and at the time of writing, new measures were
in the process of being developed and validated. As such, the measures below and in Appendix H include
assessments validated for DSM-5, and where none are available, we have included measures developed
with DSM-IV-TR criteria. Further disorder-specific assessment measures can be found on the DSM-5
website: www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures.
As mentioned earlier in this chapter, screening is designed only to highlight the existence of symptoms, not
to diagnose clients. Most of the measures described are self-reporting (i.e., they may be self-completed by
the client). Others, however, need to be administered by the AOD worker. Aside from the McLean Screening
Instrument for Borderline Personality Disorder (described briefly in Appendix H), there are few brief
measures with established reliability and validity for the identification of possible personality disorders. The
possible presence of these disorders needs to be assessed by a health professional who is qualified and
trained to do so (e.g., a registered or clinical psychologist, or psychiatrist).
10–15 Low
16–21 Moderate
22–29 High
30–50 Very high
PsyCheck
The Australian PsyCheck screening tool (Appendix K) has been shown to be a valid and useful resource for
clinicians [310]. The screening tool has three sections:
The PsyCheck manual [310] includes training on how to administer, score, and interpret the results of each
section, and the subsequent steps to take according to the screening results. If the results of the screening
tool indicate high levels of symptomology, further assessment may be warranted. The PsyCheck screening
tool has been shown to have good test-retest reliability in drug-using samples [312]. More information on
the PsyCheck screening tool is available at www.psycheck.org.au.
Currently, no studies have been conducted to validate the DASS as a measure of depression and anxiety
among people with AOD use disorders. However, one study has shown that the DASS can be used as a
reliable screen for symptoms of PTSD among people with AOD use disorders [315].
0–77 Normal
78–87 Mild
87–95 Moderate
95–98 Severe
98–100 Extremely severe
Both measures assess past month cognitive subscales related to ED: restraint, eating concern, shape
concern, and weight concern, as well as behavioural symptoms related to these concerns (e.g., frequency
of binge eating, vomiting, use of laxatives or diuretics, and overexercise) [329]. The EDE-Q has been
validated for use in samples with AOD use disorders [332]. Both instruments are available for free download
from http://www.credo-oxford.com/7.2.html.
Feedback
Following completion of assessment procedures, it is important to interpret the results for the client in a
manner that the client can understand (i.e., not just giving them numerical test scores). When feeding back
assessment results, consider the following [299]:
Again, it is important to stress that these screening measures are not diagnostic; therefore, it is important
not to label a client as having a diagnosis of a disorder unless it has been made by a suitably qualified
mental health professional (e.g., a registered or clinical psychologist, or psychiatrist). Rather, it is best to
focus on the symptoms displayed by the client.
If mental health symptoms are identified, it is important to discuss with the client what they may expect to
experience in relation to these symptoms should he/she reduce or stop AOD use. As discussed in Chapter
A4, if these symptoms are substance-induced, they are likely to dissipate if the person reduces or stops
his/her use. On the other hand, the client’s mental health symptoms may increase when he/she reduces
or stops using, particularly if he/she has been using to self-medicate these symptoms. The latter scenario
is especially common among people who have a history of PTSD symptoms. It is important that the client
knows that you will be monitoring these symptoms to determine whether further treatment may be
required.
B3
B3: Risk
assessments
Key Points
• This chapter focuses on two areas of risk: suicide and domestic or
family violence.
• Clients of AOD treatment services are at high-risk of suicide, which
is further increased by the presence of comorbid mental health
disorders.
• Risk of suicide may increase in response to significant life events,
and may fluctuate throughout treatment.
• It is vital that suicide risk assessments are an ongoing process,
with all AOD staff trained to detect the direct and indirect warning
signs of suicide, as well as the assessment and management
of suicidality. AOD workers should utilise their clinical skill and
expertise when incorporating screeners and assessments into their
practice.
• Clients of AOD treatment services are also at increased risk of
domestic or family violence.
• Risk of domestic and family violence should be incorporated into
assessment practices, and AOD workers should be familiar with
organisational policies and procedures for responding to family
violence.
• Responding to domestic and family violence within AOD services
requires a broad, comprehensive, coordinated approach involving
multiple services.
Suicidality
The term ‘suicide’ is used in reference to any self-inflicted injury resulting in death, where death was the
deliberate intention [333]. Suicidality therefore relates to any behaviours, thoughts, or intentions which
precede this act or suggest that death may be desired (e.g., self-harming, risk-taking behaviour, suicidal
thoughts, previous attempts, current plans).
Clients of AOD treatment services are at high-risk of suicide [334]. The presence of comorbid mental health
disorders further increases this risk [335-337]. A thorough assessment of suicide risk should take place in
the initial consultation phase and be monitored throughout treatment. How to assess for suicide risk, and
appropriate responses to varying levels of risk, is explained in depth below. Table 22 outlines the dos and
don’ts in regard to the management of suicidality.
Table 22: Dos and don’ts of managing a client who is suicidal
Do:
3 Ensure the client has no immediate means of self-harm; remove weapons and potentially
dangerous objects.
3 Talk to the client alone – without any family or friends present.
3 Allow sufficient time to discuss the issue.
3 Discuss limits of confidentiality.
3 Introduce suicide in an open, yet general way.
3 Be non-judgemental and empathetic.
3 Emphasise that there is help available.
3 Validate the client’s feelings and emphasise the fact that speaking with you is a positive thing.
3 Consider what the predominant concern is for the client, and how you might be able to help remedy
this concern (e.g., removal of stresses, decreasing social isolation).
3 Contact the local mental health crisis team if the client appears to be at high-risk.
Don’t:
2 Invalidate the client’s feelings (e.g., ‘All you have to do is pull yourself together’, ‘Things will work
out’).
2 Panic if someone starts talking about their suicidal feelings. These feelings are common and talking
about them is an important, encouraging first step.
2 Be afraid of asking about suicidal thoughts. Most clients are quite happy to answer such questions.
2 Worry that questions about suicide may instil the idea in the client’s mind.
2 Leave a high-risk client unattended.
Despite the need for suicide risk assessments, research suggests that many AOD services either have no
written suicide risk assessment policy, unclear procedures regarding assessment and/or intervention, or
policies and procedures of which AOD staff are not aware [340].
In response to the need for AOD staff to have access to resources that will assist with the identification
and management of suicide risk, the Suicide Assessment Kit (SAK) was developed [341]. The SAK is a
comprehensive assessment and policy package, specifically developed to help AOD services assess and
manage suicide risk. It contains three key resources for AOD staff and managers (see Table 23):
Resource Purpose
Suicide risk Designed for use at specific time points in treatment (i.e., admission, transition
screener points, discharge), or when the client is suspected to be at increased risk of
suicide.
Suicide policies Designed to help agencies develop policies and procedures for the assessment
and procedures and management of suicide risk, as well as documentation regarding file and
pro forma resource sharing, referral sources, and procedures.
A number of other supporting resources are included in the SAK, which may be useful to AOD workers
in the identification and management of suicide risk. These, along with the full SAK resource (including
training videos), may be downloaded from the SAK webpage: https://ndarc.med.unsw.edu.au/suicide-
assessment-kit.
It should be emphasised that although these resources can be incorporated into AOD workers’ everyday
practice, it is vital that risk assessments are not conducted according to a checklist or flowchart procedure.
All clinicians bring a wealth of knowledge, background, skills, and experience, all of which should inform
the evaluation and assessment of an individual client’s level of risk. The screeners and templates included
in this section (and in Appendix R) rely on AOD workers incorporating their knowledge, judgement,
expertise, and skill in the assessment of risk. Figure 11 illustrates a shared assessment space, where both
the AOD worker and client bring their respective backgrounds, and the AOD worker draws upon their
expertise to conduct the assessment.
Assessment
space
Client
AOD worker
background, needs,
skills, knowledge,
warning signs, risk
experience,
factors, protective
background
factors
• Suicidal communication: A client threatening to hurt or kill him/herself, or talking about wanting to do
so. This also includes speaking ominously, such as talking about going away, or of others being better
off without them.
• Seeking access to a method: A client looking for ways to kill him/herself by seeking access to pills,
rope, or other means.
• Making plans: A client talking or writing about death, dying, or suicide, when these are out of the
ordinary for the person.
Indirect warning signs are less easily identifiable, and require a heightened level of awareness, particularly
as many indirect signs may also occur in AOD clients who are not suicidal [341]. Regardless, they are critical
in assessing level of suicide risk. The mnemonic ‘IS PATH WARM’ (see Table 24) may be useful in assisting
AOD workers remember these signs [343], with each letter corresponding to a specific warning sign
experienced or reported in the last few months [344].
S Substance use Has the client’s AOD use changed (i.e., frequency, severity)?
Has he/she recently relapsed?
P Purposelessness Does the client express a lack of purpose in life, or reason for
living?
T Trapped Does the client feel trapped in a terrible situation from which
there is no escape?
H Hopelessness Does the client have a negative sense of self, others, and the
future, with little chance of positive change?
A Anxiety Does the client feel anxious, agitated, unable to relax, and/or
report disturbances in sleep?
Direct warning signs indicate a need for immediate assessment and intervention, and although the
presence of indirect warning signs may not indicate acute suicide risk, there is the need for follow-up
questions to determine whether suicidality is indicated. This requires a degree of judgement and skill by
the AOD worker. Careful elicitation of suicidal ideation does not increase the risk of suicide [338, 339]. When
in doubt, it is critically important that workers ask clients directly.
As mentioned previously, it is critical that suicide risk assessment be an ongoing process and not a one-
off event. Clients’ suicidality may change throughout treatment to reflect the changes in his/her AOD use,
mental health, or personal circumstances, and there is a need for AOD workers to monitor and assess for
any such changes. Whenever suicide risk is at all suspected, it is essential that AOD workers enquire as
to the presence of suicidal thoughts and/or feelings. Regular assessment of suicidality and a therapeutic
relationship in which a client feels they can talk openly will help clinicians gather the best possible estimate
of suicide risk [345].
• It can be unhelpful, or even escalate behaviour, if chronically suicidal clients are hospitalised or closely
observed in attempts to prevent suicide.
• As quality of life improves, intensity of suicidality may lessen. As such, counselling should focus on
factors that may improve quality of life.
• People who are at immediate, acute high-risk of suicide are likely to need interventions to ensure their
immediate safety (e.g., short-term hospitalisation).
Strategies that might assist workers to determine whether the risk of suicide in a person with chronic
suicidality might escalate to becoming acute include [345]:
Figure 12 provides a guide to help estimate the level of risk in chronically at-risk clients. Changes to levels
of risk are indicated by changes in the pattern of risk behaviour (i.e., frequency, type, or severity).
High lethality
of method of
High chronic self-harm Acute high-risk
Low-lethality
New
Chronic method of
emerging
low-risk self-harm
risk
• If a client is at chronic low-risk (the bottom left-hand quadrant of Figure 12), they are at relatively low-
risk of suicide and workers should focus on factors associated with improving quality of life.
• If a client at chronic low-risk begins to use more lethal methods of self-harm over a longer term,
they become at chronic high-risk of suicide (top right-hand quadrant of Figure 12). Hospitalisation at
this point will probably not be appropriate, because the chronic high-risk will likely continue beyond
the conclusion of hospital admission. Rather, clinicians should focus on improving quality of life and
assisting clients to manage issues that are driving their suicidality.
• If a client who has been chronic low-risk begins to demonstrate new symptoms or behaviours (bottom
right-hand quadrant of Figure 12), they should be closely assessed, additional risk factors should be
assessed, and clinicians should focus on improving quality of life. Hospitalisation is not appropriate
unless new behaviours suggest immediate risk of suicide.
• If a client at high chronic risk of suicide begins to demonstrate new symptoms (behavioural or mental
health issues that indicate immediate risk of suicide; top right-hand quadrant of Figure 12), the person’s
immediate safety should be ensured. A brief period of inpatient admission may be indicated, followed
by counselling on discharge focused on improvement of quality of life and monitoring suicidality.
The high prevalence of AOD clients who have experienced domestic and family violence highlights the
need for AOD workers to conduct thorough and effective assessments, and respond to the problem. Key
factors that have implications for AOD workers are illustrated in Table 25.
Table 25: Key issues in domestic and family violence and implications for AOD workers
Key factor Significance Implication for AOD workers
AOD use Among women in AOD treatment, the Attempt to identify power and control
relationship between AOD use and strategies employed by those using
family violence is thought to be bi- violence, whilst supporting and
directional (i.e., AOD use can increase preserving the abused person’s safety
the risk of violence and vice versa) [352, [354].
353].
Gender In general, women and children are Family violence also occurs in
victimised more than men, and men non-spousal, same-sex, and carer
are more likely than women to use relationships, and can involve children.
violence in relationships. Women are Risk assessment is warranted for all
also more likely than men to be injured clients, which should include exposure
through family violence, and therefore to, and use of, violence in relationships
express fear [351, 355, 356]. [350].
Comorbidity Not all families with AOD and mental Responding to AOD and mental
health conditions have family violence, health conditions needs to be broad,
but families with AOD and mental comprehensive, and involve multiple
health conditions and family violence services in a cohesive, coordinated
are at increased risk of experiencing response (see Chapter B4).
other problems, such as psychiatric
comorbidity, physical health problems,
housing and/or employment problems,
socioeconomic disadvantage, and
social isolation [350].
AOD workers should also have an understanding of the dynamics and complexities involved in domestic
and family violence, and the reasons why many people remain in violent relationships. These include [357]:
• Fear, arising from the violent person’s threats or behaviour, that the person subjected to violence will
face further violence, increased danger, or loss of life.
• Fear of stalking or abduction.
• Isolation or rejection from family, friends, and community.
• Loss of home, income, pets and possessions, or having a reduced standard of living.
• Negative impacts on children such as loss of school, friends, community, relationship with parent or
family.
The strategies listed in Table 26 may be helpful for AOD workers managing clients experiencing domestic
or family violence. AOD workers should be familiar with their organisational policies and procedures relating
to domestic and family violence, with access to supervision if needed, and knowledge of appropriate
referral and clinical pathways. Further information on domestic and family violence and child protection
guidelines specific to each Australian jurisdiction can be found via state and territory websites.
Table 26: Dos and don’ts of managing a client experiencing domestic and family
violence
Do:
Don’t:
2 Undermine the client by making them feel inadequate for not seeking help earlier. Remember he/
she may have sought help earlier, or may not have been able to.
2 Patronise or speak down to the client.
2 Give your own opinion, be judgmental, or decide who in the relationship is to blame.
2 Rush the client, or tell them what they should do.
2 Give up or become frustrated if things are taking longer than you think they should. It may be
frustrating seeing the client hurt or subjected to violence, but their actions and choices are their
decision. They must not sense your frustration.
2 Act as a go-between, provide details to his/her partner, pass on letters or messages, or facilitate
contact in any way. This is not only unethical, but places you both in danger.
B4
B4: Care
coordination
Key Points
• People with comorbid mental health and AOD use disorders often
present to treatment with various issues that need to be addressed
during the course of treatment (e.g., physical health, housing,
employment, education and training, legal issues, and family
situations).
• Evidence has linked coordinated care with improved treatment
outcomes. Specifically, the coordination of health responses into
a cohesive approach has been found to prolong client retention,
increase treatment satisfaction, improve quality of life, and
increase the use of community-based services.
• Although coordinated care may be facilitated by a coordinator
or case manager, they are not expected to provide all of the
necessary services themselves, but rather refer to, and manage the
engagement of, appropriate services.
• The principles of coordinated care can be adopted into referrals
and discharge practices, with an emphasis placed on the
importance of communication, consultation, and interagency
support.
• AOD services and AOD workers should develop links with a range
of local services and engage them in clients’ treatment where
appropriate.
• Discharge planning in close consultation with the client is integral
to the treatment process.
Engaging with other services is best thought of as a consultative process. GPs are of particular importance
as, in many cases, they have a prior relationship with the client and they are often the client’s only
consistent form of contact with the health care system. Most importantly, consultation with other services
should be based on the most essential and desired needs of the client. Although some clients may benefit
from treatment by mental health professionals, they may not be ready for such treatment and it should not
be forced at the risk of alienating them (unless they pose a risk to themselves or others). MI (discussed in
Appendix E) can help clients gain willingness to receive treatment but others may not be ready even after
such attempts are made. Each client is different and will manage his/her situation differently – the key is to
support and guide clients and facilitate treatment and access to services as required. Figure 13 illustrates
some of the services that may need to be incorporated into a coordinated approach to clinical care.
Figure 13: Services that AOD workers may need to engage in client care
Psychologist
General
practitioner Psychiatrist
AOD
Employment treatment Translation/
culture
services specific
agency
Medical Social
services services
Criminal Housing
justice services
Evidence suggests that clients place a high degree of importance on interagency cooperation in terms
of coordinated care and case management, with higher levels of service integration associated with
clients reporting that their needs have been better met [360]. Clients have described the optimal service
as one that delivers a coordinated, holistic approach, where staff are aware of the needs of clients and are
proactive in following them up, and work with other services to deliver seamless care [360]. Conversely,
a lack of coordinated care and service integration can have a negative impact on clients. Distress may
arise from the need for clients to continuously retell upsetting stories or rehash details to multiple service
providers. Confusion may also result from having a number of different health care workers involved in the
care of one person without coordination [360].
Despite the need for integrated service approaches to respond to complex problems, the practical
implementation may not be so straight-forward. The primary challenge may lie in structural barriers, service
silos, and older models of mental health support, which prevent the effective provision of holistic care
[361]. In turn, many people with mental health conditions experience a lack of coordinated care, or service
integration, and consequently fall ‘between the gaps’ [98].
Although coordinated care is facilitated by an identified coordinator or case manager, they are not
expected to provide all of the necessary services themselves, but rather refer to, and manage the
engagement of, appropriate services. The challenge for a holistic health care approach to comorbidity is
in the active engagement of multiple services and service providers, with a mixture of professional and
non-professional support [362]. AOD workers in particular, are in primary positions to coordinate care,
and incorporate the many services that reflect the particular needs of clients, to deliver the best quality
mental health services. Box 12 illustrates the continuation of case study K, following Sarah’s story as one
community mental health nurse attempts to coordinate her physical and mental health care.
Assessment:
Comprehensive
assessment of the
client’s needs
Client-centred:
Delivery: The right
Interdisciplinary
services to the right
approach to responsive
person at the right
integrated health care
time
and social support
Coordination:
Information exchange Development:
between care Comprehensive care
providers, including plan
familiy and friends
Adapted from McDonald et al. [363], Ehrlich et al. [364], Brown et al. [365], NSW Mental Health Coordinating Council
[366].
Box 12: Case study K: Managing comorbid physical, mental, and AOD use disorders:
Sarah’s story continued
Over the course of the next few months, Sarah’s community mental health nurse attempted to
coordinate the care between Sarah and her GP, ensuring Sarah remained in contact with her GP and
attended follow-up appointments. The nurse also encouraged Sarah to attend an exercise class at her
local fitness centre, and the GP made a referral to a dietician, who provided Sarah with nutritional advice
and developed a healthy eating plan. The GP worked out a smoking cessation program for Sarah, part of
which involved NRT.
The physical health assessments revealed the presence of a long-term sexually transmitted infection,
for which Sarah was treated. She told the nurse that during periods of AOD use, or in periods when her
mood was ‘high’, she’d had unprotected sex, and felt guilty and ashamed by her sexual activity. Although
Sarah’s physical health needs were being addressed, she and the nurse developed a long-term plan for
following up appointments and repeating various physical health assessments (e.g., weight and blood
pressure) at regular intervals. The nurse copied Sarah’s notes to the other agencies involved in her care.
One central continuing need was for Sarah to have assertive support and follow-up (including her notes
being passed on in the case of another move), and the acknowledgement that without this support,
there was the possibility for Sarah to ‘drift on’, and stop attending appointments. Sarah’s nurse reminded
her of her health care appointments via text message.
Key points:
• There is a need for AOD workers to place more emphasis on physical health as a priority (bearing in
mind the years of life lost in this population).
• Once the health needs of clients are recognised, holistic health care interventions such as physical
activity, smoking cessation, healthy eating, and healthy sleep patterns can follow. The importance of
compliance with physical health medications (e.g., blood pressure and diabetes medications) should
also be emphasised.
• Many clients may require more assertive follow-up, including long-term practical support (e.g.,
phone or text reminders, or someone to accompany the client to appointments).
• Communication between AOD workers, mental health services, and GPs is essential.
With coordinated approaches requiring the involvement of services and service providers in working
partnerships, there is the potential for a lack of clarity regarding roles and responsibilities of different
stakeholders [367], making communication between services even more important. Further, the nature of
competitive tendering arrangements between services to determine government funding, and focus on
occupied bed days, creates tension and competition between agencies who must work together to provide
collaborative health care [362]. For some services, this working environment may foster creativity; others
may find their collaborative efforts stifled, and the associated difficulties overwhelming [362].
An additional barrier that may prevent effective collaboration between services is the lack of an existing
model to follow. Some common principles that can be incorporated into care coordination include [368]:
Referrals
Some circumstances may necessitate the consideration of referring a client to other clinicians or services.
This may be to obtain additional services, or because the clinician feels that the client requires responses
that are beyond their own level of skills and expertise [276]. As mentioned in Chapter A3, it is vital that AOD
workers can appreciate their level of expertise and training but also have the ability to recognise their own
limits and work within their own capacity. Referring a client to a more suitable clinician is an ethical practice
that ensures appropriate treatment needs will be met, and requesting supervisor support can be useful in
this process [276].
Where possible, however, clients should be retained in AOD treatment whilst accessing other services,
rather than excluded from AOD services and referred to others. For example, a client entering residential
rehabilitation who has been identified as having a bipolar disorder may be retained in AOD treatment, but it
may be useful to obtain a short appointment with a psychiatrist who can undertake an assessment, provide
a diagnosis, and prescribe medications; the client’s condition can then be managed while he/she is in the
residential service. Increasingly, a number of employment, welfare, and medical services are providing
consultation times within AOD services to facilitate client access to these services.
In some cases, however, it may be necessary to refer clients to external services. For example, in cases of
acute psychosis and suicidality, it may be necessary to contact the local mental health crisis assessment
and treatment service to come and assess the client for admission to appropriate mental health services.
AOD workers should be aware that in instances where the client needs to leave the AOD treatment setting
to have more immediate needs met prior to addressing their AOD use (e.g., acute mental health or medical
issues), their relationship with the client should not cease. The client will still require AOD treatment after
these issues have been addressed and it is important to follow-up with the client and referral agency
regarding the provision of this treatment.
One of the biggest risks in the referral of clients to external services is the potential for clients to ‘fall through
the gaps’ and disappear from treatment altogether. People with comorbid conditions in particular often
have difficulty navigating their way through the available services. The act of trying to navigate the health
care system has been likened to a roundabout with many points of entry and many options regarding the
direction to be taken [80]. Therefore, it is crucial that the referral process focuses on linking the client with
services as smoothly as possible. This may be assisted by the development of formal links between services
regarding consultation, referral pathways, and collaboration, such as a memorandum of understanding.
Where referral is non-urgent (e.g., they do not require urgent medical or psychiatric attention), the referral
process may be passive, facilitated, or active (see Table 27). In the case of clients with comorbid conditions,
active referral is recommended over passive or facilitated referral. When referring a client to an outside
service, it is crucial that AOD workers consult with the referral agency to determine whether the client kept
the appointment, whether assistance was provided and what progress was made. This process of assertive
follow-up is particularly crucial in cases where the referral is related to a high-risk situation (e.g., suicidal
intent).
Passive referral
Passive referral occurs when the client is given the details of the referral agency in order to make his/
her own appointment. This method is almost never suitable for clients with comorbidity.
Facilitated referral
Facilitated referral occurs when the client is helped to access the other service; for example, with the
client’s permission, the worker makes an appointment with the other service on his/her behalf.
Active referral
Active referral occurs when the worker telephones the other agency in the presence of the client and
an appointment is made. The worker, with the client’s consent, provides information that has been
collected about the client with his/her professional assessment of the client’s needs. Such referral
is necessary when clients are unmotivated, unlikely, or unable to do so themselves. This method of
referral is recommended for clients with comorbidity.
When consulting with or referring clients to other services, assessment reports are often requested
by those services. When writing an assessment report for an external party the following should be
considered [276]:
• Include only relevant and important information, including reasons for referral.
• Write in a clear, simple, and objective writing style.
• Include mental state examination report if necessary.
• Be concise.
• Always cite the source of the information. For example, ‘Andrew stated that…; his parents revealed that…’
• Consider all sources of information in your conclusions.
• Avoid jargon.
• Eliminate any ambiguous, biased, or judgemental wording.
• Mark all reports ‘STRICTLY CONFIDENTIAL’.
• Avoid faxing confidential information.
A pro forma which may be useful in the referral process is included in Appendix S.
ISBAR
Assessment I think the problem might be… The client is at risk of…
South Australia Health has developed an ISBAR toolkit to assist with the safe transfer and handover of client
information in handover and discharge. They recommend that ISBAR be adapted for use to fit within each
clinical practice, and is an opportunity for different health care teams to determine which client information is
always handed over and discussed as routine practice [374].
Some examples of how to modify ISBAR to your clinical practice include [374]:
• Identify: Include client’s medical record number if available, their full name and date of birth
• Situation: What was the reason for the client’s initial presentation? What is their diagnosis? Are they on
current pharmacotherapy? What other treatments have they had, and when?
• Background: Include relevant previous history (e.g., homeless, unemployed, living with abusive ex-partner).
• Assessment: When was their last clinical assessment/investigation? What do you think they may be at risk
for?
• Recommendation: Actions required after handover/discharge.
The NSW Ministry of Health have made ISBAR a mandatory component of referring patients to hospital
drug and alcohol clinical liaison services [375], and have developed an ISBAR app which is available for free
download on the iTunes and Android app stores.
Referral to other services should involve openness with the client regarding the reasons for referral. To
assist the client in attending a referral appointment, it can be useful to discuss issues such as:
Continue to provide support to the client until an appointment with the new clinician or agency has been
arranged [276].
Discharge planning
It is important to prepare clients ahead of time for the cessation of treatment. This is known as the process
of discharge planning, and is focused on equipping the client with the skills and contacts to continue the
positive progress of treatment and avoid relapse. It is important to involve clients in their discharge planning
and make them fully aware of their options [169]. It is useful to arrange or plan follow-up consultations to
monitor how well the client is maintaining the progress made during therapy; however, a client has the
right to refuse further follow-up; if this occurs, note the refusal in the client’s record and avoid judgemental
reactions [169].
Attempt to link the client with further treatment or support and provide emergency assistance numbers.
Communicate with relevant service providers where necessary as outlined above. As with all other steps
in the treatment process, the discharge plan should be documented in the client’s record. Research has
indicated that the increasing number of health workers involved in managing complex clients creates
challenges for maintaining effective communication between all involved [376]. The likelihood of an
adverse event is increased when clients are frequently handed over, transferred or discharged, making the
importance of effective communication and accurate case notes even more vital [377]. Challenges for busy
health care staff include [378]:
• Multitasking.
• Shift changes.
• Gaps in information transfer.
• Interruptions.
• Previous handover lacks detail or was inconsistent.
It is also important to consider such aspects as stability of accommodation and social support when
planning for discharge and, with the client’s consent, to involve family and carers as they will play an
important role in maintaining treatment outcomes [276, 379]. It is useful to discuss relapse prevention and
other strategies (e.g., problem solving, goal setting, and relaxation) with the client during discharge planning
and provide the client with skills to manage high-risk situations, lapses and symptoms of mental health
conditions that may occur. Chapter B5 provides useful information regarding relapse prevention, support
and self-help groups, and other management techniques that clients may benefit from. Appendices T and
U provide useful CBT and anxiety management strategies.
This chapter aims to provide AOD workers with an overview of models of care and approaches that are
commonly used in the treatment of both AOD and mental health disorders. In Chapter B6 we discuss the
evidence regarding the efficacy of these approaches in relation to the management and treatment of
specific comorbid mental disorders.
Models of care
Prior to discussing specific treatment options, mention needs to be made of the various models that have
been proposed to treat comorbid conditions. Four approaches have been suggested (see Table 28):
• Sequential treatment.
• Parallel treatment.
• Integrated treatment.
• Stepped care.
The idea of integrated treatment for two disorders has considerable intuitive appeal, and presents a
number of advantages over other treatment approaches. Integrated treatment by a single service helps
to ensure that there is a single point of contact (the client does not ‘fall through the gaps’), there are
common objectives, treatment is internally consistent, the relationship between AOD use and mental
health conditions may be explored, and communication problems between agencies do not interfere with
treatment [32].
While applying an integrated treatment approach to comorbidity is appealing, there has been very little
research undertaken comparing the different models [380]. Many studies examining the efficacy of
integrated treatments compare them with a ‘treatment as usual’ control group, so these designs cannot
establish the efficacy of integrated treatment relative to parallel or sequential treatment. However, there is
some emerging evidence to suggest that integrated treatments may be superior to parallel or sequential
treatments in terms of improving outcomes for mental health and substance use [381-384]. There is also
growing support for the use of a stepped care approach to treating comorbidity [385-387].
Table 28: Approaches to treating comorbid AOD and mental health conditions
Sequential treatment
The client is treated for one condition first which is followed by treatment for the other condition. With
this model, the AOD use is typically addressed first then the mental health problem, but in some cases
it may be whichever disorder is considered to be primary (i.e., which came first).
Parallel treatment
Both the client’s AOD use and mental health condition are treated simultaneously but the treatments
are provided independent of each other. Treatment for AOD use is provided by one treatment provider
or service, while the mental health condition is treated by another provider or service.
Integrated treatment
Both the client’s AOD use and mental health condition are treated simultaneously by the same
treatment provider or service. This approach allows for the exploration of the relationship between the
person’s AOD use and his/her mental health condition.
Stepped care
Stepped care means the flexible matching of treatment intensity with case severity. The least intensive
and expensive treatment is initially used and a more intensive or different form of treatment is offered
only when the less intensive form has been insufficient.
AOD workers are likely familiar with traditional psychological and pharmacological approaches to the
treatment of comorbidity. Other approaches include self-help groups, e-health interventions, physical
activity, and complementary and alternative therapies. It is essential to consider the whole person and
accept that one approach is not necessarily going to work for all clients. Different clients present with
unique biological, psychological, and sociodemographic backgrounds and it is important to take these
factors into consideration when deciding on an approach, or combination of approaches, with the client.
Psychological approaches
There are a number of psychological treatment approaches that are commonly used in the treatment of
many mental health disorders [94]. These approaches include:
Many AOD workers would be familiar with these approaches as they are also used in the treatment of AOD
use disorders. In some cases, it may be necessary for a substantial reduction in AOD use and withdrawal
symptoms to occur before more intensive psychotherapies can be effective. Some clients may be
more able to respond to cognitive interventions if they are taking pharmacotherapies for their AOD use
which free them from distracting cravings and physiological withdrawal symptoms (e.g., acamprosate or
naltrexone for alcohol use disorders).
MI for AOD use disorders involves a non-judgemental collaborative discussion, which explores specific
medical, social, interpersonal, or psychiatric effects that AOD use has had on the client’s life. Just as
clients may be resistant to the idea of changing their AOD use, they may also be resistant to the notion of
addressing their comorbid mental health disorder (see Chapter B2 for a discussion of readiness to change).
MI may be used to increase the client’s motivation in this regard [388].
CBT emphasises the important role of thinking in how we feel and how we behave. There is considerable
evidence supporting the use of CBT for the treatment of depressive, anxiety, and AOD use disorders
[263, 390-392]. Appendix T describes a number of CBT techniques that may be used in the management
and treatment of AOD use and mental health conditions, including cognitive restructuring, pleasure and
mastery events scheduling, goal setting, and problem solving. A more detailed discussion of CBT may
also be found in Baker and colleagues [393] and Graham [394]. A number of the interventions designed for
specific comorbid disorders, such as Seeking Safety (for PTSD and substance use [395]) and Dual Focus
Schema Therapy (for personality disorders and AOD use [396]), are in part based on these CBT techniques.
Interventions for specific comorbidities are discussed in more detail in Chapter B6.
DBT combines behaviour-change strategies from CBT and acceptance strategies from Zen philosophy
into an approach that focuses on client validation and behavioural change [397]. Originally developed for
the treatment of adults with BPD who were also chronically suicidal, DBT has become the ‘gold standard’
evidence-based treatment for both BPD and suicidality [398]. Strategies to address changes in behaviour
consist of behavioural analyses, skills training, contingency management, cognitive restructuring, and
exposure-based strategies to reduce avoidance. Acceptance strategies include mindfulness and validation.
DBT has been found to be efficacious in treating personality disorders (including those comorbid with
AOD use) [399], and there is emerging research supporting its use for ED that are comorbid with AOD use
disorders [400] (see Chapter B6).
Relapse prevention
Clients with both mental health conditions and AOD use disorders can potentially experience a relapse of
either condition, which is likely to worsen the symptoms of the other. Even after full remission, clients with
co-occurring conditions are vulnerable to relapse due to various risk factors, including exacerbation of
mental health symptoms, a lack of social support, social pressures within neighbourhoods or AOD-using
networks, a lack of meaningful activity, or a lack of treatments for co-occurring mental health and AOD use
disorders [401].
Relapse prevention strategies that are already used in AOD treatment can also be used to reduce risk of
relapse of the mental health condition. Some simple strategies that can be useful in helping a client reduce
the risk of relapse include [299, 401-403]:
• Discuss and normalise the issue of relapse in therapy – this helps the client prepare and self-monitor.
• Enhance the client’s commitment to change – regularly review costs of use and benefits of change in
order to strengthen commitment.
• Explain that lapses are a temporary setback and that they do not need to lead to relapse. Feelings
of shame, failure, and guilt are likely to follow single lapses in AOD conditions, which is likely to be
detrimental to mental health. This presents the risk of complete relapse. To avoid this, it can be useful
to normalise lapses and explore the events that lead to a lapse, and how this could be avoided.
• Encourage the client to practise and use any of the strategies he/she has learnt about managing his/
her mental health condition.
Mindfulness training
Clients with AOD use disorders often have thoughts about using or cravings to use. These thoughts are
often automatic and tend to escalate when the client becomes aware of them. Similarly, clients who
experience depression or anxiety may find that these negative or anxiety-provoking thoughts automatically
occur and give rise to further negative or anxiety-provoking thoughts. For clients with comorbidity, this
automatic thinking may result in a cycle of negative thoughts and cravings to use.
Mindfulness is a meditative technique that encourages the person to pay attention in the present moment,
without judgement, rather than allowing the mind to wander automatically (often to negative thinking) [404,
405]. Regular practice of mindfulness allows an individual to develop the capacity to interrupt automatic
thought patterns, and be accepting, open, and curious of that experience [406]. Although mindfulness can
be a useful practice for everyone, it can be particularly helpful for people with comorbid AOD and mental
health disorders by assisting with the development of greater awareness of automatic thinking patterns
which can often maintain the mental-health-AOD-use cycle [98]. There is evidence of the efficacy of
mindfulness in the treatment of mental health disorders [407, 408], and in assisting with relapse prevention
in AOD use [409].
In general, mindfulness practices involve deliberately focusing on the physical sensations associated with
routine activities that are carried out automatically (e.g., walking, eating, and breathing). Mindfulness-based
stress reduction and mindfulness-based cognitive therapy are two specific group therapies based on
mindfulness techniques [410]. For a more detailed discussion of mindfulness, readers are referred to Segal
and colleagues [404].
Contingency management
Contingency management for people with AOD use disorders involves rewarding or reinforcing desired
behaviour in the client in a supportive manner [411]. Examples are vouchers for negative urine samples, for
treatment attendance, or for medication compliance. There is evidence that contingency management
techniques can be used successfully to treat problematic AOD use [412-417]. Studies have also found
contingency management to be effective in promoting cocaine and opiate abstinence amongst
buprenorphine-maintained clients with comorbid major depression [418], in promoting abstinence in
a cocaine-abusing, comorbid homeless group [419], and in reducing substance use and psychiatric
symptoms in stimulant users with serious mental illness [420].
Psychosocial groups within the AOD treatment setting are also much appreciated by clients with comorbid
conditions [421]. Evidence suggests that clients who attend groups consistently and for a longer time
period achieve the best results (e.g., for a year), although positive outcomes can nonetheless be achieved
by attending shorter-term groups [422]. It is important that such groups are facilitated in such a way as to
avoid confrontation. Sustained emotional distress can worsen a number of mental health conditions and a
confrontational treatment approach may be harmful to clients with comorbidity [54]. It is important to assess
Pharmacological approaches
The use of pharmacotherapies is common practice in the treatment of both AOD use and mental health
disorders. It is recommended, however, that when pharmacotherapy is used, this should be accompanied
by supportive psychosocial interventions [423, 424]. Symptoms are less likely to return on completion of
psychological treatment compared to pharmacotherapy, where relapse upon cessation is common [425].
Pharmacotherapies are beneficial, however, in helping people to manage symptoms and obtain maximum
benefit from psychotherapeutic interventions.
The introduction of pharmacotherapies must be carried out in consultation with a medical practitioner,
preferably a psychiatrist. Initial intake should establish past medication history as well as any current
medications (see Chapter B2). When prescribing medications, the following should be taken into account:
If clients are placed on medication, it is important that they understand the reason for the medication being
prescribed, and the likely benefits and risks as well as its interactions with AOD. Clients should also be
made aware of the possibility of delayed responses to the medication, potential side effects, as well as the
possibility of trying other medications if the one prescribed does not suit them.
Medication adherence
Many clients who have been identified as having a comorbid mental health disorder will have been
prescribed medication for that disorder (such as antidepressants, mood stabilisers, anti-anxiety agents,
and antipsychotics). Medications can be extremely helpful in managing mental health symptoms; however,
some people experience unpleasant and distressing side effects from these medications which may lead
to reduced compliance. Indeed, some people with a mental health disorder choose to live with some
symptoms of the disorder rather than take medication [426].
It is important for clients to be aware that in most instances there is a choice of medication but it may
take time to establish which medication is best suited to his/her needs. Finding the best fit is particularly
important for individuals with severe mental disorders such as psychotic, bipolar, and severe depressive
disorders, as psychosocial interventions alone can prove ineffective.
When medications have been prescribed, it is important to assist the client to adhere to medication
scheduling. In other illnesses such as diabetes and hypertension, medication compliance is recognised as
an important issue in regaining good health and it is addressed proactively by the use of simple techniques
to remind the client when he/she needs to take medication.
MI, contingency management and cognitive behavioural techniques have been shown to be particularly
useful in improving medication compliance [427]. The SIMPLE model [428] is a useful tool for remembering
different evidence-based interventions that can enhance medication adherence:
S Match regime to client’s daily activities (e.g., meal times). Use adherence aids
(e.g., pill boxes, alarms).
Imparting knowledge. Clearly discuss the medication with the client using
P treatment. Send reminders via mail, e-mail, or telephone. Actively listen to the
client and avoid interrupting them. Involve family or social networks where
appropriate.
Leaving the bias. Studies have found small or no relationships between
Medication interactions
It is important for AOD workers to be aware of the complex and dynamic relationship between AOD use,
mental health disorders, and prescribed psychiatric medication. During the assessment phase, workers
should explore the influence of medication on AOD use and vice versa, as well as the influence of AOD
use on mental health symptoms. This clarification will contribute to a comprehensive management and
treatment plan, with appropriate goals [276].
AOD workers should also be aware of the potential interactions between AOD use and prescribed
medications. Table 29 provides some of the interactions between AOD and prescription medication, but this
list is not exhaustive. AOD workers should also note that polydrug use is common among AOD clients, and
it may be difficult to clarify potential drug interactions [429]. Similarly, many drugs are composed of many
substances (e.g., amphetamines), which makes the potential for interaction difficult to assess [277].
Although Table 29 does not provide a comprehensive list of potential AOD and medication interactions,
AOD workers need to be aware of the ways in which AOD use and prescribed medication can affect
each other. For example, the selective serotonin reuptake inhibitors (SSRIs) fluoxetine and fluvoxamine
have been shown to affect the metabolism of methadone and buprenorphine, with the discontinuation
of fluvoxamine associated with opiate withdrawal [430]. In cases where this is unexpected, it is possible
that the client may engage in other AOD use (or decrease treatment compliance) to cope with withdrawal
symptoms, highlighting the need for worker awareness of the potential for such interactions. Similarly,
central nervous system depressants not only increase the potential for overdose and respiratory
depression when taken with each other (e.g., benzodiazepines, alcohol, opiates), but also increase the risk
of overdose when taken with medication [429].
Stimulants
Stimulants (e.g., amphetamines, MAOIs Can lead to hypertension (high
tobacco, caffeine, cocaine, blood pressure) crisis.
ecstasy)
Stimulants Antidepressants Effects can be inhibited.
Ecstasy Antidepressants Linked to high levels of serotonin,
associated with hallucinations,
mania, hypertension, nausea,
muscle rigidity, tremor (serotonin
syndrome).
Cannabinoids
Cannabinoids Antipsychotics Increases intensity and frequency
of psychosis.
Cannabis TCAs Increases the sedative effects.
Benzodiazepines
Cannabis Newer (atypical) Can cause symptoms of mania,
antidepressants confusion, and psychosis.
TCAs = tricyclic antidepressants; MAOIs = monoamine oxidase inhibitors; SSRIs = selective serotonin
reuptake inhibitors. Adapted from NSW Department of Health [277].
As such, when managing and treating clients with comorbid AOD and mental health conditions, AOD
workers need to take into account the level and type of AOD used (especially alcohol), as these may [431]:
As mentioned with regard to psychosocial groups, it is important to assess whether the client experiences
social anxiety or impairments in social judgement and social skills, as they may appear and feel awkward
in group settings [422]. It should be noted that some groups, particularly those that adopt a 12-step
philosophy, may be disapproving of the use of any medication; yet clients with comorbid mental health
disorders are often prescribed medication to help treat their mental health condition [432]. Some clients
with comorbidity, particularly those who experience religious delusions, may also have difficulty with the
strong spiritual focus of many self-help groups [422]. As with other psychosocial groups, there is evidence
that longer attendance at self-help groups has a positive impact on outcome, as does social support, with
clients who have higher levels of social support achieving better outcomes [435].
E-health interventions
E-health is the provision of health services and/or information via the Internet or associated technologies
[98]. Since its relatively recent appearance, it has been referred to as one of the most important
revolutionary additions to modern healthcare [436]. E-health interventions provide the opportunity to
overcome traditional barriers to treatment that often prevent people seeking help, including social or
cultural prejudices, stigma, difficulties accessing services, finding appropriate available services, as well
as financial and geographical barriers [437-439]. E-health interventions have the capacity to overcome
difficulties associated with face-to-face treatment, including gender differences [440], the inclusion of
more marginalised socioeconomic and cultural groups [441], and reducing the costs and increasing the
standardisation of traditional treatments [438, 442].
Advances in technology over the past decade have enabled e-health interventions to include strategies
such as self-monitoring and assessment, psychoeducation, goal setting, skill building, and feedback
through the use of telephone and videoconferencing, mobile phones, sensors, social media, virtual
reality, and gaming [443]. E-health interventions can also be used to supplement psychotherapy, or as
an alternative for people who do not want, or are not suitable for pharmacotherapy [444]. Therapy can be
conducted at home, and has 24-hour availability. Research has demonstrated that e-health interventions
allow for the delivery of clinically effective, cost effective treatment, based on gold standard programs,
which are highly engaging [445-449]. A number of e-health interventions have been developed for AOD and
specific mental health disorders. These are described in Chapter B6.
Physical activity
As discussed in Chapter B1, people with AOD use disorders are at increased risk of physical health
problems, such as cardiovascular, respiratory, metabolic, and neurological diseases [450, 451], which have
all been associated with unhealthy lifestyles (e.g., smoking, obesity, lack of exercise, poor diet) [452]. As
such, treatment interventions that are either based on nutrition, or exercise, or include these as adjunctive
interventions, are promising approaches for addressing physical comorbidities [453]. Research has found
that people with psychiatric conditions who engaged in regular exercise, report better health-related
quality of life [454].
General population studies have also found significant relationships between mental health and physical
activity, with regular exercise significantly associated with decreased prevalence of major depression,
Although the mechanisms of action are not entirely clear, research findings indicate that exercise induces
changes in neurotransmitters (e.g., serotonin and endorphins) [458, 459] which relate to mood, and can
improve reactions to stress [460, 461]. Exercise has also been associated with several psychological
benefits, including changes to body and health attitudes and behaviours, social reinforcement, distraction,
and improved coping and control strategies [213, 462]. A number of physical health interventions for AOD
and specific mental health disorders are described in Chapter B6.
B6
Goes here
specific
disorders
Ipsandi te nus, omnime corat verum
nam vitecup tatem. Nam quaero ea
ipsam quidem aut audandelique apisit
eosapid itaturi tatendi tasperrum que
est laborum rest, esecte nis rem sit
aspe quas experit re et ulpa.
B6: Managing
and treating
specific disorders
Key Points
• Symptoms of comorbid mental health conditions can be managed
and controlled while the client undergoes AOD treatment.
• Good treatment requires a good therapeutic alliance.
• Motivational enhancement, simple CBT-based strategies, relaxation
and grounding techniques can be useful in managing AOD use as
well as mental health conditions.
• Some interventions have been designed for the treatment of
specific comorbidities; however, these interventions have generally
not been well researched.
• Where there is an absence of research on specific comorbid
disorders, it is generally recommended that best practice is to use
the most effective treatments for each disorder. In some cases
this can be carried out at the same time for both disorders, but in
others it must be carefully calibrated.
• Both psychological and pharmacological interventions have been
found to have some benefit in the treatment of many comorbidities.
• When pharmacotherapy is used, this should be accompanied by
supportive psychological interventions, and workers should be
aware of the potential of interactions between medications, and
other substances.
• E-health interventions, physical activity, as well as complementary
and alternative therapies may also be considered in developing a
person’s treatment plan.
AOD workers have widely varying roles, knowledge and experience; therefore, it is not expected that
all AOD workers should be able to implement the treatments described. We do not provide detailed
information relating to the implementation of these treatment options, but rather an overview of the
available options. Where appropriate, readers are referred to existing literature and resources for more
detail about the use of particular interventions. This information may nonetheless be used by all AOD
workers to improve their understanding of best practice, and it may encourage workers to consider further
training to improve their skills in these approaches.
It should also be remembered that the provision of treatment for AOD use alone has positive effects for
those with comorbid mental health disorders [66, 92-95, 105]. As discussed previously, it is important to
note that, for many people, symptoms of depression and anxiety will subside after a period of abstinence
and stabilisation, without the need for any direct intervention [35, 290, 299]. However, if the mental health
symptoms started prior to the onset of AOD use, if symptoms persist even during periods of abstinence, or
if there is a family history of the particular disorder, the client may have a condition that is independent of
his/her AOD use, which may require treatment [263].
In terms of clients’ AOD use, the goal of abstinence is usually favoured, particularly for those whose mental
health conditions are exacerbated by AOD use. Abstinence is also preferred for those with more severe
mental disorders (or cognitive impairment) as even low-level substance use may be problematic for these
individuals [54]. Those taking medications for mental health conditions (e.g., antipsychotics, antidepressants,
mood stabilisers) may also find that they become intoxicated even with low levels of AOD use due to the
interaction between the drugs. Although abstinence is favoured, many people with comorbid conditions
prefer a goal of moderation. In order to successfully engage with the client, AOD workers should
accommodate a range of treatment goals and adopt a harm reduction approach [104].
It is fundamentally important to discern the client’s preferences regarding treatment for his/her mental
health. Just because the client has sought treatment for his/her AOD use does not necessarily mean that
he/she is ready to address his/her mental health condition. It is important that the client is not forced
to undergo treatment for his/her mental health if he/she is not ready to, as this may jeopardise the
therapeutic relationship. Ultimately, it is up to the client to decide whether he/she wants to address the
issue and how he/she would like to go about doing so.
The recommendations in this section are based on a combination of expert opinion and evidence from
research. People with AOD use disorders are commonly excluded from trials of psychotherapies and
pharmacotherapies for mental health disorders. Some interventions have been designed for the treatment
of specific comorbidities; however, these interventions generally have not been well researched. In the
absence of specific research on comorbid disorders, it is generally recommended that best practice is to
use the most effective treatments for each disorder. It should be noted that the research evidence is based
Psychological and pharmacological interventions have been found to have some benefit in the treatment
of many comorbid mental health disorders. As mentioned in Chapter B5, it is recommended that when
pharmacotherapy is used, this should be accompanied by supportive psychological interventions
[423, 424]. Symptoms are less likely to return on completion of psychological treatment compared to
pharmacotherapy, where relapse upon cessation is common [425]. Pharmacotherapies are beneficial,
however, in helping people to manage symptoms and obtain maximum benefit from psychotherapeutic
interventions.
Pharmacotherapies for mental health disorders can only be prescribed by a medical practitioner, preferably
a psychiatrist. However, it is important that AOD workers establish clients’ past medication history as well as
any current medications (see Chapter B2). AOD workers should also be aware of:
Difficulties can be faced when assessing and screening for the presence of comorbid ADHD, as symptoms
can be masked or even resemble symptoms of intoxication or withdrawal (see Chapter A4) [473-475]. Some
recommend an abstinence period of one month or more to assist with diagnosis [476, 477], but this is not
supported by the broader evidence base or the majority of experts [7, 471, 478, 479].
To assist with clinical decision making, it may be useful to involve family members or friends, who can
provide further information and clarification regarding the presence of attention problems, impulsivity, and
restlessness over the person’s lifetime [471, 480].
Clinical presentation
ADHD represents a persistent pattern of developmentally inappropriate levels of inattention, hyperactivity,
and/or impulsivity [24]. It has been estimated that approximately 60% of children will continue to
experience symptoms of ADHD as adults, whilst at least 30% will carry the full disorder through to
adulthood [481, 482]. Research indicates that attentional difficulties are more likely to persist into adulthood,
whilst impulsivity and hyperactivity tend to diminish over time [483, 484]. Adult symptoms are expressed
differently to the way in which they are expressed in childhood. These may include [485, 486]:
Difficulties with time management.
• Disorganisation.
• Procrastination.
• Lack of motivation.
• Difficulties sleeping.
• Irritability, frustration, or anger.
• Fatigue.
• Difficulties concentrating or studying (which may present as academic underachievement).
• Occupational or workplace difficulties.
• Problems forming and maintaining relationships.
• Difficulty obtaining and/or maintaining stable employment.
• History of imprisonment or frequent contact with police.
In addition, clients may present with other symptoms which are not unique to ADHD, but are common to
many mental disorders (e.g., problems sleeping, irritability, fatigue).
Do:
3 Assist the client plan activities and organise prompts or reminders (e.g., using a smartphone).
3 Encourage stress-reduction methods, such as progressive muscle relaxation.
3 Encourage physical exercise.
3 Monitor closely during times of stress – these may lead to fluctuations in symptoms and may
necessitate the adjustment of medication.
3 Involve family members and friends – educating them about the condition and treatment will
provide long-term benefits.
3 Offer to help the client engage with education courses or training, which can assist with attention
training.
Don’t:
2 Get visibly upset or angry with the client.
2 Confuse the client by conducting unstructured, unfocused sessions.
Treating ADHD
There are several treatment options available for the treatment of ADHD, including psychotherapy,
pharmacotherapy, e-health interventions, physical activity, as well as complementary and alternative
therapies (e.g., dietary supplements). The evidence base surrounding each of these treatments is discussed
below. There is a general consensus that the treatment of comorbid ADHD and AOD use should use an
integrated multimodal approach, with components of individual and/or group psychotherapy, as well as
peer and family support to enhance the effect of treatment [7, 489]. Reviews have found that combined
approaches incorporating both psychotherapy and pharmacotherapy interventions have better outcomes
than pharmacotherapy alone [477, 479].
Psychotherapy
To date only one integrated psychotherapeutic approach for comorbid ADHD and AOD has been evaluated
[500]. The intervention represents is an integration of the primary elements of the CBT programs for both
ADHD and AOD, and includes planning and organisational skills, MI, skills training, and relapse prevention
[501]. The results from this trial are yet to be published, but two case presentations with early alcohol and
ADHD outcomes from the study indicate that this may be a promising treatment [502].
There has been substantially more research conducted to examine the efficacy of pharmacological
interventions for comorbid ADHD and AOD use disorders, either as stand-alone treatments, or in
combination with psychological approaches [503]. Table 31 lists some of the pharmacological treatments
for ADHD.
In general, pharmacotherapy for ADHD has been found to be effective in AOD clients but the response
is more modest than those with single disorder ADHD [504]. In ADHD as a single disorder, the first line
of pharmacotherapy is psychostimulants; methylphenidate first line followed by dexamphetamine
if methylphenidate is ineffective [505]. Although psychostimulants are recommended as first line
pharmacotherapies for ADHD, it is essential that a medical assessment be conducted prior to prescribing
to ensure that the client does not have cardiovascular or other conditions that may contraindicate
psychostimulant prescription. Atomoxetine, a noradrenaline reuptake inhibitor, is recommended for
individuals who cannot take psychostimulants [7, 506, 507].
Adapted from Zalauf et al. [477] and Pérez de los Cobos et al. [479]. For a full list of generic brands available,
see the Therapeutic Goods Administration website (https://www.tga.gov.au/).
Although evidence supports the pharmacological treatment of those with comorbid ADHD and AOD use,
there has been contention about whether psychostimulants should be used among people with AOD use
disorder, due to their potential for misuse [508], leading some treatment guidelines to recommend that
non-stimulants be used as the first-line pharmacotherapy treatment for people with comorbid ADHD and
AOD use, despite limited evidence of their efficacy [505]. However, in view of the fact that non-stimulants
are less efficacious than stimulants in treating ADHD, and in the absence of evidence of any misuse of
long-acting stimulants in clinical trials, there is a need to balance the potential risk of misuse and diversion,
against the risk of untreated or inadequately treated ADHD [504].
Several RCTs have examined the safety and efficacy of psychostimulant treatment among people with
comorbid ADHD and AOD use disorders [509-513]. A systematic review examining psychological and
pharmacological interventions for people with comorbid ADHD and AOD use found that despite variation
between studies, the evidence largely supports the use of methylphenidate, with the majority of studies
finding significant reductions in ADHD symptoms following treatment [478]. AOD use either significantly
reduced or remained unchanged, with no studies finding any worsening of symptoms [478, 479]. Of note,
studies that reported AOD use reduction also included some form of psychotherapy as an adjunctive
therapy (e.g., relapse prevention, group or individual counselling, CBT), and no cases of medication misuse
or abuse were reported [477-479].
The use of atomoxetine, a non-stimulant medication for the treatment of comorbid ADHD and AOD use,
has been examined in several RCTs [477, 478]. While atomoxetine has demonstrated efficacy relative to
placebo for ADHD symptoms, studies report minimal effects for AOD outcomes [477, 478]. Notably, most
studies had also included different psychological interventions which were targeted towards reducing AOD
use.
E-health interventions
Emerging e-health programs have combined elements from successful CBT treatments for single
disorder ADHD into internet-based interventions. These interventions, aimed at assisting people with
ADHD structure and organise their lives, incorporate aids such as calendars, schedules, timers, reminders,
shopping lists, and cleaning and laundry schedules, all of which are easily accessible on smartphones [515].
Smartphone features such as text messages, cameras, GPS, and voice memos, may also be useful.
One RCT has evaluated an internet-based course teaching people with single disorder ADHD to use
smartphone applications to improve their everyday organisation skills [515]. The course, delivered with
therapist support, teaches participants how to effectively use their smartphone applications to better
organise their lives. Compared to wait-list control, participants randomised to receive the course illustrated
a significantly larger decrease in ADHD symptoms, including inattention and hyperactivity. One-third of
participants (33%) were deemed to have made a clinically significant improvement in organisation and
attention over the study period, as assessed by clinicians. Although this research has yet to be conducted
among people with comorbid ADHD and AOD use, the findings from this RCT are promising.
Physical activity
Although ADHD treatment is primarily focused on psychotherapy and pharmacotherapy, there is emerging
evidence to suggest that physical activity may have beneficial effects similar to those of psychostimulant
medications [516]. Research indicates that exercise interventions (frequent aerobic exercise in particular)
may assist with the management of ADHD symptoms, particularly intrusive thoughts, worry, and impulsivity
[517]. As such, exercise may be a useful adjunct to pharmacotherapy and psychotherapy for ADHD,
however, this has yet to be rigorously evaluated [517], and has not been examined in people with comorbid
ADHD and AOD use.
Dietary supplements
There has been very little research examining the use of dietary supplements for ADHD. However, two
meta-analyses have concluded that omega-3 supplementation is associated with modest ADHD symptom
improvement for single disorder ADHD in children and adolescents [518, 519]. These findings have yet to
be replicated among adults, and among people with comorbid ADHD and AOD use, but point to potential
avenues of future research.
Box 13: Case study A: Treating comorbid ADHD and AOD use: Ali’s story continued
Case study A: Treating comorbid ADHD and AOD use: Ali’s story
continued
Based on Ali’s symptoms, the AOD worker thought that it may be beneficial for Ali to see a psychiatrist
who specialised in adult ADHD. The AOD worker asked Ali whether he would be open to seeing a
psychiatrist who could assess him further and help him decide the best treatment plan. He told Ali
that he would be pleased to continue seeing him, and would be happy to liaise with both his GP and
the psychiatrist. Ali agreed and gave written consent for his AOD worker to contact his GP and the
psychiatrist and for the sharing of information between these services.
After sending this form to the GP and psychiatrist, the AOD worker stayed with Ali while he called
to make an appointment with both over the coming weeks. At the AOD worker’s suggestion, Ali put
these appointments in his phone calendar and also arranged a follow-up appointment following these
consultations. With Ali’s permission, the AOD worker also informed his family of the dates and times
of these appointments so that they could remind him and help him get to the appointments. Ali also
agreed to the AOD worker discussing his condition with his parents, as they would be able to provide
further information about his condition and help him in his ongoing treatment.
The psychiatrist who assessed Ali made a diagnosis of ADHD, noting that Ali had a range of symptoms
of inattention, hyperactivity and impulsivity. The psychiatrist told Ali that his earlier experiences with
speed and the way he described feeling calmer after a small amount of the drug was significant.
He explained that psychostimulants are one of the central treatments for ADHD, which are carefully
prescribed and monitored. Following a medical assessment conducted by Ali’s GP, the psychiatrist
prescribed psychostimulant medication, and advised Ali that it was very important for him to maintain
abstinence from the use of any other drugs, due to possible interaction effects. The AOD worker advised
Ali that he would be available for a phone call every day for the first week, to see how he was going.
Ali continued with his treatment. In addition to regular monitoring and minor adjustments to the dosage
of the ADHD medication, Ali attended individual sessions with his AOD worker, where he was provided
with a range of evidence-based interventions to help him with his speed and cannabis use. These
began with psychoeducation and information about the substances Ali had been using, focusing on the
way in which they affected his ADHD and how his ADHD symptoms impacted on his substance use. Ali
was also given coping strategies for occasions when he became tense and he began to practice and
enjoy the relaxation exercises he was taught.
One important component of the treatment plan was to help Ali organise activities in his daily life. The
AOD worker helped him organise a daily timetable, and, using different functions on Ali’s smartphone,
alarms for important events, reminders and appointments were set up. Ali’s parents helped Ali keep a
schedule and maintain his reminders and appointments in his phone.
Before his first presentation to the AOD service, Ali had never been able to maintain employment
for more than a few days, and had no meaningful educational qualifications because his school
performance was so poor. After several months, the AOD worker was able to help Ali find a place in a
community education course, and, because of the improvements in his concentration and attention, he
was able to obtain part-time work in a local newsagency. Ali and the AOD worker had also begun talking
about a plan for independent living.
Key points:
• Treatment for ADHD and AOD use should be concurrent and multimodal.
• Education about the nature of the condition for the client and the family is essential.
• The treatment of comorbid ADHD and AOD use requires long-term follow-up and more general
efforts at rehabilitation, including further education.
Psychosis
Heading
Goes here
Ipsandi te nus, omnime corat verum
nam vitecup tatem. Nam quaero ea
ipsam quidem aut audandelique apisit
eosapid itaturi tatendi tasperrum que
est laborum rest, esecte nis rem sit
aspe quas experit re et ulpa.
Psychosis
Clinical presentation
Acute psychosis represents one of the most severe and complex presentations, and one of the most
intrusive when attempting to treat AOD use [520]. During an acute episode of psychosis a person’s
behaviour is likely to be disruptive and/or peculiar. Psychotic symptoms include [521]:
• Delusions – false beliefs that usually involve a misinterpretation of perceptions or experiences (e.g.,
thinking that someone is out to get you, that you have special powers, or that passages from the
newspaper have special meaning for you).
• Hallucinations – false perceptions such as seeing, hearing, smelling, sensing, or tasting things that
others cannot.
• Disorganised speech – illogical, disconnected, or incoherent speech.
• Disorganised thought – difficulties in goal direction such that daily life is impaired.
• Catatonic behaviour – decrease in reactivity to environment (e.g., immobility, peculiar posturing,
motiveless resistance to all instructions, absence of speech, flattened affect).
• Rapid or extreme mood swings or behaviour that is unpredictable or erratic (often in response to
delusions or hallucinations; e.g., shouting in response to voices, whispering).
It is important to note that mood swings, agitation, and irritability without the presence of hallucinations or
delusions does not mean that the person is not psychotic. Workers should respond to these clients in the
usual way for such behaviour (described in this chapter), such as providing a calming environment so their
needs can be met [123].
Individuals in AOD settings commonly present with sub-acute psychosis, particularly as a result of
methamphetamine use. These clients may display a range of low-grade psychotic symptoms such as [123]:
It should also be remembered that there is much stigma and discrimination associated with both psychotic
spectrum disorders and AOD use, and some people may attempt to conceal either one or both of their
conditions. Many people with comorbid psychosis and AOD use are frightened of being imprisoned,
forcibly medicated or having their children removed. Take the time to engage the person, developing a
respectful, non-judgemental relationship with hope and optimism. Use a direct approach, but be flexible
and motivational [431].
Do:
Don’t:
2 Get visibly upset or angry with the client.
2 Confuse and increase the client’s level of stress by having too many workers attempting to
communicate with him/her.
2 Argue with the client’s unusual beliefs or agree with or support unusual beliefs – it is better to
simply say ‘I can see you are afraid, how can I help you?’
2 Use ‘no’ language, as it may provoke hostility and aggression. Statements like ‘I’m sorry, we’re not
allowed to do ____ but I can offer you other help, assessment, referral…’ may help to calm the client
whilst retaining communication.
2 Use overly clinical language without clear explanations.
2 Crowd the client or make any sudden movements.
2 Leave dangerous items around that could be used as a weapon or thrown.
Adapted from NSW Department of Health [277], Jenner et al. [123], and UK NICE Guidelines [431].
Some clients with psychotic disorders may present to treatment when stable on antipsychotic medication
and thus may not be displaying any active symptoms. These clients should be encouraged to take any
medication as prescribed, and ensure they receive an adequate diet, relaxation, and sleep because stress
can trigger some psychotic symptoms [522].
Despite the risk of further psychotic episodes, some people decide to keep using substances that may
induce psychosis. In such cases the following strategies may be helpful [123]:
Social stressors can be an added pressure for clients with psychotic conditions and the client may require
assistance with a range of other services including accommodation, finances, legal problems, child care,
or social support. With the client’s consent, it can be helpful to consult with the person’s family or carers,
and provide them with details of other services that can assist in these areas. Family members and carers
may also require reassurance, education, and support. See Chapter B4 for strategies on how to incorporate
other service providers in a coordinated response to clients’ care.
Psychotherapy
A recent Cochrane review of psychosocial treatments for co-occurring severe mental illness
(predominantly psychotic spectrum disorders) and AOD use concluded that there is no clear evidence
supporting the use of one treatment approach over another [523]. As noted by Lubman and colleagues
[524], however, it is difficult to draw any firm conclusions from the current evidence base due to issues with
study design (e.g., inconsistent or absent measures of key outcome variables, significant variation within
‘treatment as usual’ control groups). Integrated psychosocial treatments have shown some promise - in
particular, programs in which clients receive treatments addressing both disorders, in combination with
case management, vocational rehabilitation, family counselling and housing, as well as medications [525-
527].
The majority of studies examining the efficacy of psychological treatments for people with comorbid
psychotic spectrum disorders and AOD use have examined MI, either alone or in conjunction with another
therapy. Although study findings have been mixed, there is some support for MI in improving AOD use
and, when used in conjunction with CBT, improved mental state [523]. One study which added MI, CBT
and a family intervention to usual care for clients with schizophrenia comorbid with AOD use found
significant improvements in outcomes for both disorders over care as usual [528]. An Australian study which
used a 10-session intervention comprising both MI and CBT for this comorbid group also found modest
Barrowclough and colleagues [103] suggest that MI techniques may need to be adapted for clients with
psychotic disorders because disorganised thoughts and speech may make it difficult for AOD workers
to understand what the client is trying to say, and psychotic symptoms (combined with AOD use and
heavy medication regimes) may impair clients’ cognitive abilities. For this reason it is recommended that
therapists:
Several studies have examined the efficacy of CBT on symptoms of psychosis and AOD use [532, 533]; again
evidence regarding the efficacy of CBT in treating co-occurring psychotic disorders and AOD problems
is mixed. Naeem and colleagues [533] found that although CBT led to better outcomes for symptoms of
psychopathology, there were no differences between CBT and treatment as usual groups on AOD use
outcomes. Similarly, Edwards and colleagues [532] found no significant differences between the CBT and
psychoeducation groups for the key outcomes of cannabis use or psychopathology.
A small number of studies have examined contingency management as a means of treating clients
with comorbid psychotic spectrum disorders and AOD use. As discussed in Chapter B5, contingency
management involves the use of reinforcement to encourage particular behaviours (and discourage
undesired behaviours). In a systematic review of psychosocial interventions for people with comorbid
severe mental health (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, or severe depression)
and AOD use disorders, Drake and colleagues [534] found that the use of contingency management led to
improved outcomes for AOD use. These findings indicate that contingency management may be a useful
adjunct to other treatments for psychotic spectrum disorders and AOD use.
Reviews of the literature have also highlighted that residential, ‘dual diagnosis’ treatment programs may
lead to positive outcomes, particularly for people with severe psychosis and AOD use [524, 534]. Long-term
residential programs (at least one year) are more likely to be associated with positive outcomes than short-
term programs, in terms of increased abstinence from substances, and decreased risk of homelessness
[535].
Pharmacotherapy
Despite the high rates of comorbid AOD use among people with psychosis, most trials of pharmacotherapy
for psychotic spectrum disorders have excluded individuals with AOD use disorders [524]. The UK NICE
Guidelines for comorbid psychosis and AOD use recommend the use of antipsychotics, in line with the
UK NICE Guidelines on schizophrenia [536] or bipolar disorder [537], due to the lack of evidence of any
differential benefit for one antipsychotic over another for people with this comorbidity. Table 33 lists the
names of some of the more common antipsychotics.
It has been theorised that the increased AOD use found amongst those with psychotic disorders relates
to dopamine dysfunction which is better addressed by the newer (atypical) antipsychotic agents than the
There are several reasons why pharmacological interventions for the comorbid AOD use disorder may
prove more effective for this group than psychosocial treatments. Problems associated with negative
symptoms such as amotivation and cognitive impairment may restrict involvement and outcomes in
psychosocial interventions. On the other hand, greater tolerance of medication regimes may render clients
with this comorbidity more amenable to pharmacotherapy for AOD use. Caution should be taken when
selecting pharmacotherapies for AOD use and some are contraindicated in individuals with psychotic
disorders as they may exacerbate symptoms (e.g., disulfiram).
Lithium Lithicarb
Asenapine Saphris
Trifluoperazine Stelazine
hydrochloride
Adapted from the Australian Government Department of Health [541]. For a full list of generic brands
available, see the Therapeutic Goods Administration website (https://www.tga.gov.au/).
E-health interventions
Although research pertaining to the use of e-health interventions for psychosis is in the early stages,
findings to date are promising. A review of internet and mobile-based interventions for psychosis
concluded that they appear to be acceptable and feasible, and have the potential to improve clinical
and social outcomes [542]. Specifically, the interventions reviewed showed promise in improving positive
psychotic symptoms, hospital admissions, socialisation, social connectedness, depression, and medication
adherence. Interventions included web-based psychoeducation; web-based psychoeducation plus
moderated forums for patients and supporters; integrated web-based therapy, social networking, and peer
Physical activity
To date there is no evidence about the use of exercise for psychotic disorders other than schizophrenia,
or comorbid psychosis and AOD use disorder. Research conducted among individuals with schizophrenia
however, has found that physical exercise may be useful in terms of improving cognitive functioning (e.g.,
short-term memory), promoting healthy lifestyles, and managing medication side-effects [543, 544]. Studies
that have examined the efficacy of exercise interventions among people with schizophrenia have included
a range of physical activities, including basketball [545], aerobic exercise [543, 546], and yoga [547, 548].
Based on the evidence to date, aerobic activity has the most support [142, 543, 549-553], but there is also
some support for resistance training as an adjunct to other exercise [546, 554, 555]. In particular, endurance
programs of at least 12-weeks, 3 sessions per week, of general aerobic endurance training lasting at least
30 minutes duration are recommended [556].
Summary
In summary, existing research suggests that there is no ‘one size fits all’ approach for treating comorbid
psychotic spectrum and AOD use disorders [524], suggesting combinations of different therapeutic
approaches may be necessary for each individual client. Further, therapist flexibility is incredibly important
in the treatment of this group. Box 14 illustrates the continuation of case study B, following Nick’s story after
contact was made with the local AOD service for an assessment.
Box 14: Case study B: Treating comorbid psychosis and AOD use: Nick’s story
continued
The treatment goals for Nick in the long term were for him to live in supported accommodation, and
he began part time work in a supermarket. Improvements in Nick’s mental health and AOD use led to
improved social functioning, allowing him to engage in a range of activities organised for the supported
living complex, which became his permanent home. Nick continued to express bizarre ideas and still
hears voices, but he is able to cope better with these phenomena.
Key points:
• Chronic illness does not equate to untreatable illness. Psychotherapy may provide symptom relief
and improved quality of life, and all treatment approaches need to be carefully integrated.
• Medication compliance needs long-term attention.
• Physical health is often overlooked.
• A holistic approach, assessing a person’s accommodation and employment needs in addition to
their mental, physical, and AOD use disorders, is vital.
Bipolar
Ipsandi te nus, omnime corat verum
nam vitecup tatem. Nam quaero ea
ipsam quidem aut audandelique apisit
eosapid itaturi tatendi tasperrum que
est laborum rest, esecte nis rem sit
aspe quas experit re et ulpa.
Bipolar disorders
Clinical presentation
It can be particularly challenging to treat people with bipolar disorder due to the broad range of emotions
experienced, which can impact on the relationship between the client and the therapist [540]. Depending
on which phase of the disorder a client is in, they may present with either symptoms of depression or
mania/hypomania. If the person is in between episodes, they appear to be completely well. People with
bipolar disorder predominantly present to services during the depressive phases of the disorder rather than
during the periods of elation.
If experiencing a depressive episode, the client may present with low mood; markedly diminished
interest or pleasure in all, or most activities; sleep disturbances; appetite disturbances; irritability; fatigue;
psychomotor agitation or retardation; poor concentration; feelings of guilt, hopelessness, helplessness
and worthlessness; and suicidal thoughts. When experiencing mania/hypomania however, a client’s mood
is persistently elevated, and symptoms of grandiosity, flights of ideas, hyperactivity, decreased sleep,
psychomotor agitation, talkativeness and distractibility may be present. Mania and hypomania may lead to
a loss of insight, which can place the person at risk, and impact negatively on medication compliance.
The techniques outlines in Table 35 may assist in the management of a person experiencing symptoms of
mania or hypomania. If the client is experiencing a manic episode or symptoms of psychosis, consultation
with a medical practitioner is recommended for the prescription of appropriate pharmacological
interventions. Some clients may be aware that they are unwell and will voluntarily seek help; others may
lack insight into their symptoms and refuse help. In some instances a person’s manic symptoms can
put both the client and others at risk of harm. In such circumstances mental health services should be
contacted, whether the client wants such a referral to be made or not.
Do:
3 Encourage and emphasise successes and positive steps (even just coming in for treatment).
3 Take everything they say seriously.
3 Maintain eye contact and sit in a relaxed position – positive body language will help you and the
client feel more comfortable.
3 Use open-ended questions such as ‘So tell me about...?’ which require more than a ‘yes’ or ‘no’
answer. This is often a good way to start a conversation.
3 Constantly monitor suicidal thoughts and talk about these thoughts openly and calmly.
3 Encourage the client to express his/her feelings.
3 Be available, supportive and empathetic.
3 Offer realistic hope (i.e., that treatment is available and effective).
3 Encourage regular sleep, exercise and eating patterns.
3 Keep language clear, specific and simple.
3 Assist the client to identify warning signs that they may become unwell.
3 Provide contact details of counselling services and offer to make referrals if required (many
depressed people struggle to do this alone).
3 Encourage participation in healthy, pleasurable and achievement-based activities (e.g., exercise,
hobbies, work).
Don’t:
2 Make unrealistic statements or give unrealistic hope, like ‘everything will be fine’.
2 Invalidate the client’s feelings.
2 Be harsh, angry, or judgemental. Remain calm and patient.
2 Lose hope or become frustrated.
2 Act shocked by what the client may reveal.
Adapted from Scott et al. [558], Clancy and Terry [296] and Headspace [559].
Do:
Don’t:
2 Argue, criticise or behave in a threatening way towards them. Consider postponing or avoiding
discussion of issues that aggravate the client for the time being. Try to talk about more neutral
topics.
2 Get visibly upset or angry with the client. Remain calm and patient.
2 Confuse and increase the client’s level of stress by having too many workers attempting to
communicate with him/her.
2 Get drawn into long conversations or arguments with the person as these can be overstimulating
and upsetting. People with elevated moods are vulnerable despite their apparent confidence, and
they tend to take offence easily.
2 Leave dangerous items around that could be used as a weapon or thrown.
2 Laugh (or let others laugh) at the person.
2 Act horrified, worried or panic.
Psychotherapy
Although research on psychological treatments for comorbid bipolar disorder and AOD use is scarce,
one group of researchers have developed an integrated, 20-session, psychosocial group treatment
program for this comorbidity, which has shown some positive findings in relation to AOD use [560, 561]. The
program employs a cognitive behavioural relapse prevention model that integrates treatment by focusing
on similarities between recovery and relapse processes in bipolar disorder and AOD use disorder. More
recently, a briefer version of integrated group therapy (12 sessions) has been shown to be effective in terms
of its positive impact on mood and substance use [562]. When delivered by AOD workers with little or no
training in CBT, or prior experience with the treatment of bipolar disorder, this brief version of integrated
group therapy had superior outcomes relative to standard group drug counselling. Although psychological
treatments appear to have positive outcomes among people with comorbid bipolar disorder, it is not well
understood how the improvements work – i.e., whether it is the psychological therapy addressing the AOD
use, the bipolar symptoms, or both together, that are associated with positive outcomes [563].
Pharmacotherapy
For comorbid bipolar and AOD use disorders, multiple medications are often used to treat each specific
disorder, such as the use of mood stabilisers (see Table 36), antipsychotics (see Table 33), and/or
antidepressants (see Table 38) for the bipolar disorder, in conjunction with medication specifically to treat
the AOD use disorder (e.g., naltrexone for alcohol use disorder) [540]. A recent update on the treatment of
bipolar disorders recommended initiating pharmacological treatment with mood stabilisers and/or
Olanzapine Zyprexa
Quetiapine Seroquel
Aripiprazole Abilify
Solian Amisulpride
Lamotrigine Lamictal
Topiramate Topamax
Adapted from Black Dog Institute [565]. For a full list of generic brands available, see the Therapeutic
Goods Administration website (https://www.tga.gov.au/).
antipsychotics, and then later supplementing the treatment with antidepressant medication, due to the
possibility of antidepressant-induced mania [564].
The effectiveness of mood stabilisers (e.g., lithium, sodium valproate, lamotrigine) in treating comorbid
bipolar disorder and AOD use is yet to be fully established with only a small number of controlled trials
in this area. An RCT examining the effectiveness of lithium in treating adolescents with bipolar disorder
and AOD use disorders (primarily alcohol and/or cannabis) found that, relative to placebo, lithium had a
positive effect on bipolar symptoms and on AOD use [566]. A further study demonstrated that lithium had
an impact on reducing cannabis and cocaine use in people with comorbid bipolar disorder, but it is difficult
to generalise the findings of this study due to less than one-quarter of the original sample completing the
stabilisation phase and continuing into the main portion of the study [567].
Promising findings have also been found relating to the use of sodium valproate (or divalproex). In an
uncontrolled study, Salloum and colleagues [568] found beneficial effects from divalproex alone in
reducing bipolar symptoms and cocaine use. There is also some evidence to suggest that the addition of
sodium valproate may further improve the effects of lithium [540]. In an RCT of people with bipolar disorder
and alcohol use disorders, Salloum and colleagues [569] found that those randomised to receive lithium
plus valproate had a greater reduction in heavy drinking days relative to those randomised to receive
lithium alone. Manic and depressive symptoms improved equally in both groups. However, Kemp and
colleagues [567] found no additional benefits for mood and AOD use when using divalproex and lithium,
compared with lithium alone. As mentioned previously however, the findings of this study need to be
interpreted with caution given the high drop-out rate.
Lamotrigine has been found to be associated with improvements in bipolar symptoms, craving, and AOD
use in a number of open-label, uncontrolled trials [570, 571]. However, in a more recent RCT, the effects of
lamotrigine on mood and cocaine use were not significantly different to placebo, although money spent on
cocaine was reduced in the lamotrigine group [572].
It is also important to bear in mind that clients with a comorbid bipolar disorder may be less likely to comply
with medication if they enjoy their manic episodes. Measures to increase medication compliance may
be particularly pertinent among this group (discussed later in this chapter). Other strategies to promote
medication compliance among clients with comorbid bipolar disorder include the Improving Treatment
Adherence Program, which is an adjunctive psychosocial approach designed to improve treatment
adherence [577]. The Improving Treatment Adherence Program is delivered through individual sessions, a
meeting with the client’s family member and/or significant other, and follow-up telephone contacts with
the client and his/her significant other. Whilst an RCT testing this program is yet to establish the program’s
efficacy, early results indicate that the intervention appears promising both in terms of feasibility and
acceptability to clients, and also in terms of enhancing the benefits of existing treatments.
ECT is suggested as a second-line treatment option for bipolar disorder in very severe cases (e.g., in cases
of severe depression and suicidality), and in pregnant woman with severe symptoms [578]. However no
research studies to date have currently assessed the efficacy of ECT in treating co-occurring bipolar and
AOD use disorders.
E-health interventions
There are several online interventions to support the mental health of people with bipolar disorders,
including MoodSwings [579], Living With Bipolar [580], Beating Bipolar [581], the Bipolar Education
Programme [582], and HealthSteps for Bipolar Disorder [583]. Most of these interventions are in the early
stages of evaluation. Feasibility and preliminary studies of Living With Bipolar [580] and Bipolar Education
Programme [582] are promising. No online interventions have yet been developed for treating comorbid
bipolar and AOD use disorders specifically.
Physical activity
A small number of studies with relatively small samples have examined the effect of exercise on bipolar
disorders. Ng and colleagues [584] conducted a small, retrospective chart review, and found that
depression and anxiety improved among bipolar inpatients who participated in a voluntary 40-minute,
supervised group walking activity, every weekday morning, compared to non-walkers. However, there
was no clinical difference in overall improvement between walkers and non-walkers [584]. A small open
trial examining the short term effects of aerobic training on depression and bipolar disorder found that
aerobic training slightly improved symptom severity for those with bipolar disorder [585]. Another small
RCT examined the effect of a short-term, maximum endurance exercise program as an accompanying
treatment to pharmacotherapy, and found that, relative to control (gentle stretching and relaxation),
depression scores were significantly reduced among the exercise group [586].
Although the aforementioned studies provide evidence to suggest that regular physical activity can assist
in the reduction of depressive symptoms, there is preliminary research pointing to the existence of possible
exacerbation of mania among some people [587, 588]. Although exercise may be beneficial in redirecting
Dietary supplements
There have been few reviews that have examined the evidence for the safety and efficacy of dietary
supplements for bipolar disorders. Although research has found some benefit with regards to both
depressive symptoms (e.g., omega-3 supplementation [592, 593]), and mania symptoms (e.g., magnesium
supplementation [594-596]), many therapies have the potential to induce mania or interact with
pharmacotherapies (e.g., St John’s Wort [597-599]); the extent to which needs further in-depth examination.
Summary
Several psychological and pharmacological approaches for the treatment of co-occurring bipolar disorder
and AOD use appear promising, however further research is required to establish which therapeutic
approaches are particularly effective for this comorbidity. Box 15 illustrates the continuation of case study
C, following Layla after the identification of her bipolar disorder.
Box 15: Case study C: Treating comorbid bipolar and AOD use: Layla’s story continued
In addition to the use of psychotherapy and medication, the team identified the need to deal more
generally with Layla’s lifestyle, and with initial encouragement and support she was able to begin to
attend regular training sessions at the gym and, thus, begin the process of losing some of the weight
she had gained over the years. She was also able to contact some of her friends she used to swim with,
and, with the encouragement of her care coordinator, resumed her interest in music.
Key points:
• In cases of bipolar disorder comorbid with AOD use, treatments need to be coordinated and
carefully integrated.
• Although there are many effective medications to address disturbances in mood, as with all
medications, mood stabilisers can have significant side effects. In particular, mood stabilisers have
the potential to make a client feel flat.
• Strategies to address medication compliance, particularly over the long-term, are a pertinent aspect
of treatment.
• Without addressing the familial and social consequences of longstanding bipolar disorder, the
client’s quality of life will remain much diminished. As such, integrating the rehabilitative aspects
of treatment may have long-term benefits. Physical activity and exercise have physical and
psychological benefits, and may also help address some of the side effects of medications used to
treat bipolar disorder.
Depression
Depression
Clinical presentation
Depressive symptoms include low mood; markedly diminished interest or pleasure in all, or most activities;
sleep disturbances; appetite disturbances; irritability; fatigue; psychomotor agitation or retardation; poor
concentration; feelings of guilt, hopelessness, helplessness and worthlessness; and suicidal thoughts (refer
to Chapter A4).
A number of simple strategies based on CBT are also useful in managing clients with these symptoms,
including [310, 386]:
• Cognitive restructuring.
• Pleasure and mastery events scheduling.
• Goal setting.
• Problem solving.
It is important to note that many depressive symptoms (and many anxiety symptoms) will subside after a
period of abstinence and stabilisation [35, 290, 299]. It is useful to explain to clients that it is quite normal to
feel depressed (or anxious) when entering treatment but that these feelings usually improve over a period
of weeks. During and after this time, constant monitoring of symptoms will allow the worker to determine if
the client requires further treatment for these symptoms. If the client has a history of depressive episodes
in circumstances when he/she is not intoxicated or withdrawing, he/she may have an independent
depressive disorder. For these clients, it is unlikely that their depressive symptoms will resolve completely
with abstinence – indeed their symptoms may even increase. In such cases, clients should be assessed for
a depressive disorder and the treatment options described in this chapter should be considered.
Do:
3 Encourage and emphasise successes and positive steps (even just coming in for treatment).
3 Take everything they say seriously.
3 Maintain eye contact and sit in a relaxed position – positive body language will help you and the
client feel more comfortable.
3 Use open-ended questions such as ‘So tell me about...?’ which require more than a ‘yes’ or ‘no’
answer. This is often a good way to start a conversation.
3 Constantly monitor suicidal thoughts and talk about these thoughts openly and calmly.
3 Encourage the client to express his/her feelings.
3 Be available, supportive and empathetic.
3 Offer realistic hope (i.e., that treatment is available and effective).
3 Provide contact details of counselling services and offer to make referrals if required (many
depressed people struggle to do this alone).
3 Encourage participation in healthy, pleasurable and achievement-based activities (e.g., exercise,
hobbies, work).
Don’t:
2 Make unrealistic statements or give unrealistic hope, like ‘everything will be fine’.
2 Invalidate the client’s feelings.
2 Be harsh, angry, or judgemental. Remain calm and patient.
2 Act shocked by what the client may reveal.
Adapted from Scott et al. [558] and Clancy and Terry [296].
Psychotherapy
Research on psychological therapies provides support for the use of integrated psychological treatments
for comorbid depression and AOD use disorders [165, 600]. However, the small number of studies, variation
in study results, and small sample sizes used in these studies highlight the need for larger trials to be
conducted in this area [601].
The majority of studies to date have examined the use of integrated treatments that adopt a CBT approach
[272, 386, 432, 602, 603]. In a review of the literature, Hides and colleagues [601] note that CBT appears
to yield superior results for symptoms of depression and AOD use when compared to no treatment, but
there is little evidence demonstrating that CBT is more effective when compared with other forms of
psychological therapy (e.g., relaxation training, MI, integrated MI/CBT). As a way of enhancing CBT, it has
been suggested that CBT be combined with other evidence-based psychological approaches, such as
contingency management (see Chapter B5). The combination of CBT plus contingency management has
been found to be more effective than either CBT or contingency management alone in the treatment of this
comorbidity [418, 604, 605].
Another approach showing promise in the treatment of comorbid AOD use and depression is behavioural
activation. Originally developed in the 1970s, behavioural activation is based entirely on behavioural
strategies [606]. The therapy is based on the notion that problems in the lives of vulnerable people reduce
their ability to experience positive reward from their environments, leading to symptoms and behaviours
characteristic of depression. Behavioural activation aims to activate clients in specific ways that will increase
rewarding experiences in their lives. It also focuses on processes that reduce activation, such as escape
and avoidance behaviours including AOD use.
There is empirical evidence to suggest that behavioural activation is just as effective in treating depression
as combined cognitive and behavioural techniques and antidepressant medication [607, 608]. Behavioural
activation has the added benefit of being more time efficient and less complex than most other
psychotherapies, and can therefore be delivered by less experienced therapists [608]. Another advantage
of behavioural activation is that it incorporates some essential components of AOD treatment, such as
social support, emotional expression, reordering of life priorities, stress management, avoidance reduction,
symptom control and health education [609].
To date, three small RCTs have found support for the use of behavioural activation among people with AOD
use disorders. The first examined the efficacy of adding behavioural activation for depression to standard
inpatient AOD treatment among a small sample of illicit drug users with depressive symptoms [610].
The authors found that patients who were randomised to receive behavioural activation demonstrated
significantly greater improvements in depression at post-treatment compared with standard care
alone. They also reported significantly higher treatment satisfaction scores. The same treatment was
subsequently compared with an attention control condition among people in residential AOD treatment,
and was found to be superior in terms of treatment retention and levels of activation [611]. A third trial
examined the efficacy of behavioural activation paired with standard smoking cessation strategies
(including NRT) compared with standard smoking cessation strategies alone (including NRT) [612].
Participants randomised to receive behavioural activation demonstrated greater reductions in depressive
symptoms and a higher rate of smoking abstinence than did those randomised to receive standard
smoking cessation strategies. Collectively, these pilot studies provide promising support for the use of
behavioural activation among individuals with comorbid depression and AOD use, however, further trials
are needed. A large RCT comparing the efficacy of behavioural activation added to standard AOD treatment
with standard AOD treatment alone is currently underway in Australia.
Lastly, although still in the early stages, there is preliminary support for mindfulness-based relapse
prevention in the treatment of co-occurring depression and AOD use [613].
Pharmacotherapy
There is consensus amongst experts that pharmacotherapy (i.e., antidepressants; see Table 38) for
comorbid depression and alcohol use disorders is effective, provided an individualised approach is used
[424, 432]. Unless there are significant contraindications, it appears clinically appropriate to use medication
that has been proven efficacious in the treatment of major depression in those depressed patients with an
AOD use disorder.
Thase and colleagues [424] comment on the sometimes over-restrictive attitudes towards pharmacological
treatments for depressive disorders among people with AOD use disorders, where clients can present in
a state of physical and emotional despair that requires immediate intervention. Considering the safety of
Reviews have generally found that among clients with comorbid alcohol and depressive disorders,
treatment with tricyclic antidepressants (TCAs) and SSRIs has a significant effect on symptoms of
depression, but effects on alcohol use have been equivocal [424, 432, 539]. A more recent review found
mixed findings regarding depressive symptoms. Antidepressants were generally found to be effective in
treating symptoms of depression however, when the effectiveness of SSRIs were examined separately,
there were no significant treatment effects on depressive symptoms, relative to placebo [619]. Ioveno
and colleagues [619] speculated that this may be due to high placebo response rates in these trials, and
therefore further studies examining the use of SSRIs in this comorbid group are required.
Alcohol use responds well where depressive symptoms have been reduced, but sustained abstinence
is not usually achieved [620-623]. There have been some studies which have shown a relatively
negative effect on alcohol consumption in alcohol-dependent young men prescribed SSRIs [624-627].
Antidepressants that do not come under the umbrella of SSRIs or TCAs have been found to be effective in
single studies [628, 629].
Compared to the newer antidepressants, TCAs are poorly tolerated, potentially lethal in overdose, and
cause significant adverse effects when combined with other central nervous system depressants. In
contrast, SSRIs are associated with fewer side effects, have better tolerability (resulting in improved
compliance) and are safer in overdose [121, 424]. Despite their efficacy, some clients may be reluctant to
take SSRIs due to the misconception that they are ‘addictive’. SSRIs are not habit-forming; however, users
may experience a discontinuation syndrome if the medication is stopped abruptly [121]. Symptoms are
similar to some of those experienced during alcohol or opiate withdrawal (e.g., flu-like symptoms, light-
headedness, headache, nausea) [121]. When discontinuing SSRIs, the dose should be gradually tapered.
Although studies of comorbid alcohol dependence and major depression support the use of SSRIs, studies
of cocaine and opiate dependent clients do not [263]. At present, there is limited evidence to support the
use of antidepressants in treating depressed opioid dependent persons currently receiving opioid agonist
treatment. In a recent systematic review, Pani and colleagues [631] noted that the evidence in this area was
highly limited due to the small number of studies conducted, and methodological limitations within these
studies. Whilst there was some evidence of a trend towards improved outcomes for depression symptoms
and AOD use for clients receiving antidepressants as well as opioid agonists, there were no statistically
significant differences in outcomes between antidepressant and placebo groups.
For all AOD clients, extreme caution should be taken when prescribing monoamine oxidase inhibitors
(MAOIs). These medications are potentially dangerous because of the dietary and medication restrictions
involved [121]. Hypertensive crisis with intracranial bleeding and death can occur if combined with a
tyramine-rich diet or contraindicated medications (including opioid and psychostimulant substances, such
as over-the-counter cold and flu medications) [121, 263]. For this reason, MAOIs should only be used when
other medication options have failed.
It is important to note that it can take up to four weeks for an antidepressant to reach therapeutic levels in
the blood. Responses to antidepressants are typically noticeable within two to four weeks, with continued
improvement in symptoms for up to 12 weeks [633-635]. If little or no improvement in mood occurs over
the induction time specified by the drug manufacturer and the medication is being taken as prescribed,
consideration should be given to increasing the dose within the recommended range. If still little or no
improvement is observed, switching or augmenting with another antidepressant may be considered.
It is recommended that there be at least one within-class switch before considering augmentation
or other options, keeping in mind the potential for drug interactions, and the adverse effects of some
antidepressants [633-636].
Two medications that have been used for treating alcohol use disorders – naltrexone and acamprosate
– have shown moderately positive outcomes in this single disorder [637-641]. Disulfiram can also be an
effective treatment for some people with alcohol problems, particularly those who are highly motivated
and who can be closely supervised. Research suggests that naltrexone, acamprosate, and disulfiram are all
tolerated well in clients with comorbid depression [642].
Naltrexone has been found to be associated with better drinking outcomes in clients being treated with
antidepressants for their depression and anxiety [643]. With little support for the use of antidepressants
alone to reduce excessive drinking, more recent research indicates that the use of antidepressants
combined with naltrexone may lead to improved outcomes. Pettinati and colleagues found that when
sertraline and naltrexone were combined in the treatment of co-occurring depression and alcohol
dependence, there were better outcomes in terms of abstinence and relapse, relative to either sertraline or
naltrexone alone, or placebo [644].
It should also be borne in mind that at least for naltrexone, treatment beyond 12 weeks may not improve
drinking outcomes in those with alcohol use disorders alone [645]. While both acamprosate and naltrexone
are available on the Pharmaceutical Benefits Scheme for alcohol dependence, disulfiram is expensive
and only available with a private prescription. Although only a tentative finding requiring further research,
another study found that buprenorphine had better outcomes with opiate abusers with comorbid
depression than those who were not depressed [646]. This suggests that buprenorphine may prove to be
an especially useful pharmacotherapy for this sub-group.
ECT can be an effective treatment for certain patients. There is evidence that ECT is an effective treatment
for depression as a single disorder [647]; however, no research studies to date have assessed the efficacy
of ECT in treating co-occurring depression and AOD use disorders. The Royal Australian and New Zealand
College of Psychiatrists clinical practice guidelines for the treatment of depression note that ECT is a highly
efficacious treatment with a strong evidence base, particularly for severe depressive disorders [648, 649].
The UK NICE Guidelines similarly recommend that ECT be considered for treating severe depressive
disorders, or after other treatment options have been exhausted [650].
E-health interventions
Research examining e-health interventions for depression based on CBT therapies has found evidence of
successful outcomes [449], and their use as the optimal low-intensity treatment for adults experiencing
depression has been recommended by the UK NICE Guidelines [444]. Recommended programs include
Beating the Blues and MoodGYM both of which have been found to improve a range of depression
outcomes [651-653]. Neither of these programs, however, address comorbid AOD use.
A small number of e-health interventions specifically designed to treat comorbid depression and AOD use
have been evaluated. The SHADE program, consisting of nine sessions of interactive exercises based on MI
and CBT, has been associated with moderate to large effect sizes for alcohol consumption and significant
reductions in depression scores over 12-month follow-up [654, 655]. More recently, a brief (4-session)
early intervention program called the DEAL Project was developed, targeting young people experiencing
depression with harmful patterns of alcohol use [656]. The program is undertaken entirely online with
no clinician support. In evaluating the intervention, Deady and colleagues [657] found that individuals
randomised to receive the DEAL Project demonstrated a greater reduction in symptoms of depression and
alcohol use compared to individuals randomised to an attention-control condition.
One other study has examined the use of a single-session of online personalised feedback and
psychoeducation provided to college students [658]. The study compared alcohol feedback only,
depressed mood feedback only, integrated feedback, and an assessment only condition. At 1-month
follow-up, no differences in depressed mood or alcohol use were found across the conditions.
Physical activity
There is increasing evidence to suggest that regular physical exercise has psychological benefits, with
more active people illustrating lower levels of depression than sedentary people [659-661]. As mentioned
previously, exercise is relatively low-risk, is associated with wide physical health benefits, and research
has demonstrated exercise to be as effective in reducing depressive symptoms as psychotherapy and
antidepressants [185, 195, 662]. A Cochrane review concluded that physical activity (defined as aerobic,
mixed, or resistance) was moderately more effective than control interventions for treating depression,
with exercise equally as effective as psychotherapy or pharmacotherapy [663]. The UK NICE Guidelines for
depression recommend structured, supervised physical activity programs, three times a week (45 minutes
to 1 hour duration) for at least 12 weeks [650].
There is much evidence suggesting that physical activity improves levels of depression and anxiety [664,
665], both of which are risk factors for, and have been associated with, AOD use [51, 666]. Despite this
association, there is little research that has examined the role of exercise among people with comorbid
depression and AOD use disorders specifically. A study examining the effects of an 8-week structured
exercise program (treadmill and weight training), on depression and anxiety symptoms among newly
abstinent methamphetamine users in treatment, found that more exercise was significantly associated
with greater reductions in depression and anxiety symptoms, compared with the control group (health
education sessions), and compared with fewer exercise sessions [233].
A systematic review examining the effect of exercise-based interventions on AOD use found exercise was
associated with overall improvements in depression [185]. Although these findings indicate that exercise is
a potentially promising adjunctive treatment for people with comorbid depression, they also highlight the
need for further well-conducted research to be undertaken in this area.
Yoga
Yoga is a complex mind–body intervention involving spiritual practice, physical activity, breathing exercises
and meditation [669, 670]. Although the traditional goal of yoga is to unite body, mind, and spirit and
achieve self-awareness, yoga has become a popular method of maintaining physical and mental health
[669-671]. Yoga practice commonly involves postures to improve strength and flexibility, breathing
exercises to focus the mind and assist with relaxation, and meditation to calm the mind [671]. Research
has demonstrated that yoga can assist with the improvement of co-occurring mental health symptoms in
patients with physical conditions such as cancer [672, 673], menopausal symptoms [674], and pain [675].
Several systematic reviews have been conducted to assess the efficacy of yoga as an intervention for
depression. These studies have found limited to moderate support for short-term improvements in severity
of depression in yoga with meditation-based practice (rather than exercise-based practice) [676-679]. Only
one study has examined the effect of yoga breathing (Sudarshana Kriya Yoga) on depressive symptoms
among people with alcohol dependence [680]. This study found that the yoga intervention was associated
with reduced depressive symptoms compared to the control group. Although the effectiveness of yoga
as a treatment for people with comorbid AOD and depressive disorders needs further investigation,
these findings indicate that yoga may be considered as an additional treatment for clients with comorbid
depression.
Omega-3
There has been much research conducted examining the relationship between omega-3 and depressive
disorders, with some evidence that omega-3 fatty acids (primarily found in fish and seafood) are associated
with lower rates of depression [681-688]. Although several studies support omega-3 supplementation as
an antidepressant for people with depression alone, the role of omega-3 in people with comorbid AOD use
and depression has not been rigorously examined.
Research that has included people with comorbid AOD use has been largely focused on aggression,
anger, and co-occurring depression. Animal studies have found evidence of associations between
omega-3 deficiencies and increased aggressive and depressive behaviours [689]. Beier and colleagues
found reduced omega-3 levels among people with comorbid major depression and AOD use, indicating
that omega-3 may be used as a therapeutic approach for people with depression and AOD use, and
particularly those with aggressive symptoms [690]. Another placebo-controlled study of people with
AOD abuse who had histories of aggression and legal problems found that anger improved with omega-3
supplementation [691, 692]. Other studies have also examined the relationship between omega-3
St John’s Wort
St John’s Wort is the common name for the plant Hypericum perforatum, the extracts of which are
commonly used to treat depression, sometimes in order to avoid the side-effects involved with prescription
medication [696]. A systematic review of studies examining the efficacy of St John’s Wort found significantly
greater reductions in mild to moderate symptoms of depression among those taking St John’s Wort
compared to placebo [697]. However, the efficacy of St John’s Wort compared to antidepressants is not
known. The long-term side effects, particularly among pregnant women, are also unknown.
Although there is some evidence of efficacy in mild to moderate depression, the use of St John’s Wort has
been shown to have significant interactions with a range of other medications, including SSRIs and related
drugs, oral contraceptives, some anticoagulants, and some cardiac medications [698]. Further, the use
of St John’s Wort among people with comorbid AOD and depressive disorders has not been examined.
As such, AOD workers should ask their clients specifically about their use of St John’s Wort and other
complementary medicines, taking note of the potential for interactions between medications.
Summary
While these findings indicate that several psychological, pharmacological, and alternative approaches for
the treatment of co-occurring depression and AOD use disorders appear promising, further research is
required to establish which therapeutic approaches are particularly effective. It is suggested that clinical
efforts be focused on the provision of client-centred, evidence-based treatment, taking into account the
client’s needs and preferences, in a collaborative partnership. Box 16 illustrates the continuation of case
study D, following Jack after the identification of his comorbid depressive and AOD use disorder.
Box 16: Case study D: Treating comorbid depression and AOD use: Jack’s story
continued
With Jack’s consent, the AOD worker spoke with his GP, psychologist, and psychiatrist to devise some
treatment options for Jack. After presenting various options to Jack, it was decided that he would
continue with his current antidepressant medication (which was working well so far), continue to see his
psychologist weekly, and try attending some outpatient AOD group sessions for additional support. Jack
was also made aware of the possibility of pharmacological therapies to help reduce his drinking, but
he decided that he did not want to try medications at this stage. Jack continued with his antidepressant
medication and seeing his psychologist, but decided after trying a few different support groups that it
wasn’t for him. Jack received regular ongoing monitoring of his physical health from his GP, who paid
particular attention to Jack’s liver function, respiratory health and blood pressure.
In consultation with Jack’s team of health care providers, it was agreed that he would have a short
time off work and then return to work part-time, which in itself might be helpful to Jack in respect to
improving his confidence and self-esteem.
Key points:
• People with comorbid disorders do not necessarily present in any obvious way. There is higher
prevalence of older people who have continued to use AOD since cannabis and stimulants became
more readily available in the 1960s and 1970s. The need for careful history taking regarding AOD
use cannot be overemphasised.
• In some cases, mental health conditions may quickly respond to appropriate treatments. However,
comorbid mental health and AOD use disorders present a numbers of challenges – in particular the
need to address the need to maintain treatment gains in the long term (years rather than days or
weeks).
Anxiety
Anxiety
Clinical presentation
Anxiety involves excessive fear or worry, difficulty controlling this worry, and/or repetitive intrusive thoughts
or actions. Symptoms include poor concentration, inability to relax, sleep disturbances, depersonalisation,
and physical symptoms such as dizziness, faintness, headaches, nausea, indigestion, loss of sexual
pleasure, breathing difficulties, sweating, tension and muscle pain, and heart palpitations.
Each method works best if practiced daily by clients for 10–20 minutes; however, not every technique
may be appropriate for every client. These techniques are described in detail in Appendix U. Some of the
cognitive behavioural techniques described in Appendix T (i.e., cognitive restructuring, structured problem
solving, and goal setting) may also be useful in managing symptoms of anxiety [66, 385, 702, 703], but
again, no one strategy is effective for all clients. If the client experiences unpleasant effects from any
strategy, he/she should discontinue its use.
Like depressive symptoms, many anxiety symptoms will subside after a period of abstinence and
stabilisation [35, 290, 299, 704]. It is useful to explain to clients that it is quite normal to feel anxious when
entering treatment but that these feelings usually improve over a period of weeks. During and after this
time, constant monitoring of symptoms will allow the AOD worker to determine if the client requires
further treatment for these symptoms. If the client has a history of anxiety in circumstances when he/she
is not intoxicated or withdrawing, he/she may have an independent anxiety disorder. For these clients, it is
unlikely that their anxiety symptoms will resolve completely with abstinence – indeed their symptoms may
even increase. In such cases, clients should be assessed for an anxiety disorder and the treatment options
should be considered.
Do:
Don’t:
Adapted from NSW Department of Health [277] and Clancy and Terry [296].
Expert reviewers tend to agree that psychological interventions should accompany pharmacological
treatments for anxiety disorders [706], and suggest that a combination of psychotherapy and
pharmacotherapy may be uniquely effective in the treatment of individuals with comorbid anxiety and
alcohol use disorders [432, 705]. In terms of psychotherapy, a Cochrane review concluded that CBT is
effective in treating anxiety disorders [707] and, as discussed previously, there is good evidence that CBT
and MI are effective psychotherapies for particular types of AOD use disorders.
If the anxiety is acute and disabling and interfering with a response to AOD treatment, then consideration
should be given to pharmacotherapy, either for the substance use (in the case of alcohol – naltrexone,
acamprosate or disulfiram), the anxiety, or both. Although research examining the treatment of the
treatment of comorbid anxiety and AOD use is scarce [708], it would be reasonable to draw similar
conclusions for these comorbid groups as for depressed substance abusers – namely, use of a medication
such as a SSRI (which has anxiolytic properties), with a good side-effect profile, proven efficacy in the
mental health disorder and minimal negative interactions with the substance of abuse [121, 705]. Commonly
prescribed anti-anxiety medications include some of the SSRIs (and other antidepressants, e.g., venlafaxine)
listed in Table 38, and those listed in Table 40.
Despite their proven effectiveness in relieving anxiety, the use of benzodiazepines is not recommended
due to their abuse liability [121, 263, 706]. Benzodiazepines should only be prescribed among patients with
a history of problematic AOD use if there is a compelling reason to use them, there is no good alternative
(i.e., other psychological and medication options have failed), close follow-up and supervision is provided,
SSRIs = selective serotonin reuptake inhibitors; SNRI = serotonin and noradrenaline reuptake inhibitor;
TCA = tricyclic antidepressants; MAOI = monoamine oxidase inhibitor. Adapted from Lampe [709] and
the Australian Government Department of Health [630]. For a full list of generic brands available, see the
Therapeutic Goods Administration website (https://www.tga.gov.au/).
There is currently very little evidence regarding the effectiveness of psychological therapies for co-
occurring GAD and AOD use disorders [600]. Kushner and colleagues [710] developed an integrated group
CBT program for comorbid anxiety and alcohol use disorders to address symptoms of anxiety, as well as
the association between anxiety and the motivation to drink alcohol. The treatment was evaluated in an
RCT of individuals in a residential treatment program for alcohol use disorders with comorbid GAD, panic
disorder, or SAD. Those randomised to receive the CBT program treatment experienced considerably
better alcohol outcomes relative to the control group who received progressive muscle relaxation training,
and both groups demonstrated a reduction in anxiety symptoms.
Psychotherapy has been found to be equally as efficacious in the treatment of GAD as pharmacotherapies
[712]. Although experts suggest that the combined use of psychotherapy and pharmacotherapy may be
most beneficial [706], at present there have been too few studies to provide conclusive evidence [713]. As
mentioned, it also remains unclear as to whether approaches used for treating GAD as a single disorder are
equally efficacious in the treatment of comorbid GAD and AOD use disorders.
Pharmacotherapy
As mentioned, pharmacotherapy and psychotherapy have been found to be equally as efficacious
in the treatment of GAD [712], and experts suggest that the combined use of psychotherapy and
pharmacotherapy may be most beneficial [706]. Studies have found the use of SSRIs to be associated with
reductions in alcohol use [626, 714]; however, their effectiveness has not been studied in individuals with
comorbid anxiety and AOD use disorders. The use of SSRIs is considered preferable to benzodiazepines
for GAD because they are more effective in treating symptoms such as worry, tension, irritability and
concentration problems; and they have a safer side-effect profile [715]. McHugh [716] highlights the
dearth of literature addressing the safety and efficacy of benzodiazepine use in this comorbid group, and
recommends using alternative treatments as a first line of treatment, only resorting to benzodiazepines
once other options have failed.
Panic disorder
Little research has examined the treatment of panic disorder when it co-occurs with AOD use disorders. In
the absence of this evidence, the use of similar strategies to those found to be efficacious in the treatment
of panic disorder alone is appropriate. The UK NICE guidelines for the management of panic disorder
recommend a process of assessment and shared decision making to decide the first line of treatment,
which should be psychotherapy (CBT), self-help, or pharmacotherapy (SSRI or TCA antidepressants) [711].
A Cochrane review and meta-analysis have both concluded that, in the treatment of panic disorder alone,
it is equally efficacious to use psychotherapy or pharmacotherapy (SSRIs in particular), and that client
preference should be taken into account when deciding on a course of treatment [712, 721]. Furthermore,
Psychotherapy
Findings from studies examining psychological treatments designed to address symptoms of both panic
disorder and AOD use present mixed evidence. In an RCT of people with panic disorder receiving inpatient
treatment for alcohol dependence, Bowen and colleagues [722] examined CBT for panic disorder in
addition to a regular alcohol treatment program. They found that although there were improvements in
anxiety symptoms and alcohol use, there was no additional benefit of the CBT treatment component.
In contrast, Schadé and colleagues [723, 724] found the addition of CBT to psychosocial treatment for
alcohol dependence yielded superior results for anxiety symptoms, compared to treatment for alcohol
dependence alone. More recently, Kushner and colleagues [710] evaluated an integrated group CBT
program for comorbid anxiety and alcohol use disorders in a RCT of individuals in a residential treatment
program for alcohol use disorders with comorbid GAD, panic disorder, or SAD. Those randomised to
receive the CBT program experienced considerably better alcohol outcomes relative to the control group
who received progressive muscle relaxation training, and both groups demonstrated a reduction in anxiety
symptoms.
Pharmacotherapy
There is a dearth of research exploring the pharmacological treatment of co-occurring panic and AOD
use disorders. SSRIs and venlafaxine are the first line pharmacotherapy recommended for the treatment
of panic disorder as a single disorder [725]. It has been recommended that caution should be used when
treating panic disorder with antidepressants such as SSRIs and TCAs because these agents may cause an
initial worsening of panic symptoms [263]. As mentioned previously, TCAs are poorly tolerated, potentially
lethal in overdose, and cause significant adverse effects when combined with other central nervous system
depressants. In contrast, SSRIs are associated with fewer side effects, have better tolerability (resulting in
improved compliance) and are safer in overdose [424]. It is recommended that a low dose be prescribed to
start with to avoid activation of panic symptoms [263, 725].
Psychotherapy
Studies of psychological treatments for comorbid SAD and alcohol use disorders suggest that the
treatment of both disorders concurrently is no more beneficial than treatments focused on drinking alone
[723], and that concurrent treatment may even have a deleterious effect on drinking outcomes [726].
Research by Schadé and colleagues [723, 724] indicated that adding CBT and an optional SSRI to relapse
prevention treatment for alcohol dependence yielded superior results for symptoms of anxiety in people
with SAD, but did not improve drinking outcomes relative to alcohol relapse prevention treatment alone.
Another study examined the efficacy of CBT for SAD and alcohol dependence compared with CBT for
alcohol dependence only [726]. The authors found overall improvements in anxiety symptoms with no
Recently, an integrated treatment has been developed for social anxiety and alcohol use disorders, which
combines CBT and MI [727]. Preliminary findings indicate that it may be a promising approach for the
treatment of comorbid SAD and alcohol use disorders [728]. Compared to participants randomly allocated
to receive CBT for alcohol alone, participants receiving integrated CBT had better outcomes for symptoms
of social anxiety, general functioning, and quality of life [729]. Both groups reduced their alcohol use, with
no difference between groups.
Pharmacotherapy
In terms of pharmacological treatment for SAD, there is evidence to suggest that treatment with SSRIs
can be effective in reducing anxiety symptoms [730, 731]. There is also some evidence that SSRIs can be
effective at treating co-occurring SAD and AOD use disorders, although their effectiveness at reducing AOD
use may be limited [732-734]. In a double-blind, placebo-controlled trial, paroxetine was found to reduce
symptoms of social anxiety and reliance on alcohol for self-medication of anxiety symptoms, but it did not
reduce actual quantity and frequency of drinking [732, 734].
E-health interventions
As noted in previous sections, there has been an expansion of research into e-health interventions, with
growing evidence to support its use in managing and treating various disorders. A systematic review and
meta-analysis examining e-health interventions for GAD found significant post-treatment improvements for
generalised anxiety and pathological worry [735]. Indeed, the efficacy of e-health interventions was found to
be equivalent to that of CBT interventions delivered face-to-face. The review further concluded that CBT-
based interventions have a stronger evidence-base and greater efficacy compared to psychodynamic-
based interventions.
Two other meta-analyses have examined the efficacy of internet-based approaches for anxiety [736, 737].
Spek and colleagues [736] evaluated internet-based CBT for anxiety and depressive disorders and found
larger effect sizes for anxiety than depression interventions, which was suggested to be related to the
amount of therapist support provided alongside the internet-based intervention. Cuijpers and colleagues
[737] similarly demonstrated that computer-based psychotherapy was as effective for managing and
treating anxiety disorders as face-to-face treatment, regardless of disorder type.
In relation to the management of phobia and panic disorder, the UK NICE Guidelines recommend
FearFighter, a computer-based psychotherapy, as an evidence-based treatment for anxiety [444].
FearFighter is a CBT-based e-health intervention based on self-exposure therapy [738]. Research has
found that the FearFighter program is as effective as face-to-face interventions in managing and treating
panic and phobia [739].
To date, no e-health interventions have been developed for treating comorbid anxiety and AOD use.
However, an Australian program called Anxiety Online does provide links to psychoeducation surrounding
AOD use [740]. Anxiety Online comprises five e-therapy programs for GAD, SAD, panic disorder, PTSD, and
OCD. Definitive evidence regarding the efficacy of this program is lacking; however, a naturalistic study
found that the participation in Anxiety Online was associated with significant reductions in severity of all five
disorders, and increased confidence in managing one’s own mental health care. Significant improvements
in quality of life were also observed for the GAD, SAD, OCD, PTSD, and e-therapy programs, but not the
panic disorder program. Overall, treatment satisfaction was good across all five e-therapy programs.
The evidence base for the efficacy of physical exercise in reducing anxiety symptoms is smaller than that
for depression; but nonetheless indicates that exercise is efficacious in alleviating symptoms of anxiety
[711]. Aerobic and non-aerobic exercise have been found to be as effective as CBT [199], with reductions in
anxiety, tension, and irritability observed among those with GAD who participated in resistance training and
aerobics [664, 741]. Regular walking has also been found to enhance the efficacy of CBT across different
anxiety disorders [742]. Regular exercise was been found to produce greater reductions in anxiety than
relaxation for those with panic disorder [743], but is less effective than pharmacotherapy [744] or group
delivered CBT [745].
Two reviews reporting secondary psychological outcomes of studies examining the effect of physical
activity among people with AOD use found improvements in both AOD use and anxiety [185, 186]. Findings
indicate that both aerobic and anaerobic training may be effective, over an optimal duration of 9 weeks
[746]. However, there is mixed evidence regarding the optimal intensity, with some studies finding support
for light to moderate exercise, and others finding larger effect sizes with higher intensity training [186].
Yoga
Although the effectiveness of yoga as an intervention for anxiety has been evaluated in a number of
studies, the poor quality of the evidence makes it difficult to draw conclusions. Earlier systematic reviews
found minimal evidence for the efficacy of meditation therapy [747] or mindfulness-based meditation [748],
but two recent systematic reviews concluded that meditative therapies reduced anxiety symptoms [749,
750]. No research has evaluated yoga for people with comorbid anxiety and AOD use.
Dietary supplements
Some people with anxiety disorders may prefer herbal or nutritional supplements, either in addition to, or
instead of, psychological or pharmacological therapies. Systematic reviews have found limited evidence
for the efficacy of several ‘phytomedicines’, including Passiflora extract, Kava, and combinations of l-lysine
and l-arginine [751-753]. Despite its popularity, there is no convincing evidence supporting the use of
homeopathy in the treatment of anxiety disorders [754, 755]. Further, none of these supplements have been
evaluated among people with comorbid anxiety and AOD use disorders.
Summary
Research concerning both psychological and pharmacological treatments for comorbid anxiety and AOD
use disorders is sparse [708, 756] and the evidence for integrated treatments is mixed [716]. In the absence
of research examining treatments for comorbid anxiety and AOD use disorders, it may be useful to seek
guidance from treatment approaches to single disorders. More rigorous research is required in order to
determine whether the same approach for treating single disorders is equally efficacious in the treatment
of comorbid disorders. Box 17 illustrates the continuation of case study E, following Alina’s story after
identification of her anxiety disorder was made. However, as illustrated, the presence of a comorbid AOD
use disorder may complicate the management and treatment plan.
Case Study E: Treating comorbid anxiety and AOD use: Alina’s story
continued
Box 17: Case study E: Treating comorbid anxiety and AOD use: Alina’s story continued
Alina’s psychologist diagnosed her with GAD, and suggested that they try CBT for the treatment of her
anxiety and panic attacks. With the worsening of Alina’s symptoms, the psychologist took the view that
she might need longer term treatment than provided under the Medicare Better Access Scheme.
The treatment plan developed in consultation with Alina emphasised the need to deal with both her
anxiety and alcohol use. The psychologist liaised with Alina’s GP, who ordered some blood tests and
recommended a short course of medication to help Alina withdraw from alcohol. Both the GP and the
psychologist advised Alina that the first few days without alcohol would likely be the worst, but that
symptoms typically abate within one week. In particular, they highlighted a possible increase in her
anxiety during this period, but reassured Alina that this would likely subside and they would be there to
help her through.
Over the next few weeks, Alina began to see a cycle between her anxiety and alcohol use, with
alcohol providing temporary relief from her anxiety, which then worsened once the effects of alcohol
wore off. Alina began to realise how the vicious cycle led to avoidance behaviours which made her
feel depressed because she was no longer engaging in activities that she enjoyed. She also began
to appreciate that her alcohol use had become an independent problem, and that although she was
acquiring coping strategies to deal with anxiety, the potential for developing an even more serious
alcohol problem was a real possibility.
Alina’s psychologist arranged for her to attend weekly sessions of a relapse prevention program run by
local AOD services. Her psychologist also helped her to deal with avoidance behaviours with a program
of gradual exposure to situations that had previously been anxiety provoking. Although Alina responded
very well to these treatment initiatives within two to three months, they both agreed that she should
remain in contact with her psychologist over a longer term period. The frequency of sessions gradually
reduced over time.
Key points:
• Treatments for anxiety and AOD use may require client contact over a period of months, rather than
weeks.
• Without addressing AOD use, psychological treatments for anxiety may be rendered ineffective.
A person with OCD may be significantly distressed by their symptoms, and their ability to function may
be impaired. They are plagued with persistent thoughts or impulses that are intrusive and unwanted
(obsessions) and they may feel compelled to perform repetitive, ritualistic actions that are excessive and
time consuming (compulsions). Symptoms of obsessions may include:
Anxiety about obsessions may lead to vigilance about possible threats, and a compelling need for control.
A person may feel annoyed, discomforted, distressed, or panic about their obsessions, and feel driven to
perform repetitive mental or physical acts in response. Symptoms of compulsions may include:
OCD may often go under-detected among people with AOD conditions. This is thought to be due to both
a lack of training for AOD workers in the detection of OCD, and a lack of disclosure by clients who may
experience shame and embarrassment, and be intent on hiding their symptoms [757].
The techniques outlined in Table 41 may help AOD workers to manage clients with obsessive-compulsive
symptoms, whether they are transient or more entrenched.
Do:
Don’t:
Adapted from NSW Department of Health [277] and Clancy and Terry [296], Jenner et al. [123].
Although there is very little evidence regarding the treatment of co-occurring AOD use and OCD, that
which does exist suggests that treating both OCD and AOD use leads to better treatment outcomes than
treating AOD use alone [759].
There are several treatment options available for the treatment of OCD, including psychotherapy,
pharmacotherapy, e-health, physical activity, and complementary and alternative therapies. The evidence
base surrounding each of these treatments is discussed below.
Psychotherapy
There is a significant body of research supporting the efficacy and effectiveness of CBT incorporating
exposure and response prevention (ERP) for the treatment of OCD as a single disorder [760-768], including
two reviews – one systematic and one meta-analysis [769, 770]. Research has found that the effect sizes
for ERP are as large as pharmacological treatments [765], with lower rates of relapse [766, 771, 772]. As
such, CBT incorporating ERP is recommended as a first line of treatment for single disorder OCD by clinical
practice guidelines [773-775].
ERP involves repeated, prolonged and systematic confrontation with certain objects or situations that
trigger obsessional responses (exposure), and resisting the compulsive urges that arise in response to
the triggers (response prevention) [776]. The nature of the exposure therapy can be in vivo (i.e., physically
touching a light switch) or in the imagination (i.e., confronting images of loved ones dying). ERP concurrently
weakens the association between the obsessional triggers and anxiety arousal, and compulsive rituals
and anxiety reduction (i.e., ERP seeks to weaken the idea that anxiety will only reduce once compulsions
are performed [777]). Additional cognitive therapy can help clients address thought patterns that may be
underlying their obsessional fear [776]. Although ERP is considered to be the treatment of choice for OCD
[775, 778], it has been suggested that the efficacy is highly dependent on ERP being delivered consistent
with clinical guidelines [778].
The UK NICE guidelines recommend that low intensity CBT with ERP (i.e., consisting of up to 10 practitioner
hours per client) be offered to clients with mild functional impairment and those who express a preference
for a low intensity approach [775]. Low intensity treatments may include brief individual CBT with ERP,
using structured self-help materials; brief individual CBT with ERP by telephone; or group CBT. Those with
mild functional impairment who are unable to engage in low intensity CBT, or have a proven inadequate
response to low intensity treatment, should be offered a choice of either a course of SSRI or more intensive
CBT with ERP (i.e., more than 10 practitioner hours per client), as these treatments have been shown to have
comparable efficacy. Similarly, the UK NICE guidelines recommend that people with OCD with moderate
functional impairment should be offered a choice between SSRIs or more intensive CBT with ERP [775].
Despite evidence of its efficacy, ERP is not always the first line of treatment provided to clients with OCD.
This is likely due to a combination of factors, including the ease with which medication is prescribed and
is available over ERP; the fact that many workers are either unfamiliar with, or reluctant to perform ERP;
and the reluctance of some people with OCD to engage with ERP due to the anxiety-evoking nature of the
treatment [769].
• Assessment of both OCD and AOD use: This can be difficult if clients are attempting to conceal their
symptoms for fear of embarrassment, and OCD can often be confused with other psychiatric illnesses
(e.g., phobia, depression, and psychosis).
• Assessment of symptom type and quality using validated assessment tools: For example intrusive
thoughts, feelings and behaviours, detailed description of the anxiety-provoking stimuli typically
experienced, and the ritualistic behaviours performed in response.
• Psychoeducational therapy.
• Creation of a stimulus hierarchy: Listing obsessions, compulsions and anxiety-provoking stimuli, which
are then rated based on the amount of anxiety generated.
• Treatment: Concurrent delivery of ERP and AOD use treatment.
Although the findings of Fals-Stewart and Schafer [779] are promising, more evidence is clearly needed. In
particular, the cyclical nature between OCD and AOD use suggests there is a need for the development
of integrated treatments that simultaneously address both disorders [769, 780]. Stewart and O’Connor
[780] suggest that such an integrated approach may consist of psychoeducation to explore the cyclical
relationship between OCD symptoms and AOD use; targeting AOD use during ERP treatment if it is
identified as a safety behaviour (a behaviour that temporarily relieves the distress associated with
obsessions); and therapeutic work focused on increasing self-efficacy, in order to help the client believe
they can cope without AOD use [780].
Pharmacotherapy
There has been little research examining the efficacy of pharmacotherapy interventions among people with
comorbid OCD and AOD use. A Cochrane review of pharmacotherapy for anxiety and comorbid alcohol use
disorders found no rigorously conducted trials of medication treatment for comorbid alcohol misuse and
OCD [708]. In view of the lack of evidence for pharmacological interventions for comorbid OCD and AOD
use, workers may be guided by the body of research that has been conducted for single disorder OCD.
Systematic reviews and meta-analyses of RCTs examining pharmacotherapy treatments for single
disorder OCD have found that the SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and
sertraline), and the TCA antidepressant clomipramine, to be associated with reductions in symptom severity
and improvements in health-related quality of life [781, 782]. Evidence-based guidelines for the treatment
of single disorder OCD recommend that SSRIs be used as the first line of pharmacotherapy, and further
suggest that the combination of psychological and pharmacological treatments is likely to be superior to
either approach in isolation, though this has yet to be confirmed [758]. The current evidence for a combined
approach is conflicting, with some studies finding an enhanced effect from the combination of both
psychotherapy and pharmacotherapy (e.g., fluvoxamine enhancing ERP [783], and CBT [784], ERP and SSRIs
being superior to SSRIs alone [785], ERP/CBT plus SSRIs being superior to SSRI alone [786]), which is not
supported in others (e.g., d-cycloserine hastens the response to CBT, but overall effectiveness of CBT is not
enhanced [787-789]). Table 42 provides a list of SSRIs for the pharmacological treatment of single disorder
OCD.
Adapted from Australian Government Department of Health [630]. For a full list of generic brands
available, see the Therapeutic Goods Administration website (https://www.tga.gov.au/).
E-health interventions
Although there have yet to be any e-health interventions developed specifically for comorbid OCD and
AOD use, there have been several e-health interventions developed for OCD as a single disorder. Research
examining computerised CBT programs for OCD have found evidence of effectiveness [790-794], with
effects similar to those found in clinician-delivered CBT sustained to three and four months [790, 793, 795,
796]. There is also evidence to suggest a dose-response relationship in regards to computerised CBT
programs, with greater symptom improvements found among those who have completed more homework
[792]. However, studies have found that clinician-assisted programs with limited contact are associated
with better outcomes than completely computerised programs with no human contact, and the addition of
a therapist coach has been linked to treatment adherence and lower dropout rates [797].
A small number of e-health programs based on ERP have also been developed. It has been suggested that
the complex nature of OCD coupled with the exposure-based intervention may have deterred researchers
from translating treatments into online interventions [798]. Furthermore, the findings from studies examining
the efficacy of computerised ERP interventions have been mixed. A computerised ERP intervention called
BT Steps/OC Fighter was found to be less efficacious in reducing OCD symptoms than a more expensive
clinician-delivered ERP, but more efficacious than relaxation training [792]. The findings from this study
suggest that the primary benefit of having a clinician was to ensure people maintain their engagement in
the exposure process [769]. Given these findings, the UK NICE Guidelines recommend that BT Steps/OC
Fighter should not be used in the treatment of OCD [444].
Another ERP program, ICBT, has been found to be more efficacious in reducing OCD and depressive
symptoms, and improving general functioning compared to active control (online, non-directive supportive
therapy) [793]. Although encouraging, further research is needed in the area of ICBT and OCD [798].
Physical activity
There is preliminary evidence to suggest that physical exercise may be beneficial for people with single
disorder OCD. One pilot study of people with OCD maintained on SSRIs found an improvement in self-
reported OCD symptoms and depression after six weeks of a walking intervention, which remained stable
for one month post–treatment [799]. A second study found that the combination of a 12-week moderate
aerobic exercise program with psychotherapy or pharmacotherapy reduced OCD symptom severity, which
was maintained at 6-month follow-up [800]. The study found that significantly lower OCD symptoms,
anxiety, and negative mood levels were reported immediately following each 20–40 minute exercise
session, compared to the beginning of the session [801]. However, there is no evidence to date on the
efficacy of physical exercise for the treatment of comorbid OCD and AOD use disorder specifically.
As mentioned previously, SSRIs have been associated with various dose-dependent side effects, including
nausea, diarrhoea, dizziness, headaches, insomnia, sedation, anxiety, sexual dysfunction, and decreased
libido [802]. As the dose required for a clinically significant improvement in OCD symptoms is typically
higher than is required in the treatment of depressive disorders, the potential for unwanted side effects is
substantially increased [803]. As such, several studies have examined alternative therapies in the treatment
of single disorder OCD.
In a systematic review of these approaches, there was some evidence that mindfulness meditation,
electroacupuncture, yoga, nutrient glycine, borage, and milk thistle may have a positive impact on OCD
symptoms [804]. However, it is important to note that a number of these studies used methodologically
weak designs, and none examined use of these therapies among people with comorbid OCD and AOD use.
Summary
There are currently no integrated treatments for co-occurring OCD and AOD use disorders, and evidence
from only one RCT among people with comorbid OCD and AOD use favouring the concurrent treatment of
these disorders [779]. Although there is limited evidence for the treatment of comorbid OCD and AOD use,
results from single disorder OCD studies suggest there is strong and consistent evidence to recommend
the use of ERP or CBT as the first line of treatment in single disorder OCD. Box 18 illustrates the continuation
of case study F, following Jenny’s story after the identification of her OCD had been made.
Box 18: Case study F: Treating comorbid OCD and AOD use: Jenny’s story continued
Case Study F: Treating comorbid OCD and AOD use: Jenny’s story
continued
The AOD consultant liaison nurse arranged for Jenny to see both a mental health and AOD worker. With
Jenny’s involvement, they devised a treatment plan. This involved consultation with Jenny’s GP, a home
visit by a psychologist, comprehensive assessments, and concurrent treatment of Jenny’s OCD and
alcohol and benzodiazepine use. Although Jenny’s AOD treatment was managed by the AOD service
and her GP, it became evident that the supply of drugs from the Internet contained medication of
varying dosage and qualities, which made it very difficult for clinicians to establish the quantity Jenny
had been consuming.
Jenny received concurrent treatment of both pharmacotherapy and CBT with ERP, which addressed her
OCD and alcohol and benzodiazepine use. In addition to the gastritis, Jenny had problems with her liver
function, which required long-term follow up with a hepatologist. Jenny’s treatment for her OCD and
AOD use took place over several months and included exposure to her previously avoided situations.
When this phase of treatment was completed, a longer–term process of monitoring and support was
put in place to ensure that her treatment gains were maintained.
Key points:
• OCD is a condition with a much higher prevalence than had previously been assumed, but
symptoms can be mistaken for anxiety.
• People with OCD commonly use substances that reduce their levels of anxiety, but may not
necessarily reveal their use of AOD to health professionals.
• There are considerable problems associated with the use of medications obtained from the internet.
• There is a need to monitor ongoing physical health complications of comorbid disorders.
PTSD
Heading
Goes here
Ipsandi te nus, omnime corat verum
nam vitecup tatem. Nam quaero ea
ipsam quidem aut audandelique apisit
eosapid itaturi tatendi tasperrum que
est laborum rest, esecte nis rem sit
aspe quas experit re et ulpa.
Trauma and post traumatic stress disorder (PTSD)
Clinical presentation
Trauma refers to an experience in which a person is exposed to, witnesses, or is confronted with a situation
in which they perceive that their own, or someone else’s, safety is at risk [24]. Trauma may be a one-off
event or it may have occurred over a period of time. Examples of traumatic events include (but are by no
means limited to) combat exposure, being in a place of war, experiencing a natural disaster (e.g., fire, flood),
actual or threatened physical or sexual assault, being in a life-threatening accident, being kidnapped, taken
hostage, or threatened with a weapon, or witnessing any of these events.
Reactions following exposure to a traumatic event are varied, and can include anxiety or fear-based
symptoms, aggression or anger-based symptoms, or dissociative symptoms. Although behavioural
disturbances following a traumatic event are to be expected, for some people, the reaction to the event
can result in prolonged and significant distress, as well as impaired social and occupational functioning
[698]. Symptoms may be especially long-lasting when the trauma is interpersonal and intentional (e.g.,
torture, sexual violence), and if the trauma occurred in childhood [805]. Following exposure to a traumatic
event, an individual may experience symptoms of PTSD (described in Chapter A4) such as:
• Recurrent ‘re-experiencing’ of the traumatic event, through unwanted and intrusive memories,
recurrent dreams or nightmares, or ‘flashbacks’.
• Persistent avoidance of memories, thoughts, feelings or external reminders of the event (such as
people, places or activities).
• Persistent negative mood, and feeling a distorted sense of blame of self or others, or feeling detached
from others, and less interested in activities.
• Persistent symptoms of increased physiological arousal, including hypervigilance towards distressing
cues, sleep difficulties, exaggerated startle response, increased anger and concentration difficulties.
As mentioned in Chapter B2, it is crucial that clients are not forced to discuss any details about past events
if they do not wish to. It is preferable that clients develop good self-care and have skills to regulate their
emotions before they delve deeply into their traumatic experiences or are exposed to the stories of others;
however, choice and control should be left to the client [281]. In-depth discussion of a person’s trauma
experiences should only be conducted by someone who is trained in dealing with trauma responses [346].
Table 43: Dos and don’ts of managing a client with trauma-related symptoms
Do:
3 Display a comfortable attitude if the client chooses to describe his/her trauma experience.
3 Give the client your undivided attention, empathy and unconditional positive regard.
3 Normalise the client’s response to the trauma and validate his/her feelings.
3 Praise the client for his/her resilience in the face of adversity.
3 Praise the client for having the courage to talk about what happened.
3 Use relaxation and grounding techniques where necessary.
3 Educate the client on what to expect if they undergo detoxification (e.g., a possible increase in
trauma-related symptoms).
3 Maximise opportunities for client choice and control over treatment processes.
3 Monitor depressive and suicidal symptoms.
Don’t:
Adapted from Ouimette and Brown [815], Elliot et al. [281], and Marsh et al. [346].
Brief psychoeducation about common reactions to trauma and symptom management has also been
found to be of benefit to AOD clients who have experienced trauma [816]. It is important to normalise
clients’ feelings and convey that such symptoms are a typical and natural reaction to an adverse traumatic
event; they are not ‘going crazy’. Letting them know that their reactions are quite normal may also help to
alleviate some of the shame and guilt they have been feeling about not recovering from the trauma sooner.
It is also important that trauma sufferers hear that what happened was not their fault, especially for those
who have experienced sexual assault. An information sheet for clients on common reactions to trauma is
provided in the Worksheets section of these Guidelines. Clients may also find the relaxation techniques
described in Appendix U useful for managing trauma symptoms.
Elliot and colleagues [281] also identify a number of measures that can be taken at a service level to help
prevent the amplification of trauma symptoms. Staff approaches, programs, procedures, and the physical
setting can be modified to create a place perceived as safe and welcoming. Such an environment is one
in which there is sufficient space for comfort and privacy, the absence of exposure to violent or sexual
material (e.g., staff should screen the magazines in the waiting area) and sufficient staffing to monitor
the behaviour of others that may be perceived as intrusive or harassing. Many common procedures and
As discussed in Chapter B7, it is also essential that workers attend to their own responses to working with
traumatised clients through self-care. Hearing the details of other’s trauma can be distressing, and in some
cases may lead to vicarious traumatisation or secondary traumatic stress [817]. By attending to one’s own
self-care and engaging in clinical supervision, the likelihood of developing secondary traumatic stress may
be reduced. Chapter B7 provides more detail on strategies for promoting and enhancing AOD worker self-
care and reducing burnout.
Treating PTSD
People with co-occurring PTSD and AOD use are often considered more difficult to treat than people
with either condition alone [89, 818]. Comorbid PTSD and AOD use is associated with difficulties recruiting
and retaining clients in treatment, poor treatment adherence and outcomes, as well as less time spent
abstinent post-treatment [89, 819-821].
Due to the inter-relatedness of PTSD and AOD use, experts recommend that these conditions be treated
in an integrated fashion [281, 822-824]. Some clinicians maintain the view that the AOD use must be
treated first [825, 826], or that abstinence is necessary before PTSD diagnosis and management can be
attempted [825]. In practice however, this approach can lead to clients being passed between services with
little coordination of care [827]. Ongoing AOD use may impede therapy, but it is not necessary to achieve
abstinence before the commencement of PTSD treatment [31]. Improvements can be obtained even in the
presence of continued substance use [828, 829].
There are several treatment options available for the treatment of PTSD, including psychotherapy (e.g.,
past- and present-focused therapies), pharmacotherapy, e-health interventions, physical activity, and
complementary and alternative therapies (e.g., yoga). The evidence base surrounding each of these
treatments is discussed below.
Psychotherapy
A number of psychotherapeutic interventions have been developed for the treatment of comorbid
PTSD and AOD use over the two decades; however, few have undergone rigorous evaluation. Existing
approaches may be divided into two types: past-focused and present-focused therapies [824, 830, 831].
A recent Cochrane review concluded that individual past-focused psychological interventions delivered
alongside AOD treatment can reduce PTSD severity and AOD use, but that there is very little evidence to
support the use of present-focused individual or group-based interventions [832].
Past-focused therapies
Past-focused therapies are typically delivered individually, and include the use of exposure techniques
in which the client is exposed to reminders of the trauma. Exposure-based treatments have long been
considered the ‘gold standard’ in treating PTSD [833, 834]. Similar to exposure for phobias, exposure
therapy for PTSD involves gradual exposure to the feared object or situation; in this case, traumatic
memories. Traditionally, exposure therapy for PTSD was considered inappropriate for people with AOD use
A number of clinical researchers have begun investigating the efficacy of integrated exposure-based
programs that address PTSD and AOD use simultaneously. Typically this involves psychoeducation
regarding each disorder and their interrelatedness, coping skills training, relapse prevention, and imaginal
and/or in vivo exposure (i.e., exposure to memories and physical reminders of the trauma respectively)
[288, 838-840]. Support for these programs is growing, with an increasing number of studies providing
evidence for their safety and efficacy. Participants in these studies did not demonstrate a worsening of
symptoms or high rates of relapse; on the contrary, they demonstrated improvements in relation to both
AOD use and PTSD outcomes [828, 829, 839, 841, 842]. However, the extant research is largely limited to
small pilot studies, with only two large RCTs published to date, both of which were conducted in Australia
[828, 829].
Mills and colleagues [828] examined the efficacy of an integrated exposure-based therapy called COPE
among individuals with a range of AOD use disorders. The authors found that COPE led to significantly
greater reductions in PTSD severity compared to treatment as usual for AOD use, at that this reduction
in PTSD symptoms was accompanied by significant reductions in AOD use and severity of dependence.
A detailed guide to this treatment has been published by Back and colleagues [288]. Sannibale and
colleagues [829] compared the efficacy of integrated CBT for PTSD and alcohol use with supportive
counselling for alcohol use. Participants who had received one or more sessions of exposure therapy
exhibited a twofold greater rate of clinically significant change in PTSD severity compared to those who
receive supportive counselling.
In a more recent RCT, Foa and colleagues [837] examined the efficacy of exposure therapy and concurrent
naltrexone in treating PTSD and alcohol use disorders. Exposure therapy was not found to be superior
to supportive counselling in reducing PTSD symptoms: however, it was associated with reduced risk of
relapse at 6-month follow-up. Although no studies have directly compared concurrent treatment with
integrated treatment, the results of these trials indicate that integrated treatment may be more efficacious
in the treatment of this comorbidity than concurrent treatment.
Present-focused therapies
Present focused therapies are typically integrated CBT-based treatments which focus on providing clients
with coping skills without revisiting the traumatic event [830]. These interventions are typically delivered
in individual or group formats. As mentioned previously, a recent Cochrane review concluded that there
is very little evidence to support the use of present-focused individual or group-based interventions
[832]. Similarly, in their narrative review of integrated treatments for PTSD and AOD use disorders, van
Dam and colleagues [831] concluded that there was no convincing evidence for the use of integrated
present-focused treatments over routine AOD treatment. Several present-focused treatments have been
developed [843], but that which has undergone the most extensive evaluation is Seeking Safety [395].
Seeking Safety aims to help people attain safety from trauma/PTSD and AOD abuse. The treatment has
been conducted in group and individual format in a variety of settings (outpatient, inpatient, residential).
Two RCTs have found that the outcomes for individuals who receive Seeking Safety are comparable to
those who receive relapse prevention or health education in terms of their AOD use and PTSD symptoms
[844, 845]. More recently, Boden and colleagues found [846] improved AOD outcomes for Seeking Safety
relative to treatment as usual, but no difference between groups in regards to PTSD outcomes. Further
information and training materials may be found at www.seekingsafety.org.
Pharmacotherapy
Australian guidelines for the treatment of PTSD [847] recommend that pharmacotherapies be used as an
adjunct to trauma-focused CBT if the person has not gained benefit from psychological treatment. There
is, however, little evidence to suggest that combining psychological and pharmacological interventions
leads to improved outcomes. When pharmacotherapies are considered, SSRIs are the recommended first
line option (see Table 38). The use of mirtazapine and TCAs is recommended only as a second-line option,
and phenelzine may be considered for people with treatment-resistant symptoms. However, as noted
previously, extreme caution should be used when be prescribing TCAs and MAOIs.
Trials of pharmacotherapy for PTSD comorbid with AOD use disorders have examined the use of
the antidepressants sertraline, desipramine, and paroxetine, as well as naltrexone and disulfiram,
pharmacotherapies for alcohol use disorders [837, 849-853]. Early work by Brady and colleagues
examining the use of sertraline provided initial evidence of safety and evidence of efficacy among people
with less severe alcohol dependence and earlier onset PTSD [849, 850]. More recently, Hien and
colleagues [851] investigated the use of sertraline in combination with the psychotherapy Seeking Safety.
In this study,
Seeking Safety plus sertraline was found to be superior to Seeking Safety with placebo in reducing PTSD
symptoms. Improvements in alcohol use and dependence were equivalent between groups.
Petrakis and colleagues [852] conducted an RCT comparing the efficacy of desipramine (a noradrenergic
antidepressant) and paroxetine (a serotonergic antidepressant) with and without adjunctive naltrexone
among veterans with comorbid PTSD and alcohol dependence. Both groups of antidepressants produced
a significant decrease in PTSD symptoms, with greater reductions in alcohol use seen among those who
received desipramine. Adjunctive use of naltrexone was associated with a greater reduction in craving,
but did not confer any advantage over placebo in terms of alcohol use. These findings are contrary to
those found in Foa and colleagues [837] who found naltrexone to be associated with both reductions in
craving and alcohol use among individuals with this comorbidity.
Petrakis and colleagues [853] also investigated the use of naltrexone and disulfiram, administered either
alone or in combination, compared with placebo. All groups demonstrated equivalent improvement in
PTSD symptomology, but the use of either naltrexone, disulfiram, or the combination of these
medications led to greater improvements in alcohol use than placebo. However, unwanted side effects
were more common among individuals who received the combination of naltrexone and disulfiram.
There are currently no e-health programs that focus on comorbid AOD use disorders and PTSD. There is,
however, some evidence that internet-delivered therapy, either as the sole treatment or with the support
of a therapist, can be somewhat beneficial in reducing PTSD symptoms, particularly if supported by low-
level clinical care [847]. Internet programs that have been shown to have moderate treatment effects have
employed CBT techniques, in the form of psychoeducation, exposure (often in the form of writing about
one’s trauma experience), anxiety management, and cognitive restructuring. In particular, two Australian
programs – PTSD online and PTSD program – have shown particular promise [740, 854]. Notably, both
programs provide links to psychoeducation on AOD use.
PTSD program comprises seven online lessons, a summary/homework assignment for each lesson, an
online discussion forum for each lesson moderated by the therapist, regular automatic reminder and
notification emails, and instant messaging to allow secure messaging with a clinician. In a small RCT,
Spence and colleagues [854] found significantly greater reductions in PTSD symptom severity among
individuals randomised to receive PTSD program compared to waitlist control. Individuals who received
PTSD program also reported high levels of satisfaction with the treatment.
More recently, mobile apps for PTSD have begun to be developed. PTSD Coach, in particular, has
demonstrated initial promise. Developed by the US Department of Veterans Affairs to help individuals who
have PTSD symptoms better understand and self-manage their symptoms [857], PTSD Coach is based on
evidence-based CBT principles and can be used both as a stand-alone application as well as a supportive
application during therapy. It consists of psychoeducation, self-assessment, information about referral and
treatment, CBT-based exercises to reduce negative trauma-related cognitions, and tools to strengthen
social support and psychological resilience. An online version of the application is also available (http://
www.ptsd.va.gov/apps/PTSDCoachOnline/). A study examining user satisfaction, perceived helpfulness,
and usage patterns among veterans receiving PTSD treatment found that participants were very satisfied
with PTSD Coach and perceived it as being moderately to very helpful in managing their PTSD symptoms
[858]. These findings offer preliminary support for the acceptability and perceived helpfulness of PTSD
Coach and suggest that it has potential to be an effective self-management tool for PTSD. Although
promising, future research and validation is needed.
Physical activity
A small number of uncontrolled pilot studies have found aerobic exercise to be associated with
improvements in PTSD symptoms [859-862]. Promising findings were also provided by a small controlled
trial which found greater reductions in PTSD symptoms among individuals randomised to receive exposure
therapy with exercise augmentation compared to those randomised to receive exposure therapy alone
[863]. A more rigorous evaluation of the impact of exercise on PTSD symptoms was recently completed
in Australia. Rosenbaum and colleagues [864] compared the efficacy of a 12-week exercise program
(consisting of three 30-minute resistance-training sessions per week and a walking program) provided as
an adjunct to inpatient care for PTSD, to inpatient care alone, in an RCT. Individuals randomised to receive
Yoga
A recent review of the literature concluded that yoga appears to have benefits for individuals with PTSD,
particularly in relation to hyperarousal symptoms [865]. The predominance of research to date has
consisted of small, uncontrolled pilot studies; however, a recently completed RCT provides stronger
evidence in support of yoga as an alternative therapy for PTSD. van der Kolk and colleagues [866]
compared the efficacy of a 10-week yoga program to supportive health education (both delivered for one
hour per week) among women with chronic treatment resistant PTSD. Significantly greater reductions in
PTSD symptom severity were observed among those randomised to undertake yoga compared to the
supportive health education program, with effect sizes comparable to those observed for well-established
psychological and pharmacological interventions. At the end of the program, 52% of those in the yoga
group no longer met criteria for PTSD compared to 21% in the control group. The authors suggest that yoga
may improve the functioning of traumatised individuals by helping them to tolerate physical and sensory
experiences associated with fear and helplessness and to increase emotional awareness and affect
tolerance [866].
Studies examining the efficacy of yoga among individuals with comorbid PTSD and AOD use disorders are
lacking; however, there is some evidence to suggest that yoga may be beneficial among individuals with
this comorbidity. A small Australian RCT comparing a multicomponent yoga breath program to waitlist
control among heavy drinking male veterans found a significantly greater reduction in PTSD symptoms
in the yoga group compared to waitlist control, and a corresponding small, non-significant reduction in
alcohol use [867]. Another small trial of women with subthreshold and diagnostic levels of PTSD examined
the impact of yoga on AOD use. Reductions in risky AOD use were observed; however, this study excluded
women with AOD use disorders [868]. Further research among individuals with comorbid PTSD and AOD
use disorders is needed, as well as research to determine the best style of yoga, and the optimal frequency
and duration of practice.
Summary
The importance of providing trauma-informed care in the context of AOD treatment is now well recognised.
Due to the inter-relatedness of PTSD and AOD use, an integrated approach to the treatment of these
disorders is recommended. Several psychotherapeutic interventions have been developed for the
treatment of comorbid PTSD and AOD use; but few have undergone rigorous evaluation. The evidence
to date suggests that individual past-focused psychological interventions delivered alongside AOD
treatment show most promise. There is little evidence to support the use of present-focused individual or
group-based interventions. Findings from pharmaceutical trials indicate that pharmacotherapies (SSRIs in
particular) may be a useful adjunctive treatment if sufficient benefit has not been gained from psychological
interventions. E-health interventions, physical exercise and yoga also appear to convey benefit among
individuals with PTSD; however, further research is needed to determine efficacy in PTSD populations and
individuals with comorbid AOD use disorders in particular. Box 19 illustrates the continuation of case study
G, following Emily’s story after identification of her PTSD disorder was made.
Case Study G: Treating comorbid PTSD and AOD use: Emily’s story
continued
While Emily was an inpatient, the psychologist took the opportunity to talk with her a little more
about her past trauma, continuing to normalise her symptoms, providing psychoeducation and self-
management techniques, and exploring the relationship between her trauma-related symptoms and
her substance use. The psychologist suggested that Emily might like to try a residential rehabilitation
program for women only, where her trauma-related symptoms could also be addressed. Emily had
previously been reluctant to enter residential rehabilitation but she had not ever heard of a women’s-
only service.
The psychologist organised for a telephone assessment with the residential program, and Emily entered
the program following her detoxification. While the program was hard, Emily benefited greatly from the
trauma-informed approach taken by the service. Importantly, Emily felt safe and over time gradually
opened up more about her life. She engaged in a combination of group and individual therapy. Her
individual therapy in particular focused on providing integrated treatment for both her PTSD and AOD
use.
It was during one of these sessions that Emily made a link between the onset of her substance use and
previous traumatic events. Unbeknownst to the therapist or any other treatment provider, Emily had
been sexually abused by a male relative from the age of 5 to 11 years when she left home to live with
her grandparents. Emily drank cough medication when she was little as it made her feel good when
she was upset. She also reported using her father’s Valium. After moving to her grandparents’ house,
which also involved a change of schools, she starting hanging out with new friends who liked to drink
and smoke cannabis. Her substance use and truancy from school caused continual fights with her
grandparents, who threw her out when she was 16 years old. Emily quit school and moved into a shared
house with people who introduced her to heroin around age 17. Within a year she had developed a
‘habit’.
As Emily’s treatment progressed, she began to open up about numerous assaults, including rapes,
which had occurred in the context of the drug-using environment, but did not report any PTSD
symptoms in relation to these experiences. While she was clean she was also involved in a car accident.
She suffered major injuries and was not able to get into a car for 2 ½ years. She reported residual
trauma symptoms, and had previously worked with a psychologist on this. Her therapy continued to
concentrate on the domestic violence, for which she was currently experiencing the most distress, and
later the sexual abuse she experienced as a child. Emily was aware that it would likely take a long time
for her to come to terms with what she had experienced. Emily successfully completed the residential
rehabilitation program, and continued to receive ongoing psychological treatment for her PTSD and
substance use.
Key points:
• Symptoms of PTSD and other mental disorders may only become apparent during AOD treatment.
• Many clients have experienced multiple traumas and re-victimisation.
• It is recommended that treatments for PTSD and AOD use should be carefully integrated.
ED
nam vitecup tatem. Nam quaero ea
ipsam quidem aut audandelique apisit
eosapid itaturi tatendi tasperrum que
est laborum rest, esecte nis rem sit
aspe quas experit re et ulpa.
Eating disorders (ED)
ED (i.e., anorexia nervosa, bulimia nervosa, binge eating disorder) and AOD use frequently co-occur [869].
The co-occurrence of ED and AOD use disorders is particularly complex and challenging, in terms of
assessment and treatment, associated physical health complications, and the potential negative cognitive
impacts of both disorders [870]. Assessment can be made even more difficult by a tendency of people with
ED to minimise or deny symptoms, due to deliberate deception or a genuine lack of self-awareness [871]. It
is however, important that this comorbidity be identified; the consequences of comorbid ED and AOD use
are severe, and can include medical complications [872], additional, severe psychiatric comorbidities [873-
875], suicidal ideation and attempts [874, 876], and mortality [877, 878].
It is vital for AOD workers to be able to recognise the clinical and subthreshold signs of ED, and have some
knowledge about simple management strategies.
Clinical presentation
ED are characterised by disturbances in eating behaviours and food intake that impair psychosocial
functioning and/or physical health. This may involve:
• Food restriction (e.g., limiting the amount of food eaten each day by reducing portion size, eliminating
food types such as fats or carbohydrates, or not eating at all).
• Vomiting and purging.
• Overexercise.
• Binge eating (i.e., consuming an objectively large amount of food in a short period of time,
accompanied by a sense of feeling out of control).
The majority of the physical symptoms associated with ED are related to the effects of starvation, but
are also due to effects of bingeing, purging, or overexercising [879]. People with ED, particularly bulimia
nervosa, may show few outwards signs of their disorder [880], and any visible physical signs may be
complicated by AOD use. For example, AOD use can influence features that are usually associated with
the assessment of EDs, such as weight, appetite and food restriction [880]. Furthermore, people with an
ED may experience eating-related symptoms which are similar to those associated with AOD use, such
as cravings and patterns of compulsive use [24]. AOD workers should therefore endeavour to maintain a
direct, non-judgemental approach during assessment, and seek to obtain as much additional information
as possible (e.g., from family and/or friends with the client’s consent) [881]. The level of care required will be
dependent on illness severity, the presence of any medical complications, dangerousness of behaviours,
and any other psychiatric comorbidities (e.g., depression, anxiety) [882].
AOD workers should also be aware of the potential interplay between ED and AOD use, and keep this in
mind when conducting assessments. There may be AOD use related to the ED; for example, the use of
tobacco, stimulants, diet pills, laxatives, diuretics, or caffeine to control weight or supress appetite [883]. As
such, assessment should include a focus on the use of AOD as a weight loss mechanism, as well as the
role it may have in emotion regulation [884].
Symptoms of ED
Anorexia nervosa
The most profound clinical feature of anorexia nervosa is dramatic weight loss. Anorexia nervosa can be
conceptualised as a disorder of control and denial; the rigid control of food intake and weight is thought to
cause or prevent a life event or mood (e.g., attract romance, reduce anxiety, deter abuse) [885]. Although
• Fatigue.
• Low blood pressure.
• Abdominal pain or discomfort, constipation.
• Cold sensitivity or intolerance.
• Lethargy or hyperactivity.
• Loss of hair.
• Dry skin.
• Lanugo hair on the body (e.g., fine hairs on the back, face, arms).
• Bruising.
• Loss of menstruation.
• Dehydration.
• Neurological abnormalities.
• Osteoporosis.
• Slowed heart rate.
A thorough assessment of anorexia nervosa needs to include a comprehensive physical exam in order
to identify any potential medical complications or other abnormalities that require immediate medical
attention [882].
Bulimia nervosa
• Fatigue.
• Bloating and constipation.
• Abdominal pain and distension.
• Calloused knuckles.
• Hoarse voice.
• Delayed digestion.
• Hypokalaemia (low potassium).
• Muscle spasms.
• Heart palpitations.
• Nausea.
• Poor kidney function.
• Dental erosion.
The DSM-5 has classified binge eating disorder as an independent ED [24], for episodes of binge eating
which occur without compensatory weight control methods. As with bulimia nervosa, binge eating disorder
is accompanied by the sense of loss of control, which can include eating until uncomfortably full, eating
more quickly than normal, eating when not physically hungry, eating in isolation, and feeling disgusted
or guilty afterwards [24, 882]. Care should be taken not to confuse binge eating disorder (a psychiatric
condition) with obesity (a medical condition), even though they may physically resemble each other.
Symptoms include [882]:
• Obesity.
• Hyperlipidaemia (elevated lipids in the blood).
• Type 2 diabetes.
Common to anorexia nervosa, bulimia nervosa and binge eating disorder are a dysfunctional system of
evaluating a person’s self-worth, which, rather than being based on personal qualities and achievements
across various domains (e.g., academic accomplishments, athletic ability, work achievements, values,
relationship qualities), is focused on weight, size, shape and appearance [888]. People with bulimia nervosa
and binge eating disorder experience feelings of loss of control over their eating, and are at increased risk
of additional psychiatric comorbidities. In bulimia nervosa, binge eating is thought to result from severely
restricting food intake, but those with binge eating disorder do not illustrate the same intake restrictions
between binge episodes [882].
Managing ED
Despite the differences between ED in terms of clinical characteristics and observable symptoms, there
are some strategies that AOD workers can utilise to manage these disorders. The general principles
of managing and treating ED should include the establishment of a trusting, collaborative, therapeutic
relationship, taking care to avoid any potential power struggles [889]. The techniques outlined in Table 44
may help AOD workers to manage clients with ED symptoms.
Table 44: Dos and don’ts of managing a client with symptoms of eating disorders
Do:
3 Encourage and emphasise successes and positive steps (even just coming in for treatment).
3 Take everything they say seriously.
3 Approach the client in a calm, confident and receptive way.
3 Be direct and clear in your approach.
3 Use open-ended questions such as ‘So tell me about...?’ which require more than a ‘yes’ or ‘no’
answer. This is often a good way to start a conversation.
3 Constantly monitor suicidal thoughts and talk about these thoughts openly and calmly.
3 Encourage the client to express his/her feelings.
3 Focus on feelings and relationships, not on weight and food.
3 Be available, supportive and empathetic.
3 Encourage participation in healthy, pleasurable and achievement-based activities (e.g., exercise,
hobbies, or work).
3 Encourage, but do not force, healthy eating patterns.
3 Assist the client to set realistic goals.
3 Involve family or friends in management or treatment strategies.
3 Be patient in order to allow the client to feel comfortable to disclose information.
3 Explain the purpose of interventions.
Don’t:
Adapted from NSW Department of Health [277], Clancy and Terry [296], and World Health Organisation
Collaborating Centre for Evidence in Mental Health Policy [879].
Treating ED
ED are complex psychiatric illnesses that impair psychological, social and physical functioning. It has been
argued that the treatment of comorbid ED and AOD use should be provided using an integrated approach
to minimise the potential for deterioration in one disorder when symptoms of the other improve [873, 890].
Regardless of the eventual treatment plan, the assessment of ED should involve a multidisciplinary team
of health and mental health workers, and include a thorough physical exam (with blood tests) to identify
complications that may need immediate attention and/or hospitalisation [882, 883, 891]. There is limited
evidence about the concurrent treatment of ED and AOD use disorders [892].
There are several treatment options available for the treatment of ED alone, including psychotherapy,
pharmacotherapy, e-health interventions, physical activity, as well as complementary and alternative
therapies. The evidence base surrounding each of these treatments is discussed below, in regards to each
ED.
The treatment of anorexia nervosa should begin with a comprehensive assessment, evaluating both
medical and psychiatric risks. This process should be ongoing throughout treatment, as clinical needs and
priorities of the client may change [893]. Clinical practice guidelines on the treatment of ED from the Royal
Australian and New Zealand College of Psychiatrists [893, 894] recommend that the initial assessment of
anorexia nervosa incorporate the following information:
• Collection of a thorough history (including dietary restrictions, weight loss, disturbances in body image,
fears about weight gain, bingeing, purging, excessive exercise, use of medications or AOD to lose
weight or suppress appetite).
• Investigate medical complications and assess level of risk (physical exam to assess BMI, heart rate,
blood pressure, temperature, metabolic tests).
• Psychiatric comorbidity.
• Cognitive changes due to starvation (e.g., slowed thought processing, difficulty concentrating).
• Possible contributing factors (e.g., family history of ED, developmental difficulties, dieting or other
weight loss causes).
Psychotherapy
Currently, there are no evidence-based psychotherapies for the treatment of anorexia nervosa, either as a
single disorder or comorbid with AOD use disorders [882]. The efficacy of psychotherapy in the treatment
of ED comorbid with AOD use has not been examined [884]. In terms of single disorder anorexia nervosa,
the most evaluated interventions, and those with the highest levels of theoretical support, include CBT and
CBT-enhanced (CBT-E), focal psychodynamic therapy, interpersonal psychotherapy (IPT), and cognitive
analytic therapy [896]. Other treatments include specialist supportive clinical management (SSCM), the
Maudsley model of anorexia nervosa treatment for adults (MANTRA), MI, and other psychodynamic
approaches [893]. There is, however, limited empirical evidence to support any of these treatments [893].
CBT-E is an extension of CBT and is focused on educating clients about being underweight and
starvation, and assists with the initiation and maintenance of regular eating patterns. Included in the
therapy are components that focus on self-efficacy and self-monitoring, which are thought to be crucial
to the treatment [897]. Focal dynamic therapy focuses on therapeutic alliance, pro-anorectic behaviour,
self-esteem, behaviours viewed as acceptable, associations between interpersonal relationships and
eating, and the transfer back to everyday life [897]. A large RCT comparing CBT-E and focal dynamic
psychotherapy to optimised treatment as usual (defined as outpatient psychotherapy and structured care
from a family doctor) over 10 months found that all groups demonstrated substantial weight gains, with
no difference between groups in regards to BMI [897]. Despite no treatment differences, those in the focal
psychotherapy group had higher rates of recovery compared to optimised treatment as usual at 12 months
follow-up.
Another RCT comparing CBT, IPT and SSCM for single disorder anorexia nervosa found that significantly
more of those in the SSCM group no longer met diagnostic criteria for anorexia nervosa (36%), compared
to those in the CBT group (8%) and IPT group (0%) at the conclusion of treatment [898]. However, at seven
years follow-up, there were no significant differences between groups. SSCM combined features of clinical
management and supportive psychotherapy including education, care, support, fostering of a therapeutic
relationship, praise, reassurance, and advice. A central feature of SSCM is a focus on the abnormal
nutritional status and dietary patterns typical of anorexia nervosa. Normalisation of eating and restoration of
weight are emphasised, and clients are provided with information on a range of strategies to promote this.
IPT is a structured, dynamic intervention, focused on addressing interpersonal and relationship difficulties
[898, 899].
MANTRA is a more recently developed social-cognitive IPT that draws on MI, cognitive remediation and
the involvement of carers. It focuses on addressing intrapersonal and interpersonal processes that are
thought to be fundamental to the maintenance of the disorder. An RCT examining the efficacy of MANTRA
found that it was no more effective than SSCM, and recovery rates were low in both groups [900]. Although
there is a lack of clear evidence, there are several large RCTs that are currently being conducted for single
disorder anorexia nervosa, evaluating the efficacy of CBT, couples-based CBT, ERP (described previously in
relation to the treatment of OCD), SSCM, focal psychodynamic therapy, and cognitive remediation therapy
[893, 901].
Pharmacotherapy
Research suggests that pharmacotherapy alone should not be the primary treatment for single disorder
anorexia nervosa [893, 902]. Although atypical antipsychotics (see Table 33), SSRIs (fluoxetine), and
olanzapine have been used in clinical settings, research indicates there is no conclusive evidence of any
effect on the primary psychological features of anorexia nervosa or weight gain [882]. Nonetheless, it has
been suggested that olanzapine is currently the best pharmacotherapy available for anorexia nervosa,
particularly for those who cannot access other intensive treatments [903]. A comprehensive review of
pharmacotherapy for single disorder anorexia nervosa found that olanzapine increased weight gain and
improved depression, anxiety, aggression and obsessive-compulsiveness [904]; however, the evidence
is weak and there is the possibility of adverse side effects [893]. No studies to date have examined the
efficacy of the pharmacological treatment of comorbid anorexia nervosa and AOD use disorders.
As with the approach to treating anorexia nervosa, the Australian clinical practice guidelines for single
disorder ED recommend that treatment for bulimia nervosa begins with a comprehensive assessment
which includes [893]:
• Inquiry into behaviours; especially binge eating (i.e., uncontrolled episodes of overeating excessive
amounts of food), weight control behaviours that may compensate for binge eating (e.g., self-induced
vomiting, laxative/diuretic use, restricting food intake, overexercising, use of AOD to control weight).
• Cognitions of weight/shape overvaluation, and preoccupations with body image and/or eating.
The increased risk of medical complications, particularly obesity, Type 2 diabetes, and hypertension, makes
physical assessment among those with suspected bulimia nervosa essential [905]. As with the physical
assessment of those with anorexia nervosa, this should include weight, height, pulse rate, blood pressure
and BMI. Additional tests should be undertaken to assess for hypokalaemia and dehydration (associated
with purging behaviours), cardiac function (e.g., electrocardiogram), and glucose levels, as indicated [893].
If psychological treatment is being provided by a clinician without medical training, the Australian clinical
practice guidelines for single disorder ED recommend the inclusion of a GP to assist with assessment and
ongoing care [893].
Psychotherapy
There is very little evidence about the concurrent treatment of AOD use and bulimia nervosa, due in part
to the exclusion of those with AOD use disorders from controlled psychotherapy trials for bulimia nervosa
(and ED more broadly) [892, 906]. There is, however, some evidence to suggest that treating a person’s
AOD use disorder may lead to improvements in bulimia nervosa [892]. O’Malley and colleagues [907]
conducted an RCT of treatments for women with alcohol dependence, in which they compared the efficacy
There are currently three evidence-based treatments for bulimia nervosa as a single disorder, including
CBT, IPT, and DBT, in addition to preliminary evidence for integrative cognitive-affective therapy [892].
There is robust evidence supporting a CBT treatment approach [908, 909], with both national and
international clinical guidelines recommending the use of CBT as the first line of treatment [893, 902, 910].
On average, an estimated 30–50% of patients treated with CBT attain binge-purge abstinence [911, 912],
with treatment usually consisting of 12–20 sessions over 3–5 months. Further, CBT appears to be superior
to pharmacotherapy (i.e., antidepressants) for achieving abstinence in single disorder bulimia nervosa, and
improvements have also been observed in psychiatric comorbidities such as depression, self-esteem and
social functioning [913].
Despite the high rates of remission, some clients with bulimia nervosa remain symptomatic after
completing treatment [892]. As such, an enhanced version of CBT (CBT-E, mentioned previously [914])
was developed and found to be more efficacious than other CBT approaches. CBT-E addresses other
features that often co-occur with bulimia nervosa, including low self-esteem, clinical perfectionism, mood
intolerances, and interpersonal difficulties [888]. The first controlled trial of CBT-E among people with
bulimia nervosa suggests that it may be a promising treatment for complex cases of bulimia nervosa [915].
IPT has been found to be as effective as CBT in the treatment of bulimia nervosa and binge eating disorder
as single disorders [916]. DBT has also been found to be effective in the treatment of single disorder bulimia
nervosa [882], and incorporates cognitive behavioural change strategies with mindfulness strategies to
address interpersonal effectiveness, self-acceptance, self-regulation, and distress tolerance. It has been
suggested that this treatment has promise for the treatment of other comorbid psychiatric disorders [917],
including comorbid AOD use [400].
Integrative cognitive-affective therapy utilises components from CBT, IPT and DBT into the treatment
of single disorder bulimia nervosa [918]. The treatment focuses on personality and attitude as well as
the symptoms of bulimia nervosa and behavioural change, and addresses interpersonal insecurity,
self-perception, low self-esteem and negative affectivity [882]. An RCT comparing integrative cognitive-
affective therapy to CBT-E found improvements in both groups with no significant differences between
groups at four months follow-up [919].
Pharmacotherapy
Meta-analyses and RCTs have found that TCAs (such as those listed in Table 38) may be efficacious for
people with single disorder bulimia nervosa [920, 921], but they are accompanied by side effects which limit
their utility. High dose fluoxetine, or other SSRIs, as well as the antiepileptic drug topiramate, have been
found to be efficacious for both bulimia nervosa and binge eating disorder [893]. Although the Australian
clinical guidelines for the treatment of ED recommend the use of antidepressants or antiepileptics (such
as topiramate) when psychological treatment is not available, they highlight the fact that pharmacotherapy
trials have rarely followed-up study participants over the long term, suggesting that the consequences of
long-term use and duration of recommended pharmacotherapy treatment remain unknown [893]. There is
evidence that supports the combination of both psychotherapy and pharmacotherapy [920, 921], although
findings are not consistent. Despite the fact that SSRIs have been used to effectively treat people with
bulimia nervosa and people with alcohol use disorders [884], there have been no RCTs that have examined
the efficacy of pharmacotherapy among people with comorbid bulimia nervosa and AOD use disorders.
The Australian clinical practice guidelines for single disorder ED recommend the same comprehensive
assessment for binge eating disorder as those described for bulimia nervosa [893].
Psychotherapy
Similar to bulimia nervosa, the first line of recommended treatment for addressing single disorder binge
eating disorder is CBT [893]. The Australian clinical guidelines for the treatment of single disorder ED have
combined recommendations for both bulimia nervosa and binge eating disorder, and, as with bulimia
nervosa include CBT, DBT and IPT [882, 893]. These psychological approaches are argued to be the
treatments of choice for binge eating disorder [922, 923], resulting in the greatest rates of remission and
improvements in associated psychopathology [911, 924]. As with single disorder bulimia nervosa, CBT has
been found to be more effective than pharmacological interventions for the treatment of binge eating
disorder [925, 926]. However, to date, no studies have examined psychotherapy for people with binge
eating disorder comorbid with AOD use.
Pharmacotherapy
To date, there have been no studies of pharmacotherapy for comorbid binge eating and AOD use
disorders and limited evidence among those with binge eating as a single disorder. Emerging evidence
suggests that pharmacotherapy may be beneficial for some people with binge eating disorder [927]. RCTs
examining the efficacy of SSRIs (fluvoxamine [928], sertraline [929], fluoxetine [930], and citalopram [931]),
serotonin and noradrenaline reuptake inhibitor (SNRIs; duloxetine [932]), mood stabilisers (topiramate [933-
935]), antiobesity medications (orlistat [936]) and psychostimulants (lisdexamfetamine [937]) have found
reductions in the frequency of binge eating episodes BMI decreases, and overall clinical improvement.
The mood stabiliser topiramate has also been evaluated for efficacy and safety for single disorder binge
eating disorder in several RCTs [933-935]. Although topiramate has been associated with adverse side
effects (e.g., participants dropping out of trials with headache, paresthesias or pins and needles sensations),
these studies found that compared to placebo, topiramate was associated with significantly greater
reductions in binge frequency, BMI and weight loss. Orlistat, an antiobesity medication, has also been
examined for efficacy in three RCTs to date [926, 936, 938]. These trials found that although weight loss was
enhanced with orlistat, the frequency of binge eating was not reduced.
Given the lack of clear evidence, the Australian clinical guidelines for the treatment of ED recommend that
pharmacotherapy be considered when psychotherapy is not available, or as an adjunctive treatment to
psychotherapy. They further recommend that SSRIs be used for binge eating disorder, and topiramate or
orlistat be considered for those with comorbid obesity [893].
E-health interventions
Although there are no e-health interventions for comorbid ED and AOD use disorders there has been some
research conducted into the use of e-health interventions for single disorder ED. A systematic review of
internet-based interventions for single disorder ED (outpatient treatment incorporating an internet-based
component) found that, relative to waitlist control, ED symptoms reduced more successfully for binge
eating than restrictive eating with the use of an internet-based therapy [939]. There is no clear evidence as
to which e-health intervention has the most empirical support, although self-help CBT has been highlighted
as an effective, accessible, time and cost effective alternative to clinician delivered CBT [940]. The majority
of studies have focused on internet-based CBT for bulimia nervosa (rather than anorexia nervosa), with
the online components ranging from e-mail-based therapy, adjunctive internet-based guidance, to online
CBT [939]. The review found that internet-based therapies that were bolstered by face-to-face contact via
A systematic review of smartphone applications for ED identified six interventions [942], with varying levels
of empirically supported content. A second review [943] identified two approaches that had incorporated
empirically supported manual–based psychotherapies, both developed for bulimia nervosa, into
technological platforms [944, 945]. Preliminary findings indicate no substantial differences in effectiveness
between face-to-face CBT and the applications. However, other research has argued that the provision of
self-help via technology without clinical guidance may not be beneficial [946], although the optimal type
and amount of guidance is not known.
Physical activity
The role of exercise as adjunctive therapy for people with ED is controversial, despite the fact that physical
activity can play an important role in both ED and AOD use, in terms of treatment, recovery, and relapse
prevention [947]. The benefits associated with exercise in ED include the promotion of physical activity
and weight loss to people with binge eating disorder [948], and the potential prevention and restoration of
bone mass in people with anorexia nervosa [949]. However, based on the belief that exercise may interfere
with weight gain or reinforce the psychological/pathological symptoms of ED, it is not uncommon for ED
treatment providers to limit the amount of physical activity, allowing little or no exercise [947]. There is also
the potential that physical activity may lead to compulsive ‘overexercising’ [950].
Although physical activity has not been evaluated among people with comorbid ED and AOD use, several
studies have examined exercise in people with single disorder ED and have found moderate physical
activity to be associated with weight gain in underweight people with anorexia nervosa [951, 952]. One
small pilot study has been conducted examining a graded exercise program based on ideal body weight
and percentage body fat, with exercises ranging from stretching, to strengthening and low-impact
cardiovascular exercise three times per week for three months [951]. The exercise group demonstrated
improvements in weight gain as well as quality of life, which were substantially greater than the inactive
control group, whose quality of life decreased over the study period.
Another study examined the effectiveness of an exercise program on weight gain among women with
anorexia nervosa, bulimia nervosa and binge eating disorder in an inpatient treatment facility, and found
that 60 minutes of supervised exercise conducted four times per week was associated with 40% more
weight gain than the inactive control group [952]. The exercises included stretching, yoga, Pilates, strength
training, balance, exercise balls, aerobic exercise (e.g., walking or skipping), recreational games, or other
enjoyable activities [952]. It is suggested that moderate physical activity facilitates weight gain by improving
emotional well-being, increasing appetite, and reducing body-image and appearance-related distress
[947].
Although preliminary evidence supports the positive impact of exercise for people with ED, it remains
unclear as to how clinicians should approach physical activity among underweight people, or people who
may be normal weight but have been treated for compulsive exercise in the past [947]. Despite promising
research, the evidence suggests that caution should be taken when recommending exercise for people
with ED, particularly anorexia nervosa, as the presence of behaviours which are indicative of problematic
exercise may negatively impact on the long-term course of illness [947, 953], and thus, hinder potential
positive outcomes.
Research into complementary and alternative therapies for comorbid ED and AOD use disorders has
examined yoga, acupuncture, therapeutic massage, hypnosis, herbal medicine, light therapy, spiritual
healing, and art therapy [954]. Despite the breadth of research, no intervention has been identified as an
effective, evidence-based treatment for this comorbidity. While the research in this area continues to
develop, there are promising preliminary findings relating to the use of yoga [955-957], hypnosis [958-960]
and therapeutic massage [961, 962].
Summary
Despite much research, there is little evidence upon which to provide clear guidance on the treatment
of comorbid ED and AOD use disorders. Research from single disorder ED suggests that comprehensive
assessments conducted by a multidisciplinary team should be followed by psychotherapy as the first line
of treatment (CBT-based approaches for both bulimia nervosa and binge eating disorder). Although there
is some evidence that pharmacotherapy may be a useful adjunct to the treatment of single disorder ED
(particularly binge eating disorder), the evidence is not conclusive and Australian clinical guidelines do not
recommend its use in the absence of psychotherapy [893]. Box 20 illustrates the continuation of case study
H, following Charlotte’s story after she presented to an AOD service for benzodiazepine and stimulant use.
As illustrated, the presence of a comorbid ED and AOD use disorder is not easily identifiable, and can be
difficult to treat.
Box 20: Case study H: Treating comorbid ED and AOD use: Charlotte’s story continued
After several weeks, in a joint session with Charlotte and her mother, Charlotte’s mother mentioned
that she was still concerned about Charlotte, particularly about her apparent obsession with running up
and down the stairs. When questioned further, Charlotte’s mother said that she had been running up
and down the stairs repetitively, every evening, sometimes for an hour or more. She often did this after
meal times. Earlier in the week Charlotte’s mother found her in the kitchen in the middle of the night and
suspected she had eaten the lasagne and pavlova she had made for the following day’s family meal.
She also thought that she had heard Charlotte vomiting soon after eating.
The AOD worker spoke privately with Charlotte, and Charlotte said that she had been exercising to lose
weight, as she was unhappy with her size and shape, and had been taking the stimulants to stop feeling
hungry. She also said that the stimulants gave her energy throughout the day, although she had trouble
sleeping and often felt agitated and on edge. Charlotte said that she liked taking Valium to help her get
to sleep and calm down. It also became evident that, instead of going to classes at university, Charlotte
had been going to the gym and running on the treadmill. She told the AOD worker that if she was ever
unable to get to the gym at her usual time, she felt incredibly anxious and couldn’t stop thinking about it.
It was not unusual for Charlotte to spend several hours running on the treadmill at the gym every day.
The AOD worker consulted with an ED specialist, who arranged with Charlotte and her mother to attend
an assessment. Charlotte was moderately underweight (with a BMI of 17) and the specialist arranged for
a complete physical assessment, including her heart rate, blood pressure, temperature, metabolic tests,
assessments for any cognitive changes, and contributing factors. Charlotte’s family were encouraged
to maintain involvement with her ongoing treatment, and the specialist devised a plan that included
psychoeducation with her family’s involvement, and MI, medical stabilisation, reversal of the cognitive
effects of starvation, and psychological treatment. However, because of the complexities involved
in Charlotte’s bulimia nervosa, including the use of stimulants and benzodiazepines, the specialist
recommended inpatient treatment at a specialised ED facility.
Key points:
• ED can be difficult to identify in people with AOD use disorders.
• Once an ED has been identified, it is vital that the client receives a comprehensive physical
assessment by a medical professional. The primary focus is on stabilising the client’s physical health
and restoring cognitive function, and then psychotherapy can begin.
• The AOD worker should maintain client engagement, even if a referral to an ED specialist is made.
Personality
Personality disorders
Clinical presentation
Clients with personality disorders have frequent and enduring problems in coping and interpersonal
interaction. Symptoms can include:
• Manipulative behaviour.
• Impulsivity.
• Social impairments.
• Emotional detachment.
• Suspiciousness.
• Difficulty accepting responsibility or accommodating others.
• Emotional instability and hypersensitivity.
• Pervasive and persistent anger/aggression.
• Being overly self-involved.
• Excessive dependence on others.
• Inflexible, maladaptive responses to situations.
Clients with personality disorders tend to have difficulty forming a genuinely positive therapeutic alliance.
They tend to frame reality in terms of their own needs and perceptions and not to understand those of
others. They are also limited in their ability to receive, accept or benefit from corrective feedback; therefore,
progress is likely to be slow and uneven [94].
Engagement and rapport building form an intensely important part of therapy and, as a result, these
areas may require more time and attention than they do in other clients. Clients with personality disorders
may have trouble engaging in treatment due to a history of poor relationships with AOD and other health
professionals, a bias towards suspiciousness or paranoid interpretation of relationships, or a chaotic
lifestyle, making appointment scheduling and engaging in structured work more difficult [103]. Structure
and firm boundaries are very important components of the therapeutic process when managing clients
with symptoms of personality disorders.
Do:
3 Place strong emphasis on engagement to develop a good client–worker relationship and build
strong rapport.
3 Set clear boundaries and expectations regarding the client’s role and behaviour. Some clients may
seek to test these boundaries.
3 Establish and maintain a consistent approach to clients and reinforce boundaries.
3 Anticipate compliance problems and remain patient and persistent.
3 Plan clear and mutual goals and stick to them; give clear and specific instructions.
3 Help with the current problems the client presents with rather than trying to establish causes or
exploring past problems.
3 Assist the client to develop skills to manage negative emotions (e.g., breathing retraining,
progressive muscle relaxation, cognitive restructuring).
3 Take careful notes and monitor the risk of suicide and self-harm.
3 Avoid judgement and seek assistance for personal reactions (including frustration, anger, dislike)
and poor attitudes towards the client.
3 Listen to and evaluate the client’s concerns.
3 Accept but do not confirm the client’s beliefs.
Don’t:
There are several treatment options available for the treatment of personality disorders, including
psychotherapy, pharmacotherapy, e-health interventions, as well as complementary and alternative
therapies (e.g., omega-3). The evidence base surrounding each of these in regards to the treatment of BPD
and ASPD is discussed below.
Psychotherapy
In general, research on psychological treatments for BPD is promising. The Cochrane collaboration
reviewed psychological treatments for BPD [967] and reported that studies of DBT have generally found
few differences between DBT and treatment as usual in terms of BPD symptoms and hospitalisations.
DBT treatments may be too time-consuming and technically demanding for staff and clients in AOD
treatment settings. For clients with alcohol use disorders, it has been suggested that good outcomes are
possible using alcohol-focused treatments alone. However, it is acknowledged that opiate and cocaine
abusers with a personality disorder present a more severe client profile. There is evidence that a diagnosis
of BPD makes retention in residential AOD treatment difficult, as people with BPD are significantly more
likely to drop out of treatment, even after taking into account other relevant factors [968]. Experts agree
that AOD clients with personality disorders should be given more intensive psychological attention in order
to promote the therapeutic alliance and retain them in treatment [969]. However, although it is important to
address the client’s maladaptive personality traits, this will not be effective unless carried out in a long-term
treatment program.
Three programs have been designed and evaluated for clients with comorbid BPD and AOD use disorders:
Dialectical Behaviour Therapy-S (DBT-S) [399, 970-973], Dual Focus Schema Therapy (DFST) [396, 974], and
Dynamic Deconstructive Psychotherapy (DDP) [975, 976], all of which show promise.
DBT-S [970] is a complex, skills-based, psychological intervention based on DBT (modified for people with
comorbid BPD and substance use), which was developed using some of the same principles of CBT. The
client is supported with strategies to promote abstinence, and remain engaged in treatment. A systematic
review examining the efficacy of interventions for comorbid BPD and AOD use [966] found four studies
had tested DBT-S among this group [399, 977-979]. Findings indicated that DBT-S led to improved BPD
symptoms and more AOD abstinent days than community-based treatment, greater treatment retention
and reductions in self-harm.
DDP [975] is a modified form of psychodynamic psychotherapy, and was initially developed for particularly
challenging cases of BPD, including those with co-occurring AOD disorders. In a systematic review of
the literature, Lee and colleagues [966] found three studies had evaluated DDP among those with co-
occurring BPD and AOD use. These studies found that DDP had a significantly greater effect on symptoms
of both BPD and alcohol use disorder compared to treatment as usual (i.e., treatment in the community),
which were maintained over 30 months [976, 980, 981].
DFST is a combination of relapse prevention and therapy focused on early maladaptive schemas (such
as continuing negative self-beliefs, negative beliefs about others or events), as well as coping styles [966,
982]. In their systematic review, Lee and colleagues [966] found one study had examined the efficacy of
DFST for co-occurring BPD and AOD use [983]. The study findings did not show any benefit of DFST over
individual drug counselling for BPD or AOD use, with greater reductions in AOD use found among those in
individual drug counselling.
Although these treatments have been evaluated among people with comorbid BPD and AOD use
disorders, the evidence is limited by the small sample sizes of studies which have evaluated these
treatments [966, 984].
Pharmacotherapy
Although pharmacotherapy has been used in practice to treat BPD, there is a dearth of research examining
its efficacy [984]. A Cochrane review of pharmacotherapies for BPD found little support for the use of
pharmacotherapies for BPD but concluded that more trials are needed, especially to ascertain the
usefulness of antidepressants [985]. A more recent review concluded that whilst mood stabilisers (such
as those listed in Table 36) and antipsychotics (such as those listed in Table 33) can be effective at treating
some specific symptoms of BPD, the evidence does not support effectiveness for overall severity of BPD
E-health interventions
There are some initial findings from a pilot study suggesting that mobile phone applications can be used
as an effective adjunct to DBT for individuals with co-occurring BPD and AOD use disorders. Rizvi and
colleagues [987] developed and tested the feasibility, acceptability, and effectiveness of DBT Coach,
a mobile phone application designed to improve the generalisation of a specific skill taught in DBT.
Participants found DBT Coach to be helpful and easy to use, and over the course of the pilot study there
was a decrease in depression, emotion intensity, and urge to use AOD. As people with comorbid BPD and
AOD use are at increased risk of relapse, treatment non-adherence and poorer outcomes compared to
those with either disorder alone [969, 988, 989], these preliminary findings represent an innovative way of
assisting and improving treatment compliance.
Although there has been some preliminary research with promising results for the treatment of BPD with
omega-3 [990], at present there is no further evidence to support the use of complementary or alternative
approaches in the management or treatment of BPD, either as a single disorder or comorbid with AOD use.
Nonetheless, physical exercise may be a useful part of a treatment approach for people with BPD, with
research indicating that obesity among people with BPD increases over time, escalating the risk of obesity-
related chronic medical conditions [991]. BPD has been associated with arteriosclerosis, hypertension, liver
disease, and CVD [992]. Although there has been no research examining the effect of physical activity on
symptoms of BPD, one study recommends initial interventions include improved sleep and scheduled
exercise. It should be noted however, that this recommendation is based on theory, and lacks supportive
evidence [993]. As such, while it may be prudent for people with BPD to maintain healthy living practices,
which may include physical activity, a healthy diet, and adequate sleep (see Chapter B1), to date there is no
evidence regarding the effect of these practices on symptoms of BPD.
There is a dearth of research regarding the psychological and pharmacological treatment of both ASPD
as a single disorder, as well as comorbid ASPD and AOD use. More research has been conducted among
incarcerated populations, which may be reflective of the difficulty accessing and engaging those with
ASPD in treatment within the community [994]. Further, many studies focus on changes to symptoms and
behaviour of ASPD, rather than changes to personality [994].
Psychotherapy
A Cochrane review of psychotherapies for ASPD with and without comorbid AOD use disorder examined
11 studies and was unable to draw firm conclusions from the available evidence [995]. Of the 11 studies
included in the review, eight were conducted among people with comorbid ASPD and AOD use disorders
[974, 996-1002]. No study found significant changes to specific ASPD behaviours (e.g., offending,
aggression, impulsivity); however, several found significant reductions in AOD use following treatment. The
addition of contingency management and/or CBT to standard methadone maintenance was found to be
superior compared to standard methadone maintenance alone [998]. Further, contingency management
plus standard methadone maintenance has been associated with significantly greater counselling session
attendance and improvements in social functioning compared to standard methadone maintenance alone
Pharmacotherapy
Although several studies have examined pharmacological interventions among people with ASPD as a
single disorder, the limited evidence does not provide enough support for conclusive recommendations.
These studies have investigated the use of antiepileptics (carbamazepine [1003], phenytoin [1003-1005],
sodium valproate [1003], and divalproex sodium [1006]); antidepressants (desipramine [1007, 1008]
and nortriptyline [1009]); dopamine agonists (bromocriptine [1009], and amantadine [1008]); and opioid
antagonists (naltrexone [1010]).
Despite the limited evidence, there has been some research conducted among people with comorbid
ASPD and AOD use. A Cochrane review examining pharmacological treatments for ASPD found that two
drugs (nortriptyline and bromocriptine) were associated with improved outcomes compared to placebo
control conditions among those with comorbidity [1011]. Compared to placebo, those with ASPD and AOD
use disorder who were taking nortriptyline illustrated a greater reduction in alcohol use and dependence
[1009]. In the same study, the use of bromocriptine was found to reduce anxiety symptoms for those
with depression/anxiety and AOD use disorders [1009]. However, no changes to ASPD symptoms were
observed.
Based on the lack of consistent evidence, the UK NICE Guidelines do not recommend treating ASPD, nor
comorbid ASPD and AOD use disorders, with pharmacological interventions. They also advise against
treating underlying behavioural symptoms with pharmacotherapy [1012].
E-health interventions
At the time of writing, there was no internet-based treatment for ASPD either as a single disorder or
comorbid with AOD use.
At the time of writing, there has been no research to support the use of complementary or alternative
therapies among people with co-occurring ASPD and AOD use, or ASPD as a single disorder. Similarly, no
research has examined the effects of exercise interventions among this group.
Summary
In general, there is relatively little research to guide treatment for comorbid personality and AOD use
disorders. The first line of treatment for those with comorbid BPD and AOD use should be psychotherapy,
with several interventions having been specifically developed for this group. Similarly, psychological
interventions should be the first line of treatment for those with comorbid ASPD and AOD use, although the
evidence is less well-developed.
Without evidentiary support, pharmacological intervention is not recommended for the treatment of either
comorbid BPD and AOD use, or ASPD and AOD use, highlighting the need for further well-conducted
studies to be undertaken in this area.
Box 21 illustrates the continuation of case study H, following Luke’s story after the AOD worker consulted
with a forensic psychologist. As illustrated, it may be necessary to involve multiple services in the delivery
of care to a person with comorbid personality and AOD use disorders.
Case Study I: Treating comorbid ASPD and AOD use: Luke’s story
continued
Luke’s AOD worker liaised with a forensic psychologist and Luke was comprehensively assessed. The
forensic psychologist reported that Luke met criteria for a diagnosis of ASPD. His AOD worker had also
arranged for Luke to undergo a physical health assessment, and Luke was found to have hepatitis C.
Over several meetings, Luke developed a reasonable relationship with the psychologist and indicated
that he had reached a point where he ‘needed to turn things around’. In consultation with his AOD
worker, Luke decided to begin suboxone treatment for his heroin dependence, while at the same time
receiving psychological treatment for his ASPD. The AOD worker contacted housing services in an
attempt to help find Luke stable accommodation, and Luke began treatment for his hepatitis C.
Luke’s treatment plan also included his attendance at a group program for people with ASPD which
was based on cognitive behavioural principles. Most of the others in this group also had histories of
problematic AOD use. The treatment plan emphasised the need for long–term contact with Luke and
his family. After three months, Luke had reached a stable dose of suboxone, was regularly attending
his group cognitive behavioural sessions, as well as individual CBT sessions with his psychologist and
AOD worker. The AOD worker arranged for treatment to continue and provided a report to the court with
favourable recommendations.
The long–term treatment plan emphasised the need for continued multi-agency cooperation and
preparing to deal with factors that could jeopardise long–term stability. These included plans to address
life and relationship stressors, and manage the several occasions when Luke failed to attend for
appointments.
Key points:
• Where the ASPD is associated with AOD use, both sets of problems should be addressed
concurrently and the approaches carefully coordinated.
• The need for multi-agency cooperation and information sharing is important and, in the case of
comorbidity, interventions need to be planned over months and years rather than weeks.
• Provide frequent reality orientation (e.g., explain where the person is, who they are, and what your role
is).
• Provide reassurance.
• Attempt to involve family, friends or carers.
• Attempt to have the client cared for by familiar healthcare workers, in familiar surroundings.
Cognitive impairment
In the process of treatment, it may become clear that the client has impaired or poor functioning in one or
many areas of cognition, such as verbal or non-verbal memory, information processing, problem-solving,
reasoning, attention and concentration, decision-making, planning, sequencing, response inhibition and
emotional regulation. Sometimes these cognitive impairments can result in behaviour that is mistakenly
interpreted as the result of poor motivation or lack of effort. These cognitive difficulties often bear no
relation to mental illness and are frequently the result of heavy AOD use or intoxication [276].
When a client is experiencing some level of cognitive impairment, the effectiveness of therapeutic
approaches can be diminished unless care is taken to adapt the approach to address these difficulties.
Table 46 presents some simple techniques which can be useful in overcoming cognitive impairment [276].
• Present information to be remembered both verbally and visually (e.g., draw diagrams).
• Repeat and summarise key information.
• Ask client to recall information from previous sessions, and suggest techniques to improve recall
(e.g., writing things down, using memory aids).
• Review key points from previous sessions at the start of each session to compensate for poor
memory.
• Remind client of appointment times and keep appointments at routine times.
• Emotional – feelings of shock, numbness, disbelief, loss of control, fear, panic, confusion, anger,
sadness, guilt, desire to blame, or hostility. The person is likely to fluctuate between different emotional
states.
• Psychological – in addition to these emotions, clients may also have a preoccupation with the
deceased, or a sense of the presence of the deceased. Temporary cognitive impairments are also
common (e.g., concentration and memory complaints).
• Physical/behavioural/social – inappropriate behaviour (e.g., laughter), gastro-intestinal complaints,
decreased sex drive, tension, headaches, sleep disturbances, fatigue, lethargy, avoidant or
absentminded behaviour, withdrawal, social interaction changes, appetite changes, restlessness,
crying, or obsessive behaviour.
Table 47: Dos and don’ts of managing a client with symptoms of grief or loss
Do:
3 Encourage the acceptance of the reality of the situation (e.g., discuss the loss, encourage client to
attend gravesite), as well as the identification and experience of feelings (positive and negative)
associated with loss.
3 Help the client find a suitable way to remember, but also reinvest in life.
3 Continually monitor levels of depression and suicidal thoughts and act accordingly; risk is increased
during periods of grief (e.g., the first 12 months after a death, anniversaries, holidays).
3 Be aware and understanding of feelings associated with grief, including anger.
Don’t:
2 Avoid the reality of the situation or the feelings associated with it (e.g., use the name of deceased).
2 Judge or be surprised at how the client reacts – every person is different.
2 Time-limit the client when discussing grief, it can be a slow process.
2 Be afraid to seek assistance.
The following signs may indicate that a client could potentially become aggressive or violent [277]:
• Appearance: intoxicated, dishevelled or dirty, bloodstained, bizarre, carrying anything that could be
used as a weapon.
• Physical activity: restless or agitated, pacing, standing up frequently, clenching of jaw or fists, hostile
facial expressions with sustained eye contact, entering ‘off limit’ areas uninvited.
• Mood: angry, irritable, anxious, tense, distressed, difficulty controlling emotions.
• Speech: loud, swearing or threatening, sarcastic, slurred.
• Worker’s reaction: fear, anxiety, unease, frustration, anger.
If a client becomes aggressive, threatening or potentially violent, it is important for AOD workers to respond
in accordance with the policies and procedures specific to their service. It is also important for AOD workers
to have knowledge of how to respond to challenging behaviour, including physical threats or actual
violence, in their work with AOD clients. Table 48 outlines some general strategies for managing aggressive
clients.
Do:
Don’t:
Adapted from NSW Department of Health [277] and Marsh et al. [276].
Phases of aggression
This section has been adapted from information provided by Sunshine Coast Mental Health Service [1015]
and NSW Department of Health [277]. Aggressive episodes may be broken down into more detailed
phases. Gaining an understanding of these phases and some of the symptom-control strategies is useful in
controlling anger and aggression. Figure 16 outlines these phases of aggression.
Phase 1 is the initial triggering event which elicits the aggression. This can be any number of things that are
perceived by the client as threatening or frustrating. Some useful ways to avoid this primary phase include:
Phase 2: Escalation
Phase 2 is the escalation phase. It is important to recognise and address signs of distress or conflict and
use appropriate techniques to try and de-escalate the situation. Common signs of escalation include
pacing, voice quivering, quick breathing, flushed face, twitching, dilated pupils, tense appearance, abusive,
intimidating and derogatory remarks, and clenched fists.
The LASSIE model is a useful tool for communication and de-escalation of the situation in this phase:
L Listen actively: allow the client to run out of steam before you talk.
E Encourage the client to try these options: assist the client to follow through.
Phase 3: Crisis
Phase 3 is the crisis phase, in which the client reacts with aggressive behaviour. The aggression can often
be released indiscriminately and it is best for workers to remove themselves and any clients during this
stage unless the service has other policies on dealing with violence, aggression, self-defence and/or
restraint.
Phase 4: Recovery
Phase 4 is the recovery phase in which tension tends to reduce; however, the person is still in a state of
high arousal and, if this phase is not handled properly, aggressive behaviour may reignite. It is important to
be supportive and empathic to the client at this stage, but do not crowd or threaten him/her. It is important
that workers be given the opportunity to debrief. Any violence should be documented in the client’s file.
Phase 5 is the post-crisis depression stage. Generally the client feels fatigued and exhausted and may
show feelings of guilt and dejection at having had an outburst. Support may be required from workers
during this stage.
Concluding remarks
Although much of this review of treatments leaves many questions to be answered, there are some guiding
principles that tend to be repeated throughout. It is clear that much more research is needed before
definitive practices that will improve outcomes for both mental health and AOD use disorders can be
prescribed. Despite this, it can be generally concluded that treatments that work for a single disorder will
lead to some improvements in comorbid clients, if not in both disorders. Although integrated treatments
appear beneficial for some disorders, further investigation is needed [756].
For most comorbidities, both psychotherapy and pharmacotherapy interventions have been found to
have some benefit. Both of these require some basic knowledge or qualifications on the part of the AOD
worker. In particular, psychosocial interventions tend to be based on motivational and cognitive behavioural
approaches and AOD workers will benefit significantly if trained in these intervention styles. It is generally
acknowledged that manual-based psychological interventions are easy to administer and are the most
effective for CBT-style treatments. For pharmacological interventions, an important role of AOD workers is
to inform themselves of the benefits, interactions and possible side effects of the medications prescribed
for their clients. Workers can assist their clients with suggestions for medication scheduling as well as
providing compliance therapy.
B7
B7: Worker
self-care
Key Points
• Working directly with clients with comorbid AOD and mental
health conditions can be an incredibly rewarding and satisfying
experience, but is not without considerable challenges. AOD
workers often experience high levels of stress and are at risk of
burnout.
• The most common workplace stress for AOD workers is the stress
associated with workload and time pressures, but other stressors
include concerns about whether your work is making a difference,
whether you have the necessary skills and are effective in your
role, whether your work is valued and adequately remunerated,
workplace conflict, lack of supervisory and collegial support, and
job uncertainty.
• As such, it is important that AOD workers ensure they take the time
for self-care. Strategies incorporating a holistic approach to AOD
worker self-care reduce psychological responses to client trauma
and workplace stress, and increase the capacity to respond to
workplace situations.
• Active coping strategies can help reduce the risk of clinical
burnout, and include physical, emotional, and professional self-
care. Further, workplace engagement and appreciating the impact
and value of your work can reduce the risk of burnout.
• Clinical supervision can also help reduce workplace stress and
burnout by providing a mechanism of support for staff.
Working with clients who have co-occurring AOD and mental health conditions can be a fulfilling and
satisfying experience. Having the opportunity to work directly with clients, and to observe and share the
triumphs and tribulations of their personal journeys, can be extremely professionally rewarding. However,
working in this area is not without considerable challenges. Although a manageable level of workplace
stress is normal and can even be motivating, AOD workers often experience high levels of stress, and in
Burnout
Burnout is the term used to describe the experience of long-term strain and exhaustion. It is typically a
response to work overload when there is prolonged and intense stress, accompanied by ineffective coping
strategies [276]. Components of burnout and active coping strategies are illustrated in Figure 17.
Burnout can lead to reduced job satisfaction and performance, and may lead AOD workers to become
exhausted, detached from clients, and feel ineffective and cynical about the profession [276, 277].
Workplace stress and risk factors that have been associated with burnout include [276]:
BURNOUT
It is important that AOD workers who believe that they are at risk of burnout approach their supervisors,
and seek arrangements for support including the use of relevant Employee Assistance Programs where
available. Further, active coping has been associated with reduced levels of stress and reduced likelihood
of burnout [276]. Active coping strategies are similar to holistic self-care strategies (see Figure 17) and
include the following [276]:
• Physical self-care: Maintaining a balanced, healthy diet, sleeping well, exercise, ensuring there is time
for relaxation and leisure activities.
• Emotional self-care: Ensuring opportunities to talk and debrief.
• Professional self-care: Maintaining support, clinical supervision, professional development, time-
management, and taking the opportunity to address work-related concerns, demands, unfairness, or
inequity.
Research suggests that workplace engagement and appreciation of the value of work can reduce the risk
of burnout, particularly for AOD workers [1016].
Evidence indicates that mental health and AOD workers who receive quality supervision are better able to
function across multiple domains, manage their stress more effectively, and are less likely to experience
burnout. Some of the demonstrated benefits of clinical supervision include greater job satisfaction,
confidence and self-capacity [1019-1021], reduced staff turnover [1022], improved development of complex
clinical skills and delivery of evidence-based practice [1018, 1023, 1024], reduced stress and burnout [1020,
1025, 1026], better communication between staff [1019, 1021], and the transfer of newly acquired skills
from training into practice [1027, 1028]. Further, less experienced AOD workers can benefit from clinical
supervision by receiving feedback on their interpersonal style, counselling skills, and ongoing appraisal
[1029]. As such, clinical supervision can improve the quality of client–AOD worker relationships and enhance
treatment outcomes [1029].
In 2011, NSW Health updated their clinical supervision guidelines for AOD services. These may also be
useful for clinicians in other states. The guidelines are not prescriptive, but make recommendations
for best practice. They are intended to be applicable across disciplines, to all workers in AOD services
who are responsible for providing services to clients. As such, the guidelines are designed to provide a
comprehensive framework for local operations, and encourage some degree of consistency [1018]. These
guidelines are accessible via the NSW Health website: www.health.nsw.gov.au.
groups
Part C:
C: Specific
population
groups
Key Points
• Cultural and contextual factors, such as the client’s cultural
background, age, sex, gender, sexual orientation, stability of
accommodation, whether he/she lives in remote locations, and
whether treatment is coerced, need to be taken into account when
treating clients.
• Overall, treatments and services for AOD use and comorbidity
have arisen from research on the dominant culture of city-dwelling
Westernised adults. This is not to say that these techniques will
not work with clients from different backgrounds, but rather that
approaches may need to be adapted depending on individual
clients’ characteristics.
A number of social groups require special consideration with regard to the management and treatment of
comorbidity. It is important that AOD workers are aware of specific factors that may affect the management
and treatment of people belonging to these groups so that they may tailor treatment appropriately. Much
of what is discussed below applies to those with single AOD or mental health disorders as well as those
with comorbid conditions.
Indigenous Australians
The standards of physical and mental health among Indigenous Australians are poor in comparison with
the wider Australian community. Research shows that although there are proportionately more Indigenous
people than non-Indigenous people who refrain from drinking [1030], those who do drink are more likely
to do so at high-risk levels [1030, 1031]. Between 2008–2012, Indigenous men died from alcohol-related
causes at a rate four and a half times higher than their non-Indigenous counterparts, while this rate was six
times higher for Indigenous women [1032]. As a result, it is possible that heavy drinking may be normalised
within some communities and this could act as a barrier to people seeking treatment [1033].
Indigenous people are also over-represented in inpatient mental health services, with twice as many
Indigenous than non-Indigenous people hospitalised for a mental illness between 2008–2010 [1030].
Across Australia, the most common mental health conditions requiring hospitalisation were substance-
induced mental and behavioural disorders (36%), schizophrenia spectrum and other psychotic disorders
(25%), depressive and bipolar disorders (15%), and anxiety disorders (14%). Further, in 2012–13, Indigenous
people were almost three times as likely to report high or very high levels of psychological distress [1035].
In 2008–2012, the suicide rate for Indigenous people across all age groups was double the non-Indigenous
suicide rate, and five times as high for young Indigenous Australians aged 15–19 years [1035].
It has been suggested that the factors which contribute to elevated rates of psychiatric morbidity in
Indigenous communities include the destruction of social infrastructure, rapid urbanisation and poverty,
cultural, spiritual and emotional alienation, loss of identity, family dislocation, and increased AOD
consumption [1036-1040]. Lee and colleagues [1041] conducted a study of Indigenous women accessing
treatment for co-occurring mental health and AOD use disorders. They found that women perceived
negative early life events (e.g., domestic violence, physical and sexual abuse) as being associated with the
onset of their AOD and mental health conditions. They reported that comorbidity led to severe and wide-
ranging negative outcomes, such as general poor health, diminished social networks, unemployment, and
financial instability; and they also reported that it had a serious negative impact on their ability to care for
themselves and others (e.g., with some women reporting children being removed from their care).
The trauma suffered by the stolen generations as a result of the assimilation policies of the Australian
Government has direct relevance to the psychological adjustment of Indigenous Australians by severely
disrupting and damaging the quality of early parent–child attachment. A number of studies have found
evidence of a direct link between the quality of early relationships and the development of depression in
adulthood [1042-1046]. Indigenous people may be at increased risk of poor treatment outcomes due to
poor physical health, social disadvantage, comorbidity, and the burden of grief through suicide, homicide,
and incarceration [1047, 1048].
Although only limited data exists regarding comorbidity specifically among Indigenous communities,
Roxbee and Wallace [1049] report that there are high rates of comorbidity, along with complexities in
causality and treatment, which are unique to Australian Indigenous populations. Studies have shown an
association between depression, anxiety, suicide, and alcohol dependence in Indigenous communities
[1050, 1051]. In addition, frequency of alcohol consumption in Indigenous communities has been found
to be correlated with hallucinations, paranoia, self-mutilation, and panic [1038, 1052, 1053]. A survey of
Aboriginal admissions to Bloomfield hospital in 1995 showed significant rates of comorbidity [1054]. There
is also more recent evidence to suggest that substance use and self-harm behaviour are rising in the
Indigenous community [1055, 1056]. Moreover, Indigenous Australians who experience comorbid disorders
are likely to have poorer outcomes than those experiencing a mental health or AOD use disorder alone
[1057]. However, there is some emerging evidence that interventions for comorbid conditions can lead to
beneficial outcomes in Indigenous populations. An RCT conducted by Nagel and colleagues [1058] found
Existing mainstream models of practice in the AOD field have overwhelmingly been developed within
Western systems of knowledge. As a result, they are not necessarily generalisable to other cultures and
may ignore important Indigenous perspectives and needs. Therefore, despite Indigenous Australians
having a heterogeneous mix of diverse languages and customs, it is important that AOD workers be aware
of general issues and try to familiarise themselves with more specific information regarding the Indigenous
population in their community. Reports on this particularly vulnerable group emphasise the need for access
to culturally appropriate and comprehensive services to address these problems, and the need for local
links with Indigenous services and consultants [99, 1051].
There are a number of general issues to be aware of when working with Indigenous clients [169, 1031, 1060-
1065]:
• The concept of family (including extended family and relatives) and community in Indigenous culture is
very important and includes immediate and extended relations. With the permission of the client, family
members should be included in therapy as much as possible, and the client should be treated within
the context of their community. Families are a strength that can be drawn upon to complement mental
health and AOD treatment [1041]. Community and Indigenous support groups may also be useful
services.
• Many Indigenous Australians have a holistic concept of health, which is often referred to as social and
emotional wellbeing [1059]. This multifaceted concept reflects the Indigenous cultural concept of
health, which includes physical, psychological, social, cultural, and spiritual health and the importance
of connections to land, culture, family, spirituality, ancestry, and community. These connections are
maintained through generations, and contribute to an individual’s wellbeing. As such, incorporation of
these factors is essential during treatment. Integrated or coordinated services are therefore particularly
important for addressing AOD and mental health conditions [1041, 1048].
• There are high rates of trauma, grief, and loss in Indigenous communities as Indigenous people are
faced with death and serious illness within their extended family more often than non-Indigenous
people, and at a younger age. There are also issues of unresolved grief, continued cultural loss and
intergenerational trauma regarding the European colonisation and mistreatment since then (e.g., stolen
generations). Approaches should address underlying issues of repeated trauma, stress, and grief [1060].
• Stigma and victimisation continue to exist today, and are likely to impact on mental health and AOD use.
Issues of domestic violence, poverty, and family AOD use are also likely to play a key role.
• When working with Indigenous clients with apparent psychotic symptoms, it is important to clarify the
cultural appropriateness of such symptoms. For example, it is not uncommon for some Indigenous
people to hear recently departed relatives and see spirits representing ancestors. This kind of spiritual
experience is culturally valid and therefore is not a symptom of psychosis.
• Workers should be aware of the impact of intensely distressing levels of shame that many Indigenous
clients experience. This shame can be exacerbated when dealing with a non-Aboriginal worker.
Involving an experienced Aboriginal worker in the client’s care can help achieve the best outcomes.
• Use appropriate language (e.g., avoid jargon, or technical or medical terminology, use culturally
appropriate terms to describe AOD) and include appropriate written materials to reinforce key verbal
messages.
• Consider that you may be viewed as a member of a culture that has caused damage to Indigenous
culture. Anticipate and prepare a plan to deal with issues of anger, resentment and/or suspicion.
Engagement is likely to require increased attention.
• Enclosed spaces may increase anxiety in Indigenous clients.
• Direct questioning can be perceived as being threatening and intrusive and therefore should be kept
to a minimum. A method of three-way talking may often be helpful, in which a client uses a third person
(such as a family member) as a mediator to exchange information with the service provider.
Workers should also be aware of the cultural diversity within Indigenous populations, which is often
overlooked [1066]. Differences in cultural identity extend to different languages, accessing traditional
lands, practising traditional culture, laws and governance, as well as family and kinship structures [1067].
Recognising and responding to the complexities of Indigenous identity involves acknowledging the
significance of diverse language and family groups, as well as the differences in gender relationships, all of
which can involve complex relationships which determine the level of interaction between family and kin
[1059]. The different forms of distress experienced by Indigenous people, as well as the different pathways
to recovery, need to be identified, which depend on a diverse range of beliefs and experiences [1068].
Following interviews with Indigenous women experiencing comorbidity, Lee and colleagues [1041]
identified a number of improvements that could be made to services to better address the needs of
Indigenous people with mental health and AOD use disorders, including:
• Better integration of mental health and AOD services, and greater collaboration between these services
and other organisations (e.g., housing, education).
• More promotion of available services (e.g., active presence of mental health/AOD workers at local
community events).
• More information and group family support for families and carers of people with co-occurring AOD
and mental health conditions.
• Support groups to be run at local services to allow clients to share experiences with others in similar
situations and to reduce isolation [1069].
• More childcare options available for clients seeking help from inpatient services.
• Greater use of outreach services in remote areas as a means of simplifying access to relevant
services (e.g., rehabilitation, mental health, withdrawal management) and creating a less ‘medicalised’
environment.
• Services better addressing factors that make it difficult for people to get appointments (e.g., inflexible
appointment times, unreliable transportation to services).
AOD workers may find the IRIS (described in Chapter B2) useful in assisting to identify Indigenous clients
with AOD and mental health conditions and mental health risks [323].
Due to the multicultural nature of Australian society, it is imperative that AOD workers develop an
awareness of issues pertaining to working with people who belong to CALD groups. Each geographic area
has its own unique cultural mix and AOD workers should learn as much as possible about the cultures
represented in their treatment populations. In particular, AOD workers should be aware of conventions
of interpersonal communication (e.g., communication style, interpersonal interactions), expectations of
family, understanding of healing, views of mental illness, and perceptions of substance use. However, it is
fundamental not to make assumptions based on the client’s culture – just because he/she is from a certain
cultural background, that does not mean that he/she necessarily subscribes to the values and beliefs of
that culture [94]. Reid and colleagues [1071] recommend consultation with the separate ethnic communities
to develop culturally relevant strategies for AOD treatment.
It has been suggested that information about three aspects of clients’ lives is of crucial importance when
treating CALD clients [276]:
• Context of migration: If the client migrated to Australia, why they left their country of origin, how they
got to Australia, their legal status, whether they have residency, any trauma experiences in the context
of their country of origin or migrating to Australia (e.g., refugees of war). Helping clients to place their
AOD and mental health conditions in the context of such experiences can help to reduce shame and
increase self-compassion.
• Subgroup membership: Ethnicity, gender, sexual orientation, area in which they live, refugees or
immigrants, religious affiliation.
• Degree of acculturation: Traditional (client adheres completely to beliefs, values, and behaviours of
his/her country of origin); bicultural (client has a mix of new and old beliefs, values, and behaviours);
acculturated (client has modified his/her old beliefs, values, and behaviours in an attempt to adjust);
assimilated (client has completely given up his/her old beliefs, values and behaviours and adopted
those of the new country).
Even migrants from English-speaking countries are likely to struggle with cultural confusion and stresses
associated with changes in environment, jobs, social supports, and lifestyle. Migrants may experience a loss
in social and occupational status if their qualifications are not recognised in Australia or face issues such
as high unemployment levels, overcrowded living conditions, isolation, poverty, racial discrimination, and
family conflict.
Below is a range of useful points which may improve assessment and treatment in CALD clients generally:
• Where possible, and with the client’s permission, involve the family in treatment. Allow the client to pick
who from his/her family or community participates.
• Try to find out before the session if the client requires an interpreter, and allow the client to make
decisions about if/when an interpreter is needed. Keep in mind that even clients with basic English
proficiency might benefit by having an interpreter because describing symptoms, especially feelings,
can be very difficult when English is a second language. Be sure the dialect is correct and be aware that
some clients may have a preferred gender for the interpreter. Allow the interpreter to brief the client on
the role that they will play. Even when families are involved in the client’s treatment, it is inappropriate
to use family members as interpreters. The client may not wish to divulge certain information to his/
her family, or family members may not want certain information disclosed to people outside the family,
and may edit what is being said. When using interpreters, be aware that some meaning can be lost in
translation and address issues of confidentiality.
• Be sure to address the client appropriately and pronounce his/her name correctly.
• Discuss the client’s expectations of treatment.
• Ensure that all treatment options are clearly explained, including rationale, and processes.
• Keep what you know about mental illness in mind but ensure that you try to understand the client’s
cultural understanding of his/her problems. People from different cultures often have different views
on what constitutes mental illness. The DSM-5 [24] makes it clear that diagnoses can only be made
if the person’s behaviour is abnormal within his/her culture. While there are similarities in the forms
of illnesses across different cultures, the specific symptoms and signs vary for different societies. For
example, a man in Australia with psychosis may talk of aliens controlling his thoughts, while a man in Fiji
might blame black magic. It is also not uncommon for people from some cultures (particularly South-
East Asian countries) to express psychological distress through somatic (physical) symptoms [277].
• Be aware that some CALD clients may come from collectivist cultures (in which greater emphasis is
placed on group identity, goals, and concerns than is placed on individual ones) and may require a
greater involvement of family and community for successful treatment.
• Be aware of gender and age. Some cultures may have specific concerns about appropriate gender and
age relations, such as talking about some subjects with a member of the opposite sex or a younger
person.
• Maintain a focus on healing, coping, or rehabilitation, rather than on cure.
• Set aside at least twice the usual time, especially if you need to use an interpreter.
• Be mindful of embarrassment and cultural taboos.
• Be clear, concrete, and specific.
• Look for verbal and non-verbal signs of discomfort or confusion. Do not take silence as consent or
agreement. The client may have had negative experiences in the past when accessing services, so
consider making time to discuss these experiences and learn about any discrimination they may have
experienced, as this may help to build trust.
• Support the client and his/her family in accessing other relevant services. CALD clients may not have
knowledge of services that are available to them, so be aware of other services that could be helpful
and offer to connect them directly by making a referral and help coordinate their care (see Chapter B4)
[277, 1074].
Fundamentally, treatment for GLBTI individuals is the same as for any other client group and should
focus on the specific needs of the client [402]. GLBTI clients represent a diverse group of people from
varying backgrounds; thus, like all other clients, a holistic view should be adopted considering all aspects
of the client’s presentation. While all GLBTI clients are different, it is important to be aware of the context
in which GLBTI clients’ problems may develop. For instance, the development of a same-sex attracted
identity usually occurs within a context of stigma and internal pressure [1083]. This can produce feelings of
shame, isolation, guilt, lying, maladaptive sexual patterns, and loss of social support among other things,
all increasing the risk of mental health and substance use problems. Thus, comorbidity among GLBTI
individuals is likely to be a consequence of being in a minority group within the community, rather than
being same-sex attracted. Ritter and colleagues [1077] identified several key features for working with
GLBTI clients that are associated with positive outcomes:
Sexuality and related issues require sensitive exploration and may require the AOD worker to assist the
client with safety, support, accommodation, harm reduction, and education needs that may arise. It is
important to consider and use professional judgement in raising and discussing issues of sexual orientation;
for instance [1084]:
• How comfortable is the person with his/her sexuality and with talking about it with others?
• Has he/she told family/friends? How have these people reacted (or how will they)?
• Is it his/her decision to tell someone or is he/she being forced?
• How much support does he/she have?
• Is he/she financially, physically, or emotionally independent?
Engagement is fundamentally important as well as confidentiality issues. AOD workers should also be
aware that, for some clients (especially young clients), issues surrounding gender and sexual orientation
may be a principal concern and may demand increased attention during treatment.
Research has found that people living in remote areas are less likely than major city residents to endorse
evidence-based interventions as useful for mental health treatment, and are less likely to perceive
psychologists, psychiatrists, GPs, and social workers as helpful in the treatment of mental health
conditions [1091]. There is also evidence that people living in remote areas are also more likely than those
living in major cities to identify non-evidence-based treatments (e.g., alcohol and painkillers) as helpful
interventions for mental health conditions, highlighting the need for effective communication focused on
best-practice treatment and management of mental health in rural and remote areas [1091].
Although accessing treatment has been identified as a particular challenge in this population group,
recently developed self-guided approaches, such as bibliotherapy or e-health interventions, have proven
to be effective as have alternatives to face-to-face methods (e.g., telephone, email, internet) where
geographical isolation and lack of specialist services are obstacles [1092]. For example, MoodGYM is a
free online CBT self-help program for depression (www.moodgym.anu.edu.au) that has been shown to be
effective in treating symptoms of depression [653], and Anxiety Online comprises five e-therapy programs
for GAD, SAD, panic disorder, PTSD, and OCD (www.mentalhealthonline.org.au) [740]. Although definitive
evidence regarding the efficacy of Anxiety Online is lacking, a naturalistic study found that the participation
in the program was associated with significant reductions in severity of all five disorders, and increased
confidence in managing one’s own mental health care.
In terms of feasibility and acceptability of these approaches, there is evidence that clinicians working
in rural areas are optimistic about the use of e-health interventions; however, there was a preference
for these approaches to be integrated alongside existing services, and used as an adjunct rather than
alternative to more traditional face-to-face approaches [1093]. The Rural Mental Health Study found that
one in five (18%) people with internet access (75% of the total sample) would consider using e-health
interventions, which was associated with being younger, male, a carer, having a 12-month mental health
problem, and having used internet-based treatments in the past [1094]. These findings suggest that
e-health interventions have the potential to address the limitations of service accessibility among people
living in rural and remote areas, and resistance to e-health may be overcome by enhancing community
education and program familiarity [1094]. In an RCT examining participants with comorbid depression and
AOD use, the efficacy of computerised CBT/MI was compared to face-to-face treatment with both urban
and rural participants [1095]. Similar improvements were observed in depression, alcohol, and cannabis use
when compared with face-to-face treatment, and the computerised delivery was acceptable to people in
both urban and rural locations, even among people who indicated a preference for face-to-face therapy.
AOD workers need to be aware of the particular issues related to AOD use in their communities.
Professional networking with local health providers, and fostering trust, non-judgemental acceptance,
and confidentiality with clients, may be particularly important in rural/remote communities. In small rural
communities, anonymity is very difficult to maintain, presenting a range of additional challenges for the AOD
workers. Therefore issues of confidentiality are particularly crucial.
Homeless persons
Homelessness refers not only to sleeping rough. It also includes staying with friends or relatives with no
other usual address (e.g., couch surfing), staying in specialist homelessness services, and living in boarding
houses or caravan parks with no secure lease and no private facilities. As highlighted in the Australian
Government White Paper on homelessness, homelessness does not simply mean that people are without
shelter. A stable home provides safety and security as well as connections to friends, family, and a
community [1099].
There tend to be higher rates of AOD use and mental health conditions among homeless people as
compared to the Australian general population (see Table 49) [42, 1100, 1101]. A 2007–2008 survey of
homeless individuals from Sydney reported complex AOD use histories and extensive polydrug use [1102].
Forty-two percent of participants reported severe levels of depression and 57% screened positive for
current PTSD. More than one third (37%) had received a lifetime diagnosis of schizophrenia or another
psychotic disorder.
People who are homeless present with a range of physical, financial, housing, substance, social, and
psychological problems, and they are at high risk of victimisation [1102, 1103]. Hence it is important to
adopt a holistic and pragmatic view when identifying treatment needs (see Chapter B4). The complexity
of problems experienced by people who are homeless is compounded by having reduced access to
services and resources [1104], and it is very difficult to provide mental health or AOD treatment to those
without access to stable housing [1101]. Attention to immediate basic needs is often more important than
diagnosing a specific condition, as successful treatment is difficult if basic needs are not met [1104]. Do they
have access to primary care and from whom? Is the client likely to be able to follow through with treatment
and recommendations? Will they seek help in the future? Can they afford specific treatments/medications?
Thus, treatment should be guided by the perceived needs of the client, as well as AOD worker judgement.
Recent evidence indicates that homeless clients from less integrated services are more likely to experience
additional difficulties accessing help due to the lack of coordination between homelessness, mental health,
and AOD services [360]. Services working together and coordinating care into a cohesive approach has
been identified by clients as an area of great importance. Clients from more integrated services are more
likely to have a case coordinator and report positive outcomes than those from less integrated services
[360]. Lack of integration between services can not only result in clients ‘falling through the gaps’ and being
bounced between homelessness, AOD, and mental health services, but can also result in a need for clients
to continuously retell details of distressing stories, confusion, and lack of client and service awareness [360].
Chapter B4 contains further information about care coordination and working with other services.
Being homeless involves additional stigmatisation to the already marginalising attitudes directed towards
individuals with AOD and mental health conditions. It is important to recognise the additional difficulties
faced by these clients and be patient and attentive during treatment despite obvious difficulties [1105]. The
following strategies may be useful when working with homeless clients [360, 1104]:
• Become familiar with any street outreach programs or resettlement services operating in your area.
• Help the client establish skills and knowledge in obviously deficient areas, as this may provide practical
living abilities. It may be necessary to read documents for the client, and assist in the filling out of forms,
and other basic tasks due to low literacy levels or other difficulties.
• Be patient and flexible, and aware that homeless people are unlikely to attend all appointments
or complete homework tasks. AOD workers need to remain optimistic, non-judgemental, process-
oriented, and focused on long-term treatment goals.
• Where possible and beneficial, encourage clients to consider family relationships, and engage with
clients’ families. Be aware that this may not be easy or practicable, and ensure clients are engaged in
the decision to contact their family.
• Be proactive in following up clients, and work with other services to coordinate care.
Women who misuse substances are more likely than men, or non-misusing women, to have experienced
sexual, physical, or emotional abuse as children, as well as domestic violence [1109-1112]. In addition, AOD
use can often lead to revictimisation via dangerous or risky situations such as unsafe sex and prostitution
[1109]. Among women engaging in AOD treatment, the rates of depression, anxiety, and personality
disorders are particularly high [1113]. Poor self-esteem and self image, high rates of suicide attempts, and
comorbid ED are also particularly common to women with AOD use issues [1114, 1115]. Because of the
high rates of trauma in female clients, often perpetrated by men, it is imperative to provide a treatment
environment in which women feel safe and secure [276]. The following strategies can be helpful in working
with female clients [276, 1108]:
Men
In contrast to women, it is important to be aware that men may be less forthcoming with information
concerning mental health, which may affect their help-seeking behaviour. There are a number of barriers
that may prevent men accessing mental health treatment, including [1116]:
Physical, sexual, and emotional abuse are highly prevalent among men accessing AOD treatment settings,
and, as with female clients, treatment should be trauma-informed, bearing in mind feelings of shame,
guilt, and powerlessness that can be the result of abuse [276]. Men are also at considerably higher risk of
completed suicide than women, and are more likely to choose lethal means for suicide attempts, which
highlights the need for risk assessments (see Chapter B3) [276]. There are also strong associations between
Coerced clients
Clients may be coerced into treatment through a variety of channels; for instance, through the judicial
system, via family and friends, schools or workplaces, or through child protection or other services.
However, AOD workers should not assume treatment will be ineffective as a result [1117]. In fact, coercion
into treatment may present an opportunity which the client may never have previously considered, and
evidence suggests that some individuals who have been legally coerced to participate in treatment stay
in treatment longer and do equally as well, or better than, people not under legal coercion [1118]. It is
important for the AOD worker to present it as a positive opportunity from which the client may experience
some benefit. A positive attitude on behalf of the AOD worker and efforts in engaging a coerced client are
key to a productive outcome. The role of educational and motivational interventions may require more
attention.
Nevertheless, there are some special considerations that AOD workers ought to be aware of when dealing
with coerced clients. First, confidentiality may be complicated and needs to be clarified from the outset of
treatment, both with the referrer and the client. Open communication is required regarding the boundaries,
rights and obligations concerning confidentiality, and these should be clarified prior to the commencement
of treatment [276]. Similarly, conflicts of interest between the views of the AOD worker and the conditions
under which the client accesses treatment may arise and should be addressed [96, 1087].
Harm reduction is also an important consideration when dealing with coerced clients [276]. This may often
be a more satisfactory goal for clients but court orders and familial requests are likely to be based on an
expectation of abstinence [96]. The AOD worker, however, can play an important role in clarifying what
the realistic goals are for each client. Often, a lack of knowledge and understanding of dependence and
treatment results in unrealistic expectations, particularly in relation to the opioid treatment program (i.e.,
methadone and buprenorphine substitution) and the need to be abstinent from all drugs.
Coerced clients may be accessing treatment services for the first time, or may be accessing a different
type of service. This provides the opportunity for a thorough assessment which may identify previously
undiagnosed comorbid disorders, and presents an opportunity for treatment. AOD workers should focus
on building a therapeutic relationship, and avoid overly intrusive questions that might be perceived as
judgemental [276]. Barber [1119] suggests that in cases of coercion the worker should adopt a negotiation or
mediation role and follow six steps in this process. These steps are:
• Clear the air with the client (including a positive attitude and efforts with engagement).
• Identify legitimate client interests.
• Identify non-negotiable aspects of intervention.
• Identify negotiable aspects of intervention.
• Negotiate the case plan.
• Agree on criteria for progress.
When working with justice health specifically, appropriate referrals and consultation with corrective
services need to take place. A client being released from custody should be reviewed to ensure that he/
she has all medications post-release and that he/she is aware of services, referred to and accepted by
service providers where necessary [1120].
Comorbidity across disorders is common [42, 269, 1124-1126]. A number of epidemiological studies and
government initiatives have identified adolescents and young adults as a group at risk for comorbid AOD
and mental health conditions [42, 67, 1127-1131]. The US National Comorbidity Survey reported that the co-
occurrence of AOD use disorders and mental illness was highest amongst those aged 15–24 years [1132].
In addition, the Australian National Comorbidity Project [109] identified young people as being at increased
risk of poor treatment outcomes and social disadvantage as a result of having comorbid AOD and mental
health conditions [1133]. A review of community studies of adolescent AOD use, abuse, and dependence
revealed that 60% of children and youth with an AOD use disorder had a comorbid diagnosis, with conduct
disorder and oppositional defiant disorder the most common, followed by depression [1130].
An Australian study among substance-abusing youth (aged 16–22 years) attending community drug
treatment services found high rates of lifetime and current mental health disorders (69% and 50%,
respectively) [67]. Almost half the sample (49%) fulfilled criteria for a current mood or anxiety disorder,
and this was more pronounced in female participants (61%). Rates of major depression and PTSD were
particularly high, and were both associated with significant morbidity. Not only does research suggest that
there is an increased prevalence of comorbidity among young people but there is evidence to suggest that
adolescents with AOD and co-occurring mood and anxiety disorders also display greater severity of AOD
use and associated problems, including increased disability and suicidal behaviour, and reduced academic
performance and social abilities [1134-1139].
Adolescence and young adulthood can be a difficult, turbulent time for many people, with issues of
change, development, identity formation, experimentation, rebellion, and uncertainty impacting upon
an individual’s thoughts, feelings, and behaviour [276]. Thus, it is a vulnerable time for mental health and
substance use. It is also often the time in which the first presentations of psychosis and symptoms of
depression and anxiety emerge [402]. It should be noted that the presentation of mental illness may be
different in young people compared to adults. For example, children who have experienced trauma may
not have a sense of reliving the trauma, but rather they may engage in repetitive play activities that re-
enact the event. AOD workers who work with children or adolescents should refer to the DSM-5 [24] and be
aware of possible variations of symptom expression.
It is important to recognise that AOD and mental health conditions take place in different physical,
attitudinal, psychological, and social contexts for young people, and treatment needs to be tailored
accordingly [94, 1140]. For instance, treatment should be ‘youth friendly’ and include follow-up for missed
appointments, ease of access, prompt screening and assessment, drop-in capability, flexibility, strong links
to other relevant agencies to ensure holistic treatment, and interventions that recognise different cognitive
capacities and developmental/maturational lags [402]. AOD workers may need to modify the treatment
process to avoid client distraction and rebellion (e.g., creating a more active and informal environment) and
place special emphasis on engagement (patience and skill is required in addition to the use of appropriate
language and questioning and relating to young people on their level).
In regards to confidentiality, most young people would be considered to be ‘mature minors’ by the age of
around 14 or 15 years. In this case there is no obligation to provide information to the parents unless other
legal and reporting constraints operate, and confidentiality must be respected [276]. In most circumstances,
It may be particularly useful to provide young clients with practical and concrete strategies concerning
mental health and AOD use (particularly relapse prevention and urge control). For instance, a behavioural
treatment program consisting of stimulus control, urge control, social contracting, problem solving,
relationship enhancement, anger management, and communication skills training has been shown to be
particularly effective in continued abstinence in adolescents with AOD issues [1142], while cognitive and
behavioural therapies have indicated positive outcomes for mental health disorders [1143-1146]. Towers
[1147] argues that it is unrealistic to expect many young people to completely cease using all substances
and engaging in other risk-taking behaviours (such as driving at high speeds, promiscuity), at least initially.
Therefore, it is particularly important to include harm reduction strategies when working with young people.
As young people are fundamentally different from adults in ways that are likely to affect treatment
utilisation, adherence, and outcomes [1148-1151], it would be inappropriate to simply replicate adult-
focused treatment for young people. Rather, this group requires specialised treatment, focused on meeting
developmental and engagement needs. These should include [98, 402]:
• Youth-friendly approach.
• Follow-up for missed appointments.
• Focus on accessibility.
• Prompt screening and assessment.
• ‘Drop-in’ capacity.
• Flexibility.
• Strong links with other services, and provision of coordinated care (see Chapter B4).
• Treatments that reflect different cognitive capabilities and developmental differences.
E-health interventions, described in Chapter B5, may be particularly useful for this population [98, 1152-
1155]. AOD workers should also be aware that it may take longer to establish rapport and trust within
therapy, and adopting a more flexible approach (e.g., consider working outside traditional treatment
settings, by talking and playing pool or going to a café), may help build rapport [276].
Older people
The world’s population is ageing rapidly, with the proportion of adults aged over 60 years expected
to double from around 605 million to 2 billion people between 2000 and 2050 [1156]. Increased life
expectancy, better health care and decreased infant mortality across Australia are contributing to the
increasing proportion of older people in the Australian community, and there is a need for AOD workers to
be aware of the presentation and management of comorbid mental health disorders among older people,
and how these differ from younger populations [277].
More than 20% of adults aged over 60 years have a mental health or neurological condition, the most
common of which are dementia and depression, and one-in-four deaths from self-harm are among this
age group [1156]. However, mental illness is often difficult to identify due to comorbidity with physical
health problems, injuries, and disabilities. Older people may have many contributing risk factors for mental
illness, including bereavement, loss of social roles due to ill health or retirement, social isolation, financial
difficulties, diminishing cognitive function, and reduced capacity to self-care and manage their affairs
[277]. Depression and suicide are also easily overlooked among older adults, and people who are socially
isolated without supportive networks are at particular risk [277].
• Reduced capacity to metabolise, distribute, and eliminate drugs; as such, the risk of AOD-related harm
may increase if AOD use is not reduced as a person becomes older.
• An increase in disposable income, which may increase AOD consumption and associated problems.
• Life changes including new patterns of socialising, retirement, bereavement, and social isolation.
• More medications available for a range of conditions, which may be a contributing factor in the
increased use of psychoactive substances.
• Opioids and hypnotic sedatives are increasingly used by older Australians, which can be harmful when
used with other substances (e.g., alcohol).
• Increased use of opioid substitution programs, needle and syringe programs, and treatments for blood-
borne viruses has prevented many premature AOD-related deaths, and, as a result, many long-term
illicit drug users survive into older age and thus require ongoing treatment.
In general, older adults may be less likely to seek help for comorbid mental health and AOD use disorders
[1160]. Several barriers that may prevent older adults from accessing treatment include [1161]:
• Transport, mobility, language, visual, or hearing difficulties, particularly for those who are frail or
housebound, in rural or remote areas.
• Social isolation.
• Lack of time – older people may have other time commitments, including the need to care for others
(e.g., spouse, friends, or grandchildren).
• The unappealing and unwelcoming nature of mixed-age clinical services, which older people may find
chaotic.
• Ageism, negative stereotypes, attributing problems to the aging process.
• A lack of awareness about mental health and AOD use problems among older people
• Reluctance to ask older people sensitive questions that may be embarrassing.
• The perception that older people are too old to change their behaviour.
• The belief that it is wrong to ‘deprive’ older people from their final pleasures in life.
• Inability to identify symptoms of AOD and mental health conditions in older people.
• Social isolation which can result in serious problems going undetected.
It is critical to be aware that older adults with comorbid mental health and AOD disorders are not a
homogenous group, and AOD workers and other health care providers will play a vital role in ensuring
access to interventions. The following may be useful for AOD workers managing and treating older adults
[1161]:
• Ensure AOD programs are age-specific, supportive, non-confrontational, aim to build self-esteem and
foster an environment of respect.
• Ensure risk assessments are conducted (see Chapter B3), and depression, loneliness, and loss are
addressed. Assist the client to take steps to rebuild their social networks.
• Be flexible and conduct sessions at an appropriate pace.
• Where appropriate, involve families and carers.
• With the client’s consent, involve staff members who are interested and experienced in working with
older adults.
Appendices
Appendix A: Other guidelines
Other Australian guidelines
Australian Department of Health and Ageing. (2007). Alcohol treatment guidelines for Indigenous
Australians. Canberra, Australia: Australian Government Department of Health and Ageing.
http://remoteaod.com.au/sites/default/files/images/alc-treat-guide-indig%5B1%5D.pdf
Australian General Practice Network. (2007). Management of patients with psychostimulant use
problems: Guidelines for general practitioners. Canberra, Australia: Australian Government Department
of Health and Ageing.
http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/
Content/9BFD29DFA6DE474CA2575B4001353B2/$File/psygp07.pdf
Cash, R. & Philactides, A. (2006). Clinical treatment guidelines for alcohol and drug clinicians. No. 14: Co-
occurring acquired brain injury/cognitive impairment and alcohol and other drug use disorders. Fitzroy,
Australia: Turning Point Alcohol and Drug Centre Inc.
https://www2.health.vic.gov.au/
Crane, P., Buckley, J., & Francis, C. (2012). Youth alcohol and drug good practice guide 1: A framework for
youth alcohol and other drug practice. Brisbane, Australia: Dovetail.
http://dovetail.org.au/media/40155/dovetail_guide01doutput.pdf
Croton, G. (2007). Screening for and assessment of co-occurring substance use and mental health
disorders by alcohol and other drug and mental health services. Wangaratta, Australia: Victorian Dual
Diagnosis Initiative Advisory Group.
http://www.nada.org.au/media/14706/vddi_screening.pdf
Encompass Family and Community. (2014). Youth alcohol and drug practice guide 4: Learning from each
other: Working with Aboriginal and Torres Strait Islander young people. Brisbane, Australia: Dovetail.
http://dovetail.org.au/media/101008/guide%2004%20learning%20from%20each%20other.pdf
Gordon, A. (2009). Comorbidity of mental disorders and substance use: A brief guide for the primary
care clinician. Canberra, Australia: Commonwealth Department of Health and Ageing.
www.nationaldrugstrategy.gov.au/internet/drugstrategy/Publishing.nsf/content/
FE16C454A782A8AFCA2575BE002044D0/$File/mono71.pdf
Jenner, L., Baker, A., Whyte, I., & Carr, V. (2004). Psychostimulants: Management of acute behavioural
disturbances: Guidelines for police services. Canberra, Australia: Australian Government Department of
Health and Ageing.
http://nceta.flinders.edu.au/files/2514/3130/6038/Guidelines_for_Police_Services.pdf
Appendices 205
Other Australian guidelines (continued)
Jenner, L. & Lee, N. (2008). Treatment approaches to users of methamphetamine: A practical guide for
front line workers. Canberra, Australia: Australian Government Department of Health and Ageing.
http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/Publishing.nsf/
content/8D2E281FAC2346BBCA25764D007D2D3A/$File/tremeth.pdf
Lee, K., Freeburn, B., Ella, S., Miller, W., Perry, J., & Conigrave, K. (2012). Handbook for Aboriginal alcohol
and other drug work. Sydney, Australia: University of Sydney.
http://nceta.flinders.edu.au/files/1613/5847/3861/handbook_online-version2.pdf
Marsh, A., Dale, A. & Willis, L., O’Toole, S., & Helffott, S. (2013). Counselling guidelines: Alcohol and other
drug issues. Perth, Australia: Drug and Alcohol Office.
http://remoteaod.com.au/sites/default/files/images/Counselling%2BGuidelines%2B2013.pdf
Marsh, A., Towers, T. & O’Toole, S. (2012). Trauma-informed treatment guide for working with women
with alcohol and other drug issues (2nd edition). Perth, Australia: Improving Services for Women with
Drug and Alcohol and Mental Health Issues and their Children Project.
McIver, C., McGregor, C., Baigent, M., Spain, D., Newcombe D. & Ali, R. (2006). Guidelines for the medical
management of patients with methamphetamine-induced psychosis. Parkside, Australia: Drug and
Alcohol Services South Australia.
https://www.sahealth.sa.gov.au/wps/wcm/connect/cbad29804178755b94d1ff67a94f09f9/
Guidelines+methamphetamine-induced+psychosis-DASSA-Oct2013.
pdf?MOD=AJPERES&CACHEID=cbad29804178755b94d1ff67a94f09f9
Network of Alcohol and Other Drugs Agencies. (2015). NADA practice resource for women engaged in
in alcohol or other drug treatment. Sydney, Australia: Network of Alcohol and Other Drugs Agencies.
http://www.nada.org.au/media/75320/working_with_women_engaged_in_aod_treatment.pdf
NSW Health Department. (2009). NSW clinical guidelines for the care of persons with comorbid mental
illness and substance use disorders in acute care settings. Sydney, Australia: NSW Department of
Health.
http://www.health.nsw.gov.au/mhdao/programs/mh/Publications/comorbidity-report.pdf
NSW Department of Health. (2007). Mental health reference resource for drug and alcohol workers.
Sydney, Australia: NSW Department of Health.
http://www.nada.org.au/media/8033/mhrr.pdf
NSW Department of Health. (2008). NSW Health drug and alcohol psychosocial interventions. Sydney,
Australia: NSW Department of Health.
www.health.nsw.gov.au/policies/gl/2008/pdf/GL2008_009.pdf.
206 Appendices
Other Australian guidelines (continued)
NSW Department of Health. (2015). Guidelines to consumer participation in NSW drug and alcohol
services. North Sydney, Australia: NSW Department of Health.
http://www0.health.nsw.gov.au/policies/gl/2015/pdf/GL2015_006.pdf
Victorian Dual Diagnosis Initiative. (2012). Our healing ways: Putting wisdom into practice: Working with
co-existing mental health and drug and alcohol issues: Aboriginal way. Melbourne, Australia: Victorian
Dual Diagnosis Initiative Education and Training Unit.
http://nceta.flinders.edu.au/files/8113/5847/3546/Healing_Ways_Manual.pdf
Western Australian Network of Alcohol and other Drug Agencies. (2011). Healthy eating for wellbeing: A
nutrition guide for alcohol and other drug agency workers. Perth, Australia: Western Australian Network
of Alcohol and other Drug Agencies.
http://www.wanada.org.au/Download-document/496-Healthy-Eating-for-Wellbeing-A-Nutrition-
Guide-for-Alcohol-Other-Drug-Agency-Workers.html
Winstock, A. & Molan, J. (2007). The patient journey: KIT2: Supporting GPs to manage comorbidity in the
community. Sydney, Australia: NSW Department of Health.
http://www.health.nsw.gov.au/mhdao/Documents/pj-kit2.pdf
Appendices 207
Appendix B: Other useful resources
Other useful resources
Back, S., Foa, E., Killeen, T., Mills, K.L., Teesson, M., Cotton, B.D., Carroll, K.M., Brady, K.T. (2015). Concurrent treatment
of PTSD and substance use disorders using prolonged exposure (COPE): Therapist guide. Oxford, UK: Oxford
University Press.
Baker, A., Kay-Lambkin, F., Lee, N. K., Claire, M. & Jenner, L. (2003). A brief cognitive behavioural intervention for
regular amphetamine users. Canberra, Australia: Australian Government Department of Health and Ageing.
Baker, A. & Velleman, R. (2007). Clinical handbook of co-existing mental health and drug and alcohol problems.
London, UK: Routledge.
Clancy, R. & Terry, M. (2007). Psychiatry and substance use: An interactive resource for clinicians working with
clients who have mental health and substance use problems [DVD-ROM]. Newcastle, Australia: NSW Health.
Graham, H. (2003). Cognitive-behavioural integrated treatment (C-BIT): A treatment manual for substance misuse in
people with severe mental health problems. Chichester, UK: Wiley.
Lee, N., Jenner, L., Kay-Lambkin, F., Hall, K., Dann, F., Roeg, S., et al. (2007). PsyCheck: Responding to mental health
issues within alcohol and drug treatment. Canberra, Australia: Commonwealth of Australia.
http://www.psycheck.org.au
http://www.mentalhealth.wa.gov.au
Miller, W. and Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd Edition). New York, NY:
Guildford Press.
Comorbidity information booklets by Mills K.L., Marel C., Baker A., Teesson M., Dore G., Kay-Lambkin F., Manns L.,
Trimingham T. (2011). Sydney, Australia: National Drug and Alcohol Research Centre.
http://www.comorbidity.edu.au
http://www.health.gov.au/
http://www.aasw.asn.au/document/item/4551
Reilly, P. M. & Shopshire, M. S. (2002). Anger management for substance abuse and mental health clients: A
cognitive behavioural therapy manual. Rockville, MD: US Department of Health and Human Services.
208 Appendices
Other useful resources (continued)
Alcohol, Tobacco www.atdc.org.au The peak body representing the NGO, not-
and Other for-profit Alcohol, Tobacco and Other Drug
Drugs Council (ATOD) sector in Tasmania.
of Tasmania Inc
(ATDC)
Association of www.aadant.org.au Peak body for the alcohol and other drug
Alcohol and Other sector in the Northern Territory.
Drug Agencies NT
(AADANT)
Appendices 209
Other useful resources (continued)
Drug and Alcohol www.danaonline.org Peak body representing alcohol and other
Nurses of drug nursing in Australia.
Australia (DANA)
210 Appendices
Other useful resources (continued)
Appendices 211
Other useful resources (continued)
Northern Territory http://www.ntcoss.org.au/ The peak body for the social and
Council of Social community sector in the Northern Territory.
Service (NTCOSS)
212 Appendices
Other useful resources (continued)
Western Australian www.wanada.org.au The peak body for the non-profit AOD sector in
Network of Western Australia.
Alcohol and Other
Drug Agencies
(WANADA)
Ybblue www.beyondblue.org.au/ybblue Aims to aid young people (as well as their family
and friends) in talking about and seeking help for
depression.
Youth Coalition for www.youthcoalition.net The peak youth affairs body in the ACT and
the ACT responsible for representing the interests of
people aged between 12–25 years of age, and
those who work with them.
Appendices 213
Appendix C: Research and information organisations
Australian Centre for Addiction Research www.acar.net.au
214 Appendices
Appendix C: Research and information organisations
(continued)
Substance Abuse and Mental Health Services www.samhsa.gov
Administration, US
Appendices 215
Appendix D: DSM-5 and ICD-10 classification cross-
reference
DSM-5 disorder classification ICD-10 classification ICD-10 coding
216 Appendices
Appendix D: DSM-5 and ICD-10 classification cross-
reference (continued)
DSM-5 disorder classification ICD-10 classification ICD-10 coding
Appendices 217
Appendix E: Motivational interviewing
A useful tool in AOD client management is motivational interviewing (MI), irrespective of whether the
client suffers co-occurring mental health conditions. MI can be beneficial for clients with comorbidity by
increasing treatment motivation, adherence and behaviour change [528, 1162-1165], although it may not
prove effective in all cases [1166]. A number of useful resources for MI are given in Appendix B, including
Miller and Rollnick [389], Baker and Velleman [1167], and Clancy and Terry [296] from which this section
draws upon.
Principles of MI include:
Thus MI aims to rouse feelings of ambivalence and discomfort surrounding current behaviour in order
to motivate change. In the first two editions of MI, Miller and Rollnick conceptualised MI as having two
phases: building motivation (Phase 1) and consolidating commitment (Phase 2). In the current (third) edition
however, the sequential phases of MI have been relaxed, and reconceptualised as four overlapping
processes (Figure 18, Table 50) [389]:
• Engaging: the establishment of a meaningful connection and therapeutic relationship between the
client and AOD worker, and is a prerequisite for everything that follows.
• Focusing: the development and maintenance of a specific direction in conversation about change.
• Evoking: the elicitation of the client’s own motivations for change, which has always been at the heart
of MI. It can be achieved when there is a focus on a particular change and the client’s own ideas and
feelings about how to achieve it are harnessed (i.e., the client talks themselves into changing).
• Planning: involves developing commitment to change and formulating a specific plan of action. It is
often the point where a client begins to talk about when and how to change, as opposed to whether
and why.
Planning
Evoking
Focusing
Engaging
218 Appendices
Table 50: Questions regarding each MI process
Engaging
Focusing
Evoking
Planning
This technique involves a questioning method that does not invite short answers; this increases information
flow and trust, and invites the client to reflect and elaborate. In the engaging and focusing processes
of MI, open questions help the AOD worker understand the client’s frame of mind, find a clear direction
for change, and strengthen the relationship between client and AOD worker [389]. Certain kinds of open
questions are particularly suited to the different processes involved in MI (e.g., engaging, evoking). AOD
may also find the range of open questions provided in Table 51 useful [402], which have been grouped
according to the stages of change model [292]. The goal of these questions is to elicit self-motivational
statements from the client [402].
In clients displaying symptoms of co-occurring mental health conditions, these questions should be
simplified. Compound questioning (two questions in one sentence) should be avoided [1168].
Appendices 219
Affirming
The client, rather than the AOD worker, produces change in MI, and as such, the process of MI relies on the
client’s own personal strengths, efforts and resources. Affirmation can be general (the AOD worker respects
the client as a person of worth, who has the capacity for growth, change, and the choice about whether
to do so), and specific (recognition of the client’s strengths, abilities, intentions, and efforts) [389]. Affirming
involves accentuating the positive (rather than attempting to produce change through making the client
feel bad) [389], with direct compliments and statements of appreciation and understanding. This helps
build rapport, self-efficacy and reinforces open exploration. In clients displaying symptoms of co-occurring
mental health conditions, this can be inspiring and build rapport enormously [1168].
Reflective listening
This technique involves listening to what the client is saying, forming an understanding of what the client is
talking about and then giving voice (reflecting) to that understanding. This can be a mere substitution of the
client’s words, a guess at the unspoken meaning, an observation about the client’s emotions or suggesting
the next sentence in the client’s paragraph (known as continuing the paragraph). Good reflective listening
keeps the client talking, exploring, and considering. It is also specific in the sense that the AOD worker
selects specific information on which to reflect.
The depth of reflection increases with the level of the AOD worker’s experience and expertise. Simple
reflections can be useful, but can sometimes lead to slower progress if the AOD worker is not able to add
complexity and depth by interpreting the spoken and unspoken content, anticipating what may come next
[389]. Some examples of how to initiate reflective listening include [389]:
In clients displaying symptoms of co-occurring mental health conditions, these statements should be
simple, concise and frequent. Avoid repeated reflecting of the client’s negative statements and allow him/
her time to consider these reflections [1168].
Summarising
Summaries are useful in collating, linking and reinforcing information discussed during the interviewing
process, and offer a ‘what else’ opportunity for the client to add any information that may be missing. This
should be done often to promote meaningful relationships and contrasts between statements to enhance
motivation to change [1168]. Some examples of summarising techniques include:
220 Appendices
Table 51: Example of open questions according to elicit self-motivational statements
Pre-contemplation Problem recognition (e.g., ‘I guess • What things make you think that this is a problem?
there might be more of a problem that • What difficulties have you had in relation to your AOD use?
I thought’) • What difficulties have you had in relation to your mood?
• In what ways has this been a problem for you?
• How has your use of AOD stopped you from doing what you want to do?
Contemplation Expression of concern (e.g., ‘I’m • What worries do you have about your AOD use?
worried about this’) • What can you imagine happening to you?
• Tell me more about preventing a relapse to using… why is that so important to you… what is it like when you
are ill?… And how about your family – what effect did it have on them? How important are these issues to
you?
• Can you tell me some reasons why drinking or using may be a health risk? Would you be interested in
knowing more about the effects of drinking/using? How important are these issues to you?
• What would your best friend/mum say were your best qualities? Tell me, how would you describe the
things you like about yourself?... And how would you describe you the user?... How do these two things fit
together?... How important are these issues to you?
Action Intention to change (e.g., ‘This isn’t how • You seem a bit stuck at the moment. What would have to change to fix this?
I want to be’) • What would have to happen for it to become much more important for you to change?
• If you were 100% successful and things worked out exactly as you would like, what would be different?
• The fact that you are here indicates that at least a part of you thinks it is time to do something. What are the
reasons you see for making a change? What would be the advantages of making a change?
• What things make you think that you don’t need to worry about changing your AOD use?
• And what about the other side… What makes you think that it’s time to do things a bit differently?
• If you were to decide to change what might your options be?
Maintenance Optimism (e.g., ‘I think I can do this’) • What would make you more confident about making these changes?
• Are there ways you know about that have worked for others? Is there anything you found helpful in any
previous attempts to change?
• What are some of the practical things you would need to do to achieve this goal? Do they sound
achievable?
• What encourages you that you can change if you want to?
• What makes you think that if you did decide to make a change, you could do it?
Appendices
Adapted from NSW Department of Health [402].
221
Informing and advising
Although MI adopts a client centred approach, this does not mean that offering advice or information to
clients is inappropriate. There are some circumstances where it is certainly appropriate (e.g., if the client
requests information). However, MI does not involve dispensing unsolicited information in a directive style.
Instead, MI involves [389]:
Miller and Rollnick [389] recommend using the ‘elicit-provide-elicit’ approach when exchanging information
with a client.
Elicit
Provide
Elicit
• Ask for the client’s interpretation, understanding, or response: ask open questions, use reflection, allow
the client time to process and respond to the information.
Additional strategies
In addition to these five core communication skills, some key strategies have been developed to build
intrinsic motivation for change and resolve ambivalence. This is achieved by assisting the client to present
his/her own arguments for change in order to [389]:
Typical day
Often a client deems certain aspects of his/her life irrelevant to treatment or they are insignificant to the
client and overlooked and therefore not disclosed during therapy. However, knowing these things can help
a worker engage with the client. It can also provide a more holistic view of the person as well as invaluable
information concerning daily habits, significant environments, important relationships and people in the
222 Appendices
client’s life. Furthermore, this can highlight to the client aspects of his/her life that he/she had not been
aware of (e.g., ‘I hadn’t realised I was drinking that much’).
In order to attain this information it can be useful to ask the client to explain how he/she spends an average
day. Encourage the client to pick an actual day (e.g., last Wednesday) rather than what they do ‘most days’.
Allow the person to continue with as little interruption as possible. If necessary, prompt with open-ended
questions (e.g., ‘What happened then?’ or ‘How did you feel?’). Review and summarise back to the client
after he/she has finished, and clarify that you have summarised accurately.
Once you have a reasonably clear picture of how the client’s use (and any co-occurring mental health
symptoms) fits into a typical day and any current concerns, ask the client’s permission to provide feedback
from your assessment (e.g., ‘I’m getting a feel for what’s going on in your everyday life at the moment,
you’ve mentioned several things that are concerning you’).
Summarise these problem areas briefly, using those issues raised by the client in the ‘typical day’
discussion (e.g., quality of life, health, mood, drug use). When the client is providing information about their
typical day, it gives the AOD worker opportunities to ask more detail about behaviour patterns, feelings, and
mood changes. Areas of concern often emerge naturally from such discussions [389].
This technique involves a conscious weighing up of the pros and cons of certain behaviours (e.g., drug
use). This can be used as a way of neutral counselling, where the worker is not trying to steer the client
into making one choice over another, but instead allowing the client to make their own choice about
personal change [389]. Clients are often aware of the negative aspects involved in certain behaviours but
have never consciously assessed them. The decisional balance is a frequently used motivational strategy,
particularly when clients are displaying ambivalence regarding their substance use and for when you want
to determine their stage of change in regard to their substance use.
For clients who have difficulty in articulating things they like about using, you may need to offer a menu of
options for them to choose from, although you should do this sparingly. Remember you are trying to find
out what this client likes about using, not what you think he/she might like about it! Encourage the client to
write down these good things (a useful template is included at the end of this MI summary).
Briefly summarise the good aspects of AOD use. Next, ask the client about the not-so-good things about
his/her AOD use. Try to avoid using negative words such as the ‘bad things’ or ‘problems’. The AOD worker
could ask questions such as:
• ‘So we have talked about some of the good things about using drugs, now could you tell me some of
the less good things?’
• ‘What are some of the things that you don’t like about your drug use?’
• ‘What are some of the not-so-good things about using?’
Again you may have to offer a menu of options or ask questions (based on collateral information) like ‘How
does your family feel about your using?’ but avoid suggesting that an issue should be of concern, and
do not put any value judgement on the beliefs of the client by saying something like ‘Don’t you think that
Appendices 223
getting arrested twice is a bit of a problem?’ The success of MI rests on the client’s personal exploration of
his/her AOD use, and the good and not-so-good effects that it has on him/her. Explore each element in full
with appropriate use of the core communication skills, such as the use of open questions and reflection.
Unlike the good things, the less good things need to be explored in detail. If the client claims AOD use
reduces his/her mental health symptoms, explore this in particular detail: for instance, enquire about
longer-term effects [1168]. It is important to remember you are after the client’s perspective of the less
good things. It can be useful to ask follow up questions such as:
It can be particularly useful (especially when not-so-good aspects are not forthcoming) to explore the
other side of the positive consequences of using listed. For example, if the high was listed as an advantage,
explore the ‘come-down’ that inevitably followed and the length of this crash (which will usually have lasted
longer than the euphoria).
It is then useful to assess, through the use of a scale from 1-10, the client’s perspective of how important
an issue is. Beside each pro and con the client should rate it on the importance it holds for him/her. This
ascertains to what extent cons are a concern for the client. Many workers make the mistake of assuming
that just because the client acknowledges a not-so-good thing about AOD use, this automatically presents
a direct concern for them.
• ‘You said some of the things you like about using were… and then you said that there was another side
to it… you said some of the not so good things about using were…’
Skill is required here in order to emphasise the not-so-good things. It can be useful to give the client a
chance to come to his/her own conclusions, for example:
• ‘Now that you’ve gone through both sides, where does this leave you? ‘
• ‘How do you feel about your drug use now?’
If ambivalence is evident, attempt to explore the reasons that underlie this imbalance and re-establish the
initial reasons for wishing to quit/cut down. Incorporate information on health and psychological effects
of continued use. Guide the client through a rational discussion of issues involved, and carefully challenge
faulty logic or irrational beliefs about the process of quitting. Positive reinforcement and encouragement
are crucial, but if you encounter resistance from the client, do not push them.
NOTE: Use this strategy with caution for clients with high levels of anxiety or those who are not ready
to deal with the pressure of increased ambivalence. In addition, do not leave a depressed client in
psychological distress for too long after using the decisional balance strategy [1168]. Avoid using this
strategy with a client who is currently tempted to use. Distraction is a better strategy to use with someone
who is currently tempted rather than to discuss the things they like about using [296].
224 Appendices
Elaboration
Once a motivational topic has been raised, it is useful to ask the client to elaborate. This helps to reinforce
the theme and to elicit further self-motivational statements. One good way of doing this is to ask for specific
examples and for clarification as to why (how much, in what way) this is a concern.
Querying extremes
Clients can also be asked to describe the extremes of their concerns, to imagine worst consequences. This
can sometimes help when a client is expressing little desire for change. For instance you may ask:
It can also be useful to ask the client the best possible consequences that might happen after pursuing a
change (e.g., exploring the opposite extreme), such as:
• “What could be the best results if you did make the change?”
• “If you were completely successful in making the changes you want, how would things be different?”
This involves discussing routines and day-to-day stresses. Some questions might be:
Looking back
Sometimes it is useful to have the person remember times before the problem emerged, and to compare
this with the present situation. Ask the client what life was like ‘before’: before substance use problems;
before legal, work or relationship difficulties; before mental health problems etc. Focus on positive
memories, hopes, dreams, plans or successes the person may have once had. If the person’s history
is negative, it may still be useful to explore ‘what it was like’, not necessarily in an attempt to process
or resolve issues from that time, but primarily to understand what may have brought about the current
situation and behaviours. For example:
• ‘Do you remember a time when things were going well for you? What has changed and how?’
• ‘What were things like before you started using?’
• ‘What were you like back then? What were your plans? What has changed and why?’
• ‘How has your use of alcohol/drugs influenced things?’
The goal is for the client to obtain some perspective from the immediacy of his or her circumstance and to
observe how things have changed over time. If the client has positive views on how things were before the
problem emerged, highlighting the discrepancy between how things are currently, and the possibility of life
being better again can help motivate the client.
NOTE: In clients with symptoms of a co-occurring depressive condition, this strategy should be avoided or
used with caution [1168].
Appendices 225
Looking forward
Similarly, it can be helpful for clients to visualise the future should they embark on the change or should
they remain the same. Some questions might include:
As with querying extremes, you could also ask the client to anticipate the future if no changes are made
(e.g., ‘Suppose things continue as they are now and you don’t make any changes, what will your life be
like in 5 years from now?’). The difference between looking forward and querying extremes is that in this
looking forward method, the AOD worker is asking for the client’s most realistic assessment of the future
rather than their imagined ‘extreme’ outcome.
NOTE: In clients with symptoms of a co-occurring depressive condition, this strategy should be avoided or
used with caution [1168].
It can be useful to ask clients about their goals and what is most important to them and compare this to the
current situation. Rather than perceiving a people as unmotivated, it may be more useful to understand the
different goals and priorities [389]. Explore the ways in which the problem behaviour is inconsistent with, or
undermines important values and goals for them. When the highest or most central values and goals have
been defined, you can ask how the problem you are discussing (e.g., drinking/using) fits into this picture.
For example:
Exploring what matters most to a person can also help build rapport, and as such, this strategy can be used
in the engaging process. Exploring goals and values need not be limited to benefits that could result from a
particular change; the process can also be used to learn about the client’s priorities and life values.
Strengthening commitment
Although some people experience a specific moment in which their desire to change suddenly crystalises,
for most people this is a gradual process. As such, it is common for clients’ commitment to taking action to
fluctuate over time [389]. MI is a method of facilitating the natural growth of commitment. The AOD worker
will consolidate all issues raised by the client, and help him/her to build their commitment to change
while also planning a concrete action plan. Ambivalence will still possibly be present, and if encountered
continue the use of the strategies and microskills outlined above. It can be useful to encourage the client to
confront the idea and process of change. For example:
226 Appendices
Although abstinence is one possible goal, some people may not be ready to stop completely and may opt
for reduced or controlled use. In MI, the client has the ultimate responsibility for change and total freedom
of choice to determine his/her goal for treatment. The AOD worker’s role is to assist the client to determine
treatment goals and guide the realisation of those goals. Goals may often change during the course of
treatment, and an initial goal of cutting down may become a goal of abstinence as the client’s confidence
increases.
In clients with co-occurring mental health conditions, abstinence is the most appropriate goal [1168] as
mental health symptoms may be exacerbated by AOD use. In particular, those with more severe mental
disorders (or cognitive impairment) may have adverse experiences even with low levels of substance use
[54]. Those taking medications for mental health conditions (e.g., antipsychotics, antidepressants) may
also find that they become intoxicated even with low levels of AOD use due to the interaction between
the drugs. Although abstinence is favoured, many people with comorbid conditions prefer a goal of
moderation. It is possible to accept a client’s decision to use and provide harm reduction information
without condoning use.
Explore any fears or obstacles that are identified in the change process and assist the client with problem
solving for each of these. Explore any concerns with the management of withdrawal symptoms (e.g.,
irritability, insomnia, mood disturbances, lethargy, and cravings to use) if this is raised. Education and
support are essential components of getting through withdrawal.
Finally, when the client begins behaviour change, try manipulating the environment to exaggerate positive
outcomes (e.g., involve family, increase social interaction, use encouragers and compliments), particularly in
clients with co-occurring mental health conditions in order to strengthen resolve [1168].
Appendices 227
Good things & not-so-good things worksheet
228 Appendices
Appendix F: Mental state examination
Appearance
Physical appearance? (posture, grooming, clothing, signs of AOD use, nutritional status)
Behaviour
General behaviour? Behaviour to situation and to examiner? (angry/hostile, unco-operative, withdrawn,
inappropriate, fearful, hypervigilant)
Speech
Rate, volume, tone, quality and quantity of speech?
Appendices 229
Mood and affect
How does the client describe his/her emotional state (mood)? What do you observe about the person’s
emotional state (affect)? Are these two consistent and appropriate?
Thought content
Delusions, suicidality, paranoia, homicidality, depressed/anxious thoughts?
Perception
Hallucinations? Depersonalisation? Derealisation?
Cognition
Level of consciousness? Attention? Memory? Orientation? Abstract thoughts? Concentration?
230 Appendices
Appendix G: Integrated Motivational Assessment Tool (IMAT)
Motivation regarding AOD treatment
Preparation /
Pre-contemplation Contemplation Action Maintenance
Determination
Pre-contemplation
Contemplation
Preparation /
Determination
Action
Appendices
231
Source: NSW Department of Health (2007). Mental health reference resource for drug and alcohol workers. Sydney, Australia: NSW Department of Health.
Appendix H: Additional screening tools
The General Health Questionnaire (GHQ) is a self-report screening instrument which detects the presence
of psychological symptoms [1169]. It has demonstrated adequate reliability and validity in both the 12- and
28-item forms, on which a client rates each statement on a four-point scale [1169, 1170]. The GHQ is easy to
administer and score and can be used by a range of health professionals; however, this instrument must be
purchased. Generally a score of 10 or more on the GHQ is considered indicative of significant psychological
distress and the presence of an underlying psychological disorder. However, it has been suggested
that approximately 75% of drug users could be expected to obtain scores of 10 or more upon entering
treatment; therefore, clients need to be reassessed after entering treatment [1014]. If the client continues to
score 10 or more, a more in-depth psychological assessment should be conducted.
Shorter forms of the SCL-90-R have been developed, including the Brief Symptom Inventory with 53 items
and the Symptom Assessment, each of which show adequate reliability and validity [1174]. However, the
long and short forms of the SCL-90-R are copyrighted and must be purchased by registered psychologists
[1171]. There are both a pen and paper and computerised versions of the SCL-90-R. The former takes 12-15
minutes to complete, is designed for adolescents over the age of 13 years and for adults. A Year 8 reading
age is required.
The Brief Psychiatric Rating Scale is an 18-item clinician-administered scale measuring a broad range
of psychiatric symptoms, as does the SCL-90-R. It has been shown to be effective in various substance
use populations [1175, 1176]. However, the reliability and validity of the scale is dependent upon clinical
expertise and specific training and therefore may be less appropriate in the AOD sector [320]. It was initially
devised as an instrument to assess the symptoms of schizophrenia on five sub-scales of thought disorder,
withdrawal, anxiety/depression, hostility and activity [1177, 1178].
The Psychiatric Diagnostic Screening Questionnaire consists of 132-items designed to screen for over
13 different DSM-IV-TR [23] Axis I disorders, including alcohol/drug related disorders [1179]. Reports have
found the questionnaire to have good validity and reliability along with strong sensitivity and high negative
predictive value indicating most cases are detected and most non-cases are indeed non-cases [1179, 1180].
These psychometric properties are fundamentally important in a screening instrument and suggest the
measure might have broad applicability in numerous health care settings including AOD [84].
The Beck Depression Inventory (BDI or BDI-II) is a 21-item self-report instrument intended to assess the
existence and severity of symptoms of depression [1181, 1182]. Each item is ranked on a four-point scale.
The BDI-II has been shown to be a reliable and valid measure of depression particularly in substance
misusing populations [1183, 1874]. The Beck Hopelessness Scale is a 20-item scale designed to detect
negative feelings about the future and has been found to be a good predictor of suicide attempts [1185].
It has been shown to have high internal consistency and test-retest reliability. Instruments such as this can
be helpful in ongoing treatment where particular thoughts can continue to be monitored through this and
other suicidal thoughts instruments. The Beck Scale for Suicidal Ideation is a 21-item scale assessing
intention to commit suicide [1186]. It has been found to be a valid predictor of admission to hospital for
suicidal intention and has high internal consistency and test-retest reliability [320]. The Beck Anxiety
232 Appendices
Inventory [1187] consists of 21 items, each describing a common symptom of anxiety. The respondent is
asked to rate how much he or she has been bothered by each symptom over the past week on a four-
point scale. The items are summed to obtain a total score that can range from 0 to 63. The Beck Anxiety
Inventory has similarly shown good reliability and validity for the measurement of anxiety symptoms,
though discriminant validity has been questioned [1187-1189]. The Beck scales are quite simple to
administer but scoring and interpretation must be supervised by a registered psychologist and the cost is
high.
The Spielberger State Trait Anxiety Inventory also measures anxiety [1190] and requires a registered
psychologist for scoring, interpretation and the purchasing [320]. The reliability and validity are adequate
in general populations, but are unknown within the AOD sector [320, 1190]. The scale consists of 40-items,
rated on a four-point scale and takes approximately 10 minutes to complete.
The Traumatic Life Events Questionnaire (TLEQ) is a 23-item self-report measure of 22 types of
potentially traumatic events including natural disasters, exposure to warfare, robbery involving a weapon,
physical abuse and being stalked [1191]. For each event, respondents are asked to provide the number of
times it occurred (ranging from ‘never’ to ‘more than 5 times’) and whether fear, helplessness or horror was
present (‘yes/no’). The TLEQ has been used successfully within substance-abusing populations. Recent
studies have suggested that the psychometric properties of this measure are adequate [1192].
The Trauma History Questionnaire (THQ) developed by Green [1193] is a 24-item self-report measure that
examines experiences with potentially traumatic events such as crime, general disaster, and sexual and
physical assault using a ‘yes/no’ format. For each event endorsed, respondents are asked to provide the
frequency of the event as well as their age at the time of the event. The THQ has demonstrated adequate
test-retest reliability.
The PTSD Symptom Scale Self-Report is a screening tool for PTSD which has been used successfully in
AOD populations [1194, 1195]. The modified version of the scale only takes 10-15 minutes to administer and
measures both frequency and severity of symptoms [1195]. The scale consists of 17 items corresponding to
17 DSM-IV-TR [23] criteria which are rated on a four-point scale of symptom presence.
The PTSD Checklist [1196] is a self-report scale where respondents rate the extent to which they
experience each of the DSM-5 PTSD key symptoms. It consists of 20 items corresponding to DSM-5
criteria, which are rated on a five-point severity scale. Whilst no studies have currently examined the
psychometric properties of the PCL for DSM-5 in AOD use disorder samples, the previous version of the
checklist for DSM-IV-TR has been shown to have good reliability and validity within AOD populations [1197,
1198]. However, it is important to note that scores on the DSM-5 version of the PCL cannot be directly
compared with scores on the DSM-IV-TR version, due to a change in the rating scale (from 1-5 to 0-4) and
an increase in the number of items (from 17 to 20). The checklist is freely available online (http://www.ptsd.
va.gov/professional/assessment/adult-sr/ptsd-checklist.asp) but access is restricted to trained clinicians.
The McLean Screening Instrument for Borderline Personality Disorder is a 10-item measure which
requires dichotomous (yes or no) answers to questions which correspond to DSM-IV criteria for BPD [1199].
The measure has been shown to have good test-retest reliability and internal consistency [1199], as well as
good convergent and concurrent validity [1200]. Reliability and validity are also good when the measure is
used to assess BPD in young people [1201]. However, whilst the measure appears to be a feasible way of
screening for the presence of BPD symptoms, the authors recommend that the instrument should not be
used as a standalone instrument for diagnosing BPD. Instead, it should be used in conjunction with other
forms of clinical assessment [1199].
Appendices 233
Appendix I: CANSAS-P
AppendixCANSAS-P
I: CANSAS-P
– Self-rated version of the Camberwell Assessment of Need
Name:
Date of completion:
Met need
No need
want to
answer
Unmet
I don’t
need
1. Accommodation
What kind of place do you live in? □ □ □
2. Food
Do you get enough to eat? □ □ □
3. Looking after the home
Are you able to look after your home? □ □ □
4. Self-care
Do you have problems keeping clean and tidy? □ □ □
5. Daytime activities
How do you spend your day? □ □ □
6. Physical health
How well do you feel physically? □ □ □
7. Psychotic symptoms
Do you ever hear voices or have problems with your thoughts? □ □ □
8. Information on condition and treatment
Have you been give clear information about your medication? □ □ □
9. Psychological distress
Have you recently felt very sad or low? □ □ □
10. Safety to self
Do you ever have thoughts of harming yourself? □ □ □
11. Safety to others
Do you think you could be a danger to other people’s safety? □ □ □
234 Appendices
No need = this area is not a serious problem for me at all
Met need = this area is not a serious problem for me because of help I am given
Unmet need = this area remains a serious problem for me despite any help I am given
Met need
No need
want to
answer
Unmet
I don’t
need
12. Alcohol
Does drinking cause you any problems? □ □ □
13. Drugs
Do you take any drugs that aren’t prescribed? □ □ □
14. Company
Are you happy with your social life? □ □ □
15. Intimate relationships
Do you have a partner? □ □ □
16. Sexual expression
How is your sex life? □ □ □
17. Child care
Do you have any children under 18? □ □ □
18. Basic education
Any difficulty in reading, writing or understanding English. □ □ □
19. Telephone
Do you know how to use a telephone? □ □ □
20. Transport
How do you find using the bus, tram or train? □ □ □
21. Money
How do you find budgeting your money? □ □ □
22. Benefits
Are you getting all the money you are entitled to? □ □ □
Source: Slade, M., Thornicroft, G., Loftus, L., Phelan, M., & Wykes, T. (1999). CAN: Camberwell Assessment
of Need. London, UK: Royal College of Psychiatrists.
Appendices 235
Appendix J: Kessler psychological distress scale (K10)
Name...............................................................Date...................................
For all questions, please circle the answer most commonly related to you. Questions 3 and 6 automatically
receive a score of one if the proceeding question was ‘none of the time’.
Total:
Test: Kessler, R.C. (1996). Kessler’s 10 Psychological Distress Scale. Boston, MA: Harvard Medical School.
Normative data: National Survey of Mental Health and Well-being, Australian Bureau of Statistics 1997
236 Appendices
Appendix K: The PsyCheck Screening Tool
Client’s Name: DOB:
Service: UR:
Complete this section when all components of the PsyCheck have been administered.
Summary
Re-screen using the PsyCheck Screening Tool at the conclusion of four sessions.
Appendices 237
PsyCheck general screen
Clinician to administer this section
The following questions are about your emotional wellbeing. Your answers will help me get a clearer
idea of what has been happening in your life and suggest possible ways that we might work together to
relieve any distress you may be experiencing. We ask these questions of everybody, and they include
questions about mental, physical and emotional health.
1. Have you ever seen a doctor or psychiatrist
for emotional problems or problems with your No Yes
‘nerves’/anxieties/worries? □
Details
2. Have you ever been given medication for emotional problems or problems with your ‘nerves’/
anxieties/worries?
□ No, never
238 Appendices
PsyCheck risk assessment
Clinician to administer this section
If the person says ‘Yes’ to recently thinking about ending his/her life (Question 5), complete the suicide/
self-harm risk assessment below. Specific questions and prompts and further guidance can be found in
the PsyCheck User’s Guide.
Risk factor Low risk Moderate risk High risk
1. Previous attempts: Consider lethality and recency of attempts. Very recent attempt(s) with moderate
lethality and previous attempts at high lethality both represent high risk. Recent and lethal attempts of
family or friends represent higher risk.
History of harm to □ Previous low lethality Moderate lethality □High lethality, frequent
self
History of harm in Previous low lethality □ Moderate lethality High lethality, frequent
family members or
close friends
2. Suicidal ideation: Consider how the suicidal ideation has been communicated; non-disclosure may not
indicate low risk. Communication of plans and intentions are indicative of high risk.
Consider non-direct and non-verbal expressions of suicidal ideation here such as drawing up of wills,
depressive body language, ‘goodbyes’, unexpected termination of therapy and relationships etc. Also
consider homicidal ideation or murder/suicide ideation.
Intent No intent □ No immediate intent □ Immediate intent
Appendices 239
Self reporting questionnaire (SRQ)
Client or clinician to complete this section
First: Please tick the ‘Yes’ box if you have had this symptom in the last 30 days.
Second: Look back over the questions you have ticked. For every one you answered ‘Yes’, please put a
tick in the circle if you had that problem at a time when you were NOT using alcohol or other drugs.
1. Do you often have headaches? No □ Yes è
2. Is your appetite poor? No □ Yes è
3. Do you sleep badly? No □ Yes è
4. Are you easily frightened? No □ Yes è
5. Do your hands shake? No □ Yes è
6. Do you feel nervous? No □ Yes è
7. Is your digestion poor? No □ Yes è
8. Do you have trouble thinking clearly? No □ Yes è
9. Do you feel unhappy? No □ Yes è
10. Do you cry more than usual? No □ Yes è
11. Do you find it difficult to enjoy your daily activities? No □ Yes è
12. Do you find it difficult to make decisions? No □ Yes è
13. Is your daily work suffering? No □ Yes è
14. Are you unable to play a useful part in life? No □ Yes è
15. Have you lost interest in things? No □ Yes è
16. Do you feel that you are a worthless person? No □ Yes è
17. Has the thought of ending your life been on your mind? No □ Yes è
18. Do you feel tired all the time? No □ Yes è
19. Do you have uncomfortable feelings in the stomach? No □ Yes è
20. Are you easily tired? No □ Yes è
Source: Lee, N., Jenner, L., Kay-Lambkin, F., Hall, K., Dann, F., Roeg, S., ... Ritter, A.. (2007).
PsyCheck: Responding to mental health issues within alcohol and drug treatment.
Canberra, Australia: Commonwealth of Australia.
240 Appendices
Appendix L: Depression Anxiety Stress Scale (DASS 21)
Name: Date:
Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement
applied to you over the past week. There are no right or wrong answers. Do not spend too much time
on any statement.
The rating scale is as follows:
Source: Lovibond, S.H., & Lovibond, P.F. (1995) Manual for the Depression Anxiety Stress Scales (2nd. ed).
Sydney, Australia: Psychology Foundation.
Appendices 241
DASS-21 Scoring Template
Sum scores for each scale. Multiply total for each scale by 2.
D = Depression
A = Anxiety
S = Stress
S
A
D
A
D
S
A
S
A
D
S
S
D
S
A
D
D
S
A
A
D
242 Appendices
Appendix M: The Primary Care PTSD Screen (PC-PTSD)
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in
the past month, you:
1. Have had nightmares about it or thought about it when you did not want to? No □ Yes
2. Tried hard not to think about it or went out of your way to avoid situations that
No □ Yes
reminded you of it?
3. Were constantly on guard, watchful, or easily startled? No □ Yes
4. Felt numb or detached from others, activities, or your surroundings? No □ Yes
Source: Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., ... Sheikh, J.
I. (2004). The Primary Care PTSD Screen (PC-PTSD): Development and operating characteristics.
Primary Care Psychiatry, 9, 9-14.
Appendices 243
Appendix N: Trauma Screening Questionnaire (TSQ)
Please consider the following reactions which sometimes occur after a traumatic event. This
questionnaire is concerned with your personal reactions to the traumatic event which happened
to you. Please indicate (Yes/No) whether or not you have experienced any of the following at least
twice in the past week.
1. Upsetting thoughts or memories about the event that have come into your
No □ Yes
mind against your will
2. Upsetting dreams about the event No □ Yes
3. Acting or feeling as though the event were happening again No □ Yes
4. Feeling upset by reminders of the event No □ Yes
5. Bodily reactions (such as fast heartbeat, stomach churning, sweatiness,
No □ Yes
dizziness) when reminded of the event
6. Difficulty falling or staying asleep No □ Yes
7. Irritability or outbursts of anger No □ Yes
8. Difficulty concentrating No □ Yes
9. Heightened awareness of potential dangers to yourself and others No □ Yes
10. Being jumpy or being startled at something unexpected No □ Yes
Source: Brewin, C. R., Rose, S., Andrews, B., Green, J., Tata, P., McEvedy, C., ... Foa, E. B. (2002) Brief screening
instrument for post-traumatic stress disorder. British Journal of Psychiatry, 181, 158-162.
244 Appendices
Appendix O: Psychosis Screener (PS)
1. In the past 12 months, have you felt that your thoughts were being directly
No Yes
interfered with or controlled by another person
1a. Did it come about in a way that many people would find hard to believe, for
No Yes
instance, through telepathy?
2. In the past 12 months, have you had a feeling that people were too interested
No Yes
in you?
2a. In the past 12 months, have you had a feeling that things were arranged so as
No Yes
to have a special meaning for you, or even that harm might come to you?
3. Do you have any special powers that most people lack? No Yes
3a. Do you belong to a group of people who also have these special powers? No Yes
4. Has a doctor ever told you that you may have schizophrenia? No Yes
Source: Degenhardt, L., Hall, W., Korten, A., & Jablensky, A. (2005). Use of brief screening instrument for
psychosis: Results of a ROC analysis. Technical report no. 210. Sydney, Australia: National Drug and Alcohol
Research Centre.
Appendices 245
Appendix P: Indigenous Risk Impact Screener (IRIS)
1. In the last 6 months have you needed to drink or use more to get the effects you want?
1. No 2. Yes, a bit more 3. Yes, a lot more
2. When you have cut down or stopped drinking or using drugs in the past, have you experienced any
symptoms, such as sweating, shaking, feeling sick in the tummy/vomiting, diarrhoea/runny gonna,
feeling really down or worried, problems sleeping, aches and pains?
2. Sometimes when I
1. Never 3. Yes, every time
stop
3. How often do you feel that you end up drinking or using drugs much more than you expected?
1. Never/Hardly ever 2. Once a month 3. Once a fortnight
5. More than once a
4. Once a week 6. Most days/Every day
week
4. Do you ever feel out of control with your drinking or drug use?
1. Never/Hardly ever 2. Sometimes 3. Often 4. Most days/Every day
5. How difficult would it be to stop cut down on your drinking or drug use?
1. Not difficult at all 2. Fairly easy 3. Difficult 4. I couldn’t stop or cut down
6. What time of the day do you usually start drinking or using drugs?
2. In the 3. Sometimes in the
1. At night 4. As soon as I wake up
afternoon morning
7. How often do you find that your whole day has involved drinking or using drugs?
1. Never/Hardly ever 2. Sometimes 3. Often 4. Most days/Every day
Source: Schlesinger, C. M., Ober, C., McCarthy, M. M., Watson, J. D., & Seinen, A. (2007). The development
and validation of the Indigenous Risk Impact Screen (IRIS): A 13-item screening instrument for alcohol and
drug and mental risk. Drug and Alcohol Review, 26, 109-117.
246 Appendices
Appendix Q: Adult ADHD Self-Report Scale (ASRS)
The questions on the back page are designed to stimulate dialogue between you and your patients
and to help confirm if they may be suffering from the symptoms of attention-deficit/hyperactivity
disorder (ADHD).
Description: The Symptom Checklist is an instrument consisting of the eighteen DSM-IV-TR criteria.
Six of the eighteen questions were found to be the most predictive of symptoms consistent with
ADHD. These six questions are the basis for the ASRS v1.1 Screener and are also Part A of the
Symptom Checklist. Part B of the Symptom Checklist contains the remaining twelve questions
Instructions:
Symptoms
1. Ask the patient to complete both Part A and Part B of the Symptom Checklist by marking an X in the
box that most closely represents the frequency of occurrence of each of the symptoms.
2. Score Part A. If four or more marks appear in the darkly shaded boxes within Part A then the patient
has symptoms highly consistent with ADHD in adults and further investigation is warranted.
3. The frequency scores on Part B provide additional cues and can serve as further probes into the
patient’s symptoms. Pay particular attention to marks appearing in the dark shaded boxes. The
frequency-based response is more sensitive with certain questions. No total score or diagnostic
likelihood is utilized for the twelve questions. It has been found that the six questions in Part A are the
most predictive of the disorder and are best for use as a screening instrument.
Impairments
1. Review the entire Symptom Checklist with your patients and evaluate the level of impairment
associated with the symptom.
2. Consider work/school, social and family settings.
3. Symptom frequency is often associated with symptom severity, therefore the Symptom Checklist
may also aid in the assessment of impairments. If your patients have frequent symptoms, you may
want to ask them to describe how these problems have affected the ability to work, take care of
things at home, or get along with other people such as their spouse/significant other.
History
1. Assess the presence of these symptoms or similar symptoms in childhood. Adults who have
ADHD need not have been formally diagnosed in childhood. In evaluating a patient’s history,
look for evidence of early-appearing and long-standing problems with attention or self-control.
Some significant symptoms should have been present in childhood, but full symptomology is not
necessary.
Appendices 247
Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist
Sometimes
right side of the page. As you answer each question,
Very Often
Rarely
Never
Often
place an X in the box that best describes how you
have felt and conducted yourself over the past 6
months. Please give this completed checklist to your
healthcare professional to discuss during today’s
appointment.
Part A
248 Appendices
Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist
Part B
Appendices 249
The Value of Screening for Adults With ADHD
Research suggests that the symptoms of ADHD can persist into adulthood, having a significant
impact on the relationships, careers, and even the personal safety of your patients who may suffer
from it. [1-4] Because this disorder is often misunderstood, many people who have it do not receive
appropriate treatment and, as a result, may never reach their full potential. Part of the problem is
that it can be difficult to diagnose, particularly in adults.
The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist was developed in conjunction with
the World Health Organization (WHO), and the Workgroup on Adult
Thomas Spencer, MD
Associate Professor of Psychiatry
As a healthcare professional, you can use the ASRS v1.1 as a tool to help screen for ADHD in adult
patients. Insights gained through this screening may suggest the need for a more in-depth clinician
interview. The questions in the ASRS v1.1 are consistent with DSM-IV criteria and address the
manifestations of ADHD symptoms in adults. Content of the questionnaire also reflects the importance
that DSM-IV places on symptoms, impairments, and history for a correct diagnosis. [4]
The checklist takes about 5 minutes to complete and can provide information that is critical to
supplement the diagnostic process.
References:
1. Schweitzer JB, et al. Med Clin North Am. 2001;85(3):10-11, 757-777.
2. Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. 1998.
3. Biederman J, et al. Am J Psychiatry.1993;150:1792-1798.
4. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
Washington, DC, American Psychiatric Association. 2000: 85-93.
Source: Kessler, R.C., Adler, L., Ames, M., Demler, O., Faraone, S., Hiripi, E., ... Walters, E.E. (2005). The World
Health Organization Adult ADHD Self-Report Scale (ASRS). Psychological Medicine, 35, 245-256.
250 Appendices
Appendix R: Suicide risk screener scorer and
Appendix R: Suicide Risk Screener
interpretation
Client: Screen completed by: Date:
I need to ask you a few questions on how you have been feeling, is that ok?
1 In the past 4 weeks did you feel so sad that nothing could cheer you up?
☐ All of the time ☐Most of the time ☐Some of the time ☐A little of the time ☐None of the time
2 In the past 4 weeks, how often did you feel no hope for the future?
☐ All of the time ☐Most of the time ☐Some of the time ☐A little of the time ☐None of the time
3 In the past 4 weeks, how often did you feel intense shame or guilt?
☐ All of the time ☐Most of the time ☐Some of the time ☐A little of the time ☐None of the time
4 In the past 4 weeks, how often did you feel worthless?
☐ All of the time ☐Most of the time ☐Some of the time ☐A little of the time ☐None of the time
5 Have you ever tried to kill yourself? Yes* ☐ No ☐
If Yes:
a. How many times have you tried to kill yourself? ☐Once ☐Twice ☐3+
b. How long ago was the last attempt? ________ (mark below) Have things changed since? ___________
☐In the last 2 months ☐2-6 months ago ☐6-12 months ago ☐1-2 years ago ☐More than 2 years ago
6 Have you gone through any upsetting events recently? (tick all that apply) Yes ☐ No ☐
☐Family breakdown ☐Conflict relating ☐Child custody ☐Chronic ☐Impending legal
to sexual identity issues pain/illness prosecution
☐Loss of loved one ☐ Relationship ☐Trauma ☐Other (specify)
problem _____________________________________
7 Have things been so bad lately that you have thought about killing yourself? Yes* ☐ No ☐
If Yes:
a. How often do you have thoughts of suicide? __________________________________________________
b. How long have you been having these thoughts? ______________________________________________
c. How intense are these thoughts when they are most severe?
☐Very intense ☐Intense ☐Somewhat intense ☐Not at all intense
d. How intense have these thoughts been in the last week?
☐Very intense ☐Intense ☐Somewhat intense ☐Not at all intense
If No: skip to 10
8 Do you have a current plan for how you would attempt suicide? Yes* ☐ No ☐
If Yes:
a. What method would you use? __________________________________ (Access to means? ☐ Yes ☐ No)
b. Where would this occur? ________________ (Have all necessary preparations been made? ☐ Yes ☐ No)
c. How likely are you to act on this plan in the near future?
☐Very likely ☐Likely ☐Unlikely ☐Very unlikely
9 What has stopped you acting on these suicidal thoughts? ____________________________________________
___________________________________________________________________________________________
10 Do you have any friends/family members you can confide in if you have a serious problem? Yes ☐ No ☐
a. Who is/are this/these person/people? _______________________________________________________
b. How often are you in contact with this/these person/people? ____________________________________
☐Daily ☐A few days a week ☐Weekly ☐Monthly ☐Less than once a month
11 What has helped you through difficult times in the past? ____________________________________________
___________________________________________________________________________________________
☐* indicates a high or moderate risk answer
Appendices 251
Client: Screen completed by: Date:
☐Agitated ☐ Intoxicated
☐ Disorientated/confused ☐ Self-harm
☐ Delusional/ hallucinating ☐ Other: ______________________________
NOTE: If client presents as any of the above and is expressing thoughts of suicide, risk level is automatically HIGH
Source: Deady, M., Ross, J., & Darke, S. (2015). Suicide Assessment Kit (SAK): A comprehensive assessment
and policy development package. Sydney, Australia: National Drug and Alcohol Research Centre.
252 Appendices
Appendix S: Referral pro forma
Referral From:
PATIENT DETAILS
Aboriginal/TSI: □ Yes □ No □
Phone _______________________________
Appendices 253
REASON FOR REFERRAL
□ □ Diagnostic assessment
□ □ Psychoeducation
□ Cognitive behavioural therapy (CBT)
□ □ Interpersonal therapy
□ □ Other: ………………………………………………
PRESENTING PROBLEM
□ □ Other: ………………………………………………
CURRENT MEDICATIONS
RISK ASSESSMENT
254 Appendices
Appendix T: Cognitive behavioural techniques
Cognitive behavioural therapy (CBT) has been identified as one of the most effective ways of treating
co-occurring depression and substance use difficulties [310, 386, 540]. A number of simple CBT-based
strategies are useful in managing clients with these symptoms, including:
• Cognitive restructuring.
• Pleasure and mastery events scheduling.
• Goal setting.
• Problem solving.
Cognitive restructuring
Cognitive restructuring is a useful method for controlling symptoms of depression (and anxiety) and is
based on the premise that what causes these feelings is not the situation itself but, rather, the interpretation
of the situation [1202]. The idea is that our behaviours and feelings are the result of automatic thoughts
which are related to our core (deeply held) beliefs. Therefore, feelings and behaviours of anxiety,
depression, relapse etc. are the result of negative thoughts and beliefs that can be modified. A simple
process of recognition and modification of these thoughts and beliefs can be conducted with clients using
the A–E model depicted below.
A. Antecedent – Event
that triggers automatic
thoughts
Appendices 255
In this model there is an initial event (the antecedent) which leads to automatic thoughts (beliefs about the
event). These thoughts have resulting feelings and behaviours (consequences). Because these thoughts
are automatic and often negative, they are rarely based on any real-world evidence – it is therefore
necessary to look for evidence either supporting or disproving evidence (dispute automatic thoughts).
Finally, developing rational alternative explanations to automatic thoughts can result in a new interpretation
of the antecedent (alternative explanation). This process allows the client to stop and evaluate the thought
process and realise how he/she comes to feel that way. A client worksheet is included in the Worksheets
section of these Guidelines to walk clients through the thought recognition and modification process.
Some common negative automatic thoughts and beliefs which can be challenged by using cognitive
restructuring exercises include:
Mental filter
Overgeneralisation
Expecting that just because something has failed once that it always will.
‘I tried to give up once before and relapsed. I will never be able to give up.’
Catastrophising
‘I had an argument with my friend, now they hate me and are never going to want to see me again.’
Should statements
Thinking in terms of ‘shoulds’, ‘oughts’ and ‘musts’. This kind of thinking can result in feelings of guilt, shame
and failure.
Personalising
People frequently blame themselves for any unpleasant event and take too much responsibility for the
feelings and behaviours of others.
‘It’s all my fault that my boyfriend is angry, I must have done something wrong.’
256 Appendices
Discounting positive experiences
Client information sheets on common negative thoughts and cognitive restructuring are included in the
Worksheets section of these Guidelines.
A problem-solving worksheet for clients is included in the Worksheets section of these Guidelines.
Goal setting
Goal setting is a useful strategy to help clients with both AOD treatment as well as depression/anxiety
symptom management. For example, one goal might be to spend more time partaking in rewarding
activities each week.
Goal setting can keep therapy on track and also enables progress to be measured over time. It allows the
client to experience feelings of control and success, which may counter common feelings of hopelessness
and worthlessness. Goal setting also ensures that therapy remains client-focused which increases
motivation and helps the therapist ascertain what the client’s central concerns are. However, it is important
that the focus is on the process of goal pursuit rather than outcome and expectations of achievement;
it is important that happiness is not conditional upon goal achievement or else failure may exacerbate
depressive symptoms [1208].
• Geared towards the client’s level of motivation and concern (client’s stage of change – see Chapter B2
of these Guidelines).
• Negotiated between client and AOD worker.
• Specific and achievable – it is important that the client begins to gain a sense of mastery by achieving
his or her goals.
• Based on process rather than outcome.
• Short term – break down overall goals into shorter-term ones in order to increase motivation and
feelings of success.
Appendices 257
• Described in positive rather than negative terms – for example, the goal to ‘decrease feelings of
apprehension and worry at parties’ is expressed in negative terms. The same goal, expressed in positive
terms is ‘I will try to relax and enjoy myself at parties’.
• Not necessarily limited to AOD use (e.g., improving social adjustment and functioning, reducing criminal
behaviour).
Pleasure and mastery events scheduling is a behavioural technique to help clients engage in activities that
give them a sense of pleasure and achievement in a structured way. It can be very difficult for clients to
simply resume previous levels of activity, so this strategy enables clients to use a weekly timetable in which
they can schedule particular activities. It is important for clients to start with activities that are simple and
achievable.
Clients might be encouraged to think of just one activity they can do for achievement and one for pleasure
each day. Each week more activities can be added to form a list. A worksheet is provided in the Worksheets
section of these Guidelines for clients to complete; it also includes a list of possible starting points. Clients
may also need to be reminded of the fact that they deserve to feel good and that motivation generally
follows activity rather than the reverse and, thus, the key is initiation of such activity. The gradual pattern
of experiencing the emotional and physical benefits of pleasure and achievement can break the negative
thought cycle.
258 Appendices
Appendix U: Anxiety management techniques
Relaxation techniques are also a common means to manage the distressing and distracting symptoms of
anxiety [701]. Some useful relaxation methods include:
Each method works best if practiced daily by clients for 10-20 minutes, but again, not every technique may
be appropriate for every client.
1. Take three deep abdominal breaths, exhaling slowly each time, imagining the tension draining out of
your body.
2. Clench your fists. Hold for 10 seconds (AOD workers may want to count to 10 slowly), before releasing
and feeling the tension drain out of your body (for 15 seconds).
3. Tighten your biceps by drawing your forearms up toward your shoulders and make a muscle with both
arms. Hold, then relax.
4. Tighten your triceps (the muscles underneath your upper arms) by holding out your arms in front of you
and locking your elbows. Hold, then relax.
5. Tense the muscles in your forehead by raising your eyebrows as high as you can. Hold, then relax.
6. Tense the muscles around your eyes by clenching your eyelids shut. Hold, then relax. Imagine
sensations of deep relaxation spreading all over your eyes.
7. Tighten your jaws by opening your mouth so widely that you stretch the muscles around the hinges of
your jaw. Hold, then relax.
8. Tighten the muscles in the back of your neck by pulling your head way back, as if you were going to
touch your head to your back. Hold, then relax.
9. Take deep breaths and focus on the weight of your head sinking into whatever surface it is resting on.
10. Tighten your shoulders as if you are going to touch your ears. Hold, then relax.
11. Tighten the muscles in your shoulder blades by pushing your shoulder blades back. Hold, then relax.
12. Tighten the muscles of your chest by taking in a deep breath. Hold, then relax.
13. Tighten your stomach muscles by sucking your stomach in. Hold, then relax.
14. Tighten your lower back by arching it up (don’t do this if you have back pain). Hold, then relax.
15. Tighten your buttocks by pulling them together. Hold, then relax.
16. Squeeze the muscles in your thighs. Hold, then relax.
17. Tighten your calf muscles by pulling your toes towards you. Hold, then relax.
18. Tighten your feet by curling them downwards. Hold, then relax.
Appendices 259
19. Mentally scan your body for any leftover tension. If any muscle group remains tense, repeat the
exercise for those muscle groups.
20. Now imagine a wave of relaxation spreading over your body.
When teaching clients breathing retraining, it is important they understand and feel the difference between
shallow, chest-level breathing and controlled, abdominal breathing. A good way to do this is to ask clients
to practice each type of breathing. However, it is important to inform clients who are extremely anxious that
they may experience trouble breathing deeply and may need to try this when feeling less anxious (some
clients may always have trouble with this). Encourage clients to increase their breathing speed. Ask them to
place their hand gently on their abdomen and feel how shallow and rapid their breathing is, only the chest
moves up and down. Compare this with abdominal breathing based on the following instructions for the
client provided by Lee and colleagues [310]:
Controlled breathing techniques can help reduce overall levels of tension and are a useful strategy to use
when faced with high-anxiety or high-risk situations when relapse is likely. A client worksheet for abdominal
breathing is included in the Worksheets section of these Guidelines.
Calming response
This is a quick skill developed by Montgomery and Morris [1211] to reduce the discomfort of unwanted
feelings. The basic steps involve the client mentally detaching from the situation and thinking ‘clear head,
calm body’ as they take one slow deep breath. As they exhale they relax.
1. Sit comfortably in a chair, close your eyes and breathe deeply. Clear your mind of all thoughts and
images.
260 Appendices
2. Imagine a place where you feel safe and relaxed; this could be a real or imaginary place. Think in as much
detail as possible: What are the sounds? What are the smells? What do you feel? What do you see? What
time of day is it? Are you alone or with somebody else?
3. Think about how your body feels in this place (e.g., Are your muscles relaxed? Is it warm? Is your breathing
and heart rate slow or fast?).
4. Stay in this relaxed state for a moment and remember how it feels so you can return to it when you need
to.
5. Slowly clear your mind again and return to the ‘here and now’ and the sounds around you. Stretch your
arms and legs and when you are ready, open your eyes.
A client worksheet for visualisation in provided in the Worksheets section of these Guidelines.
Grounding
For most clients suffering anxiety symptoms, most breathing and relaxation techniques are effective; however,
for sufferers of panic or trauma, some relaxation and breathing strategies can occasionally trigger flashbacks,
intrusive memories, panic, fear and dissociation. AOD workers can assist these clients and reduce traumatic
and panic reactions by focusing the attention of these clients on the outside world rather than the internal
trauma. This process is known as ‘grounding’ (or distraction, centering, or healthy detachment) [395].
There are different forms of grounding outlined below; different strategies work best for different clients and
it is important to use a strategy appropriate to the individual. The examples of grounding techniques provided
below are adapted from Najavits [395].
• Rub nice smelling hand cream slowly into hands and arms and notice the feel and smell.
• Say encouraging statements to yourself such as ‘You’re okay, you’ll get through this’.
• Think of favourites of any kind of object (e.g., cars) or animal.
• Think of a place where you felt calm and peaceful, describe where you were, what was around you and
what you were doing.
• Plan something nice for yourself such as a bath or a good meal.
• Think of things you look forward to doing in the next few days.
Appendices 261
Worksheets
Worksheets
Identifying negative thoughts
It can be useful to categorise your negative thoughts in order to identify the process that is occurring.
Some common negative automatic thoughts and beliefs which can be challenged by using cognitive
restructuring exercises include:
All or none (black and white) thinking ‘If I fail partly, it means I am a total failure.’
Mental filter Interpreting events based on what has happened in the past.
‘I can’t trust men, they only let you down.’
Overgeneralisation Expecting that just because something has failed once that it
always will.
‘I tried to give up once before and relapsed. I will never be
able to give up.’
Catastrophising Exaggerating the impact of events – imagining the worst
case scenario.
‘I had an argument with my friend, now they hate me and are
never going to want to see me again.’
Mistaking feelings for facts People are often confused between feelings and facts.
‘I feel no good, so therefore I am no good.’
Should statements Thinking in terms of ‘shoulds’, ‘oughts’ and ‘musts’. This kind
of thinking can result in feelings of guilt, shame and failure.
‘I must always be on time.’
Personalising People frequently blame themselves for any unpleasant
event and take too much responsibility for the feelings and
behaviours of others.
‘It’s all my fault that my boyfriend is angry, I must have done
something wrong.’
Discounting positive experiences People often discount positive things that happen.
‘I stayed clean because I didn’t run into any of my using
mates.’
Sources: Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: Guildford Press.
Jarvis, T., Tebbutt, J., & Mattick, R. (1995), Treatment approaches for identifying unhelpful thoughts, alcohol
and drug dependence. Chichester, UK: John Wiley and Sons
Cognitive restructuring
Unhelpful thoughts produce negative emotions and behaviours and often these thoughts can be
extreme and inaccurate. However, this automatic process can be broken through awareness and thought
restructuring.
The more aware you are of the way you think and the things you say to
yourself in stressful circumstances, the better prepared you will be to think
differently.
A. Activating event
REALITY TESTING:
• What is the evidence for and against my thinking being true?
• What unhelpful thinking patterns are operating?
• What are facts and what are my feelings?
ALTERNATIVE EXPLANATIONS:
• Are there any other possible reasons to explain this?
• Is there another way I could think about this?
• Is there a more helpful way of thinking about this?
• What would others think if they were in this kind of situation?
GOAL-DIRECTED THINKING:
• Are my thoughts helping me to achieve my goals?
• What can I do that will help me deal with the problem?
• How can I minimise the negative effects?
• How can I think about this in a way that will help me to feel good
about my life and myself?
• If it is something that has already happened, how could I do
better next time?
Once you have challenged your unhelpful or negative thought, the final step is to replace the thought
with more logical, positive or realistic ones. Check to see if there are new consequences (thoughts and
beliefs) for your new thought.
For example, when you are bored you may say to yourself, ‘I’m all alone, life is awful’. This leads to
feelings of uselessness, worthlessness and sadness, and even less motivation to do anything. Once you
examine the thought you may find you have ‘catastrophised’ the situation and come to an overly negative
conclusion. There is evidence of friends and family but you just haven’t called them. Try thinking ‘I’ve got
friends I can call them now or I can just enjoy doing something by myself’. This might help you feel a bit
more positive and in control, and motivated to act. We call these new thoughts alternate interpretations.
Cognitive restructuring worksheet
A B C
Beliefs/ Consequences: Challenge negative thoughts
Activating
thoughts/ feelings/
event/trigger
interpretations behaviours
____________________________________________________________________________________
2. Step back and view problem objectively and without emotion, as if it were happening to someone else.
(Brainstorm a list of possible solutions, good and bad, real and unreal)
4. Cross out any silly or impossible options. With those that remain, write down the short-term and long-
term consequences and the pros and cons.
1. ____________________________________________________________________________________
2. ____________________________________________________________________________________
3. ____________________________________________________________________________________
(What do you need to do to implement it? Did it work? Why/why not? Would another solution work better?)
Goal setting worksheet
I want to…
(e.g., routine)
(e.g., family)
By…
(e.g., today)
A list of examples is included on the next page to help start you off.
Source: Bourne, E.J. (1995). The anxiety and phobia workbook. Oakland, CA: New Harbinger Publications.
Controlled abdominal breathing
1. Rate your level of anxiety on a scale from 1 to 10.
2. Sit as comfortably as possible in a chair with your head, back and arms supported, free legs and close
your eyes (if you like).
3. Place one hand on your abdomen right beneath your rib cage.
4. Inhale deeply and slowly, send the air as low and deep into your lungs as possible. If you are breathing
from your abdomen, you should feel your hand rise, rather than your chest.
5. When you have taken a full breath, pause before exhaling. As you exhale, imagine all of the tension
draining out of your body.
6. Do 10 slow abdominal breaths. Breathe in slowly counting to four, before exhaling to the count of four
(four seconds in, four seconds out). Repeat this cycle 10 times. Hold final breath for 10 seconds, then
exhale.
2. Imagine a place where you feel safe and relaxed – this could be a real or imaginary place. Think in as
much detail as possible:
• Is it warm?
4. Stay in this relaxed state for a moment and remember how it feels so you can return to it when you
need to.
5. Slowly clear your mind again and return to the ‘here and now’ and the sounds around you. Stretch your
arms and legs and when you are ready open your eyes.
Food and activity diary
Date Time of Food eaten Physical activity Mood
day
Adapted from Western Australian Network of Alcohol and other Drugs Agencies (2011). Healthy eating for wellbeing: A nutrition guide for alcohol and
other drug consumers. Perth, Australia: WANADA.
Common reactions to trauma
After a traumatic event, it is common to experience a range of reactions.
Feelings of sadness/depression
It is common to:
It can be common to feel as though the traumatic event has left you with a lack of control, or as though you
cannot trust anyone.
Feelings of anger
Sometimes you might find yourself experiencing anger and even directing it towards your loved ones.
This includes:
Physical arousal
This includes difficulty falling asleep or an interrupted sleep, irritability, finding it hard to concentrate,
getting startled easily or feeling constantly on edge, sweating or a racing heartbeat.
Avoidance reactions
You may find yourself avoiding all reminders of the trauma (e.g., places,
people) or even the memories of, and feelings associated with the traumatic
experience itself.
Changed behaviours:
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