Using a Holistic Approach to Treat Clients with Complex Co-Occurring Disorders
By Guy Oberwise, LCSW, Mood Disorders Coordinator at Timberline Knolls Residential Treatment Center in Lemont, Ill. Guy is also a primary therapist and Clinical Training Coordinator at TK.
April 1, 2011
Complex co-occurring disorders— three or more diagnosable addictions or disorders—occur regularly in clients, causing them continued struggle with finding a meaningful life. This article will discuss how to effectively treat those clients that come to our offices, hospitals or residential treatment centers with complex co-occurring disorders.
It is imperative for treatment professionals to understand how to holistically treat clients who have complex co-occurring disorders. These types of clients, for example, have been diagnosed with an eating disorder, substance dependence, major depression, impulse control (self harm behaviors) and post traumatic stress disorder and/or anxiety disorder. They have spent many years trying to live a life battling these mental disorders and addictive diseases. Not until the mid 1980s did programs begin using the terms “co-occurring disorders” and “dual diagnosis” while attempting to treat co-morbid mood, thought and addictive disorders. These more comprehensive approaches address the whole person from a biopsycho-spiritual approach (Stillman-Corbitt, 2009).
As a social work professional, it is essential to arm clients with key recovery tools, allowing them to have hope for the future and an understanding of how to manage these disorders and addictions. “The treatment field is now confronted with an equally daunting challenge: a skyrocketing degree of acuity and complexity seen in outpatient and inpatient settings alike. Individuals presenting for care with a simple history of alcohol dependence and depression are a rare find.” (Stillman-Corbitt, 2009)
After over 25 years treating clients in a variety of settings, it was only in the last five years that there was a realization of the importance of treating clients with a holistic approach. There are several key tools available to clients that can provide the recovery structure they will need to lead them on a path of recovery.
The first key recovery component to understand is that the recovery path is not linear in nature. It is not a step-by-step process, but one based on continual growth, occasional setback and learning from experience. Recovery begins with an initial stage of awareness in which a person recognizes that positive change is possible. This awareness enables the client to move on to fully engage in the work of recovery.
“The answer is that as treatment providers we can not prioritize in a linear manner. We must find ways in which to integrate modalities that will address the underlying drives of addiction (both substance and process), behaviors related to said addictions, as well as alleviate the debilitating symptomology of mood, eating and trauma related disorders” (Stillman-Corbitt, 2009).
The second key component of recovery is that it must be individualized and person- centered. There are multiple pathways to recovery based on an individual’s unique strengths and resiliencies. Helping clients see their strengths and skills and their unique talents to replace their old addictive behaviors is an important part in establishing a new path to recovery. (The 10 Components of Recovery, SAMSHA.Gov)
We must realize the progression of these disorders and diseases and lay strong clinical treatment foundations to integrate specific approaches which will assist in the client’s recovery. These clinical treatment foundations include Dialectical Behavior Therapy (DBT), 12 Step Recovery, Experiential Treatment Methods, and a Family Systems Approach. Expressive therapies, psychodynamic therapies, trauma treatment and family therapy work when these four clinical foundations are integrated and delivered within the context of structured phases of recovery.
By developing a phase process which integrates the above mentioned clinical treatment foundations into the phases of recovery, each phase can offer its own unique challenge and opportunity for personal growth. During the first phase, clients focus on achieving abstinence from addictive, self-destructive and self-defeating behaviors. The second phase looks at developing character and acquiring healthy coping skills. The third phase helps clients prepare for life after treatment by beginning to build communities and assembling healthy social networks. Remember, most clients cling to failure, and when they make one mistake, there is the feeling that his or her life is over. Yet recovery is a process in which it is crucial for clients to understand that he or she does not have to be perfect. Gaining mastery of the clinical treatment foundations throughout the phases of recovery helps sustain a person through the turbulence that comes with daily living.
Two of the most effective therapies in treating complex clients are dialectical behavioral therapy and the 12 step approach to recovery. DBT was initially developed for women diagnosed with borderline personality disorder. Recently there have been numerous research articles describing the effectiveness of utilizing DBT in substance abuse treatment (Platter, 2010). In DBT, the focus is on creating a dialectical lifestyle that reflects balanced behavioral emotions and balanced cognition. Similarly, using the 12 step program results in creating a balanced lifestyle (Platter, 2010).
The overall goal of DBT is to create a meaningful life through learning, and using positive skills in the face of difficult emotions, invalidating environments, problem- thinking patterns and old ways of living. DBT is extremely effective in treating clients who have self-harming behavior, eating disorders or other addictive behaviors, as well as those with an Axis II diagnosis.
One characteristic of working with complex clients and those with addictions is their extreme thinking. Mindfulness is useful in learning how to control your mind so that it does not control you. By using mindfulness skills, clients can begin to achieve a balanced state of thinking. Wise mind is the middle ground; recovery involves finding that middle ground and staying balanced. The literature for 12 step also discusses emotional mind:
“Suddenly the thought crossed my mind that if I were to put an ounce of whiskey in my milk it could hurt me on a full stomach. I ordered a whiskey and poured it into the milk. I vaguely sensed I was not being any too smart, but felt reassured as I was taking the whiskey on a full stomach. The experiment went so well that I ordered another whiskey and poured it into more milk… that didn’t seem to bother me so I tried another (p. 36).”
This reading illustrates how emotional mind can be a “trickster” and will create the illusion of being reasonable. This concept is extremely important in recovery, as it emphasizes how an individual can not rely on his or her own thinking and willpower for the answers (p. 36).
The use of DBT skills and the 12 step recovery process will give your clients some tangible tools to help in their battle against these disorders. There are countless examples of how these two therapies have helped clients in their recovery process.
In my work with complex clients who have the inability to express their emotions openly, expressive therapies such as art, dance movement and equine, are of vital importance. They allow clients an alternative form of expressing their feelings. Most clients who have suffered from addictions, chronic depression or trauma only have the same negative, but familiar, coping skills to fall back on when faced with extreme emotion: drinking, drug use, purging, restricting, self injury, isolation, impulsivity. It is our job as clinicians to help our clients see new ways of coping with their diseases and disorders to help clear a pathway toward a meaningful life.
Dance/movement therapy promotes the creative process and enhances healthy capacity with activities such as exploring tension and relaxation through movement and connecting these movements to certain times in life. (Pratt, 2009)
Equine assisted therapy has been found to be useful in assisting clients in getting in touch with their feelings and emotions. Working with horses also may be used to break through a client’s defensive barriers, and requires them to develop fresh insight and perspective for dealing with their old patterns and problems in a way that conventional office therapy does not. (Knox and Lentini, 2009) Through my work, I have seen first hand the positive results of how expressive therapies and experiential processes can bring change to a client’s ability to express emotion.
When treating clients with complex co-occurring disorders, it is important to have a variety of sound clinical foundations and tools to assist in the process of healing and give your clients hope and faith in creating a meaningful life of recovery.
About Timberline Knolls Residential Treatment Center
Timberline Knolls Residential Treatment Center is located on 43 beautiful acres just outside Chicago, offering a nurturing environment of recovery for women ages 12 and older struggling to overcome eating disorders, substance abuse, mood disorders and co-occurring disorders. By serving with uncompromising care, relentless compassion and an unconditional joyful spirit, we help our residents help themselves in their recovery. For more information, visit www.timberlineknolls.com or call 877.257.9611.
A List of Works Cited
Alcoholic Anonymous World Services, Inc. Alcoholic Anonymous 4th Edition, New York City: Alcoholic Anonymous World Services; 2001.
Knox, Michelle and Lentini, J.A. “A Qualitative and Quantitative Review of Equine Facilitated Psychotherapy with Children and Adolescents.” The Open Complimentary Medicine Journal. 2009. Pgs 51-57.
Platter, Bari K. “The Key Elements of DBT Mirror the Philosophy of 12 Step work. 2010.” Pg 1-4.
Rosalie Rebollo Pratt, Ed.D. Art, Dance, and Music Therapy. 2004. Pages 827-841.
SAMHSA.GOV. National Mental Health Information Center. “The 10 Components of Recovery.” (year).
Stillman-Corbitt, Shari. “Beyond Co-Occurring Disorders - An Integrated Approach to Treatment in the Age of Multiple Diagnoses.” 2009, April. Pg 2-5.
Wickstrom, Jancey. “Dialectical Behavioral Therapy Overview.” 2009.
