THIRD

EDITION

GUIDELINES ON THE MANAGEMENT OF

co-occurring alcohol and other drug and mental health
conditions in alcohol and other drug treatment settings

Christina Marel, Ewa Siedlecka, Alana Fisher, Kevin Gournay, Mark

Deady, Amanda Baker, Frances Kay-Lambkin, Maree Teesson,
Andrew Baillie & Katherine L Mills
© The Matilda Centre for Research in Mental Health and Substance Use, Faculty of Medicine and Health at the
University of Sydney, 2022

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 Matilda Centre, The
University of Sydney, Sydney NSW 2006 Australia.

ISBN 978-1-74210-535-2

Design/typeset by Netfront.

Disclaimer
These Guidelines were funded by the Australian Government Department of Health and Aged Care and developed by
the Matilda Centre for Research in Mental Health and Substance Use to support health services and AOD (alcohol
and/or other drug) treatment service workers to more accurately identify and manage the needs of clients with
co-occurring mental health conditions. The information contained in these Guidelines is provided for general
information purposes only, and does not constitute medical or professional advice. 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 and professional advice, as appropriate.

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, The University of Sydney does not warrant or represent that the Guidelines
are entirely free from error or omission. They are made available on the understanding that The University of Sydney
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 The University of Sydney 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 The University of Sydney. 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.

Copies available at www.comorbidityguidelines.org.au

Suggested citation:

Marel C, Siedlecka E, Fisher A, Gournay K, Deady M, Baker A, Kay-Lambkin F, Teesson M, Baillie A, Mills KL. (2022).
Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and other drug
treatment settings (3rd edition). Sydney, Australia: Matilda Centre for Research in Mental Health and Substance Use,
The University of Sydney.

The updating of these Guidelines through the Matilda Centre for Research in Mental Health and Substance Use at
the University of Sydney was supported by funding from the Australian Government Department of Health and Aged
Care.
Acknowledgments i

Acknowledgments
We would like to express our sincere gratitude to the members of the expert panel, discussion forums,
key-stakeholders, and all other people who have made contributions to this important document.

Specifically, we would like to acknowledge and thank Keiron Andrews, Zoe Baynes, Georgia Bolt, Manhara
Brownlee, Jeff Buckley, Tarryn Burrows, Catherine Cox, Fleur Creed, Clare Davies, Michael Doyle, Peter
Fairbanks, Marlyn Gavaghan, Suraj Ghimire, Chris Gough, Martina Greenaway, Kay Holland, Melanie
Holland, Jennifer Holmes, Fern Hunter, Jody Kamminga, Michelle Kudell, Evelyn Lavell, Nicole Lee, Steve
Leicester, Gai Lemon, Vivian Leung, Tanja McLeish, Goodwell Mhlanga, Jane Moreton, Rebecca Morrison,
Huong Nguyen, Latha Nithyanandam, Chloe Oosterbroek, Kim Pearce, Stephanie Penny, Lesley Porter, Luke
Powell, John Reilly, Nikki Ridley, Elizabeth Stubbs, Adrian Webber, and Christine Webster.

We would also like to thank James Gooden, Sharlene Kaye, Julia Lappin and Sarah McGuire for providing
invaluable advice, support, feedback and comment.

Several of our colleagues and friends from the Matilda Centre provided helpful assistance and advice
during the set-up and testing of our online consultation platforms, to whom we extend our deepest
appreciation and thanks, in particular: Louise Birrell, Cath Chapman, Chloe Conroy, Anna Grager, Katherine
Haasnoot, Ashling Isik, Maddy Keaveny, Ivana Kihas, Erin Kelly, Paul Newman, Natalie Peach, Corey
Tutt, and Jack Wilson. Thank you also to Melissa Gray for providing additional assistance during the
consultation sessions, Meaghan Lynch for her invaluable advice and support, as well as Sam Lynch and
Kate Ross for their assistance and support.

We would also like to acknowledge and thank Sylvia Eugene Dit Rochesson, who was involved in
conducting extensive literature searches and updating of the evidence for this document. Erin Madden
also provided vital project support across all phases of the development of the third edition, for which we
are extremely grateful.

Our sincere thanks also go to the Australian Government Department of Health and Aged Care 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.
 ii Expert panel

Expert panel
Prof Steve Allsop National Drug Research Institute

Prof Michael Baigent Department of Psychiatry, Flinders Medical Centre, College of Medicine and
Public Health, Flinders University; Drug and Alcohol Services South Australia

Dr Michelle Banfield Australian National University

Nicky Bath LGBTI Health Alliance

A/Prof Mathew Rural Clinical School of Western Australia, University of Western Australia
Coleman

Gary Croton Victorian Dual Diagnosis Initiative, Albury Wodonga Health

Andrés Otero Forero Queensland Transcultural Mental Health Centre, Addiction and Mental Health
Services, Metro South Health

Dr James Gooden Turning Point

Ms Paula Hanlon Lived Experience Consultant; The Matilda Centre, University of Sydney

Jennifer Harland Drug and Alcohol Nurses of Australasia

Mr Logan Harvey The Matilda Centre, University of Sydney; Drug Health Service, Western Sydney
Local Health District

Corinne Henderson Mental Health Coordinating Council

Dr Suzie Hudson Network of Alcohol and other Drugs Agencies

Chris Keyes Central and Eastern Sydney Primary Health Network

A/Prof Julia M Lappin Faculty of Medicine, University of New South Wales

A/Prof Adrienne IMPACT Institute, School of Medicine, Deakin University

O'Neil

Jacqueline Pritchard Justice Health and Forensic Mental Health Network

Prof Ann Roche National Centre for Education and Training on Addiction, Flinders University

Dr Wei-May Su HETI Higher Education; School of Medicine, The University of Notre Dame

Dr Sarah Wayland Faculty of Medicine and Health, University of New England

Kim Ziapur Western Australian Network of Alcohol & other Drug Agencies
Discussion forum iii

Discussion forum
Jim Adsett Goldbridge Rehabilitation Services

Sam Biondo Victorian Alcohol and Drug Association

Lucy Burnett Uniting ReGen

Gerard Byrne We Help Ourselves (WHOS)

Charlotte Byrne Gateway Health

A/Prof Richard Hunter New England Local Health District

Clancy

Marie Degrazia Ballarat Community Health

Ms Jeni Diekman Fresh Therapeutics Pharmacy

Deborah Dowsett Moonyah Salvation Army

(Mulla)

Fay Edebohls EACH, Inner East

Meredith George Homeless Youth Dual Diagnosis Initiative, Ballarat Health Services

Susan Hill South West TAFE, Victoria

Kate Hocknull Uniting Medically Supervised Injecting Centre

Donna Hunter Supportworks

Daniel Ip Alcohol and other Drugs QHealth Program, Merrihealth

Jaime Jenkinson Eastern Health

Janine L Johnston Everymind, Hunter New England Health

(Charnley)

Debby Kadarusman Sonder

Anita Mahoney Swinburne University of Technology

Sharon Majerovic Drug ARM

Elliott McMahon Launch Housing

Anita McRae Murrumbidgee Primary Health Network

Maycon Merlo Star Health

Bojana Mladenovic Odyssey House Victoria

Adrian Papworth Court Support Services, Melbourne Magistrates' Court

 iv Discussion forum

Jo Penhallurick Community Mental Health Drug and Alcohol Research Network

Suzanne Powell Ballarat Community Health

Laura Quinlan Child and Youth Mental Health Service, Queensland Health

Sam Raven South Australian Network of Drug and Alcohol Services

Nicola Roberts Queensland Health

Dr Caroline Salom Institute for Social Science Research, The University of Queensland

Kay-Sheree Spurling Windana

Anne Stedman Hunter TAFE; Mental Health Carers NSW

Stephanie Stephens Directions Health Services

Joanne Telenta COORDINARE, South Eastern NSW Primary Health Network

Esther Toomey Central and Eastern Sydney Primary Health Network

Sharon Toyne St Vincent de Pauls Society Drug and Alcohol Recovery Service
Contents v

Contents
Acknowledgments i What is obsessive-compulsive disorder 53
(OCD)?
Expert panel ii
What are trauma-related disorders? 56
Discussion forum iii
What are feeding and eating  60
Appendices viii disorders (ED)?

Worksheets ix What are personality disorders? 63

What are substance-induced disorders? 67
Abbreviations x
What do discrepancies between  70
Glossary xii classification systems mean for
AOD workers?
In a nutshell... xiii
Part B: Responding to co-occurring 71
About these guidelines 1 conditions
Part A: About co-occurring conditions 7 B1: Holistic health care 74
A1: What are co-occurring conditions? 9 What is a holistic health care framework? 76
Why do co-occurring conditions occur?  11 Smoking 76
Does causality matter? 14 Diet 78
A2: How common are co-occurring 17 Physical activity 81
conditions and why are they of concern?
Sleep 84
How common are mental disorders? 17
Multiple health behaviours 85
How common are co-occurring mental 18
disorders among clients of AOD treatment What does this mean for AOD workers? 86
services?
B2: Trauma-informed care 88
What are the harms associated with 20
co-occurring disorders? What is trauma-informed care? 90

What is the impact of co-occurring 21 Recognising trauma and its impact 91

mental disorders on treatment Practitioner approaches, programs, and 91
outcomes? procedures
A3: Guiding principles  23 Creating a safe environment 93
A4: Classification of disorders 32 Barriers to providing trauma-informed  94
care
The diagnostic classification systems 33
Is my service trauma-informed? 95
What is attention-deficit/hyperactivity 35
disorder (ADHD)? B3: Identifying co-occurring conditions 96
What are schizophrenia spectrum  37 Case formulation 98
and other psychotic disorders?
Informal assessment 102
What are bipolar disorders? 42
Standardised screening and  114
What are depressive disorders? 47 assessment
What are anxiety disorders? 49 General health and functioning 118
vi Contents

General mental health instruments 119 Attention-deficit/hyperactivity 177

disorder (ADHD)
Specific mental health instruments 122
Clinical presentation 178
General AOD instruments  123
Managing ADHD symptoms 179
Feedback 126
Treating ADHD 180
B4: Assessing risk 128
Summary 183
Risk assessment 129
Psychosis 186
Suicidality 129
Clinical presentation 187
Domestic and family violence 140
Managing symptoms of psychosis 188
B5: Coordinating care 145
Treating psychotic spectrum 190
What is coordinated care? 147 disorders
Barriers to effective coordinated care 149 Summary 196
Stigma and discrimination 150 Bipolar disorders 198
Referrals 151 Clinical presentation 199
Communicating with other services 153 Managing symptoms of bipolar 199
Communicating with the client about 155 Treating bipolar disorders 202
referral
Summary 207
Discharge planning 156
Depression 209
B6: Approaches to co-occurring 157
conditions Clinical presentation 210
Models of care 158 Managing depressive symptoms 210
Approaches to co-occurring conditions 160 Treating depressive disorders 211
Psychological approaches 160 Summary 220
Pharmacological approaches  165 Anxiety 221
Medication adherence 166 Clinical presentation 222
Medication interactions 167 Managing symptoms of anxiety, 222
panic, or agitation
Electroconvulsive therapy (ECT) 170
Treating anxiety disorders 223
Self-help groups 170
Generalised anxiety disorder (GAD) 225
E-health and telehealth interventions 171
Panic disorder 227
Physical activity 172
Social anxiety disorder (SAD) 228
Complementary and alternative 172
therapies Summary 233

B7: Managing and treating specific 174 Obsessive compulsive disorder 234
(OCD)
disorders
Clinical presentation 235
Managing symptoms of OCD 235
Contents vii

Treating OCD 237 Treating substance-induced  284

disorders
Summary 242
Summary 284
Trauma, post traumatic stress  243
disorder (PTSD), and complex Other conditions 285
PTSD
Confusion, disorientation or delirium 286
Clinical presentation 244
Cognitive impairment 286
Managing trauma-related symptoms 245
Grief and loss 288
Treating PTSD 247
Aggressive, angry, or violent behaviour 291
Summary 254
Concluding remarks 295
Eating disorders (ED) 256
B8: Worker self-care 296
Clinical presentation 257
Burnout 297
Symptoms of ED 258
Compassion fatigue 299
Anorexia nervosa 258
Vicarious trauma 300
Bulimia nervosa 259
Holistic self-care: AOD workers 301
Binge eating disorder 260
Clinical supervision 301
Managing ED 260
Part C: Specific population groups 303
Treating ED 262
Aboriginal and Torres Strait Islander  304
Treating anorexia nervosa 262 people
Treating bulimia nervosa 265 People from culturally and  311
linguistically diverse backgrounds
Treating binge eating disorder 267
Summary 270 People who identify as gender and  315
sexual diverse
Personality disorders 272 Sex workers 318
Clinical presentation 273 Rural and remote populations 319
Managing symptoms of personality  273 Homelessness  322
disorders
Women 325
Treating personality disorders  275
Men 326
Borderline personality disorder 276
(BPD) Coerced clients 327
Antisocial personality disorder 278 Incarcerated clients 328
(ASPD) Young people 329
Summary 280 Older people 331
Substance-induced disorders 282 References 453
Clinical presentation 283
Managing substance-induced  283
symptoms
viii Appendices

Appendices
Appendix A: Other Australian 335 Appendix V: CAGE Substance Abuse 411
guidelines Screening Tool
Appendix B: Other useful resources 339 Appendix W: Drug Abuse Screening 413
Test (DAST-10)
Appendix C: Sources of research, 341
information and other resources Appendix X: Drug Use Disorders 415
Identification Test (DUDIT)
Appendix D: DSM-5-TR and ICD-11 350
classification cross-reference Appendix Y: The Michigan Alcohol 420
Screening Test (MAST)
Appendix E: Motivational interviewing 352
Appendix F: Case formulation table 368 Appendix Z: Suicide risk screener 421
scorer and interpretation
Appendix G: Mental state 369
examination Appendix AA: Referral pro forma 424

Appendix H: Integrated Motivational 372 Appendix BB: Cognitive behavioural 426

Assessment Tool (IMAT) techniques

Appendix I: Additional screening tools 373 Cognitive restructuring 426

Appendix J: CANSAS-P 376 Structured problem solving 428

Appendix K: Depression Anxiety 378 Goal setting 428

Stress Scale (DASS 21) Pleasure and mastery events 429
Appendix L: Indigenous Risk 381 scheduling
Impact Screener (IRIS) Appendix CC: Anxiety management 430
Appendix M: Kessler psychological 384 techniques
distress scale (K10) Progressive muscle relaxation 430
Appendix N: The PsyCheck 386 Controlled or abdominal breathing 431
screening tool
Meditation 432
Appendix O: Adult ADHD Self-Report 391
Scale (ASRS) Calming response 433
Appendix P: The International 395 Visualisation and imagery 433
Trauma Questionnaire (ITQ)
Grounding 433
Appendix Q: Life Events Checklist 399
for DSM-5 (LEC-5)
Appendix R: Primary Care PTSD 402
Screen for DSM-5 (PC-PTSD-5)
Appendix S: PTSD Checklist for 404
DSM-5 (PCL-5)
Appendix T: Psychosis Screener (PS) 407
Appendix U: Alcohol Use Disorders 408
Identification Test (AUDIT)
Worksheets ix

Worksheets
Identifying negative thoughts 436
Cognitive restructuring  437
Structured problem-solving  441
worksheet
Goal setting worksheet 442
Pleasure and mastery worksheet 444
Progressive muscle relaxation 446
Controlled abdominal breathing 447
Visualisation and imagery 448
Food and activity diary 449
Common reactions to trauma 450
Common reactions to grief and 451
loss
Wellbeing plan 452
 x Abbreviations

Abbreviations
ACT Acceptance and Commitment DFST Dual Focus Schema Therapy
Therapy
DSM Diagnostic and Statistical Manual
ADHD Attention-Deficit/Hyperactivity of Mental Disorders
Disorder
DUDIT Drug Use Disorders Identification
AOD Alcohol and Other Drugs Test
ASPD Antisocial Personality Disorder ECT Electroconvulsive Therapy
ASRS Adult ADHD Self-Report Scale ED Eating Disorders
ASSIST Alcohol, Smoking and Substance EDE Eating Disorder Examination
Involvement Screening Test
EDE-Q Eating Disorder Examination-
AUDIT Alcohol Use Disorders Identification Questionnaire
Test
EMDR Eye Movement Desensitisation and
BDI Beck Depression Inventory Reprocessing
BMI Body Mass Index ERP Exposure Response Therapy

BPD Borderline Personality Disorder FBT Family-Based Treatment

CAN Camberwell Assessment of Need GAD Generalised Anxiety Disorder

CANSAS Camberwell Assessment of Need GHQ General Health Questionnaire

Short Appraisal Schedule
GP General Practitioner
CBT Cognitive Behaviour Therapy
ICAT Integrative Cognitive-Affective
CBT-E CBT-Enhanced Therapy
CIDI Composite International Diagnostic ICBT Integrated CBT
Interview ICD International Classification of
CPT Cognitive Processing Therapy Diseases

CPTSD Complex PTSD IGT Integrated Group Therapy

CVD Cardiovascular Disease IPDS Iowa Personality Disorder Screen

DASS Depression Anxiety Stress Scale IPT Interpersonal Psychotherapy

DAST-10 Drug Abuse Screening Test-10 IRIS Indigenous Risk Impact Screen

DBT Dialectical Behavioural Therapy ITQ International Trauma Questionnaire

DBT-S Modified DBT K10 Kessler Psychological Distress

Scale
DDP Dynamic Deconstructive
LAI Long Acting Injectable
Psychotherapy
Abbreviations xi

LEC-5 Life Events Checklist for DSM-5 RCT Randomised Controlled Trial
MANTRA Maudsley Model of Anorexia Nervosa RIMA Reversible Inhibitor of Monoamine
Treatment for Adults oxidase A
MAOI Monoamine Oxidase Inhibitors RRFT Risk Reduction through Family
MAST Michigan Alcohol Screening Test Therapy
rTMS Repetitive Transcranial Magnetic
MBT Mentalisation Based Treatment
Stimulation
MHCC Mental Health Coordinating Council
SAD Social Anxiety Disorder
MI Motivational Interviewing
SAK Suicide Assessment Kit
MoCA Montreal Cognitive Assessment
SAMHSA Substance Abuse and Mental
NaSSA Noradrenaline and Specific Health Services Administration
Serotonergic Agent
SAPAS-SR Standardised Assessment of
NDIS National Disability Insurance Personality – Abbreviated Scale
Scheme
SCL-90-R Symptom Checklist-90-Revised
NHMRC National Health and Medical
SNRI Serotonin and Noradrenaline
Research Council
Reuptake Inhibitor
NICE National Institute for Health and
SRQ Self-Reporting Questionnaire
Care Excellence
SSCM Specialist Supportive Clinical
NMDA N-methyl-D-aspartate
Management
NRI Noradrenaline Reuptake Inhibitor
SSRI Selective Serotonin Reuptake
NRT Nicotine Replacement Therapy Inhibitors
NSMHWB National Survey of Mental Health TCA Tricyclic Antidepressants
and Wellbeing TGA Therapeutic Goods Administration
OCD Obsessive-Compulsive Disorder
TLFB Timeline Follow Back
PCL-5 PTSD Check List for DSM-5

PC- Primary Care PTSD for DSM-5

PTSD-5
PE Prolonged Exposure

PHQ Patient Health Questionnaire

PS Psychosis Screener

PTSD Post Traumatic Stress Disorder

RANZCP Royal Australian and New Zealand

College of Psychiatrists
xii Glossary

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 is
drug (AOD) use used interchangeably with ‘substance use disorders’ and includes the use of
disorders 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 Specialised services that are specifically designed for the treatment of AOD
settings 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.

Co-occurring Use of the term ‘co-occurring conditions’ in these Guidelines refers to the
conditions co-occurrence of one or more AOD use conditions with one or more mental
health conditions.

Mental disorders Refers to the presence of a mental disorder (other than AOD use disorders) as
defined by the DSM-5.

Mental health Refers to those with a diagnosable mental disorder as well as those who
conditions display symptoms of disorders while not meeting criteria for a diagnosis of a
disorder.
In a nutshell... xiii

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 AOD and mental health conditions. They represent an
update and revision of the second edition of these Guidelines, published in 2016.

Population estimates indicate that more than one-third of people with an AOD use disorder have at
least one co-occurring mental 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 co-occurring AOD and mental health conditions means that AOD workers are
frequently faced with the need to manage complex psychiatric symptoms whilst treating clients’ AOD
use. Furthermore, clients with co-occurring mental health conditions often have extensive trauma
histories, and a variety of other medical, family, and social problems (e.g., housing, employment, welfare
and legal problems). As such, it is important that AOD workers adopt a holistic and trauma-informed
approach to the management and treatment of co-occurring conditions that is based on treating the
person, not the illness (see Chapter B1 and Chapter B2).

The first step in responding to co-occurring AOD and mental health conditions is being able to identify
the person’s needs (see Chapter B3 and Chapter B4). Despite high rates of co-occurring mental
disorders among clients of AOD services, it is not unusual for these co-occurring conditions to go
unnoticed, mostly because AOD workers are not routinely looking for them. It is a recommendation of
these Guidelines that all clients of AOD treatment services be screened and assessed for co-occurring
mental disorders 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 Chapter B6 and Chapter B7). 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. Co-occurring conditions are not
an insurmountable barrier to treating people with AOD use disorders. Indeed, research has shown that clients
with co-occurring mental health conditions can benefit just as much as those without co-occurring
conditions from usual AOD treatment.

Some clients with co-occurring conditions may require additional treatment for their mental health
problems (see Chapter B7). The evidence base regarding interventions designed for the treatment of
specific co-occurring conditions is growing, but still in its infancy. Where there is an absence of specific
research on co-occurring AOD and mental disorders, it is recommended that best practice is to use the
most effective treatments for single disorders. Both psychosocial and pharmacological interventions
have been found to have some benefit in the treatment of many co-occurring disorders. 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.
xiv In a nutshell...

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 coordinated 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 B5). Worker self-care and the provision of training and support for AOD
workers are also essential to the provision of effective care for co-occurring conditions (Chapter B8).
About these guidelines 1

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 co-occurring 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 co-occurring mental health conditions.
• The Guidelines are based on the best available evidence at the time of writing 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 development of the first
edition of the ‘Guidelines on the management of co-occurring alcohol and other drug and mental health
conditions in alcohol and other drug treatment settings’ (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 co-occurring mental health conditions. Building on the success of the first
edition [2], the Australian Government Department of Health funded the update and revision of these
Guidelines to bring them up to date with the most current evidence, and these were published in 2016
[3]. Funding for the development of an accompanying online training program was also provided and
was launched in 2017. Since their publication in 2016, more than 23,500 hard and electronic copies of
the second edition have been distributed across Australia, and the Guidelines are also being used as a
recommended text in vocational and educational training courses across Australia. At the time of writing,
more than 7,400 people were registered users of the online training program and more than 1,700 people
had completed the full program.

The impact of the Guidelines is demonstrated not only by their popularity, but by their perceived utility.
Evaluations of both the first and second edition of the Guidelines and its accompanying online training
program found them to be relevant and useful to clinical practice, enabling AOD workers to respond
to co-occurring AOD and mental health conditions with greater confidence [2, 4]. More specifically, in
an evaluation of the online training program, the vast majority of participants (>94%) reported that
 2 About these guidelines

the program had increased their knowledge, confidence, and capacity to address comorbidity in their
practice. Moreover, 89% reported using what they had learnt in their clinical practice, and 58% reported
improved client outcomes [4].

While the Guidelines have proved to be an extremely successful clinical resource, the scientific evidence
regarding the management and treatment of co-occurring disorders has grown considerably since the
second edition was published. As such, the Australian Government Department of Health and Aged
Care funded researchers at the Matilda Centre for Research in Mental Health and Substance Use at the
University of Sydney, 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 co-occurring 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 co-occurring 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 co-occurring mental health conditions, it is anticipated that the outcomes for people with co-
occurring 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 co-occurring mental health conditions. The
Guidelines are not a substitute for training; rather, they should be used in conjunction with appropriate
co-occurring AOD and mental health 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 different patterns of co-occurring conditions are seen across
different health services [5]. For example, AOD treatment services are most likely to see co-occurring
About these guidelines 3

depressive, anxiety, and personality disorders; mental health services, on the other hand, are more likely
to see people experiencing schizophrenia and bipolar disorder co-occurring with AOD use disorders [6].

These Guidelines have been developed with the assumption that the management and treatment of co-
occurring AOD and mental health conditions will be provided by trained practitioners. AOD workers differ
in their job descriptions, education, training, and experience. This may range from people who are highly
qualified with little experience to those with fewer qualifications but much experience [7]. The amount of
time that AOD workers spend with clients also varies widely depending on the type of service provided,
and the presentation of the client. For example, AOD workers may have very brief contact with clients who
present in medical or psychiatric crisis (who may then be referred to other services); they may work with
them for one week if they are entering detoxification, or they may work with them for several months or
years if they present for substitution therapy, residential rehabilitation, or outpatient counselling.

Given the differences in AOD workers’ roles, education, training, and experience, it is not expected that all
AOD workers will be able to address co-occurring conditions to the same extent. Each AOD worker should
use these Guidelines within the context of their 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 B7). The provision of opportunities
for continuing professional development for AOD staff in the area of co-occurring mental health
conditions should be a high priority for AOD services.

Relationship with existing guidelines

These Guidelines should be used in conjunction with existing guidelines and discipline-specific practice
standards. There are a growing number of guidelines being developed on the management and treatment
of people with co-occurring mental health and AOD use disorders across jurisdictions and disciplines.
Some other existing guidelines which AOD workers may find useful are listed in Appendix A. These
Guidelines have drawn on these and other key resources and reference is made to them throughout this
document.

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 Workforce [8] 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 to the second edition of the
Guidelines [3]. Like the first and second editions, these Guidelines are based on the best available
research evidence, developed in consultation with an expert panel of academic researchers, clinicians,
people with lived experience, family members and carers (see p.ii and iii). In addition to reviewing,
 4 About these guidelines

synthesising, and updating the evidence to date with guidance from our expert panel, feedback on
the second edition of the Guidelines was obtained from key-stakeholders (including people with lived
experience of AOD and mental health conditions, clinicians, academics, family and carers) via two
national discussion forums open to interested key stakeholders (conducted online due to COVID-19
restrictions which allowed for a larger number of participants to attend from across Australia), an online
survey seeking feedback on the second edition, and written submissions from any person wishing to
provide feedback.

Both clinical and scientific knowledge about what treatment modalities may help people experiencing
co-occurring AOD and mental health conditions 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 and telehealth 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.

Figure 1: Holistic health care framework:

Holistic health care Physical and mental health

Given the multitude of problems with

which clients present to treatment, the Mental
goal of any service should be to improve health

clients’ quality of life across all domains,

including health, social welfare and
housing, employment, criminal justice and,
of course, AOD and mental health. As such,
these Guidelines adopt a holistic health
Environmental Physical
care approach to the management and factors health
treatment of co-occurring AOD and mental
health conditions, which is based on the
adage ‘Treat the person, not the illness’ [9].
It is essential to consider the whole person,
taking into account psychological, physical,
and sociodemographic perspectives when Social
factors
consulting with clients with co-occurring
mental health conditions (Figure 1).
About these guidelines 5

Comparison with 2016 Guidelines

Structure
The structure of the third edition of the Guidelines is similar to the second edition, and is formatted in
four parts:

• Part A addresses the nature and extent of co-occurring AOD and mental health conditions and
discusses why it is important for AOD services to respond. Information regarding the prevalence,
guiding principles, and classification of disorders is contained in Part A.

• Part B contains information on how to respond to co-occurring conditions, including the provision
of holistic and trauma-informed care, identifying co-occurring conditions, assessing risk,
coordinating care, approaches to managing and treating specific co-occurring conditions, and
worker self-care.

• Part C addresses specific population groups.

• Appendices contain a range of useful resources, techniques, and worksheets.

Changes in diagnostic criteria

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 [10]. Although the fifth version of this
manual (DSM-5) has been in use since 2013, some studies included in the literature reviews have still
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 [11]). ICD-11 is due to come into effect from 1 January 2022. Although widely used in clinical practice
in many parts of the world, ICD is a general medical classification system and is rarely used in the type
of research studies included for review. Nevertheless, ICD is also referred to in these Guidelines and key
differences between the DSM-5 and ICD-11 classification systems are noted.

Language
Both AOD and mental health conditions are stigmatised conditions, and it is vital that any
communication regarding clients experiencing possible mental disorders – whether that communication
involves the client, loved ones or other healthcare providers – remains respectful, non-judgemental,
compassionate and client-centred. The language used throughout this document reflects that used
in the diagnostic classification systems to provide workers with the functional knowledge to identify
conditions and facilitate communication with other areas of health (e.g., mental health services). We
acknowledge that, while some people experience formal acknowledgement of their mental health
symptoms through diagnostic labelling as a way of legitimising and explaining their ongoing distress,
this is not the case for everyone; others may perceive diagnostic labelling as stigmatising, and feel a
sense of powerlessness [12]. The language AOD workers use to describe symptoms and disorders should
 6 About these guidelines

be based on the needs of the client, but as detailed in Chapter B3, formal diagnoses can only be given by
a health professional who is qualified and trained to do so (e.g., a registered psychologist or psychiatrist).

We also acknowledge that over time, preferences regarding the terms used to refer to the co-occurrence
of AOD and mental health conditions have evolved. While these Guidelines continue to be referred to as
the ‘Comorbidity Guidelines’, the term ‘comorbidity’ as a reference to co-occurring AOD and mental health
conditions, has not been used in the third edition. Rather, based on consultations with experts and key
stakeholders, the terms ‘co-occurring conditions’ or ‘co-occurring AOD and mental health conditions’
have been used throughout this document. There has been a similar evolution in terms of language
used to describe different population groups. While we have used particular language throughout this
document, we acknowledge there is no all-inclusive term and not everyone will identify with the language
used in these Guidelines. Our intention in utilising particular terminology is to describe the evidence
regarding co-occurring conditions.

Case studies
A series of case studies have been included to highlight some of the presenting issues that are
experienced by AOD clients with co-occurring mental health conditions and demonstrate some examples
of pathways through treatment.

Limitations of the Guidelines

As noted above, these Guidelines are not intended to be used prescriptively; rather AOD workers should
use their experience and expertise in applying the Guidelines within the context of their role.

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.
Part A: About co-occurring conditions
 8 Part A: About co-occurring conditions

Part A: About co-occurring conditions

Part A of the Guidelines aims to provide workers with background information about co-occurring AOD
and mental health conditions. In this document, we use the term ‘mental disorder’ when referring to
people with a diagnosable mental disorder as defined by the DSM, as well as ‘mental health condition’,
when 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. Although there may be several reasons
why two or more disorders may co-occur, it is most likely that the relationship between co-occurring
conditions is one of mutual influence (see Chapter A1).

Mental disorders are common among clients of AOD services, in particular, anxiety, depression, PTSD, and
personality disorders (see Chapter A2). In addition, there are many people who present to AOD treatment
who display symptoms of disorders while not meeting criteria for a diagnosis of a disorder. While people
who experience co-occurring conditions may have more complex profiles, they have been found to
benefit as much from traditional AOD treatment methods as those without co-occurring mental health
conditions.

When working with clients with co-occurring mental health conditions, it is recommended that AOD
services and AOD workers consider the guiding principles described in Chapter A3. Although not all AOD
workers are able to formally diagnose the presence or absence of mental disorders, it is important 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 (see Chapter A4).
A1: What are co-occurring conditions? 9

A1: What are co-occurring

conditions?
10 A1: What are co-occurring conditions?

A1: What are co-occurring

conditions?

Key points
• Although many types of co-occurring conditions exist, 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 co-occurring ‘mental disorder’ when referring to people with
a diagnosable mental 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 co-occurring conditions is one of mutual
influence.

In these Guidelines, ‘co-occurring conditions’ 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 [13]. It should be noted that there are other types of co-occurring conditions.
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 co-occurring conditions in AOD clients is tobacco
use (discussed in Chapter B1; [14–17]). 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 [18–24]. This combination of substance
use, mental and physical health conditions is often referred to as ‘multimorbidity’ [25]. While there are a
number of different types and possible combinations of co-occurring conditions, these Guidelines focus
on the co-occurrence of AOD use disorders and mental health conditions.

To be classified as having a mental disorder, a person must meet a number of diagnostic criteria (see
Chapter A4 for a discussion of the classification of mental disorders). There are, however, 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. For example, a person may exhibit depressed mood or anxiety without having a
diagnosable depressive or anxiety disorder. Although these people may not meet full diagnostic criteria
according to the classification systems, their symptoms may nonetheless impact significantly on their
functioning and treatment outcomes [26, 27]. For example, people who report symptoms of depression
but do not meet diagnostic criteria may have reduced productivity, increased help-seeking, and an
increased risk of attempted suicide [28]. Therefore, rather than viewing mental health as merely the
A1: What are co-occurring conditions? 11

presence or absence of disorder, mental health conditions can be viewed as a continuum ranging from
mild symptoms (e.g., mild depression) to severe disorders (e.g., schizophrenia or psychotic/suicidal
depression).

In this document we use the term co-occurring ‘mental disorder’ when referring to people with a
diagnosable mental disorder, as defined by the DSM [10, 29]. When using the term ‘mental health
condition’, we are referring to both people who have a diagnosable disorder as well as people who display
symptoms of disorders while not meeting criteria for a diagnosis of a disorder.

Why do co-occurring conditions occur?

There are a number of possible explanations as to why co-occurring conditions may occur (see Figure 2):

• The presence of a mental health condition may lead to an AOD use disorder, or vice versa (known as
the direct causal hypothesis).

• There may be an indirect causal relationship.

• There may be factors that are common to both the AOD and mental health condition, increasing the
likelihood they will co-occur.

Direct causal hypothesis

The AOD use may be a consequence of the mental health condition

In some cases where co-occurring conditions exist, the AOD use disorder occurs as a consequence of
repeated AOD use to relieve or cope with mental health symptoms. This relationship is often described as
the ‘self-medication hypothesis’, in that substances are used in an attempt to medicate mental health
symptoms [30–32]. 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 their AOD use. For example, people 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.

The mental health condition may be a consequence of AOD use

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 [33–35]; symptoms of mania can be induced by
intoxication with stimulants, steroids, or hallucinogens; and psychotic symptoms can be induced by
withdrawal from alcohol, or intoxication with alcohol, stimulants, cannabis, or hallucinogens [36–38].
Other disorders that can come about from AOD use include substance-induced neurocognitive disorder,
sexual dysfunction, and sleep disorder [10]. In the majority of cases, these effects subside and eventually
12 A1: What are co-occurring conditions?

disappear with abstinence [39, 40]. For some, however, symptoms may continue even after they have
stopped drinking or using substances. Regardless of whether the co-occurring disorders are classified as
independent or substance-induced, they may be associated with poorer treatment outcomes [34].

Indirect causal relationship

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 [41]. 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 [42, 43]. This poor level of education may
lead to later life difficulties (e.g., unemployment) that may lead to other problems, such as depression
[44, 45]. Similarly, the reverse is possible, whereby a depressive disorder may lead to difficulties
completing study and work commitments, which may in turn lead to difficulties finding employment,
increasing the risk of problematic levels of AOD use [46–48].

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 [49–57]. For example, both AOD and mental health
conditions have been associated with lower socioeconomic status, cognitive impairment, the presence
of conduct disorder or behavioural disinhibition 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 [49, 58–60]. An increasing body of research has focused on epigenetics; that is, the way in which
a person’s environment and experiences can influence gene expression. For example, childhood trauma
and adversity has consistently been associated with alterations in the expression of genes that have
been associated with the development of mental health and AOD use disorders [61]. Importantly, research
has also shown that psychotherapy can also impact positively on genetic expression [62]. However, just
as with other risk factors, underlying genetic vulnerability may increase the risk of developing a disorder
– it does not mean a person is predestined to develop an AOD use disorder or depression, for example.
A1: What are co-occurring conditions? 13

Figure 2: Explaining co-occurring conditions

Direct causal hypothesis

Mental health
AOD USE condition

Mental health condition AOD USE

Indirect causal hypothesis

AOD USE Intermediary factors Mental health

condition

Mental health Intermediary factors

condition AOD USE

Common factors hypothesis

AOD USE Common factors Mental health

condition
14 A1: What are co-occurring conditions?

Does causality matter?

In the past, there has been a focus on establishing the order of onset of conditions to identify which
is the primary disorder. Conditions may occur in any order, or they may develop at the same time. The
evidence regarding the typical order of onset of disorders is not consistent, and differences have been
observed between males and females [63, 64]. It appears, however, that social anxiety disorder (SAD),
specific phobia, and post traumatic stress disorder (PTSD) tend to predate the AOD use disorder in
most – but not all – cases, whereas generalised anxiety disorder (GAD), panic disorder, depression, and
dysthymia, tend to have their onset after the onset of an AOD use disorder [63, 65].

Establishing the order of onset of conditions can be useful in understanding the relationship between
conditions, and in developing a case formulation (see Chapter B3). It is important to note, however,
that once co-occurring 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 [65, 66] (see Figure 3).
Regardless of how the co-occurrence came about, both conditions may serve to maintain or exacerbate
each other. For example, a person may engage in AOD use to reduce symptoms of depression; however,
research suggests that repeated use may lead to increased depression [33]. It is also possible that the
relationship between disorders may change over time [66, 67]. For example, depression may trigger
alcohol use on some occasions, while it may be the result of alcohol use on others [68]. Irrespective of
what order co-occurring conditions have developed, the strategies used to manage these conditions are
the same.
A1: What are co-occurring conditions? 15

Figure 3: Example of a relationship of mutual influence between AOD use and mental
health conditions

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
symptoms. Increased Increased AOD use
tolerance to AOD

Temporary relief
from mental health
symptoms
A2: How common are co-occurring
conditions and why are they of
concern?
A2: How common are co-occurring conditions and why are they of concern? 17

A2: How common are co-occurring

conditions and why are they of
concern?

Key points
• Mental disorders are common among clients of AOD services.
• The most common co-occurring mental disorders are anxiety, depression, PTSD, and
personality disorders.
• In addition to those with mental 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 co-occurring mental health conditions may have more complex profiles,
they have been found to benefit as much from traditional AOD treatment methods as those
without co-occurring mental health conditions.

How common are mental disorders?

In Australia, mental and AOD use disorders are the fourth leading cause of burden of disease (12% of total
burden) following cancer (18%), cardiovascular disease (CVD; 14%), and musculoskeletal conditions (13%)
[69]. Research conducted on the general population indicates that approximately one in two people will
develop a mental disorder at some point in their life [63, 70]. The Australian National Survey of Mental
Health and Wellbeing (NSMHWB) conducted in 2007 found that more than 41% of Australian adults (45%
of men and 38% of women) had experienced a substance use, anxiety, or mood disorder in their lifetime
[63]. The projected lifetime prevalence of these disorders is 28%, 25%, and 23% respectively [71]. Just
over 10% of Australian adults had experienced two classes of mental disorders, and just over 4% had
experienced three [63].

The 2007 NSMHWB also found that one in five Australian adults (18% of men and 22% of women) had a
substance use, anxiety, or mood disorder in the past year, representing close to 3.2 million Australian
adults [72]. Approximately 25% of people with mental disorders were found to have two or more classes
of mental disorder [73]. The prevalence of single and co-occurring substance use, anxiety, and affective
(i.e., mood) disorders among Australian men and women from the NSMHWB is depicted in Figure 4. The
overlapping portions of the circles indicate the proportion of the population who have co-occurring
disorders. For example, 1.3% of men and 0.8% of women have a substance use and anxiety disorder only.

Recently released preliminary findings from the 2020-21 NSMHWB report comparable estimates of
lifetime (44%) and past year (21%) mental disorder. Findings from the 2017-2018 Australian National
18 A2: How common are co-occurring conditions and why are they of concern?

Health Survey [74] have shown that mental and behavioural conditions continue to affect around one in
five Australians (20.1%), making these conditions the most commonly experienced chronic conditions
in Australia. Furthermore, comparisons with the previous 2014-2015 survey suggest that both anxiety-
related conditions and depression are becoming more prevalent in the Australian community, affecting
13.1% (an increase from 11.2% in 2014-15) and 10.4% (an increase from 8.9% in 2014-2015) of Australians
respectively [74]. Despite significant government investment in mental health services, the potential for
a shadow pandemic of mental ill health as a consequence of the COVID-19 pandemic remains a concern,
particularly among young Australians [75].

Figure 4: Prevalence (%) of single and co-occurring DSM-IV affective, anxiety and
substance use disorders amongst Australian males (left) and females (right) in the past
year

Males Females

SUBSTANCE USE SUBSTANCE USE

4.3 1.7
ANXIETY
1.3 ANXIETY
0.8
6.7 12.6
0.9 0.6
0.6 0.2
2.0 3.9

AFFECTIVE AFFECTIVE

1.9 2.5

Source: Teesson et al. [73].

How common are co-occurring mental disorders among

clients of AOD treatment services?
General population estimates indicate that 35% of Australians with a substance use disorder (31% of
men and 44% of women) have at least one co-occurring mood/affective or anxiety disorder (see Figure 5),
but this rate is even higher among people entering AOD treatment programs. Although reported rates vary
across studies, it is estimated that at least 47% of people seeking AOD treatment have a current mental
disorder [76], and at least one in three have multiple co-occurring conditions [77–81]. Thus, in many
service settings, co-occurring mental disorders are the norm rather than the exception.
A2: How common are co-occurring conditions and why are they of concern? 19

The most frequently seen mental disorders among people seeking AOD treatment mirror those observed
in the general population. Although estimates vary substantially between studies depending on the
methods and timeframes used to assess for conditions, the most common are anxiety disorders (12 –
91%), most commonly GAD (1 – 75%); depression (27 – 85%); PTSD (5 – 66%); and personality disorders, in
particular ASPD (2 – 72%) and borderline personality disorder (BPD; 16 – 48%); bipolar disorders (4 – 53%);
obsessive-compulsive disorder (OCD; 1 – 52%); and psychotic disorders (2 – 41%) [76, 81–83]. Although
less common, studies have also found elevated rates of eating disorders (ED; 2 - 34%), and attention-
deficit/hyperactivity disorder (ADHD; 2 - 6%) [76, 83]. Despite these high rates, these conditions often go
unrecognised. It should also be borne in mind that the prevalence of mental disorders may vary between
substances, however, little research has been conducted comparing the rates of mental disorders across
different types of AOD use disorders [76].

Figure 5: Prevalence (%) of mental disorders in the past year among adults with
substance use disorders in the 2007 National Survey of Mental Health and Wellbeing
50

45 Men Women Total

40

35

30
Percentage

25

20

15

10

0
D

SD

D
ia

ia
er

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de

de

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GAD = generalised anxiety disorder; PTSD = post traumatic stress disorder; panic disorder (with or without
agoraphobia); OCD = obsessive compulsive disorder; agoraphobia (without panic disorder).
20 A2: How common are co-occurring conditions and why are they of concern?

The number of potential combinations of disorders and symptoms is also 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 [84, 85]. People who
display a number of symptoms of a disorder but do not meet criteria for a diagnosis are sometimes
referred to as having a ‘subsyndromal’ or ‘partial’ disorder. Although these people may not meet full
diagnostic criteria according to the classification systems (described in Chapter A4), their symptoms
may nonetheless impact significantly on their functioning and treatment outcomes [84, 86–89].

What are the harms associated with co-occurring disorders?

The high prevalence of co-occurring mental disorders means that AOD workers are frequently faced with
the need to manage complex psychiatric symptoms, which has been cited as a major challenge and
ongoing training gap for almost two-thirds (62%) of Australian AOD workers [7]. Clients with co-occurring
mental and AOD use disorders present to treatment with a more complex and severe clinical profile,
including poorer general physical and mental health, greater drug use severity, and poorer functioning
(see Figure 6) [90–93]. The presence of co-occurring mental health conditions may also place an
enormous strain on clients’ families and others close to them, both emotionally and financially.

Figure 6: Harms associated with co-occurring mental health and AOD use conditions
A2: How common are co-occurring conditions and why are they of concern? 21

What is the impact of co-occurring mental disorders on

treatment outcomes?
The influence of mental disorders on treatment outcomes in clients with AOD use disorders is not
straightforward and may be influenced by a number of factors [87, 94]. Although some studies have
shown that clients with co-occurring mental disorders have poorer treatment outcomes [79, 87, 91, 95,
96], others have clearly demonstrated that clients with co-occurring conditions benefit from treatment
just as much as those without co-occurring conditions in terms of their AOD use, general physical and
mental health, and functioning – even those with severe mental disorders [78, 87, 92, 97–102]. However,
while both those with and without co-occurring conditions follow a similar course in terms of their
treatment outcomes (i.e., both groups improve), those with co-occurring conditions continue to drink or
use more, be in poorer physical and mental health, and display poorer functioning following treatment.
That is, they present to treatment with a more severe clinical profile, and despite similar levels of
improvement, continue to demonstrate a poorer clinical profile at follow-up. These findings indicate
that AOD services and AOD workers do exceptionally well at treating AOD use (despite the poorer clinical
profile described in the previous section) and its associated disability, but that the disability associated
with the co-occurring condition remains.
A3: Guiding principles
A3: Guiding principles 23

A3: Guiding principles

Key points
When working with clients with co-occurring mental health conditions, it is recommended that
AOD services and AOD workers take the following principles into consideration:

• First, do no harm. • Adopt a client-centred approach.

• Work within your capacity. • Adopt a trauma-informed care approach.
• Engage in ongoing professional • Emphasise the collaborative nature of
development. treatment.
• Recognise that the management of • Have realistic expectations.
co-occurring conditions is part of AOD • Express confidence in the effectiveness of
workers’ core business. the treatment program.
• Provide equity of access to care. • Adopt a non-judgemental attitude.
• Adopt a ‘no wrong door’ policy. • Adopt a non-confrontational approach to
• Recognise that co-occurring conditions treatment.
are common and that all clients should • Involve families and carers in treatment.
be routinely screened for co-occurring
• Involve peers in treatment.
conditions.
• Consult and collaborate with other health
• Conduct ongoing monitoring of symptoms
care providers.
and assessment of client outcome.
• Ensure continuity of care.
• Focus on engaging the client in treatment.
• Adopt a holistic approach based on
treating the person, not the illness.

When working with clients with co-occurring mental health conditions, it is recommended that AOD
services and AOD workers take the following principles into consideration. AOD services need to provide
the infrastructure, policy, and systems support for AOD workers to put these principles into practice. The
implementation of these principles may help to engage the client in treatment, enhance the therapeutic
alliance, and increase the likelihood of improved client outcomes.

First, do no harm
The principle ‘first, do no harm’ 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 or to the
community more broadly. In the example of pharmacological treatment, harms to consider may include
interactions between substances, overuse, and potential for dependence or misuse [103].
24 A3: Guiding principles

Work within your capacity

In line with the principle above, each AOD worker should work within their capacity to address co-
occurring 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 co-occurring
conditions to the same extent. It is essential that appropriate supervision be provided to AOD workers
working with clients with co-occurring conditions, particularly those with less experience working with
mental health conditions [104].

Engage in ongoing professional development

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. In addition to being able to identify and
manage co-occurring conditions, staff should also be trained in appropriate referral processes (see
Chapter B5; [105]). 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. Indeed,
mental health training for AOD workers is also valued by clients and may strengthen workers’ credibility,
insofar as trained staff are seen to have the knowledge to help with clients’ medication and emotional
needs [106]. AOD workers should seek out, and actively engage in, training that addresses co-occurring
conditions. It is important that professional development in this area be ongoing, as it is an ever-evolving
area of research. AOD workers are encouraged to update their knowledge by accessing new research and
training opportunities, and new clinical guidelines as they emerge (Appendix B and Appendix C provide
some useful resources and research organisations).

Recognise that the management of co-occurring conditions

is part of AOD workers’ core business
AOD treatment services and AOD workers need to recognise that working with co-occurring mental health
conditions is part of their core business. Indeed, managing co-occurring mental disorders is the core
business of all health care providers.

Provide equity of access to care

Cases have been documented where clients of AOD services have received prejudicial treatment or been
refused entry to treatment due to the presence of co-occurring disorders. All clients, regardless of their
mental health status, are morally and legally entitled to equal access to the highest quality of care [107].
A3: Guiding principles 25

Adopt a ‘no wrong door’ policy

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. Care should be coordinated, connected, and streamlined
so that clients are assessed and treated appropriately regardless of the ‘type’ of treatment service
and to reduce unnecessary referral [108]. When a person presents at a facility that is not equipped to
provide a particular type of service, they should be guided to appropriate facilities (using active referral
methods discussed in Chapter B5), with follow-up by staff to ensure that they receive appropriate care
[102, 109–111]. 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
co-occurring presentations is provided in Figure 7. It should be noted, however, that it can be difficult to
discern which areas should take primary responsibility for individual cases as the severity of conditions
may be interpreted differently by various service providers.

Figure 7: Clinical governance

AOD services Mental health services

Primarily responsible for people severely Primarily responsible for people severely
incapacitated by current substance use and incapacitated by current mental health problems
adversely affected by mental health problems. and adversely affected by substance use.

AOD and mental health services General practitioners

Shared responsibility for people severely Primarily responsible for people with mild
disabled by both substance use and mental to moderate AOD and/or mental health
disorders. The client should be treated by the conditions but with access to specialist AOD
service that best meets their needs. and mental health services as required.

Source: NSW Health [112].

26 A3: Guiding principles

Recognise that co-occurring conditions are common and

that all clients should be routinely screened for co-occurring
conditions
Despite the fact that co-occurring mental health conditions are common among people with AOD use
disorders, they are often overlooked in AOD treatment settings [113, 114], mostly because AOD workers
are not routinely looking for them. As part of routine clinical care, all clients should be screened for co-
occurring conditions. Chapter B3 discusses how to screen and assess for co-occurring conditions.

Conduct ongoing monitoring of symptoms and assessment

of client outcomes
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.

It is often difficult for clients to detect subtle changes over time. Integrated screening and assessment at
different timepoints, and provision of feedback to clients, are important steps for client engagement [115].
Ongoing monitoring is rated by health professionals as one of the top non-pharmacological strategies for
promoting treatment adherence among clients with co-occurring conditions [116]. Evidence of a reduction
in psychiatric symptoms may help to maintain client motivation. On the other hand, evidence that there
has been no change or that their psychiatric symptoms have worsened may help clients understand why
they have been using substances and alert them to the need to address these issues.

Focus on engaging the client in treatment

The development of a trusting therapeutic alliance with the client is essential to engaging the client
in the treatment process and has been linked to both improved client outcomes related to AOD use
(e.g., decrease in alcohol use) and mental health (e.g., improvement in depressive symptoms) [117–120].
Engaging clients in treatment can be difficult, particularly at the start of treatment where therapy may
be challenging and attachment needs are activated [121]. For example, in clients with personality or
psychotic disorders, difficulties engaging 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
[122]. Conversely, a positive therapeutic relationship allows clients to modify their maladaptive relational
patterns and learn how to form healthy relationships [123]. The following strategies may assist in
engaging the client in treatment [115, 121, 123–127].
A3: Guiding principles 27

• Express empathetic, optimistic, non-judgemental, and compassionate attitudes.

• Provide individualised care that includes identified strengths as well as problems.

• Adopt a holistic approach including both recovery-oriented and trauma-informed principles.

• Be flexible yet consistent with appointments.

• Protect confidentiality and privacy.

• Promote client motivation and self-efficacy.

• Work with the client’s current stage of readiness to change (as discussed in Chapter B3).

Adopt a holistic approach that focuses on treating the

person, not the illness
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 co-occurring conditions, one cannot look at the person’s AOD use and
mental health alone. Clients with co-occurring 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 their AOD
and mental health conditions. Indeed, clients appreciate when services have recognised and addressed
connections between co-occurring issues and other aspects of their life [125], and express greater
satisfaction with care when it focuses on their AOD use while supporting their other needs [128]. Clients
also need to be viewed in light of their age, gender, sexual orientation, culture, ethnicity, spirituality,
socioeconomic status, and cognitive abilities.

Adopt a client-centred approach

AOD workers are specialists in their field. It is important to acknowledge, however, that it is the client
who is the expert on themselves. It is important that AOD workers listen to what clients want to achieve
from treatment and use this as the basis of creating shared treatment goals. Listening to what clients
want will assist in identifying other services that may need to be engaged. Listening will also assist
with collaboratively developing a treatment plan that is tailored to the client and considers their social
and treatment context and readiness for change [129]. Tailoring treatment to clients’ individual needs is
associated with greater client-reported care satisfaction and perceived benefit from treatment [127, 130].

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, or for those whose AOD use is more severe [131].
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 people [132]. 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.
28 A3: Guiding principles

Although abstinence is favoured, it is recognised that many people with co-occurring conditions prefer
a goal of moderation. In order to successfully engage with the client, AOD workers should discuss
treatment considerations with their client, accommodate a range of treatment goals and adopt a harm
reduction approach [129, 133, 134].

Adopt a trauma-informed care approach

As described in Chapter B2, the provision of trauma-informed care is essential given the high rates of
trauma among clients of AOD services and the fundamental role that trauma symptoms may play in a
person’s recovery [135, 136]. Exposure to traumatic life events is almost universal among clients of AOD
services [83, 137, 138], and has been found to play a key role in both the development and maintenance
of AOD use disorders [139, 140]. A trauma-informed care approach involves recognition of the high rates
of trauma exposure and the provision of a safe environment that is healing and not retraumatising [141].
Further discussion of the elements of trauma-informed care is provided in Chapter B2.

Emphasise the collaborative nature of treatment

Clients with co-occurring conditions often feel that they have very little control over their lives. It is
important they understand that you will be working together throughout treatment, to help them
re-establish a sense of autonomy and control. Collaborative approaches to decision-making about
treatment, such as shared decision-making, have been shown to support clients with co-occurring
conditions take a more active and informed role in their decision-making about treatment, in line with
most clients’ preferences for involvement in treatment decision-making [142]. Shared decision-making
may also facilitate agreement between clinicians and clients in terms of treatment decisions and
treatment goals, as well as shared perceptions of the working alliance [142].

Have realistic expectations

It is important that AOD workers have realistic expectations regarding the course of treatment and
outcomes to be expected of clients with co-occurring conditions. It is commonly believed that clients
with co-occurring conditions are more difficult to treat, require more intensive treatments, and have
poorer treatment outcomes. However, co-occurring conditions are not an insurmountable barrier to
treating people with AOD use disorders. It is important that treatment plans are developed collaboratively
to build patient trust and treatment engagement [133], and tailored to the client’s readiness for change
[129]. As discussed in Chapter A2, research has shown that clients with co-occurring conditions can
benefit just as much as those without co-occurring conditions from usual AOD treatment [78, 99, 102,
143].
A3: Guiding principles 29

Express confidence in the effectiveness of the treatment

program
As mentioned above, positive outcomes can be achieved in clients with co-occurring conditions. AOD
workers’ confidence in the treatment will increase clients’ confidence that the treatment they are
entering can help them.

Adopt a non-judgemental attitude

Clients with co-occurring conditions 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
[144]. People with mental disorders have traditionally been viewed by society as violent, brain damaged,
intellectually disabled, unimportant, untrustworthy, or worthless. As a result, clients with co-occurring
conditions will often feel too ashamed or embarrassed to tell people about them, even health
professionals [107].

A non-judgemental approach can help reduce client’s feelings of shame [130]. AOD and other health
professionals should treat people with co-occurring conditions 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.

Adopt a non-confrontational approach to treatment

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 [132].
Emotional distress may be triggered by criticism, rejection, or an inability to deal with task demands
[145]. It is recommended instead that a non-confrontational motivational enhancement approach be
used [133]. Motivational interviewing (MI) techniques are described in Appendix E.

Involve families and carers in treatment

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.
30 A3: Guiding principles

Two useful resources are available, and may have relevant information for families, carers, and friends:

• Tools for change: A new way of working with families and carers, developed by the Network of
Alcohol and other Drugs Agencies, available as part of the Families and Carers Toolkit [146].

• Guidelines to consumer participation in NSW drug and alcohol services, developed by the NSW
Ministry of Health [147]. www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_006.pdf

Involve peers in treatment

Peer workers play an important role in the delivery of treatment for people with co-occurring conditions.
Peers provide important connections for clients, which may complement the therapeutic alliance formed
with an AOD worker [148]. Clients also view peers as useful for helping to de-stigmatise their AOD use and
mental health conditions [130]. There is some preliminary evidence to suggest that more formal peer
recovery support services are helpful across a number of AOD treatment settings in terms of reducing
AOD use and relapse rates, improving relationships with AOD workers and social supports, as well as
increasing retention in and satisfaction with treatment [149].

Consult and collaborate with other health care providers

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 [107, 150]. It is important that AOD services and AOD workers develop links with a
range of local support services to provide specialised, coordinated and continuous care for clients. Such
services include mental and community health practitioners, housing, employment, and welfare services
[105]. General practitioners (GPs) in particular play an important role in delivering care to people with co-
occurring conditions, as they are often their first and most consistent point of contact [151]. 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.

Ensure continuity of care

People with co-occurring 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 [109].
Continuity of care greatly influences whether clients feel their needs have been met and whether they
are satisfied with treatment [128]. In addition to improved satisfaction, increased continuity of care is
also linked to increased client commitment to treatment, better quality of life, improved community
functioning, and reduced violent behaviour [128]. Chapter B5 discusses methods that may be used to
refer clients to other services.
A4: Classification of disorders
32 A4: Classification of disorders

A4: Classification of disorders

Key points
• There are many different mental disorders, with different presentations. They are generally
characterised by a combination of abnormal thoughts, perceptions, emotions, behaviour and
relationships with others.
• Not all AOD workers are able to formally diagnose the presence or absence of mental disorders.
Diagnoses of mental 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 co-occurring mental health condition
undergo a medical assessment as many symptoms of mental 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 disorders. Diagnoses of mental 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.

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 (discussed in Chapter B2), and to inform treatment planning. Many more people will
present with symptoms than will meet criteria for a diagnosis of a disorder; however, these symptoms
are distressing and need to be managed nonetheless. It is hoped that the descriptions provided here
will increase AOD workers’ knowledge and awareness of different signs (i.e., what is objectively visible
about the client, such as sweating) and symptoms (i.e., what the client describes, such as sadness)
of disorders. The case studies provided throughout these Guidelines also provide examples of how
symptoms may present in clients with co-occurring mental disorders.

There are many kinds of mental disorders, with each disorder comprising a group of signs and
symptoms. A certain number of criteria for a particular disorder need to be met within a certain
timeframe for a person to be diagnosed as having that disorder. However, as described in Chapter A1,
there are many people who present to AOD treatment who display symptoms of disorders, while not
meeting criteria for a diagnosis of a disorder. For example, a person may present with depressed mood or
anxiety symptoms, without having a diagnosable depressive or anxiety disorder. Although these people
A4: Classification of disorders 33

may not meet full diagnostic criteria according to the classification systems, their symptoms may
nonetheless impact significantly on their functioning and treatment outcomes [26, 27, 152]. As such,
rather than viewing mental health as merely the presence or absence of disorder, it may be more useful
to consider mental health conditions as a continuum, ranging from mild symptoms to severe disorders
(Figure 8).

Figure 8: Continuum of mental health conditions

Mental health

Mild symptoms Severe disorders

The diagnostic classification systems

There are two main classification systems used to diagnose mental disorders:

• The Diagnostic and Statistical Manual of Mental Disorders, currently in its fifth edition (DSM-5-TR)
[10].

• The International Classification of Diseases, currently in its 11th revisions (ICD-11 [11]), which only
recently came into effect on 1 January 2022 [11].

Although these systems are similar, there are a number of important differences. The disorder
descriptions outlined in this chapter are based on the most recent edition of the DSM, released in
March 2022 (DSM-5-TR [10]), but some references are made to the ICD-11 [11]. In particular, we have
highlighted several key changes between the DSM-5-TR and ICD-11 that AOD workers should be aware
of. It should be noted, however, that these are not the only differences between the two classification
systems. It is also important to note that the disorder descriptions provided in the current versions of
both the DSM and ICD vary to those provided in earlier versions, as each edition is updated to reflect
evolutions in our understanding of disorders based on research. As such, AOD workers are encouraged
to familiarise themselves with both the DSM-5-TR and ICD-11, in particular their uses, limitations, and
recommendations regarding differential diagnosis (i.e., determining which symptoms are attributable
to which disorder). The DSM-5-TR disorders described here have also been cross-referenced with the
corresponding ICD-11 codes in Appendix D. Irrespective of any differences between classification
systems, AOD workers should be mindful that the move towards a more dimensional approach of
diagnosing mental health conditions emphasises the need for not only clinical judgement and expertise,
but of central importance, the need to consider the whole person rather than a person presenting to
treatment with a checklist of symptoms.

In these Guidelines we focus on 10 categories of disorder that are most commonly seen among people
with AOD use disorders, grouped by DSM-5-TR and ICD-11 classification (Table 1).
34 A4: Classification of disorders

Table 1: DSM-5-TR and ICD-11 classifications of most commonly co-occurring mental

disorders among people with AOD use disorders

DSM-5-TR classification ICD-11 classification

Attention-deficit/hyperactivity disorder Attention deficit hyperactivity disorder

Schizophrenia spectrum and other psychotic Schizophrenia or other primary psychotic disorders
disorders

Bipolar disorders Bipolar or related disorders

Depressive disorders Depressive disorders

Anxiety disorders Anxiety or fear-related disorders

Obsessive-compulsive disorder Obsessive-compulsive disorder

Trauma-related disorders Disorders specifically associated with stress

Feeding and eating disorders Feeding or eating disorders

Personality disorders Personality disorders and related traits or patterns

Substance-induced disorders Substance-induced psychotic disorders

Substance-induced mood disorders

Substance-induced anxiety disorders

Substance-induced obsessive-compulsive disorder

There are, however, a number of other disorder types that people 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-TR and ICD-11.

It is also important to note that many symptoms of mental disorders mimic those of physical disorders.
For example, although heart palpitations may be related to anxiety, they may be a symptom of a heart
condition. Similarly, depressed mood may be a symptom of major depressive disorder, but may also
be a symptom of hypothyroidism. For this reason, it is important that clients suspected of having a
co-occurring mental health condition undergo a medical assessment to rule out the possibility of an
underlying physical condition. This is particularly pertinent for people with advanced AOD use disorders,
who may experience malnutrition or organ damage.
A4: Classification of disorders 35

What is attention-deficit/hyperactivity disorder (ADHD)?

The core feature of ADHD is an ongoing pattern of inattention and/or impulsivity-hyperactivity, which
interferes with functioning (see Table 2).

• Inattention refers to difficulties sustaining attention to tasks that are not frequently rewarding or
highly stimulating, distractibility, and difficulties with organisation.

• Impulsivity refers to acting in response to immediate stimuli, without consideration of the

outcome.

• Hyperactivity refers to excessive motor activity and difficulties remaining still, typically evident in
situations that require behavioural self-control.

Many people experience periods of distraction and have difficulty concentrating. Similarly, many people
experience periods of excitability or zealousness, which can sometimes be described as ‘hyperactive’.
ADHD is distinct from relatively short periods of over-excitability or distraction in that it involves severe
and persistent symptoms that are present in more than one setting (e.g., home and work). The extent of
inattention and hyperactivity-impulsivity is also outside what would be expected given a person’s age
and level of intellectual functioning.

A case study example of how a person experiencing co-occurring ADHD and AOD use disorder may
present is illustrated in Box 1.

Table 2: Attention-deficit/hyperactivity disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD)

ADHD is characterised by a persistent and debilitating pattern of persistent inattention and/or

hyperactivity-impulsivity where at least five inattention or hyperactivity-impulsivity symptoms are
present. Symptoms need to have been experienced for at least six months, and several need to have been
present prior to age 12:

Inattention:
• Lacking attention to detail.
• Difficulty maintaining focus during work, study, or conversation.
• Appearing not to listen when spoken to.
• Difficulty following instructions and completing housework, work, or study.
• Difficulty organising time and materials.
• Avoiding tasks that involve constant mental energy.
• Losing material possessions.
• Easily distracted.
• Forgetting to return calls, pay bills, keep appointments.
36 A4: Classification of disorders

Table 2: Attention-deficit/hyperactivity disorder (ADHD) (continued)

Attention-deficit/hyperactivity disorder (ADHD)

Hyperactivity and impulsivity:

• Fidgeting, tapping hands or feet, wriggling in seat.
• Leaving seat in inappropriate situations.
• Inappropriately restless.
• Unable to relax or engage in activities quietly.
• Unable to keep still for extended periods.
• Talking excessively.
• Interrupting conversations.
• Difficulty waiting in line or for their turn.
• Intruding on or taking over from others.

Box 1: Case study A: What does co-occurring ADHD and AOD use look like? Sam’s story

Case study A: Sam’s story

Sam, a 25-year-old who identified as female, was referred to her local AOD service by her GP. Her
presentation followed a routine visit to her GP, during which she mentioned that her alcohol use had
increased during the COVID-19 lockdowns. She also occasionally used methamphetamines. Sam has
been living with her partner for the past two years, but there has been recent strain in their relationship,
exacerbated by the ongoing pandemic lockdowns, that has contributed to her increase in drinking,
putting further strain on their relationship. Although Sam’s partner accompanied her to her appointment
with the AOD service, they remained in the waiting room for the duration of the session. Sam had been
working in the hospitality industry but has been out of work for the past 12-months or so, due in part to
the impact of COVID-19 on the hospitality industry, but also due to Sam’s unreliability as an employee
leading to her dismissal from numerous jobs.

Sam first began drinking alcohol while at high school, though she never considered herself to have
a ‘drinking problem’. During the assessment, Sam also mentioned that she had experimented with
other substances while in high school, including taking one of her friend’s Ritalin on a few occasions,
but did not experience a ‘high’ like her other friends seemed to. When asked about her use of
methamphetamines, Sam described feelings of relaxation following their use. Sam also mentioned that
she sometimes used cannabis to help her get to sleep but found that sometimes her use of cannabis led
to outbursts of anger.

Sam had difficulties at school and left at the end of year 10. Her teachers described her as intelligent, but
her concentration and attention were poor, and she therefore frequently failed to complete her homework
and her teachers noted that she ‘underperformed’ in her exams. Sam later reported that she had great
A4: Classification of disorders 37

Box 1: Case study A: What does co-occurring ADHD and AOD use look like? Sam’s story
(continued)

difficulty revising and her attention to revision was often impaired because her ‘thoughts strayed all over
the place.’ Sam was often irritable with her siblings and lost many friends because she was notoriously
unreliable at meeting them as arranged. Sam also spoke of difficulties she had getting to sleep during
her childhood, and of sometimes feeling incredibly tired. Sam enrolled in a design course at TAFE after
leaving school but was not able to complete the course.

Key points:
• What are the primary concerns for Sam?
• Where to from here?

Case study A continues in Chapter B7.

What are schizophrenia spectrum and other psychotic

disorders?
Schizophrenia spectrum and other psychotic disorders are among the most stigmatised disorders, even
within healthcare. Historically, these disorders have not been well understood and people experiencing
them have been marginalised, ostracised, incarcerated, and institutionalised. Although the term
‘schizophrenia’ literally means ‘split mind’, these disorders are not associated with any ‘multiple
personality’ or dissociative disorders. Rather, schizophrenia refers to what is sometimes called a ‘split’
from reality.

The current classification systems consider schizophrenia to be on a spectrum of disorders that vary in
terms of symptom severity and duration, all with similar symptoms. A person experiencing schizophrenia
spectrum or other psychotic disorders can lose touch with reality. Their ability to make sense of both
the world around them and their internal world of feelings, thoughts, and perceptions is severely
altered. The most prominent symptoms are delusions, hallucinations, disorganised thinking, grossly
disorganised or abnormal behaviour, and negative symptoms (see Table 3), which are not attributable to
the effects of AOD use or withdrawal, medication use, or another physical condition (e.g., brain tumour).
In general, these symptoms are clustered into three main categories: positive, negative and disorganised
symptoms.
38 A4: Classification of disorders

Table 3: Predominant symptoms associated with schizophrenia spectrum and other

psychotic disorders

Positive symptoms: Behaviours or symptoms that are abnormally present

Delusions are fixed beliefs that usually involve a misinterpretation of perceptions or experiences and are
resistant to change in light of conflicting evidence. 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 can be either bizarre or non-bizarre.

• Bizarre delusions are those that are clearly implausible, not understandable to same-culture peers,
and not derived from ordinary life experiences (e.g., the belief that one’s brain has been removed and
replaced with someone else’s 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 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. Hallucinations can occur in any sensory modality but auditory hallucinations,
experienced as voices distinct from a person’s own thoughts, are the most common in schizophrenia and
related disorders. 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 consider a misrepresentation of reality.

Negative symptoms: Behaviours or symptoms that are abnormally absent

Negative symptoms account for much of the morbidity associated with schizophrenia but are less
prominent in other psychotic disorders. These include:
• Diminished emotional expressiveness (i.e., reductions in intensity of emotional expressiveness).
• Avolition (i.e., lack of interest in initiating or continuing with activities).
• Alogia (i.e., restricted speech fluency and productivity of thought and speech).
• Anhedonia (i.e., restricted ability to experience pleasure from positive stimuli).
• Asociality (i.e., a lack of interest in social interactions).
A4: Classification of disorders 39

Table 3: Predominant symptoms associated with schizophrenia spectrum and other

psychotic disorders (continued)

Disorganised symptoms: Jumbled thoughts, behaviours, or speech

Disorganised speech usually reflects disorganised thinking, and involves difficulty with
communication, through difficulty keeping track of conversations, switching between unrelated topics,
with incoherent words or sentences. A person’s speech might be rambling with tangential ideas, with
speech that can be difficult to understand, or even incoherent. These unconnected ideas and sentences
are sometimes called a ‘word salad’.

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 with activities of daily living. 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.

People 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. Schizophrenia spectrum and other psychotic disorders are severely disabling mental 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 a person experiencing co-occurring psychosis and AOD use disorder may
present is illustrated in Box 2.

What are the different types of schizophrenia spectrum and other

psychotic disorders?
The particular combination of symptoms a person displays, and their duration, determines what
diagnostic category they may fall into. There are five types of psychotic disorders described in the DSM-5-
TR (see Table 4):

• Schizophrenia.

• Schizophreniform disorder.

• Schizoaffective disorder.

• Brief psychotic disorder.

• Delusional disorder.
40 A4: Classification of disorders

Table 4: Types of psychotic disorders

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).
These symptoms cause significant impairment in a person’s functioning
at work, social relationships, or self-care. People are considered to have
particular ‘types’ of schizophrenia depending upon the predominance of
symptoms displayed (paranoid, disorganised, catatonic, undifferentiated,
or residual type).

Schizophreniform Schizophreniform disorder is characterised by a symptomatic

disorder presentation that is equivalent to schizophrenia except its duration is
limited to more than one month and less than six months, and it is not
necessary to have a decline in social or occupational functioning.

Schizoaffective disorder Schizoaffective disorder is characterised by the symptoms of

schizophrenia alongside a major depressive or manic episode (described
later in this chapter). This disorder may be divided into two types:
• Bipolar type (if the mood episode is manic).
• Depressive type (if the mood episode is major depressive).

Brief psychotic disorder Brief psychotic disorder is a disturbance when delusions, hallucinations,
or disorganised speech are present, with or without grossly disorganised
or catatonic behaviour, for at least one day but less than one month.

Delusional disorder Delusional disorder is characterised by at least one month of delusions.

Hallucinations and other positive symptoms of schizophrenia are
relatively absent, and functioning is not significantly impaired.
A4: Classification of disorders 41

It should be noted that there are differences between the DSM-5-TR and ICD-11 classification systems
regarding the types of psychotic disorders and their definitions. For example, ICD-11 does not distinguish
between schizophrenia and schizophreniform disorder. Further, experiences of influence, passivity or
control are recognised as separate from delusional symptoms of schizophrenia in ICD-11.

Box 2: Case study B: What does co-occurring psychosis and AOD use look like? Amal’s
story

Case study B: Amal’s story

Amal, a 21-year-old who identified as male, presented to his local AOD service at the insistence of
his parents. Both his mother and father accompanied him to his appointment and joined in the
consultation. When the AOD worker asked Amal what had brought him in, his father answered that they
had brought Amal in because of his ongoing methamphetamine use. He said that Amal lived with them,
and they had been aware of some methamphetamine use in the past. The last time they had become
aware of Amal’s methamphetamine use was approximately a year ago, and at that time Amal had
promised not to use again. Amal’s father appeared to be quite angry and explained to the AOD worker that
Amal had agreed at that time that if he were ‘caught’ using again, he would be brought straight to the
AOD service.

During the assessment, Amal’s father continued speaking and answering the AOD worker’s questions
on Amal’s behalf. The AOD worker thanked Amal’s parents for the support they showed in coming with
Amal to his appointment and for being willing to be involved in his treatment planning – she spoke of
the importance of active family involvement in helping people to achieve their goals. She asked Amal’s
parents to please go back to the waiting room for the remainder of Amal’s assessment, until she was
ready to discuss the next steps with the whole family. Once his parents left the room, Amal appeared
to visibly relax. He said they were annoying, but he was happy for them to be involved in his treatment
planning.

In talking about his methamphetamine use, Amal described periods of hallucinations and delusions
that he has experienced in the past during the context of use but had not experienced these recently.
He said that his neighbours were trying to obtain his family’s house and had poisoned all of the plants
in their front yard. After a discussion regarding various treatment options, Amal chose to try inpatient
detoxification and Amal’s family were happy with this plan.

A few days into Amal’s detoxification, he began exhibiting suspicious and paranoid behaviours. His
roommate complained to the nurse unit manager that Amal had been sitting up in his bed all night
watching him sleep and believed he had gone through his belongings. Amal was also observed
mumbling to himself. Upon questioning, Amal appeared to be highly paranoid, suspicious, watchful and
guarded, was mumbling to himself and appeared to be responding to internal stimuli.
42 A4: Classification of disorders

Box 2: Case study B: What does co-occurring psychosis and AOD use look like? Amal’s
story (continued)

Key points:
• What are the primary concerns for Amal?
• Where to from here?

Case study B continues in Chapter B7.

What are bipolar disorders?

Previously classified as mood disorders, bipolar disorders are a distinct category of disorder in the DSM-
5-TR, characterised by recurrent episodes of mood disturbances.

There are three types of mood disturbance episodes (see Figure 9, Table 5):

• Major depressive episodes.

• Hypomanic episodes.

• Manic episodes.

Figure 9: The spectrum of bipolar episodes

Manic episode

Hypomanic episode Hypomanic episode

Major depressive episode

Adapted from Black Dog Institute [153].

A4: Classification of disorders 43

The first episode of illness is most commonly a depressive illness and bipolar disorder may not be
diagnosed until treatment with antidepressant medication triggers a manic illness. Recognition of
bipolar disorders can often be difficult, and many people are not diagnosed until they have experienced a
number of years of severe mood swings. People tend to seek treatment for the depressive phases of the
disorder but not for the periods of elation, so they are often mistakenly diagnosed as having a depressive
disorder. In between episodes, the person is usually completely well. Most people with a bipolar disorder
experience their first serious mood episode in their 20s; however, the onset of bipolar disorders may
occur earlier or later in life and can be diagnosed in children as well as adults.

Table 5: Types of bipolar episodes

Major depressive episode

In a major depressive episode, five or more of the following symptoms are experienced nearly every day for
at least two weeks:
• Depressed mood most of the day, nearly every day (e.g., feels sad, empty, hopeless; appears tearful).
• Loss of interest or enjoyment in activities.
• Reduced interest or pleasure in almost all activities.
• Change in weight or appetite.
• Difficulty concentrating or sleeping (e.g., sleeping too much or too little).
• Restlessness and agitation.
• Slowing down of activity.
• Fatigue or reduced energy levels.
• Feelings of worthlessness or excessive/inappropriate guilt.
• Recurrent thoughts of death, suicidal thoughts, attempts, or plans.

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 or grandiosity.
• Decreased need for sleep.
• Increased talkativeness or pressured speech.
• Flight of ideas or racing thoughts.
• Distractibility.
• An increase in goal directed activity (e.g., at work, school, or socially).
• Excessive involvement in pleasurable activities that have a high potential for painful consequences
(e.g., buying sprees, sexual indiscretions, dangerous driving).
44 A4: Classification of disorders

Table 5: Types of bipolar episodes (continued)

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.

What is the difference between depression and mania?

Having fluctuations in feelings, mood swings, and a wide range of emotions is very common; almost
everyone can relate to emotional upheavals and changes in mood. However, when these emotions or
moods are severe to the point of impairing a person’s ability to function, there may be a disorder present.
It can be difficult to understand how depression and mania co-exist. Table 6 compares some of the key
features of both.

Table 6: Comparison of mania and depression in bipolar disorder

Mania Depression
Energy levels Increased energy, increase in activity Loss of energy, decrease in activity and
and/or goal directed activities. May interest in activities. Withdrawal from social
spend more money. contact and activities. Change in eating
patterns – loss of appetite or overeating.

Changes in Decreased need for sleep without Disrupted sleep patterns, with trouble falling
sleep pattern feeling tired. or staying asleep, waking too early, sleeping
too much. Fatigue.

Thoughts and Feeling good, high or exhilarated. May Feeling down, low, empty, hopeless, worthless,
feelings think they are chosen, special, gifted, irritable or anxious. Think they are useless, a
entitled. Increased libido. Increased burden, and the cause of their own problems.
thinking, disorganised, flood of ideas. Decreased libido. Impaired thinking,
May feel agitated, irritable, intense concentration, decision making, motivation.
emotions, argumentative. May have thoughts of death or suicide.

Speech and Pressured speech, maybe without Speech can be slowed, with few ideas. Dulled
sensations enough time to convey all of the ideas, perception and sensation, but in some cases
inappropriate. Heightened perception some senses can be heightened (e.g., taste
and sensation. and smell).
A4: Classification of disorders 45

Table 6: Comparison of mania and depression in bipolar disorder (continued)

Mania Depression
Delusions, In severe cases of mania, there may be In severe cases of depression, there can be
hallucinations grandiose delusions (e.g., may think nihilistic delusions (e.g., may think their body
they are God, or they are a superhero is decaying).
sent to save the world).

Adapted from Black Dog Institute [154].

What are the different types of bipolar disorders?

There are three main types of bipolar disorders (see Table 7):

• Bipolar I disorder.

• Bipolar II disorder.

• Cyclothymic disorder.

It is also possible for a person to have mixed episodes, whereby a person experiences several manic and
several depressive symptoms simultaneously, or rapidly alternates between them, either day-to-day, or
even within the same day.

A case study example of how a person experiencing co-occurring bipolar and AOD use disorder may
present is illustrated in Box 3.

Table 7: Types of bipolar disorders

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.

Bipolar II disorder Bipolar II is characterised by recurring mood episodes, consisting of at least

one or more major depressive episodes and at least one hypomanic episode.

Cyclothymic Cyclothymic disorder is characterised by chronic (at least two years),

disorder fluctuating 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.
46 A4: Classification of disorders

Box 3: Case study C: What does co-occurring bipolar disorder and AOD use look like?
Scott’s story

Case study C: Scott’s story

Scott, a 25-year-old who identified as male, presented to an AOD service on the recommendation of his
manager. Scott worked on a remote mining site in a ‘fly-in-fly-out’ capacity, where he worked in cycles
consisting of 14 consecutive days of 12-hour shifts, followed by 14 days of leave. In a random drug test,
Scott screened positive for amphetamine-type stimulants, and he was advised by his supervisor, who
was very supportive, to take leave to address this in his home city. Scott’s girlfriend accompanied him to
his assessment at his local AOD service.

On assessment, Scott told the AOD worker that he loved his job but found the cycles of long shifts and
long periods of leave incredibly difficult. He had recently been using stimulants more often to help
him get through the long shifts, but knew it was a risk with the random drug testing that sometimes
takes place. Scott told the AOD worker that he started smoking pot when he was about 13 years old and
remembers drinking a lot of alcohol at high school parties, though he didn’t remember drinking much
apart from at social gatherings. At university, Scott used cocaine and MDMA recreationally.

Scott had not told his GP about his AOD use but had seen him in the past about several periods of
depression that he first experienced in his teens. He said that during these times, he had experienced
very low mood, had no energy or interest in anything, and spent all of his time in his bedroom watching
TV or sleeping. Scott said that although he had at times thought that life wasn’t worth living when he was
feeling extremely low, he had never seriously considered killing himself. He said he had previously been
prescribed two different types of antidepressants but couldn’t remember what they were – he stopped
taking them because he thought they helped for a little while, but then stopped working. He had never
seen a psychologist.

When not feeling low, Scott said he considered himself as a ‘party guy’, and the type of guy that people
enjoyed being around – he loved to have fun at work. Because of the nature of his work, Scott earned a
lot of money but had been spending beyond his means on extravagant purchases and getting into debt.
He told the AOD worker that recently, he was called into his manager’s office because a couple of his co-
workers had complained about him, saying they didn’t want to work on the same shift as him, because
they thought he was behaving recklessly and dangerously, compromising their safety. Scott said he was
shocked by this and thought they were over-reacting – he didn’t think there was a problem and thought
they should all ‘lighten up’.

Key points:
• What are the primary concerns for Scott?

• Where to from here?

Case study C continues in Chapter B7.

A4: Classification of disorders 47

What are depressive disorders?

The predominant feature of depressive disorders is the presence of sad, empty, or irritable mood,
accompanied by physical and cognitive changes that significantly impair a person’s ability to function.
Differences between the depressive disorders depend largely on duration, timing, or origin.

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. People 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 wake in the morning, or sleeping too much); loss of interest in daily activities; a lack of energy,
tiredness and fatigue; restlessness, irritability, or anger; difficulty concentrating, remembering, and
making decisions; feelings of guilt or worthlessness; appetite changes (either decreased or increased
appetite); loss of sex drive; and thoughts of death or suicide.

What are the different types of depressive disorders?

There are two main types of depressive disorders (see Table 8):

• Major depressive disorder.

• Persistent depressive disorder.

A case study example of how a person experiencing co-occurring depression and AOD use disorder may
present is illustrated in Box 4.

Table 8: Types of depressive disorders

Disorder Symptoms

Major depressive Major depressive disorder is characterised by one or more major depressive
disorder episodes in which five or more of the following symptoms are experienced
nearly every day for at least two weeks:
• Depressed mood most of the day, nearly every day (e.g., feels sad, empty,
hopeless; appears tearful).
• Loss of interest or enjoyment in activities.
• Reduced interest or pleasure in almost all activities.
• Change in weight or appetite.
• Difficulty concentrating or sleeping (e.g., sleeping too much or too little).
• Restlessness and agitation.
• Slowing down of activity.
• Fatigue or reduced energy levels.
• Feelings of worthlessness or excessive/inappropriate guilt.
• Recurrent thoughts of death, suicidal thoughts, attempts, or plans.
48 A4: Classification of disorders

Table 8: Types of depressive disorders (continued)

Disorder Symptoms

Major depressive A person may have a single episode, or they may have recurrent episodes over
disorder their lifetime. The duration of depressive episodes may range from weeks to
years.

Persistent Persistent depressive disorder is a consolidation of the previous diagnoses

depressive disorder of dysthymia and chronic major depressive disorder, and is characterised by
at least two years of depressed mood more days than not, as well as other
depressive symptoms such as appetite changes, sleeping problems, fatigue,
feelings of worthlessness and hopelessness.

Box 4: Case study D: What does co-occurring depression and AOD use look like?
Sheryl’s story

Case study D: Sheryl’s story

Sheryl, a 49-year-old who identified as female, was brought in to see her GP at the insistence of one of
her adult daughters. On a routine visit home, her daughter became very concerned about her, insisted on
making an appointment for Sheryl, and also accompanied Sheryl to her GP appointment.

Sheryl told her GP that since her twin daughters had moved out of home, which occurred several months
earlier, she and her husband had separated. They had been together for 29 years. Since they all left, she
has felt depressed and does not feel like she has any purpose. She was not able to leave her home much
during the pandemic, but she was not bothered by this as she had no desire to leave the house and
lost interest in things that she used to enjoy, such as gardening. She also hadn’t kept in touch with her
friends and hadn’t even told them that her husband left. Sheryl also told the GP that she suspected that
she’s peri-menopausal and thought these feelings were ‘normal’ for this stage of life.

The GP conducted a routine medical assessment, which included Sheryl’s weight, blood pressure, and
ordered blood tests. The GP remarked that Sheryl had gained a significant amount of weight in the past
two months which surprised Sheryl, as she hadn’t been eating and had almost no appetite. Sheryl’s
daughter asked her mother why she hadn’t noticed that her clothes were tighter, and Sheryl said that she
hadn’t been getting dressed – she had been wearing pyjamas or her nightgown around the house most of
the time.

The GP asked Sheryl a little more about her sense of purposelessness, and Sheryl assured her that she
had no plans to end her life. Sheryl said that she ‘just wants to sleep’. She told the GP that she had always
had trouble sleeping and was very ‘high strung’ and anxious when she was younger, working in a high-
A4: Classification of disorders 49

Box 4: Case study D: What does co-occurring depression and AOD use look like?
Sheryl’s story (continued)

pressure job. Sheryl and her husband’s family were very conservative, so when Sheryl became pregnant,
she gave up her career to become a full-time mum, as was expected of her, but expressed that she was
also happy to do so. Sheryl told the GP that over the past few months, she’d had more trouble sleeping
and had been taking more of the sleeping tablets prescribed to her to help her get to sleep and stay
asleep throughout the night. Sheryl also said that sometimes she had been taking sleeping pills during
the day, as she had just wanted to sleep.

Key points:
• What are the primary concerns for Sheryl?

• Where to from here?

Case study D continues in Chapter B7.

What are anxiety disorders?

Feeling anxious is not necessarily problematic. Many people feel anxious because they have reason
to; for example, they may be in prolonged lockdown due to an ongoing global pandemic, be facing
economic hardship, be experiencing difficulties with housing or relationships, or may be preparing for
a presentation at work. Many people undergoing AOD treatment will experience anxiety which can be
a consequence of intoxication, withdrawal, or learning to live without using substances. This anxiety
usually reduces over time with a period of abstinence. A person’s anxiety is problematic, however, when
it is persistent, or so frequent and intense that it prevents the person from living their life in the way that
they would like.

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 in themselves are not a specific disorder, but when they are severe and bring about
a sustained change in behaviour, they may amount to panic disorder (Table 10). Panic attacks are a
symptom common to 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
panic attack symptoms mirror those of a heart attack, many people who experience them (particularly
50 A4: Classification of disorders

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.

Table 9: Symptoms of a panic attack

Panic symptoms

• Sweating. • Numbness or tingling sensations.

• Shaking. • Chills or hot flushes.
• Shortness of breath. • Nausea and/or vomiting.
• Feeling of choking. • Fear of losing control, going crazy, or dying.
• Light headedness. • Feelings of unreality or being detached from
• Heart palpitations, chest pain, or tightness. oneself.

What are the different types of anxiety disorders?

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):

• Generalised anxiety disorder (GAD).

• Panic disorder.

• Agoraphobia.

• Social anxiety disorder (SAD).

• Specific phobia.

There are some differences in the way that DSM-5-TR and ICD-11 classify anxiety disorders. In relation to
GAD, for example, while both systems base the diagnosis on the presence of anxiety and worry in relation
to different life situations, events or activities, the ICD-11 also allows for ‘free-floating anxiety’, or general
apprehension that is not focused on any particular circumstance. Another difference is in the length of
time symptoms are required to be present to receive a diagnosis (i.e., at least 6-months for DSM-5-TR
relative to ‘at least several months’ in ICD-11 [155]).

A case study example of how a person experiencing co-occurring anxiety and AOD use disorder may
present is illustrated in Box 5. It should be noted that OCD, PTSD, and acute stress disorder were
previously categorised as anxiety disorders but have been moved from this broader disorder category in
the DSM-5-TR. These disorders are described later in this chapter.
A4: Classification of disorders 51

Table 10: Types of anxiety disorders

Disorder Symptoms

Generalised anxiety GAD is marked by excessive anxiety or worry, occurring more days than not, for
disorder (GAD) at least six months, about a number of events or activities (e.g., performance
at work or school). The worry or anxiety is difficult to control and is associated
with at least three of the following:
• Restlessness or edginess.
• Being easily fatigued.
• Difficulty concentrating.
• Irritability.
• Muscle tension.
• Sleep disturbance (difficulty falling or staying asleep, restless,
unsatisfying sleep).
These symptoms cause significant distress or interfere with a person’s
occupational or social functioning.

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 their behaviour in relation to the attacks. Panic disorder is sometimes
accompanied by agoraphobia.

Agoraphobia Agoraphobia involves marked fear or anxiety about two or more of the
following, for at least six months:
• Using public transportation (e.g., buses, trains, taxis, planes, ships).
• Being in open spaces (e.g., parking lots, bridges).
• Being in enclosed spaces (e.g., shops, movie theatres).
• Standing in line or being in a crowd.
• Being outside the home alone.
The person avoids these situations because of 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.
52 A4: Classification of disorders

Table 10: Types of anxiety disorders (continued)

Disorder Symptoms

Social anxiety SAD (formerly known as social phobia) is characterised by excessive anxiety
disorder (SAD) or worry about one or more social situations for at least six months, where
their actions may be analysed by others. Examples of these kinds of situations
include meeting new people, or eating, drinking, performing, or speaking in
public. A person with SAD fears they 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.

Specific phobia Specific phobia is characterised by excessive or unreasonable fear of a specific

object or situation that causes immediate anxiety and/or panic attacks, for at
least six months. Phobic cues may include animals; blood, injury or injections;
situations involving the natural environment (such as heights or storms);
or other specific situations such as airplanes, lifts, or enclosed spaces. The
person avoids the feared places or situations, or if such situations are endured
there is considerable distress or anxiety.

Having a fear is not so unusual, but when it interferes with performing the
responsibilities in a person’s life it can become a problem. For example, having
a fear of flying is not a problem until a person finds themselves planning a
holiday overseas or that they need to travel for work.

Box 5: Case study E: What does co-occurring anxiety and AOD use look like? Declan’s
story

Case study E: Declan’s story

Declan, a 37-year-old account executive for a high-profile advertising agency, was referred to his local
AOD service after a recent hospital admission. Declan’s job is extremely stressful, with numerous social
activities and events, that he has been finding increasingly difficult. He is very fit and attends the gym
most days before work.
A4: Classification of disorders 53

Box 5: Case study E: What does co-occurring anxiety and AOD use look like? Declan’s
story (continued)

On assessment, Declan told the AOD worker that he didn’t know if he should be there at all, he didn’t
think he had much of a problem, but his recent hospital trip had scared him, and he thought it wouldn’t
hurt to see if he needed help. Declan said that his job required him to meet with important clients and
also present in client meetings, which he hated. In particular, he hated the attention and having people
looking at him when he spoke. After presenting at a meeting with important clients about 18 months ago,
Declan was asked a very difficult question and felt his mind go blank. He felt everyone looking at him
and started sweating and shaking, had difficulty breathing, with tightness in his chest accompanied by
chest pain. He thought he was having a heart attack and collapsed mid-meeting. Declan was taken by
ambulance to hospital, where he was told he had experienced a panic attack.

While his colleagues are also his mates, they have also taken to making fun of the incident, often asking
before big client meetings whether Declan will make it through, or should they have the ambulance on
stand-by. Declan has since been terrified of having another panic attack, and has been feeling increased
anxiety at client lunches, meetings, and seminars. One evening, Declan told his boss about his anxiety,
but his boss did not seem to understand the severity of Declan’s fear, and replied, ‘yes, I used to feel
nervous before presenting as well. Don’t worry, it’ll get easier the more you do it, I’ll put you down to
do a few more’. In talking to another close colleague about his anxiety about a year ago, his colleague
mentioned that he also sometimes felt nervous before big meetings but felt much better after doing a
couple of lines. Since that time, Declan has been using cocaine before client lunches and meetings and
found that it increased his confidence and reduced his anxiety.

Declan’s most recent hospital admission followed another incident where he was taken to emergency
after collapsing in a client meeting mid-presentation. He expected to be told that he had experienced
another panic attack but was shocked when he was told by the doctors that he had experienced a heart
attack. His blood tests showed recent amphetamine type substance use.

Key points:
• What are the primary concerns for Declan?

• Where to from here?

Case study E continues in Chapter B7.

What is obsessive-compulsive disorder (OCD)?

Previously categorised as an anxiety disorder, OCD now sits within the ‘obsessive-compulsive and related
disorders’ category in DSM-5-TR, which also includes body dysmorphic disorder, hoarding disorder,
trichotillomania (hair-pulling disorder), and excoriation (skin picking disorder).
54 A4: Classification of disorders

OCD is characterised by the presence of obsessions, compulsions, or both (see Table 11 and Table 12).
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.

Table 11: Predominant symptoms associated with OCD

Obsessions and compulsions

Obsessions (often referred to as ruminations) are recurring, persisting thoughts, urges, or images that
are intrusive and unwanted, and cause anxiety or distress in most people. The person attempts to ignore
or suppress their obsessive thoughts, urges or images, or counteract them with another thought or
action (i.e., by performing a compulsion).

Examples of obsessions include persistent fears of contamination, thinking they are to blame for
something, or an overwhelming need to do things perfectly.

Compulsions (often referred to as rituals) are repetitive mental acts or behaviours that a person feels
driven to perform, in response to an obsession or according to rules that must be strictly followed.
The mental acts or behaviours are aimed at preventing or reducing anxiety or distress, or preventing a
dreaded event; however, the behaviours or mental acts are not connected to what they are designed to
counteract in any realistic way, or they are clearly excessive.

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). Examples of mental acts include counting or repeating words silently.

A case study example of how a person experiencing co-occurring OCD and AOD use disorder may present
is illustrated in Box 6.

Table 12: Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder (OCD)

OCD is characterised by the presence of obsessions, compulsions, or both. The obsessions or
compulsions are time-consuming, taking at least one hour per day, or cause significant distress. As the
performance of these rituals is time-consuming, they can significantly interfere with the person’s social
and occupational functioning.
A4: Classification of disorders 55

Box 6: Case study F: What does co-occurring OCD and AOD use look like? Ayla’s story

Case study F: Ayla’s story

Ayla is a 19-year-old who is currently living with her parents. She presented to her local AOD service at the
insistence of her parents who came across her stash of cannabis when her mother was straightening her
room. Although her mother has brought Ayla to her appointment, she has remained in the waiting room
while Ayla speaks to the AOD worker.

On assessment, Ayla was at first quiet and appeared to be withdrawn. She told the AOD worker that she
had been using cannabis daily to slow down or dampen her thoughts. Ayla eventually broke down in tears
and told the AOD worker that she had been having obsessive thoughts and behaviours that she had to
perform, for a long time. Ayla said that when she was in school, she was always the last one to leave the
classroom because she had to make sure that every letter on the whiteboard had been copied down in
her notebook exactly right. She was usually late to the next class because of this repetitive checking,
and she often had difficulty sleeping because she was reliving the day’s classes in her mind, trying to
remember if she had copied down all the notes correctly. On one occasion, she was called in to see the
school counsellor because of her continual lateness. The counsellor told Ayla that she thought Ayla
might have generalised anxiety disorder and should try to ‘forget’ about her obsessive thoughts and stop
worrying so much. The counsellor told her to focus on what she wanted to do after she left school.

Ayla told the AOD worker that as she got a bit older, she started having intrusive negative thoughts about
harm befalling her family. Ayla said that if she didn’t tap her bedroom door handle seven times every time
she entered or left the room, her family would die. Seven was a meaningful number for Ayla, because she
had two parents plus two sisters plus two dogs (and herself). If Ayla didn’t feel ‘right’ about the tapping, or
if she thought she tapped eight times instead of seven, she had to start again. Ayla told the AOD worker
that her tapping then extended to a need to check and recheck all the lights in her room before leaving
her room and when going to bed. Ayla tried to explain that even when the lights were off, she would have
to carefully check the bulb and the light switch, not believing or trusting her eyes that they were off, so
needing to turn them on and back off again. When she left home, she would take pictures of the switches
and the globes and keep looking at them and also replay the ritual of turning them off over and over in
her mind.

Ayla told the AOD worker that tapping or turning the switches would provide her with a few seconds of
relief, but this was always short-lived, and she would need to repeat it to alleviate her obsessive thoughts.
Ayla said it was like ‘an itch that I just have to scratch’. She told the AOD worker that she understood
that there was no logic or rationality to her thoughts and behaviours, but she couldn’t stop herself from
performing her rituals. Ayla said she was lonely but had trouble forming and maintaining friendships
because she was always distracted by her thoughts and couldn’t engage with another person.

Since leaving school she had tried several different part-time jobs, but because she took several hours to
leave the house, she was unable to keep any of them. Her sisters and a couple of old school friends had
told her to relax, and Ayla had tried yoga, meditation, and mindfulness – all of which she found frustrating
56 A4: Classification of disorders

Box 6: Case study F: What does co-occurring OCD and AOD use look like? Ayla’s story
(continued)

and of little benefit. Ayla told the AOD worker that smoking weed was the only thing she has found useful,
as it dulled and slowed her thoughts. She said that smoking a ‘ton’ of weed was the only way she could
now get to sleep.

Ayla told the AOD worker that she was completely exhausted and just wanted the obsessions and
compulsions to stop. She said the only way she could realistically see that happening was if she ended
her life.

Key points:
• What are the primary concerns for Ayla?

• Where to from here?

Case study F continues in Chapter B7.

What are trauma-related disorders?

Trauma is a term that is widely used and may mean different things to different people. In these
Guidelines, we use the word trauma to refer to an extremely threatening or horrific event, or a series
of events, 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, life or safety is at risk [10, 11]. Examples of potentially traumatic
events include, but are by no means limited to, being involved in a road traffic accident; experiencing or
being threatened with physical or sexual assault; being in a life-threatening car or other form of accident;
combat exposure or being in a place of war or conflict; or witnessing any of these events. The most
important factor in understanding a person’s experience of an event is whether or not they perceived it to
be a traumatic event; events that may be traumatic to some people may be perceived as relatively minor,
and vice versa.

Most people will experience some emotional or behavioural reactions following exposure to a traumatic
event such as anxiety or fear, aggression or anger, depressive or dissociative symptoms. These emotional
and behavioural responses are to be expected and are a completely normal response to an adverse event.
For the majority of people, these reactions will subside and/or reduce in intensity over time without
the need for any intervention; for some people, however, these reactions may be prolonged, leading to
significant distress, as well as impairment in social, occupational and other areas of functioning [102,
156, 157].
A4: Classification of disorders 57

What are the different types of trauma-related disorders?

There are two main trauma-related disorders according to DSM-5-TR:

• Post traumatic stress disorder (PTSD).

• Acute stress disorder.

Previously classified as anxiety disorders, these disorders have been grouped with other trauma- and
stressor-related disorders in the DSM-5-TR. It should be noted that the DSM-5-TR 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-TR criteria is provided in Table 13;
however, readers are encouraged to refer to DSM-5-TR for a more detailed explanation of the changes
made between editions. A case study example of how a person experiencing co-occurring PTSD and AOD
use disorder may present is illustrated in Box 7.

Table 13: Types of trauma-related disorders

Disorder Symptoms

Post traumatic PTSD is a disorder that may develop after a person has experienced or been
stress disorder exposed to a traumatic event during which the person perceived their own (or
(PTSD) someone else’s) life or physical integrity to be at risk.

Following the event, for at least one month, the person experiences some of the
following symptoms:

• Re-experiencing: Spontaneously re-experiencing the event in the form of

unwanted and intrusive memories, recurrent dreams or nightmares, or
‘flashbacks’.

• Avoidance: Avoiding memories, thoughts, feelings, or external reminders of

the event (e.g., people, places or activities).

• Negative cognitions and mood: Feeling a distorted sense of blame of self

or others, feeling detached from others or less interest in activities, or
inability to remember key aspects of the event.

• Arousal: Aggressive, reckless, self-destructive behaviour, sleep

disturbances, hypervigilance, or increased startle response.

Symptoms may begin immediately after the traumatic event, or they may
appear days, weeks, months or even 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. Acute stress disorder may remit
within one month following exposure to the traumatic event, or it may progress
to PTSD.
 58 A4: Classification of disorders

It should be noted that unlike the DSM-5-TR, the ICD-11 has not expanded the number of symptom
clusters that are required to meet a diagnosis of PTSD. According to ICD-11, a diagnosis of PTSD continues
to be based on the presence of re-experiencing, avoidance, and arousal symptoms. However, the ICD-
11 has introduced a new diagnosis of complex PTSD that is characterised by an additional cluster of
symptoms referred to as disturbances in self-organisation (see Table 14). These disturbances in self-
organisation include difficulties in regulating emotion (e.g., problems calming down, feeling numb
or emotionally shutdown), negative self-perception (beliefs about oneself as being not good enough,
worthless, or a failure), and difficulties sustaining relationships and feeling close to others [155].
Although complex PTSD may arise in relation to any trauma, it is typically associated with prolonged or
repeated interpersonal traumas or neglect that occur during childhood [158].

A person can either be diagnosed as having PTSD or complex PTSD, but not both. That is, according
to ICD-11, a person who is experiencing re-experiencing, avoidance, and arousal symptoms, but not
disturbances in self-organisation, may be diagnosed as having PTSD; whereas a person who is
experiencing re-experiencing, avoidance, and arousal symptoms, and disturbances in self-organisation,
may be diagnosed as having complex PTSD. Although DSM-5-TR does not recognise complex PTSD
as a separate diagnosis, two of the three symptoms of disturbances in self-organisation (negative
self-perception and difficulties sustaining relationships) are included within the DSM-5-TR’s newly
added PTSD symptom cluster of negative cognitions and mood [155]. To bring these two different but
overlapping concepts together, in these Guidelines, we refer to the broad diagnosis of PTSD but highlight
that many people will experience it in its more complex form.

Another notable difference between the DSM-5-TR and ICD-11 is that the ICD-11 no longer classifies acute
stress reaction as a mental disorder, but as one of the ‘Factors Influencing Health Status or Contact with
Health Services’. In doing so, the ICD-11 recognised that these acute responses to trauma are considered
to be normal given the severity of the stressor, and usually subside within a few days following the event
or removal from the threatening situation.

Table 14: Symptoms of PTSD and complex PTSD according to ICD-11

Symptoms PTSD Complex PTSD

Re-experiencing: Re-experiencing the traumatic event(s) in the

present in the form of vivid intrusive memories, flashbacks, or
Core PTSD symptoms

nightmares; may occur via one or multiple sensory modalities and

is typically accompanied by strong or overwhelming emotions,
particularly fear or horror, and strong physical sensations.

Avoidance: Avoidance of thoughts and memories of the event or

events, or avoidance of activities, situations, or people reminiscent
of the event(s).

Arousal: Persistent perceptions of heightened current threat (e.g.,

hypervigilance, enhanced startle response).
 A4: Classification of disorders 59

Table 14: Symptoms of PTSD and complex PTSD according to ICD-11 (continued)

Symptoms PTSD Complex PTSD

Problems in affect regulation: E.g., problems calming down,

Disturbances in self-organisation

feeling numb or emotionally shutdown.

Negative self-perception: Beliefs about oneself as diminished,

defeated or worthless, accompanied by feelings of shame, guilt or
failure related to the traumatic event.

Relationship difficulties: Difficulties in sustaining

relationships and in feeling close to others.

Box 7: Case study G: What does co-occurring PTSD and AOD use look like? Julie’s story

Case study G: Julie’s story

Julie, a 35-year-old who identified as female, had presented for AOD treatment on a number of occasions
for polydrug use, although she was primarily concerned with her use of heroin and prescription opioids.
She had been using on and off for the past 20 years and struggled to control her alcohol and cannabis
use. Her longest period of abstinence from heroin was six months. At the time of her presentation, she
was receiving the Disability Support Pension and lived in accommodation provided by the Department
of Housing with her partner, though they hadn’t been together for very long. Her most recent relapse
occurred following a sexual assault by her former partner.

In Julie’s treatment file, one of Julie’s prior treating clinicians had noted a history of ‘childhood trauma’,
but no specific details. Subsequent admissions referred to this having been ‘noted on previous
admission’ with no further information provided. After Julie’s disclosure of the impact of the most recent
assault, the AOD worker asked whether she had experienced any other traumatic events during her life, in
childhood or as an adult, and provided some examples of the types of events she was referring to.

Julie was quiet for a moment and became teary, before stating that she had. The AOD worker gently
assured Julie that she did not have to talk about anything that she did not want to but asked if it would
be ok for them to ask her a few more questions so she could get an understanding of how those events
may be contributing towards where she is now. Julie consented, aware that she could stop at any time,
or take a break if needed. Julie went on to describe a history of multiple traumas including sexual abuse
by a family member that took place over several years, and a number of physical and sexual assaults. Her
most recent sexual assault occurred within the context of ongoing domestic violence by her previous
partner.
60 A4: Classification of disorders

Box 7: Case study G: What does co-occurring PTSD and AOD use look like? Julie’s story
(continued)

Key points:
• What are the primary concerns for Julie?
• Where to from here?

Case study G continues in Chapter B7.

What are feeding and eating disorders (ED)?

The predominant feature of ED is a persistent disturbance in eating or eating-related behaviours that
impacts on food intake and impairs physical health or psychosocial functioning. Some people with
ED describe symptoms similar to those associated with AOD use, such as craving and patterns of
compulsive use. It is thought this may in part be due to the shared neural pathways, including those
involved in self-control and reward; however, in general, the shared features are not well understood [10].

What are the different types of ED?

Although there are several types of ED, we have focused on three main types:

• Anorexia nervosa.

• Bulimia nervosa.

• Binge eating disorder.

Anorexia nervosa, bulimia nervosa and binge eating disorder are characterised by a dysfunctional system
of self-evaluation, which, rather than being based on personal qualities and achievements across
several domains – such as academic or athletic accomplishments, work achievements, or relationship
qualities – is disproportionately focused on weight, size, shape and appearance [159–161]. Binge eating
episodes (described in Table 15) are present in bulimia nervosa and binge eating disorder. However, the
compensatory behaviours to prevent weight gain, such as strenuous exercise, self-induced vomiting, or
misuse of laxatives, that follow episodes of binge eating in bulimia nervosa, are not a feature of binge
eating disorder. The types of eating disorders included in these Guidelines are described in Table 16.

Table 15: Binge eating episode

Binge eating episode

An episode of binge eating is characterised by both of the following:
• Eating, within a two-hour period, an amount of food that is definitely more than what most people
would eat in a similar period of time, under similar circumstances.
• A sense of lack of control regarding eating behaviours during the episode (i.e., a person feeling that
they are unable to stop eating or control what or how much they are eating).
A4: Classification of disorders 61

A case study example of how a person experiencing co-occurring ED and AOD use disorder may present is
illustrated in Box 8.

Table 16: Types of feeding and eating disorders (ED)

Disorder Symptoms

Anorexia nervosa There are three primary features of anorexia nervosa:

• Persistent restriction of energy intake.

• Intense fear of gaining weight or becoming fat, or persistent behaviour

that interferes with weight gain.

• Disturbance in self-perceived weight or shape, disproportionate

influence of body weight or shape on self-evaluation, or persistent lack of
recognition of the seriousness of the current low body weight.

Maintained body weight is below minimally normal for age, sex, development,
and physical health.

Bulimia nervosa Bulimia nervosa is characterised by three essential features, which must occur
on average at least once a week for three months:

• Recurrent episodes of binge eating.

• Recurrent inappropriate compensatory behaviours to prevent weight gain

(e.g., vomiting, use of laxatives or other medication, fasting, excessive
exercise).

• Distorted self-image that is disproportionately influenced by body shape

or weight.

People with bulimia nervosa are typically ashamed of their eating problems,
may 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
disorder binge eating that occur at least once a week for three months. The episodes of
binge eating cause significant distress to the person.
62 A4: Classification of disorders

Box 8: Case study H: What does co-occurring ED and AOD use look like? Kai’s story

Case study H: Kai’s story

Kai is a 26-year-old who identified as non-binary, and was referred to their local AOD service after being
discharged from hospital. Kai had attempted to overdose at home by taking some of their mother’s
sleeping pills, some non-prescribed opioids along with a bottle of vodka. Kai’s mother found Kai
unconscious and called an ambulance. Kai managed to convince the very busy staff at emergency that
their overdose had been an accident. Though hesitant to believe them, the doctor reluctantly agreed
to discharge Kai, provided they would contact their local AOD service the next day. Kai agreed and Kai’s
mother promised to take them.

On assessment, the AOD worker noted Kai’s loose clothing. Kai told the AOD worker that they wore baggy
clothing to not draw attention to themselves and said they came from a traditional and conservative
family. Kai said their family loved them a lot but they have struggled to understand their non-binary
identity. They have had difficulties with pronouns and have been awkward when speaking about Kai
to family or friends, which has led to increased discomfort and distance in their relationship. Kai has
struggled with feelings of shame and guilt, which have been compounded by their family’s discomfort
around them. They told the AOD worker they had been drinking a bottle of wine every day, been taking
non-prescribed opioids for at least the past few years, and smoking cigarettes.

The AOD worker also noted that Kai seemed to be lacking in energy, appeared to be slight and fragile, and
looked very cold. Kai told the AOD worker that they had previously been diagnosed with anorexia nervosa
and had been hospitalised several times in the past for refeeding and monitoring. Kai said that their
mother had always been extremely weight conscious as far back as they could remember, constantly
dieting and monitoring her own food intake as well as the intake of the rest of the family. Kai said they
had struggled with feelings of perfectionism their whole life, and felt they could control being thin. Kai
said that they were aware things ‘weren’t great’ at the moment and alcohol had been the primary caloric
intake for the past few months. They told the AOD worker that they were extremely tired, felt isolated and
alone and wanted it to stop.

Key points:
• What are the primary concerns for Kai?
• Where to next?

Case study H continues in Chapter B7.

A4: Classification of disorders 63

What are personality disorders?

The term ‘personality trait’ refers to a person’s individual patterns of thinking, feeling, and behaving.
These patterns of thinking and behaving usually begin in childhood and continue through to adulthood.
Our personality traits make us who we are – they are what make each of us unique. However, personality
traits can become problematic when they cause difficulties with relationships, education or employment,
and sometimes with the law. If patterns of thinking, feeling, or behaving are creating lots of problems in
many areas of a person’s life, they may have a personality disorder [10, 162].

Personality disorders are highly stigmatised conditions, even within mental health and healthcare more
broadly. As such, it is vital that any communication regarding clients with possible personality disorders
– whether the communication involves the client, loved ones or other healthcare providers – remains
respectful, non-judgemental, compassionate and client-centred. As mentioned in the introduction of
these Guidelines, the language used in this section and throughout this document is intended to provide
workers with the functional knowledge to identify conditions and communicate with other areas of
health (e.g., mental health services). As such, we have used diagnostic and classification terminology as
included in the DSM-5-TR and ICD-11. However, we also make reference to resources that workers may find
useful when communicating with their clients, or with broader audiences.

A wide range of personality disorders are currently recognised by the DSM-5-TR (see Table 17). All 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.
A person with a personality disorder may not necessarily become upset by their own thoughts and
behaviours but may become distressed by the consequences of their behaviours [163].

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, and dysregulated emotions and behaviour) making it difficult to determine whether a
person has a personality disorder.

It is important to note that there is a great deal of contention as to the utility of the DSM-5-TR’s current
approach to diagnosing personality disorders, and DSM-5-TR itself has proposed an alternative
model for personality disorders (see Section III of DSM-5-TR; [10]) which is more aligned with the ICD-
11 classification [164]. The ICD-11 approach first assesses whether a person meets general criteria for
a personality disorder, establishes severity (mild, moderate, or severe), and then describes the main
features that contribute to the personality disturbance based on trait domain qualifiers. These include
negative affectivity, detachment, dissociality, disinhibition, and anankastia. A borderline pattern is also
available, which corresponds to DSM-5-TR BPD.

What are the different types of personality disorders?

Based on their similarities, personality disorders are grouped into three clusters (see Table 17). Among
those with AOD use disorders, two Cluster B personality disorders, ASPD and BPD, are most prevalent and
tend to impact most upon treatment [162, 165–167].
64 A4: Classification of disorders

Table 17: Types of personality disorders

Personality disorders
CLUSTER A: ‘odd’ or ‘eccentric’ characteristics

People with Cluster A-type personality disorders often appear to be odd or eccentric. They have significant
impairment but infrequently seek help:
Paranoid personality disorder is characterised by a pattern of distrust and suspiciousness such that
others’ motives are interpreted as malevolent.
Schizoid personality disorder is characterised by a pattern of detachment from social relationships
and a restricted range of emotional expression.
Schizotypal personality disorder is characterised by a pattern of acute discomfort in close
relationships, cognitive or perceptual distortions, and eccentricities of behaviour.

CLUSTER B: ‘dramatic’, ‘emotional’, or ‘impulsive’ characteristics

People with Cluster B-type personality disorders appear to be dramatic, emotional, and erratic. Generally,
they experience significant impairment and are of considerable concern to health care providers. Of all
the personality disorders, people with Cluster B disorders most commonly present to services:
Antisocial personality disorder (ASPD) 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.
Borderline personality disorder (BPD) is characterised by a pattern of instability in interpersonal
relationships, self-image, and feeling states, with marked impulsivity and chaos.
Histrionic personality disorder is characterised by a pattern of excessive emotionality including being
dramatic, attention-seeking, and seductive.
Narcissistic personality disorder is characterised by a pattern of grandiosity and self-centredness
and thus lacking empathy for others.

CLUSTER C: ‘anxious’, ‘fearful’, or ‘avoidant’ characteristics

People with Cluster C-type personality disorders appear to be anxious and fearful and are generally less
impaired than those with Cluster B personality disorders:
Avoidant personality disorder is characterised by a pattern of social inhibition with feelings of
inadequacy and hypersensitivity to negative evaluation. Individuals tend to be needy but scared of
relationships. There is some debate that this is a form of long-term social phobia.
Dependent personality disorder is characterised by a pattern of submissive and clinging behaviour
related to an excessive need to be taken care of. These individuals tend to be indecisive and fear
abandonment.
Obsessive-compulsive personality disorder is characterised by a pattern of preoccupation with
orderliness, perfectionism, and control; thus, these individuals tend to be rigid and inefficient.
A4: Classification of disorders 65

Antisocial personality disorder (ASPD)

The main feature of ASPD (previously known as ‘psychopathy’ or ‘sociopathy’) is a pattern of personality
traits that involves the disregard of other people’s feelings or rights. People with ASPD may behave in
ways that are considered deceitful or manipulative to get their own way (e.g., behaving in a very charming
way in order to obtain something, and then indifferently once they have it [168]). The main characteristics
of ASPD are described in Table 18.

ASPD begins in childhood or early adulthood and continues into adulthood. For a diagnosis of ASPD to
be made, the person must be at least 18 years old, and have experienced some symptoms of conduct
disorder before the age of 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. For people with ASPD, this pattern of antisocial behaviour continues into
adulthood.

Table 18: Characteristics of ASPD

Main characteristics of ASPD

Difficulty following rules or conforming to social norms with respect to lawful behaviour.
People with ASPD may repeatedly be involved in behaviours that are grounds for arrest (e.g., destroying
property, harassing others, stealing, or pursuing illegal occupations).

Behaving deceptively or manipulatively. People with ASPD may be deceptive or manipulative in order
to get their own way (e.g., to obtain money, sex, or power).

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. A person with ASPD may be repeatedly involved in physical fights or
assaults and may be aggressive towards other people.

Disregard for their own or other’s safety. For example, recurrent speeding, driving while intoxicated,
multiple accidents, or high-risk sex.

Consistent and extreme irresponsibility. For example, irresponsible work behaviour, such as 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. People 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. People with ASPD may have difficulty
showing empathy towards other people or remorse for their behaviour and may instead focus on self-
interests.
66 A4: Classification of disorders

Borderline personality disorder (BPD)

BPD comprises a pattern of personality traits that involves strong emotions, issues with self-image
[169], impulsive behaviours and unstable relationships with other people. BPD is also characterised by
impulsivity, particularly in relation to behaviours that may be self-damaging. People with BPD experience
difficulties regulating their emotions and expressing their feelings to other people. They are often
described as having very intense, uncontrollable emotions, that can change suddenly. The distress
associated with such overwhelming feelings can result in some people with BPD hurting themselves or
others as a way of coping with their intense emotions [169].

As with ASPD, behaviours typically begin in early adolescence or early adulthood, and are pervasive across
several areas of a person’s life (e.g., work, study, relationships). The main characteristics of BPD are
described in Table 19.

A case study example of how a person experiencing co-occurring BPD and AOD use disorder may present
is illustrated in Box 9.

Table 19: Main characteristics of BPD

Main characteristics of BPD

Extreme efforts to avoid rejection or abandonment. Such threats of rejection may be real or
imagined. A person with BPD may be extremely sensitive to perceived signs of criticism or rejection,
because they fear the person may leave or abandon them.

A pattern of unstable and intense interpersonal relationships, characterised by the person

alternating between idealising a person and devaluing them.

Identity disturbance. Markedly and persistent unstable self-image or sense of self. This may result in
sudden changes in a person’s goals or life values, jobs or career aspirations, sexual identity, or friends.

Impulsivity, particularly in relation to behaviours that are self-damaging (e.g., spending money
irresponsibly, binge eating, substance use, unsafe sex, 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, anxiety or anger usually lasting only a few hours and
rarely longer than a few days).

Chronic feelings of emptiness.

Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical fights).

Transient, stress-related paranoid thoughts or severe dissociative symptoms (i.e., where the
person temporarily loses touch with where they are in time and/or space).
A4: Classification of disorders 67

Box 9: Case study I: What does co-occurring BPD and AOD use look like? Mira’s story

Case Study I: Mira’s story

Mira, a 23-year-old who identified as female, was transferred into her local AOD service’s opioid treatment
program following her recent release from prison. She had been imprisoned for six months for assault
and had been receiving methadone while in prison. Upon her release, Mira was living with her older sister.
Prior to her incarceration, Mira had been using a range of substances, including heroin, amphetamines,
benzodiazepines, cannabis, alcohol and tobacco. Her physical health was visibly poor.

During the assessment, Mira told her AOD worker that she had been raised by her mother and
grandmother; her mother had experienced several episodes of depression that had led to hospital
admissions. It also became clear that Mira’s mother had experienced domestic violence by her partner.
Mira eventually told her AOD worker that this man had also sexually abused her, with some of the abusive
episodes occurring before puberty. Over the course of her teenage years, Mira displayed episodes of anger
and, although she made some close friends, she very quickly alienated them with either outbursts of
anger or becoming ‘too close and clingy.’

Although Mira had several short-term relationships with men, she quickly realised that some of these
relationships were the same as those formed by her mother and involved domestic violence. Despite this
realisation, Mira experienced intense feelings of rejection at the end of her relationships, which led to
her self-harming by cutting. She had multiple episodes of hospitalisation from self-harming and suicide
attempts, the most recent of which was shortly before she went to prison. Mira told the AOD worker that
while she was in prison, she had been diagnosed by a forensic psychologist as having BPD.

Key points:
• What are the primary concerns for Mira?
• Where to from here?

Case study I continues in Chapter B7.

What are substance-induced disorders?

Substance-induced disorders are disorders that occur as a direct physiological consequence of AOD
intoxication or withdrawal. For a diagnosis of a substance-induced disorder to be made, symptoms of
the disorder must only be present following intoxication or withdrawal. If the person displays symptoms
of the disorder in the absence of intoxication or withdrawal, it is possible they may have an independent
mental disorder. It is crucial to note that not everyone with mental health symptoms who uses
substances is experiencing a substance-induced disorder, and co-occurring AOD and mental disorders
are not necessarily substance-induced. Symptoms of substance-induced disorders tend to reduce over
time with a period of abstinence [35].
68 A4: Classification of disorders

As described in Chapter A1, 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 [33–35]; symptoms of mania can be induced by intoxication with stimulants,
steroids, or hallucinogens; and psychotic symptoms can be induced by withdrawal from alcohol, or
intoxication with alcohol, stimulants, cannabis, or hallucinogens [36–38]. Other disorders that may result
from AOD use include substance-induced delirium, amnestic disorder, dementia, sexual dysfunction, and
sleep disorder.

Substance-induced psychotic disorder

It is often extremely difficult to distinguish substance-induced psychosis from other psychotic disorders.
With substance-induced psychosis, symptoms (usually delusions and/or hallucinations) tend to appear
quickly and last a relatively short time, from hours to days, until the effects of the drug wear off. For some,
however, psychosis can persist for days, weeks, months, or longer [170, 171]. It is possible that these people
were already at risk for developing a psychotic disorder which has been triggered by substance use [172].

Visual hallucinations are generally more common in substance withdrawal and intoxication than in
primary psychotic disorders [173]. 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 [174, 175]. These are often referred to as ‘ice bugs’ or ‘cocaine bugs’. Visual,
tactile and auditory hallucinations may also be present during alcohol withdrawal [176].

People with stimulant psychosis may appear 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 [177, 178]. Other
features that differentiate substance-induced psychosis from schizophrenia include higher likelihood of
polysubstance dependence, a forensic history, ASPD, trauma history, parental substance misuse, lower
likelihood of family history of psychosis; and a lack of negative and cognitive symptoms with a return
to normal inter-episode functioning during periods of abstinence [177]. A case study example of how a
person experiencing co-occurring substance-induced psychosis may present is illustrated in Box 10.

It is important to differentiate between symptoms of psychosis and delirium. Delirium presents as a

disturbance of consciousness and cognition that represents a significant change from the person’s
previous level of functioning. The person has a reduced awareness of their surroundings, their attention
wanders, questions often have to be repeated, they have difficulty concentrating, and it may be difficult
to engage them in conversation. Changes in cognition may include short-term memory impairment,
disorientation (regarding time or place), and language disturbance (e.g., difficulty finding words, naming
objects, writing). Perceptual disturbances (e.g., hallucinations) may also occur. Delirium develops
over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
For example, a person may be coherent and co-operative in the morning but in the afternoon may be
disruptive and wanting to go home to a partner who died years ago. The identification of substance-
induced delirium is particularly important for clients undergoing alcohol withdrawal as delirium may
progress to delirium tremens, a serious complication that may result in death [176].
A4: Classification of disorders 69

Box 10: Case study J: What does substance-induced psychosis look like? Michael’s
story

Case Study J: Michael’s story

Michael, an 18-year-old who identified as male, was brought to emergency by the police. Michael started
screaming at his parents one evening and threatened them with a knife. His parents called 000, and
police took Michael to the nearest hospital emergency for an evaluation. Prior to this, Michael’s parents
had noticed that he was uncharacteristically irritable and paranoid, spending long periods of time alone
in his bedroom. He did not appear to be sleeping well and was observed to be mumbling to himself. For
the past month, he had not gone to any of his university classes.

When he arrived at emergency, Michael was extremely agitated and attempted to strike the nurses and
security team. He was given intramuscular lorazepam and haloperidol, but following their administration,
tried to flee the hospital because he said the staff were trying to kill him. He appeared to be responding to
internal stimuli and would not cooperate with anyone who attempted to conduct a psychiatric evaluation.
His parents told hospital staff that he had been diagnosed with ADHD about four weeks earlier and had
been prescribed lisdexamfetamine by his treating psychiatrist.

Two weeks later, his psychiatrist had increased his lisdexamfetamine, which Michael took in the
morning, and also prescribed dexamphetamine for Michael to take every afternoon to help improve
his concentration and ability to study. After having a short sleep, Michael appeared calmer and said
that he had some exams coming up which he was very worried about, and had taken double doses of
his dexamphetamine tablets over the past three days because he didn’t want to sleep, and needed the
additional time to prepare for his exams.

Prior to his ADHD diagnosis, Michael had no psychiatric or AOD use history. His urine toxicology
was positive only for amphetamines. Michael had no history of any medical condition, no history of
seizures or head trauma. There was no family history of any psychiatric disorders. Michael’s stimulant
medications were discontinued when he was admitted to emergency, and he was treated with
risperidone. Michael also started psychotherapy. After five days, Michael was no longer experiencing any
hallucinations or delusions, and he was released from hospital with a follow-up appointment to see his
psychiatrist.

Key points:
• Symptoms of psychosis emerged within hours of Michael’s increased ADHD
medication. Following withdrawal from his medication, the psychotic symptoms
dissipated within a few days, and Michael regained insight into the situation.
• This pattern of symptoms corresponds with DSM-5-TR substance-induced psychotic
disorder, which requires delusions or hallucinations that develop during or soon
after medication intoxication or withdrawal. The fact that Michael’s symptoms
resolved within several days further supports a medication-induced psychotic
disorder – this would not be the case for an independent psychotic disorder.

Adapted from Henning, Kurtom, and Espiridion [179].

70 A4: Classification of disorders

What do discrepancies between classification systems mean

for AOD workers?
In considering the key differences between classification systems, AOD workers should be mindful that
the move towards a more dimensional approach of diagnosing mental health conditions emphasises
the need to not only use clinical judgement and expertise, but to consider the whole person, with
complex presenting issues. While there may be differences between the classification systems, these
are often of a technical nature and do not represent huge departures from the diagnoses themselves. For
example, there may be differences in which symptoms appear within a particular criterion for a disorder
as opposed to another criterion within the disorder (i.e., whether symptom A belongs in criterion B or
criterion C of a particular disorder; how many symptoms are required and over what period of time), but
the core features of disorders nonetheless remain the same. Irrespective of diagnosis, clinical focus
should stay on the person and their presenting symptoms, including their psychological, physical and
sociodemographic needs (described in Chapter B3 and Chapter B5).
Part B: Responding to co-occurring
conditions
72 Part B: Responding to co-occurring conditions

Part B: Responding to co-occurring

conditions
Part B of the Guidelines aims to provide workers with a range of options for managing and treating
mental health symptoms within a holistic health care approach that involves multiple services and
integrated care coordination. Mental health symptoms can be identified through screening and
assessment processes (see Chapter B3), or they may arise spontaneously during the client’s treatment.
There is a distinction between the management of co-occurring mental health conditions and their
treatment. 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. Without further treatment, these techniques on their own may not provide
long-term relief from symptoms; however, they may allow the client’s AOD use to be treated in the interim.
Both the management and treatment of specific co-occurring disorders are discussed in Chapter B7.

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 co-occurring conditions.
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 10 illustrates a pathway through care model, highlighting the
continuing stages of reassessment, monitoring, and client involvement.
Part B: Responding to co-occurring conditions 73

Figure 10: Pathway through care model

Person presents to AOD treatment

Screening and Involvement of

assessment other agencies and/
(see B3), including or services to deliver
assessing risk (B4) coordinated care to
the client (see B5)

Does the client have a

balanced lifestyle (see
B1)? Do they smoke,
exercise, eat, and sleep
well? With the client, consider
In partnership with
the addition of e-health
the client, consider
interventions, physical
evidence-based
activity, complementary
treatments (see B6 &
and alternative therapies, if
B7)
appropriate (see B6)

Consider increasing If yes, consider

the intensity of therapy Reassess/monitor: continuation of therapy
Is there an adequate
If no

(i.e., psychological or and relapse prevention (see

pharmacological, as response to B6). Continue to reassess/
appropriate) treatment? monitor

Reassess/monitor:
Is there an adequate
response to treatment?

If no If yes

Consider the
addition of an
adjunctive therapy,
(i.e., psychological or
pharmacological, as
appropriate) (see B6 &
B7)
74 B1: Holistic health care

B1: Holistic health care

B1: Holistic health care 75

B1: Holistic health care

Key points
• People with co-occurring AOD and mental health conditions are at increased risk of physical
health problems, with higher mortality rates than the general population.
• People with co-occurring conditions 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 can 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 particular, the role
that mental health conditions play in increasing vulnerability to physical disability and poorer outcomes
[180–182]. Consumers of mental health services have more than double the mortality rate than the
general population [183], largely attributable to CVD [184].

Risk factors for CVD are prominent among people with AOD and mental health conditions [184, 185], and
include high rates of smoking [186–188], overweight and obesity [189–191], diabetes [192, 193], poor diet
[194, 195], physical inactivity [196–198], excessive alcohol consumption [199, 200], and the use of some
antipsychotic medication [201].

Furthermore, these risk factors also place people at risk of metabolic syndrome [202]. Metabolic
syndrome is the presence of three or more of the following risk factors [203]:

• Elevated waist circumference (or central obesity).

• Raised triglycerides.

• Increased blood pressure.

• Increased glucose.

• Lowered high-density lipoprotein cholesterol.

Approximately one third of Australians have metabolic syndrome [204], which is directly affected by sleep,
physical activity, and dietary behaviours [205, 206]. People with mental disorders (e.g., schizophrenia,
bipolar disorder, depression, PTSD, BPD) are at high-risk of metabolic syndrome and associated morbidity
and mortality, particularly those prescribed antipsychotics [202, 205, 207, 208].
76 B1: Holistic health care

What is a holistic health care framework?

The multitude of risk factors for premature mortality and poor physical health among those with AOD
and mental health conditions provides the impetus for interventions that focus on overall wellbeing.
However, there has been hesitation on the part of some service providers to address multiple health
behaviours simultaneously due to the belief that making too many lifestyle changes will undermine a
person’s recovery from AOD use. While this view has been particularly prominent in relation to addressing
smoking cessation [209], it has not been confirmed by the evidence, which supports multiple health
behaviour change [209–212]. For example, two reviews of smoking cessation interventions found that
addressing smoking during AOD treatment actually enhanced long-term AOD treatment outcomes [213,
214]. AOD service providers have a significant opportunity to address multiple risk behaviours of clients
with co-occurring conditions and help reduce the risk factors and incidence of chronic disease. There are
four primary behavioural risk factors with which AOD workers should be familiar:

• Smoking.

• Diet.

• Physical activity.

• Sleep.

Smoking
Smoking rates among those attending AOD treatment are high, ranging between 48-94% [215–217].
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 [218]. Despite tobacco accounting
for the highest rate of mortality among people with AOD and mental health conditions, the focus of AOD
treatment has primarily centred on substances other than tobacco [219, 220]. There can be a reluctance
to address smoking by AOD workers due to the belief that doing so might exacerbate other AOD use [221],
and increase psychiatric symptoms and aggression [209, 222]. However, this view is not supported by
the evidence [223]. On the contrary, smoking cessation is associated with improvements in depression
[224, 225] and anxiety [226] when integrated into a treatment plan for mental disorders. Three Cochrane
reviews have examined the evidence relating to the treatment of nicotine dependence in schizophrenia
[227], depression [228] and AOD use disorders [229]. 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 [227]; the inclusion of a psychosocial mood management component to standard
smoking cessation treatment among people with current and past depression [228]; and the inclusion of
pharmacotherapy (nicotine replacement therapy [NRT], bupropion, varenicline, naltrexone, or topiramate),
with no effects on other AOD use (alcohol, opioids, stimulants, cannabis [229]).

Compounds found in tobacco smoke have been shown to increase the rate at which some psychiatric
medications are metabolised, by activating particular enzymes involved in the metabolism of those
medications [230, 231]. For people who smoke cigarettes while being treated with some psychiatric
medications, including olanzapine and clozapine, the increase in metabolism means blood
concentrations of these medications are decreased. Differences in the metabolism rates of some
B1: Holistic health care 77

psychiatric medications between those who smoke and those who do not smoke, have implications for
the required therapeutic dosages of these medications. A meta-analysis examining the effect of smoking
on the concentration to dose ratio of olanzapine and clozapine found daily doses for each should be
reduced by 30% and 50% respectively, for people who do not smoke compared to people who smoke [230].

Smoking cessation in the context of an AOD or mental disorder may mean that a person can reduce
their psychiatric medication. Crucially, the changes in metabolism associated with reducing or stopping
smoking can result in toxic or even fatal levels of clozapine or olanzapine [230–232]. As differences in
olanzapine and clozapine blood levels between people who smoke and people who do not smoke are
triggered by tobacco smoke, NRT – while useful in managing symptoms of nicotine withdrawal – cannot
counteract the effect [231]. Given the potential for toxicity, it has been recommended that doses of
olanzapine or clozapine be reduced by 30-40% three to five days after stopping smoking, with close
ongoing monitoring of blood concentration [231, 232].

Other substances that may be impacted by changes in metabolism from reducing or stopping smoking
and warrant dose reductions following smoking cessation include [233]:

• Benzodiazepines.

• Beta blockers.

• Caffeine and alcohol.

• Chlorpromazine.

• Clopidogrel (consider use of alternative among people who do not smoke, e.g., prasugrel or
ticagrelor).

• Flecainide.

• Fluvoxamine.

• Haloperidol.

• Heparin.

• Imipramine.

• Insulin.

• Methadone.

• Theophylline.

• Warfarin.

NRT can be used to minimise the physiological symptoms of nicotine withdrawal, and is available in
patches, gum, inhalers, lozenges, and microtabs [234]. NRT is not recommended without a clinical
assessment, or as a first-line treatment for AOD clients who [235, 236]:

• Are pregnant or likely to become pregnant.

• Are currently breastfeeding.

• Have significant cardiac or active vascular disease.

• Have nicotine sensitivities or allergies.

78 B1: Holistic health care

Clinicians managing clients on NRT should regularly monitor clients’ withdrawal to tailor the NRT dose,
and address triggers, cravings, and stress through accompanying psychosocial interventions. For
example, Baker and colleagues [237] provided up to 24-weeks supply of NRT to Australians who both
smoked tobacco and were diagnosed with a psychotic disorder. NRT 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, utilising a MI approach and CBT
strategies. 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. A follow-up study similarly found that both interventions were effective in maintaining
rates of reduced smoking 36-months post-intervention [238]. There is also evidence that combination
NRT (i.e., the use of more than one type of NRT together, such as patches and gum) and NRT containing
higher doses of nicotine, are more effective at improving abstinence from smoking than single-form and
lower doses, respectively [239].

Promising findings have arisen from a recent Australian RCT investigating the effects of an integrated
smoking cessation program, consisting of routine screening, assessment, treatment for smoking
(involving psychoeducation, quit kits/plans, NRT, regular feedback about progress, post-discharge
management), and smoking-cessation training for staff into existing AOD services. Compared to those
attending AOD services without the smoking cessation program, clients who received the 12-week
program reported a reduction in the average number of cigarettes smoked per day at eight-week follow-
up [240].

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
practice. For example, 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 [221, 241, 242]. Higher rates
of staff smoking with clients in AOD services are associated with lower intentions to quit among clients
[241]. Negative attitudes among treatment staff towards smoking cessation have been acknowledged as
potential barriers to effectively targeting nicotine dependence [243], with AOD staff rating treatment for
smoking as less important than treatment for other AOD use [220], and with staff who smoke themselves
less likely to initiate smoking cessation among clients, and be less successful when they do [244, 245].

Diet
Clients of AOD treatment services tend to have poor dietary habits, eating nutrient-poor, energy-dense
food, often to excess [246, 247]. It is common for people 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 [248, 249]. AOD use also impacts nutrition directly by reducing
available energy and nutrient absorption, and disrupting hormones which monitor the feeling of fullness
after eating and other food cues [246, 250]. People accessing mental health treatment also frequently
demonstrate poor dietary habits such as skipping breakfast, consuming more calories in the evening,
avoiding foods that require chewing, and a lack of structure for mealtimes [194]. Programs targeting
B1: Holistic health care 79

the preparation of nutritional food can produce lasting weight loss and improvements in mental
health symptoms among people with mental health conditions [194], and AOD workers can assist by
encouraging clients to follow Australian dietary guidelines (see Figure 11). Specifically, clients should be
encouraged to [237]:

• Eat a variety of foods that are high in fibre and low in fat.

• Eat seven or more fruits and vegetables per day.

• Drink plenty of water.

• Make healthy food choices and eat regularly.

• Manage healthy eating patterns (e.g., ensuring that breakfast is eaten every day, and eating
patterns are maintained on weekends and weekdays).

Figure 11: Australian dietary guidelines

Enjoy a wide variety of nutritious foods from these five food groups every day. Drink plenty of water.

Grain (cereal) foods,

Vegetables and
mostly wholegrain and/
legumes/beans
or high cereal fibre
varieties

Fruits

Lean meats and poultry,

fish, eggs, tofu, nuts and
seeds and legumes/ Milk, yoghurt, cheese,
beans and/or alternatives,
mostly reduced fat

Adapted from the NHMRC [251].

80 B1: Holistic health care

AOD workers may also find the spending structure displayed in Table 20 useful. Developed under the
FOODcents program to promote healthy eating on a limited budget, the spending structure was designed
to be utilised alongside the Australian Government Department of Health’s healthy eating guidelines
[252]. It is recommended that 60% of food budget is allocated to food from the ‘eat most’ group, and 10%
to the ‘eat least’ group.

While the FOODcents program is no longer available, Food Sensations is a similar education program for
families, funded by the Western Australian Department of Health, which also provides information on
healthy diet, food budgeting, meal planning, reading food labels, and food safety. At the time of writing,
free online programs are provided for organisers and participants, delivered over four weeks. Further
information and additional resources are available via the Food Sensations website: https://www.
foodbank.org.au

Table 20: FOODcents spending guide

Category Examples Recommended spending

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

Eat least Butter, margarine, oil, sugar, biscuits, 10% of budget

cake, chocolate, chips, soft drink,
coffee, salad dressing, sauce

Source: Western Australian Network of Alcohol and other Drug Agencies [253], and FOODcents [252].

There has been increasing attention paid to the connection between the mind and gut in recent years,
including how diet quality impacts mood. Growing evidence has highlighted the relationship between
microbiota in the gut and anxiety and depressive behaviours, which suggests that modifying the
gut microbiome can impact symptoms of stress, anxiety, and depression [254, 255]. Although the
communication pathways between the gut microbiome and brain are not fully understood, the immune
and hormonal systems, as well as the vagus nerve, are thought to be involved [256]. While more rigorous
research is needed to establish how microbiota can be utilised in treatment approaches, one promising
microbiota-focused treatment involves the use of probiotics, which have been shown to improve
depressive symptoms among people with depression and schizophrenia [257–259].

Evidence has also supported the relationship between diet quality and mood, with foods believed to be
beneficial for mental health. Omega-3 fatty acids, niacin, folate, vitamin B6, and vitamin B12 have been
associated with improved mental health and mood, while saturated fats and simple sugars have been
B1: Holistic health care 81

associated with poorer mental health and mood [260, 261]. ‘Western’ dietary patterns involving a high
intake of red meat, confectionary, and refined or processed foods are similarly associated with poorer
nutrition [262], whereas the Mediterranean diet [263] and diets that include more fish, reduced red meat,
and/or more fruits and vegetables [264] have been associated with high nutritional quality and improved
mood. However, it is also important to tailor diets to individual clients depending on differences in
preferences, activity levels and metabolism. Although the effects of dietary interventions on overall
mood are yet to be robustly evaluated, evidence from several systematic reviews suggest interventions
involving dietary changes (e.g., adhering to a specific diet), nutrient supplementation, and/or nutritional
counselling may be an effective adjunct to psychotherapy and/or pharmacotherapy for improving
depressive symptoms [264–268].

Physical activity
Although the physical and psychological benefits of exercise have been well established, it is estimated
that over half of Australian adults are inactive, with few achieving the recommended 30 minutes of
moderate intensity exercise most days [269]. Insufficient physical activity accounts for approximately
9% of premature mortality worldwide [270]; an estimated 46% of which could be prevented by meeting
minimum physical activity requirements [271]. As such, an increasing amount of research has focused
on the potential benefits of exercise in AOD and mental health treatment [272]. Physical activity is
highlighted as a safe alternative behaviour to AOD use, that is naturally rewarding and engaging, with
various health benefits [272, 273]. Physical activity and exercise have been associated with improved
health [274], improved depression and mood [275, 276], reduced levels of anxiety [277, 278], reduced
effects of AOD withdrawal [279–281], and are considered to be safe when exercises have been individually
tailored [282–284]. A study examining the effects of an 8-week structured exercise program (treadmill
and weight training) on depression and anxiety symptoms among people in treatment who were
newly abstinent from methamphetamine, found those in the exercise group had significantly greater
reductions in depression and anxiety symptoms compared to those in the control group (health
education sessions) [285]. Further, a dose effect was found, whereby those who had attended more
exercise sessions during the eight-week program illustrated greater reductions in depression and
anxiety compared to those who had attended fewer sessions [285].

Regular exercise is also associated with other positive behaviours, such as healthy diet and sleep
patterns [286, 287], and overall feelings of wellbeing, vitality, high energy, and motivation to maintain
healthy lifestyle practices [288–291]. Physical activity is inversely related to smoking status (i.e., people
who do not smoke are more physically active than people who smoke [292, 293]), number of cigarettes
smoked, and nicotine dependence, and recent evidence suggests that exercise may be an effective
complementary intervention to smoking cessation strategies [294–296]. Physical activity improves
cardiovascular, pulmonary, and immune functioning, which can in turn assist with the prevention
of chronic disease [297]. Smoking cessation is more successful for those who exercise during their
attempts to quit smoking [294, 298], and exercise can assist with the prevention of relapse [299].
Physical activity can also alleviate symptoms of smoking withdrawal, such as irritability, depression,
restlessness, and stress [279, 300–302].
82 B1: Holistic health care

Research suggests that although people with AOD use disorders may be interested in increasing their
levels of physical activity [303], it is unclear how frequently those in AOD treatment regularly engage in
moderate to vigorous levels of exercise [272]. Few treatment programs incorporate dedicated time for
exercise [272, 304], despite it being a rewarding, accessible, sustainable, and safe behaviour that can
be used to manage cravings and urges to use AOD [272]. Three reviews – one systematic and two meta-
analyses – 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 [305–307]. Physical activity was associated with reductions in AOD use, cravings, withdrawal
symptoms, and improved abstinence, alongside improvements in depression, anxiety, stress, and quality
of life, as well as significant fitness improvements in the exercise groups [305–307]. Exercising in calmer
environments, such as outdoors, has also been associated with greater reductions in stress [308]. Taken
in combination, these factors make physical activity an appealing, adjunctive intervention to assist with
relapse prevention among those in treatment for AOD use.

There are several physical activity and sedentary behaviour guidelines for adults, outlined in Table
21. Although associated with a range of benefits, 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 continues to be 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 [309]. 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, may assist with
program adherence and retention [310], and align with client preferences [284]. 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) [272]. 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 [272].

Evidence examining the exercise attitudes and behaviours of people in AOD treatment identified that,
although the majority of those in treatment were interested in participating in physical activities as
part of their AOD recovery, many were reluctant due to perceived barriers which included financial costs
and lack of motivation [303]. As such, techniques such as self-monitoring, goal setting, contingency
management, and relapse prevention planning may be useful [272, 310]. Wearable devices that track
physical activity (e.g., pedometers, heart-rate monitors, fitness trackers; sometimes called activity
trackers or wearable activity trackers) can increase motivation and reduce AOD use when exercise is used
as a coping strategy to manage AOD cravings [311–313]. Data from interviews conducted among people
with AOD use disorders suggests that activity trackers can help people stay accountable to an exercise
plan, strengthen motivation to remain abstinent from AOD by tracking progress in physical activity
goals, and reinforce positive changes that are being made [314]. Cardiovascular (e.g., running), resistance
(e.g., weight training), yoga, and isometric exercise have all been successfully piloted as aids to assist
smoking cessation, but need further testing in larger RCTs among AOD populations [294]. Education and
behaviour change strategies focused on diet and exercise [212] have also been shown to be effective.
B1: Holistic health care 83

Table 21: Physical activity and sedentary behaviour guidelines for adults

Physical activity and sedentary behaviour guidelines for adults (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 every day.
• Each week, adults should do either:
• 2½–5 hours of moderate intensity physical activity (i.e., out of breath but can still say a few
words), such as a brisk walk, bike riding, swimming, mowing the lawn.

• 1¼–2½ hours of vigorous intensity physical activity (i.e., out of breath, difficulty talking), such as
soccer, hockey, netball, aerobics, jogging, fast cycling.

• An equivalent combination of both moderate and vigorous activities each week.

• Incorporate muscle strengthening exercises (e.g., squats, lunges, push-ups, pull-ups, lifting weights)
at least two days each week.
• Minimise the amount of time spent in prolonged sitting (e.g., consider walking meetings or sessions,
using a standing desk, or going for a walk during lunch breaks).
• Break up long periods of sitting as often as possible (e.g., stand up and walk around when using the
phone, do squats or lunges between meetings).
• Incorporate physical activity into daily routine (e.g., use the stairs instead of a lift or escalator, get off
the bus one stop early and walk the rest of the way, walk to the park for lunch).

Adapted from the Australian Government Department of Health 2021 [315].

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 [316]. This
reluctance may be due in part 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) [316, 317]. Although some research suggests that clients
may prefer to make simultaneous behavioural changes [318, 319], 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 among people with mental health conditions [317, 320,
321]. Similarly, clinicians may feel that addressing the physical health of clients is outside the scope
of their role [316]. AOD workers may find the food and physical activity diary located in the Worksheets
section of these Guidelines useful for identifying the links between clients’ mood and feelings, their
physical activity, and food.
84 B1: Holistic health care

Sleep
Sleep problems can be experienced in many ways, and range from difficulty falling asleep, maintaining
sleep throughout the night, or waking too early or too often. Most people will experience some trouble
sleeping at some point in their lives, with less sleep associated with long work days, commuting times,
increases in evening or night work, and overuse of television, computers, or the internet [322–325]. Sleep
disturbances have been associated with the use of, and withdrawal from, AOD; in particular, alcohol [326,
327], cannabis [327, 328], tobacco [329], caffeine [330, 331], opioids [327, 332], and cocaine [327, 333].
Moreover, AOD use is associated with a higher likelihood of developing sleep disorders such as insomnia,
nightmares, sleep-related breathing disorders, and circadian rhythm disorders [334, 335]. Although
some people report using substances to promote sleep [336], in general, the direction of the relationship
is not well understood. It remains unclear as to whether sleep problems are an additional risk factor
contributing to a person’s AOD use, whether the use of AOD contributes to sleep disturbances, or both
[337]. Sleep problems are also common among people with mental health conditions, including those
with major depressive, generalised anxiety, post-traumatic stress, and bipolar disorders [338, 339].

Better understood are the poor health outcomes associated with insufficient sleep quality and duration.
The quality and duration of sleep has been linked to chronic disease, with insufficient sleep and poor
sleep quality associated with higher body mass [340, 341], weight gain [342–344], obesity [342, 343, 345],
diabetes [346], CVD [347, 348] and premature mortality [349–351]. Recent research suggests that the ideal
amount of sleep varies with age [352]. For adults aged between 18–64 years, the recommended duration
of daily sleep is between seven and nine hours [353], with the risk of chronic diseases, obesity, diabetes,
hypertension, and CVD associated with both too little (i.e., less than 6 hours) and too much sleep (i.e.,
more than 9 hours) [354–358].

Sleep quality and maintenance is equally as important as sleep duration. The American Academy of
Sleep Medicine has identified four stages of sleep, the first three of which are non-rapid eye movement
(NREM; N1-N3), and the fourth stage rapid eye movement (REM) sleep [359]. Slow wave, or deep sleep,
occurs in N3 and is considered the most restorative stage of sleep for executive functioning, typically
occurring earlier in the sleep cycle, within an hour of falling asleep [360]. With regard to interventions
that may improve sleep quality and quantity, evidence from systematic reviews supports the use of
exercise [361, 362], cognitive behaviour therapy (CBT [363–365]), acceptance and commitment therapy
(ACT [366]), mindfulness meditation [367], psychoeducation focusing on sleep hygiene [368], smartphone
applications targeting sleep disturbances (e.g., CALM [369, 370]), muscle relaxation [365], music [371],
aromatherapy [372], and environmental modifications (e.g., the use of ear plugs and a sleep mask [365,
373]). Of these interventions, exercise, CBT, ACT, smartphone applications, and muscle relaxation have
been evaluated among people with either mental and/or AOD use disorders. However, mindfulness
meditation, psychoeducation focusing on sleep hygiene, music, aromatherapy, and environmental
modification have yet to be evaluated among people with either of these disorders. Moreover, none of
these interventions have been evaluated among people with co-occurring disorders.

The American Academy of Sleep Medicine [374] recommends the healthy sleep habits outlined in Table
22.
B1: Holistic health care 85

Table 22: Healthy sleep habits

Sleep 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 to eight hours sleep.
• Do not go to bed unless tired.
• Get out of bed if not asleep within 20 minutes but avoid electronic devices or too much light
exposure.
• Practise relaxing bedtime rituals (e.g., mindfulness, meditation, relaxation 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.
• Avoid electronic devices for at least 30 minutes before bedtime.
• Do not eat large meals before bedtime. If hungry, have a light, healthy snack.
• Exercise regularly.
• Maintain a healthy diet.
• Avoid caffeine in the afternoon and evening.
• Avoid alcohol before bedtime.
• Reduce fluid intake before bedtime.

Adapted from the American Academy of Sleep Medicine [374].

Multiple health behaviours

There have been several trials of multiple health behaviours and healthy lifestyles interventions
among people with mental health disorders, all of which have included a smoking component. These
interventions typically include strategies to address multiple health risk behaviours for CVD within the
one intervention package, allowing for links between these behaviours to be drawn and addressed in
context, and people to focus on one behaviour first (e.g., sleep), experience early success, and then apply
that success to other health behaviours that they may be more reluctant to shift (e.g., smoking). Baker
and colleagues [375] conducted a pilot trial to reduce CVD risk in 43 people with acute psychotic disorder,
using MI with CBT, accompanied with NRT. The study found significant reductions in CVD risk and
smoking, and participants indicated high levels of satisfaction with the program.

In a similar trial, Goracci and colleagues [376] implemented a three-month community healthy lifestyle
intervention to people with either recurrent depression or bipolar disorder. The intervention involved
weekly individual 45-60-minute sessions focusing on lifestyle factors such as sleep, exercise, nutrition,
life balance, energy, and smoking cessation, although everyone in the trial was also receiving ongoing
pharmacotherapy for their respective mental disorder. Compared to people receiving pharmacological
maintenance augmented with clinical management visits, people who received the lifestyle intervention
86 B1: Holistic health care

were less likely to experience relapses of depressive and manic symptoms and demonstrated greater
reductions in body mass index (BMI) and waist circumference. Relative to baseline, people receiving the
intervention also experienced improvements in sleep quality [376].

In the only trial conducted among people with co-occurring mental disorders and AOD use, Juel and
colleagues [377] evaluated a community lifestyle intervention encompassing smoking cessation
guidance, dietary advice, and structured exercise. Relative to baseline, participants reported consuming
fewer fast-food meals and caffeinated beverages, as well as improved quality of life, after the 24-month
intervention. However, sleep duration decreased over the study period, and AOD use remained unchanged
[377].

Kelly and colleagues [210] recently conducted an RCT to evaluate Healthy Recovery; an eight-session group-
based intervention focused on addressing multiple CVD risk factors within an AOD treatment setting. The
five-week intervention focused on reducing smoking, increasing fruit and vegetable intake and levels
of physical activity, using a combination of health-focused psychoeducation, goal setting, monitoring,
MI, and CBT. In evaluating the intervention, Kelly and colleagues [210] found that people randomised to
receive Healthy Recovery significantly reduced the number of cigarettes smoked daily and increased the
variety of fruit consumed relative to AOD treatment alone, though levels of physical activity and servings
of fruit and vegetables did not change.

What does this mean for AOD workers?

There is strong evidence that supports the need for holistic approaches to health care and AOD treatment
that deliver the appropriate services to clients at the right time. From their first encounters with
clients – even those who appear physically healthy and not currently experiencing any issues relating
to their medication, diet, sleep, physical exercise or smoking - AOD workers should proactively provide
preventative information about all of these factors to support clients in maintaining good health. Holistic
health care includes the involvement of multiple services in a coordinated client-centred approach. AOD
workers should be prepared not only to address the mental and physical wellbeing of their clients, but
also involve, and partner with, other services that can provide complete, individualised care.

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.
B1: Holistic health care 87

Box 11: Case study K: Managing co-occurring physical, mental, and AOD use disorders:
Con’s story

Case study K: Con’s story

Con, a 59-year-old who identified as male, first came into contact with AOD services when he was in his
20s and entering treatment for heroin dependence. At that time, he had been using heroin for about 10
years and was very unwell. Con had a history of psychosis dating back to his 20s, for which he was taking
antipsychotics and had been managed by a community mental health team. In his 20s and 30s however,
Con lived an itinerant lifestyle and moved around a lot. Despite the best efforts of mental health services,
it was very difficult to maintain his engagement with services. During times of engagement, Con had not
always been stable on his antipsychotics. He experienced several episodes of active psychosis where his
outreach team were unable to complete their visits because he would not let them into the house and
would be yelling and screaming incoherently. During those episodes, Con seemed genuinely terrified that
he would be harmed, which resulted in the police being called and Con being hospitalised.

Twenty years later, Con was living in stable housing and taking antipsychotics. He was being managed
in the community and still receiving methadone. Although he had some family, they were all based in
Queensland and Con, living alone in NSW, was quite isolated. Over the past five years, Con had three
strokes and while he had made good recovery, he still had difficulty with his memory and attention. He
was also diagnosed with diabetes several years earlier, which was not well managed. As a result, Con had
several toes amputated. Although he was receiving assistance from nursing services who were visiting
him at home and dressing his wounds, they stopped their visits when Con was drunk during their visits
one too many times. Con was also recently visited by the police after he called to report neighbourhood
noise. On their arrival, they did not hear any noise and Con could not remember calling them. One of Con’s
mental health workers suspected that Con was hearing voices.

Key points:
• What are the primary concerns for Con?
• Where to from here?

Case study K continues in Chapter B5.

B2: Trauma-informed care
B2: Trauma-informed care 89

B2: Trauma-informed care

Key points
• A history of trauma exposure is almost universal among clients of AOD services.

• Trauma-informed care is a service delivery approach whereby AOD services recognise the high
rates of trauma exposure among their clients and its potential impact; respond by integrating
that knowledge into policies, procedures, and practices; and provide a safe environment (both
physically and psychologically) that accommodates the needs of clients presenting with a
history of trauma.

• The goal of trauma-informed care is to create treatment environments that are more healing
and less re-traumatising for both clients and staff.

• A trauma-informed care approach has multiple layers, both at the level of the organisation
(e.g., policies and procedures) and the individual (e.g., client-AOD worker interactions).

• An essential component of trauma-informed care is the provision of adequate training and

support to AOD workers (e.g., supervision, peer support).

• It is also important for AOD workers to develop an awareness of their own vulnerabilities and
maintain good self-care practices.

A history of trauma exposure (as defined in Chapter A4) among clients of Australian AOD treatment
services is the norm rather than the exception, with more than 80% reporting having experienced a
traumatic event in their lifetime [83, 137, 138, 378]. Most clients have experienced multiple traumas,
and more than half have experienced trauma during childhood [83, 137, 138, 378]. The types of events
experienced are many and varied, but the most commonly reported include having been physically
or sexually assaulted, witnessing a serious injury or a death, being threatened with a weapon, or held
captive [83, 137, 138]. Given these high rates of trauma it is not surprising that up to two-thirds of
Australians entering AOD treatment services also experience PTSD [76]. Regardless of whether a person
goes on to develop PTSD or any other mental disorder, traumatic events are often life-changing, and can
redefine a person’s views about themselves (e.g., feeling weak, bad, or worthless), the world around them
(e.g., the world is not safe), and how they relate to it (e.g., people cannot be trusted). These beliefs may be
particularly well-entrenched in those who have experienced childhood trauma [379].

A history of trauma exposure may be integrally linked with the person’s current AOD use. A number
of clients who have experienced trauma describe their AOD use as an attempt to self-medicate the
thoughts and feelings they have experienced as a consequence of trauma, and there is evidence from
a variety of studies to support such a relationship [30]. Although AOD use may provide short-term
90 B2: Trauma-informed care

relief, growing tolerance to the effects of AOD can lead to increased use in an effort to obtain sufficient
symptom reduction. In the absence of AOD, PTSD symptoms may worsen, making it difficult for clients
to maintain abstinence or reduced use [380]. It should be noted however, that, as with symptoms
of depression and anxiety, on average, PTSD symptoms also decline in the context of well managed
withdrawal [381–383]. Nonetheless, given the high rates of trauma exposure and PTSD among people with
AOD use disorders, and the fundamental role that trauma symptoms may play in a person’s recovery,
experts have strongly advocated for trauma-informed care approaches to be adopted in AOD treatment
settings [136, 141, 384].

What is trauma-informed care?

Trauma-informed care is a service delivery approach whereby AOD services: i) recognise the high rates
of trauma exposure among their clients and its potential impact on clients’ circumstances; ii) respond
by integrating that knowledge into policies, procedures, programs and practices; and iii) create a safe
environment that accommodates the needs of clients presenting with a history of trauma [141]. Physical
and psychological safety are core to the fundamental goal of trauma-informed approaches, which is to
create treatment environments that are more healing and less re-traumatising for both clients and staff
[141].

A trauma-informed care approach has multiple layers, both at the organisational and individual level
[385, 386]. Ideally, services will adopt a trauma-informed approach that is visible in all aspects of the
organisation and reflected in policies and procedures. Such an organisational approach provides a
framework that supports all service staff (e.g., administrative reception staff, cleaners, security and
kitchen staff, management, board members), not just those involved in clinical care, to implement
trauma-informed care at the individual level in all interactions and processes. That is, from when a
potential client makes first contact with a service, all the way through treatment to discharge, and
follow-up [385]. In this chapter, we focus on aspects of trauma-informed care that may be employed by
AOD workers at the individual level and suggest that at a minimum, all staff working with AOD clients
should: i) have an awareness of the extent of trauma exposure among their clients; ii) understand the
consequences of trauma exposure and its potential to impact on recovery; iii) be able to recognise the
signs and symptoms of PTSD and other mental disorders; and, iv) integrate that knowledge into their
practice in ways that are relevant to their role and capacity [136, 387].

It should be noted that there is a distinction between trauma-informed care and trauma-informed
practice. Trauma-informed practice involves the provision of psychological treatment for trauma-related
symptoms by trained and accredited professionals [388]. While these treatments may form part of a
trauma-informed care approach (i.e., they may form part of treatment planning), trauma-informed care
can still be provided in their absence. It is nonetheless useful for AOD workers to be aware of the evidence
base regarding effective treatments and options that may be available to clients should they wish to
engage in these treatments. AOD workers are encouraged to read about this evidence base described in
Chapter B7.
B2: Trauma-informed care 91

Recognising trauma and its impact

Given the high rates of trauma exposure among people entering AOD treatment, it is recommended that
AOD workers and services adopt a ‘universal precautions’ approach; that is, operating on the assumption
that all clients have experienced trauma [136, 385]. Operating under this assumption does not, however,
negate the need to assess clients individually. Trauma exposure should be routinely assessed sensitively
by suitably trained practitioners. Before conducting trauma assessments, workers should seek training
and supervision in dealing with trauma responses.

Incorporating some questioning into most initial assessments signals that this is a standard process
that is important in both understanding why people present to treatment and in determining appropriate
treatment pathways; however, each AOD worker must use their judgement and expertise in determining
when it is clinically appropriate to ask more detailed questions based on a client’s presentation. In
some situations, for example, it may be more beneficial to raise the issue of trauma some weeks after
the initial assessment interview, once the client feels safer and a therapeutic relationship has been
developed [389]. Further information on identifying client trauma histories is provided in Chapter B3.

Responding to trauma: Practitioner approaches, programs,

and procedures
A number of models have been developed to guide organisations and individual workers in incorporating
trauma-informed care into their policies, programs, procedures and practices. Links to some of these are
available at the end of this chapter. Common to all of them are six guiding principles [385]:

i. Safety: Ensuring clients and staff feel physically and psychologically safe with respect to the
physical setting and interpersonal interactions.

ii. Trustworthiness and transparency: Making decisions with transparency to build and maintain
trust.

iii. Peer support: Promoting mutual support to aid in healing and recovery.

iv. Collaboration and mutuality: Leveling power differentials and recognising that everyone plays
a role in recovery and care.

v. Empowerment, voice, and choice: Recognising and building upon individuals’ experiences and
strengths (including their strength in coming through their traumatic experiences and seeking
help), and helping clients to establish a sense of control.

vi. Cultural, historical, and gender issues: Acknowledging and addressing the impact of
historical trauma, overt discrimination, and implicit biases.

At the organisational level, creating a trauma-informed approach requires continual review of policies,
procedures, and programs to identify possible areas of re-traumatisation [386]. AOD workers should
similarly regularly undertake a review of their own individual practices to identify areas for potential
improvement. Many common procedures and practices used in AOD services may potentially
92 B2: Trauma-informed care

re-traumatise. For example, aggressive or confrontational group techniques can trigger memories of
past abuse, are counterproductive, and may lead clients who have been exposed to trauma to revert to
previous coping strategies, for example dissociating or shutting down, and further AOD use. This may
then lead to the client being labelled as ‘treatment-resistant’, with consequent feelings of failure and
self-blame [136].

A focus on building trust is essential in AOD worker-client interactions. Many clients’ traumas have
occurred in the context of interpersonal relationships in which their trust, safety and boundaries have
been violated. They may also have had personal information used against them in the past, making
it difficult for them to trust others [390, 391]. Attention to boundaries, and the use of language that
communicates the values of empowerment and recovery is important [392]. Clients of AOD treatment
services with severe co-occurring mental health conditions may also have experienced traumatic
events within the context of receiving health care (e.g., if they have been forcibly restrained or secluded
in the context of receiving involuntary mental health treatment) [393]. These experiences can be deeply
traumatic, trigger memories and feelings of past trauma, and have an ongoing impact on the person and
their ability to trust healthcare providers.

For those who have experienced interpersonal trauma in particular, healthcare providers may also
be seen as authority figures and some interactions may imitate the interpersonal dynamics that
were evident in an abusive relationship. There is an inherent power imbalance in the helper–helped
relationship and AOD workers must do their best to reduce this inequity [390, 394, 395]. Many clients
also fear judgement on the part of their healthcare providers, so it is important that AOD workers 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. Recognising clients for their resilience in the face of adversity is important, even if past adaptations
and ways of coping, such as AOD use, are now causing problems. Understanding AOD use as an adaptive
response can help to reduce a client’s guilt and shame, and provides a framework for developing new
skills to better cope with symptoms [384].

An additional part of the process of building a sense of trust and safety is helping clients to regain a
sense of control, as both trauma and AOD use disorders are characterised by feeling out of control. For
example, rather than telling a client that, ‘It’s time for your doctor’s appointment’, providing clients with
choice and control by saying, ‘It’s time for your doctor’s appointment, are you still ok to meet with them now?’.

Stability is also key to establishing a sense of safety [396]. A structured program in which clients know
what to expect and have clear transparent expectations can be helpful. Sometimes clients who have
experienced trauma may be physically and mentally ‘on guard’, so it can be helpful to avoid surprises,
use slow, calm movements, a gentle tone of voice, and not encroach on their personal space. It can also
be helpful to advise clients what to expect in terms of their progress through treatment. As mentioned
in Chapter B7, some clients experience an increase in trauma-related symptoms when AOD use is
reduced or ceased. Preparing the client to expect that their trauma-related symptoms may increase, and
normalising these reactions, may make it easier for clients to manage their symptoms.
B2: Trauma-informed care 93

Creating a safe environment

Creating a safe environment relates to creating an environment in which clients and staff have a sense
of both physical and psychological safety. As such, it pertains to the services’ physical surroundings, as
well as practitioner approaches, programs, procedures, and policies that have been described earlier in
this chapter, that can be modified to create a space that is safe and welcoming, and where the likelihood
of re-traumatisation is minimised.

Many clients who have experienced trauma will feel on guard, fearing violence at the hands of another
client, or other forms of unwanted attention. They may also fear that they will not be able to escape
a situation in which they feel threatened, particularly if they are in secure or locked wards. These
settings can be reminiscent of other times in their life when they have not been able to escape unsafe
environments. It is important to pay attention to the physical environment, ensuring that there is [384,
392, 397]:

• Adequate lighting and common areas are well-lit.

• Sufficient space for comfort and privacy.

• Clear pathways to building entrances and exits.

• Sufficient staffing to monitor the behaviour of others that may be perceived as intrusive or
harassing.

• No groups of people loitering at the entrances and exits.

• An absence of exposure to violent, sexual, or offensive material in common areas (e.g., magazines
left in the waiting area; television programs, films or music that may be playing).

• Welcoming language is used on signage.

The ideal safe environment is one that is free from the risk of harm; however, it is unlikely that all
potential environmental triggers can be completely eliminated. Triggers are highly variable and unique to
individuals and their experiences, but they can be minimised and clients supported to use coping skills
in the event that they are triggered [392].

A safe environment is also one in which clients feel that they are able, should they wish to, talk about
their trauma, and their reactions to it, without judgement. If a client does become triggered or distressed
by trauma symptoms, it is important that avoidance or suppression of thoughts or feelings is not
encouraged, as avoidance symptoms, rather than re-experiencing symptoms, have been associated
with the perpetuation of trauma-related symptoms [398]. Similarly, avoidance or suppression may also
intensify feelings of guilt and shame. For those who have experienced abuse, it may closely re-enact
the experience of being told to keep quiet about it [384]. This does not mean that clients should be
pushed to revisit events or disclose information if they are not ready to do so. Rather, it means that it
is understandable that the person may be upset by thoughts and feelings that may arise, and that they
should be allowed to engage with them in order to help process the trauma emotionally. Ideally, clients
will have developed good self-care skills, and will have skills to regulate their emotions, before they delve
into their own traumatic experiences, or are exposed to the stories of others; however, choice and control
should be left to the client [384]. Notwithstanding, even in the absence of details of a client’s trauma, AOD
94 B2: Trauma-informed care

workers can help to reinforce a sense of safety by assisting clients in the use of anxiety management
techniques such as breathing retraining, progressive muscle relaxation, and grounding techniques, to
help manage their symptoms. These techniques are described in detail in Appendix CC.

Barriers to providing trauma-informed care

Despite its intuitive appeal, AOD services have been somewhat slow to adopt trauma-informed care at
the organisational level, which presents a challenge for AOD workers wishing to adopt this approach fully
into their practice. There may be several reasons for this, many of which are organisational, but some
relate to AOD workers individually [399]; we highlight a selection of these barriers below.

Firstly, despite the pervasiveness of trauma exposure and PTSD among AOD clients, and the potential
impact on treatment, both are largely unrecognised at the service level as few services systematically
assess for a history of trauma exposure among their clients, with most preferring to put the onus on
the client to raise the issue. However, for a multitude of reasons, including shame and an inability to
trust, most clients are unlikely to volunteer information about their past trauma experiences unless
specifically asked [400].

The reluctance to assess for trauma is often related to concerns regarding client safety, specifically,
fears regarding the ability of clients to manage the emotions that may be elicited [401]. Although well-
intentioned, this practice is likely to be doing more harm than good; while some people may become
upset when talking about these events, talking about the trauma does not overwhelm or re-traumatise
the majority of people, and most people describe the process as a positive experience, when it is
conducted in an empathic manner [402]. Further, research has shown that these fears can be allayed
with appropriate staff training in trauma inquiry [403].

Second, AOD workers may understandably be concerned about their capacity to respond. Trauma training
is not a core feature of most certification courses. In Australia, it has been estimated that less than two-
thirds of Australian AOD workers have undergone some form of trauma training [404], and AOD workers
themselves have identified this as a priority training need [7].

There are also concerns regarding the potential impact of client trauma on the wellbeing of AOD workers
themselves and the potential for secondary traumatic stress, discussed in Chapter B8. An essential
component of providing trauma-informed care is the provision of adequate training and supports (e.g.,
supervision, peer support) to AOD workers, developing an awareness of one’s own vulnerabilities, and
maintaining good self-care practices (see Chapter B8) [385].

Finally, until recently, there was very little empirical evidence to guide treatment responses. There is,
however, a growing body of evidence that supports the use of integrated trauma-focused treatments for
PTSD and AOD use disorders, which is outlined in Chapter B7.
B2: Trauma-informed care 95

Is my service trauma-informed?
As mentioned previously, a number of models have been developed to guide organisations and individual
workers in incorporating trauma-informed care into their policies, programs, procedures and practices.
Tools that have been developed to support services in providing trauma-informed care include:

• Metro North Mental Health – Alcohol and Drug Service. (2019). Model of Care: Trauma Informed Care and
Practice for Alcohol and Drug Treatment. Available at: https://insight.qld.edu.au/shop/model-of-care-
trauma-informed-care-and-practice-for-alcohol-and-drug-treatment

• NSW Mental Health Coordinating Council (MHCC). (2018). Trauma-informed Care and Practice
Organisational Toolkit (TICPOT) + other associated resources. Available at: https://www.mhcc.org.au/
resource/ticpot-stage-1-2-3/

• Kezelman, C., & Stavropoulos, P. (2020). Organisational guidelines for trauma-informed service
delivery. BlueKnot Foundation. Available at: https://professionals.blueknot.org.au/resources/
publications/organisational-guidelines-for-trauma-informed-service-delivery/

• Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s Concept of Trauma and
Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: SAMHSA.

• Brown, V. B., Harris, M., & Fallot, R. (2013). Moving toward trauma-informed practice in addiction
treatment: A collaborative model of agency assessment. Journal of Psychoactive Drugs, 45(5), 386-393.

• Marsh, A., Towers, T., & O’Toole, S. (2012). Trauma-informed treatment guide for working with women with
alcohol and other drug issues. Perth, Western Australia: Improving Services for Women with Drug and
Alcohol and Mental Health Issues and their Children Project.
B3: Identifying co-occurring
conditions
B3: Identifying co-occurring conditions 97

B3: Identifying co-occurring

conditions

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
co-occurring conditions to go unnoticed [405], mostly because AOD workers are not routinely looking for
them. 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 co-occurring conditions as part of routine
clinical care. This chapter describes methods of the screening and assessment for mental health
conditions, which should form part of the case formulation process for all clients.

Assessing and identifying the client’s needs is the first step. It is important to recognise whatever needs
the client may have as such needs will undoubtedly impact upon AOD treatment. Early diagnosis and
treatment of mental disorders can improve treatment outcomes [406–409]. 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 (coordinating care is
discussed further in Chapter B5). It is equally important that other issues identified (e.g., problems
98 B3: Identifying co-occurring conditions

involving employment, housing, medical care) are dealt with appropriately, as such issues 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 [410, 411]. The case formulation process should be collaborative, in
that the AOD worker contextualises the client’s experiences and knowledge of themselves within their
own clinical expertise [410]. 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 with
which clients present. As discussed in Chapter A2, clients of AOD treatment services, and those with
co-occurring 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 [412]), the likelihood
of developing a mental health condition is influenced by the interaction of 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 should be considered the first step to devising (and later revising) the client’s
treatment plan. There is no standardised approach to case formulation [413], but it is crucial that a
range of different dimensions be considered. These include the history of presenting issue/s, AOD use
history (type, 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,
gender identity, 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
conditions [200, 414]. 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 people whose mental health requires further investigation by a professional
trained and qualified in diagnosing mental disorders (e.g., registered or clinical psychologists, or
psychiatrists).

Abstinence is not required to undertake the screening process [415]. The potential clinical issues
that these conditions can present suggest that screening for co-occurring mental health conditions
B3: Identifying co-occurring conditions 99

should always be completed in the initial phases of AOD treatment. Early identification allows for early
intervention, which may lead to better prognosis, more comprehensive treatment, and the prevention of
secondary disorders [406, 416, 417].

Diagnostic assessment should ideally occur subsequent to a period of abstinence [418, 419], or at least
when the person is not intoxicated or withdrawing [420]. While the length of this period is not well
established, a stabilisation period of between two to four weeks is recommended [421, 422]. 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 [39, 418]. 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 [102, 423, 424]. 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 and assessment are ongoing processes rather than one-off events, which involve the
monitoring of clients’ mental health symptoms. Ongoing screening and assessment are 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 [425] suggests that a combination of both informal and standardised assessment
techniques is the best way to develop a case formulation, though some researchers also suggest that
building a formulation framework using the 5Ps model may be useful [389, 426]. In this framework, case
formulation is determined by identifying the ‘5Ps’ [427]:

• Presenting issues.

• Predisposing factors.

• Precipitating factors.

• Perpetuating factors.

• Protective factors.

Figure 12 depicts how both informal and standardised assessment 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, provide support to the client, and improve treatment outcomes
(see Chapter A3) [428, 429].
100 B3: Identifying co-occurring conditions

Figure 12: The ongoing case formulation process

Treatment Discharge

Informal assessment Use of standardised screening & assessment tools

(including mental state examination) (as required)

Intake

Note: Figure 12 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.

An example of how the 5Ps model can be used to build a case formulation, with Lena’s case study (Box
12) and the case formulation template (Appendix F), is illustrated in Table 23. This is just one example of
how AOD workers may develop a case formulation, and not all client factors will necessarily apply to the
template.

Box 12: Case study L: Example case formulation: Lena’s story

Case study L: Lena’s story

Lena is a 27-year-old who identified as female, who had been living in a major city for most of her life. She
had been living in the family home with her younger brother since their mother died five years earlier;
their father died by suicide when Lena was 12 years old. He was diagnosed with depression several years
earlier. Lena was sexually assaulted several times by a male neighbour when she was 5 or 6.

Lena had been working as a programmer at a web-design company for the past 18-months but lost her
job last week after several conflicts with her co-workers resulted in complaints being made against her,
and for missing several important client meetings because she had overslept. The day Lena lost her job,
she immediately went home, locked herself in her bedroom and self-harmed. Since that time, she had
been drinking a couple of bottles of wine every day and was thinking about taking an overdose of her
Aropax medication.

Seeing that Lena had not left her room in a week, her concerned brother coaxed her out and brought
her to their local hospital emergency. Prior to the loss of her job, Lena’s mood was stable, and she had
B3: Identifying co-occurring conditions 101

Box 12: Case study L: Example case formulation: Lena’s story (continued)

not self-harmed or had any suicidal thoughts in the past two years. She was seeing a psychologist and
a psychiatrist regularly, but had not maintained her routine appointments, preferring to have her GP
prescribe her Aropax. Lena’s psychiatrist had previously diagnosed her with co-occurring depression, BPD
and alcohol use disorder.

Lena had a bachelor’s degree in computer science. She used to play hockey but gave up last year after
several injuries. She was in a one-year on/off relationship with a female partner who she had been friends
with since University, and there had been recent arguments concerning the direction of their relationship.
Lena described a fear of being abandoned in relationships and had very intense relationships with
friends/family.

Adapted from PsychDB [430].

An example of how Lena’s presenting issues, predisposing, precipitating, perpetuating and protective
factors may be developed into a case formulation is illustrated in Table 23. As biological and social
factors often influence psychological symptoms, it can be useful to complete the biological and social
sections of the table first, followed by the psychological section last.

Table 23: Example of a case formulation for Lena

Biological Psychological Social

(e.g., genetic factors, (e.g., resilience, (e.g., socioeconomic
medications, physical personality, thoughts, background,
health) feelings, behaviours) relationships, family,
school, work, cultural
factors, spirituality,
community, social
supports and
connectedness)

Predisposing factors • Possible family • Fear of • History of childhood

Factors over a person’s history of mental abandonment trauma
lifetime that may disorders • Early death of father
have contributed to • Death of mother
problem

Precipitating factors • Increase in alcohol • Re-experiencing • Recent loss of job

Any triggers or events use feelings of • Difficulties with
that have initiated or abandonment after interpersonal
exacerbated problem loss of job relationships
102 B3: Identifying co-occurring conditions

Table 23: Example of a case formulation for Lena (continued)

Perpetuating factors • Current dose of • Lack of • Ongoing

Factors that may paroxetine may be adaptive coping disagreement
maintain problem or sub-therapeutic mechanisms led to in romantic
make it worse if not use of self-harm to relationship
addressed cope, and thoughts • Disengaged from
of suicide psychologist and
psychiatrist

Protective factors • Medically healthy • University educated • Good support

Internal and external • Previous from brother who
supports engagement with brought her to
psychologist/ hospital
psychiatrist • Interest in being
physically active

Adapted from PsychDB [430].

Informal assessment
The informal assessment takes the form of a semi-structured interview and should cover the following
[389]:

• Mental state.

• Source of referral and current health care providers.

• Presenting issues.

• AOD use history.

• Current situation.

• Personal, medical, and family history.

• Risk factors for CVD and other health conditions.

• Trauma history.

• Psychiatric history.

• Risk assessment.

• Criminal history.

• Strengths and weaknesses.

• Readiness for change.

• Beliefs about self, others, and the world.

For an effective assessment, it is important to provide a non-judgemental, empathetic, private, and

confidential environment. Any limits to confidentiality should also be explained.
B3: Identifying co-occurring conditions 103

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 24. It should be noted
that all of the factors above 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) [389].
Observations regarding cognitive functioning, such as poor concentration or memory, should also be
noted and may require referral to a neuropsychologist [389]. Appendix G provides a form which may be
useful in guiding notetaking for the mental state examination.

Table 24: Assessment of mental state

Appearance

How does the client look?

Posture – slumped, tense, bizarre.

Grooming – dishevelled, make-up inappropriately applied, poor personal hygiene.
Clothing – bizarre, inappropriate, dirty.
Nutritional status – weight loss, not eating properly.
Evidence of AOD use – intoxicated, flushed, dilated/pinpoint pupils, track marks.
104 B3: Identifying co-occurring conditions

Table 24: Assessment of mental state (continued)

Behaviour

How is the client behaving?

Motor activity – immobile, pacing, restless, hyperventilating.

Abnormal movements – tremor, jerky or slow movements, abnormal walk.
Bizarre/odd/unpredictable actions.

How is the client reacting to the current situation and assessor?

Angry/hostile towards assessor/others.

Uncooperative or withdrawn.

Over familiar/inappropriate/seductive.

Fearful, guarded, hypervigilant.

Speech and language

How is the client talking?

Rate – rapid, uninterruptible, slow, mute.

Tone/volume – loud, angry, quiet, whispering.
Quality – clear, slurred.
Anything unusual about the client’s speech?

How does the client express themselves?

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).
Tangentiality/loosening of associations (replies to questions are irrelevant or may refer to the appropriate
topic but fail to give a complete answer).
Absence/retardation of, or excessive thought and rate of production.
Thought blocking (abrupt interruption to flow of thinking so that thoughts are completely absent for a few
seconds or irretrievable).
B3: Identifying co-occurring conditions 105

Table 24: Assessment of mental state (continued)

Mood and affect

How does the client describe their emotional state (i.e., mood)?

Down/depressed; angry/irritable; anxious/fearful; high/elevated.

What do you observe about the client’s emotional state (i.e., affect)?

Depressed – flat, restricted, tearful, downcast.

Anxious – agitated, distressed, fearful.

Irritable, hostile.

Labile – rapidly changing.

Inappropriate – inconsistent with content (e.g., laughs when talking about mother’s death).

High/elevated – excessively happy or animated.

Thought content

What is the client thinking about?

Delusional thoughts (e.g., bizarre, grandiose, persecutory, self-referential).

Preoccupations: paranoid/depressive/anxious/obsessional thoughts; overvalued ideas.
Thoughts of harm to self or others.
Does the client believe that their thoughts are being broadcast to others or that someone/thing is
disrupting or inserting their own thoughts?

Perception

Is the client experiencing any misinterpretations of sensory stimuli?

Does the client report auditory, visual, olfactory, or somatic hallucinations? Illusions?
Are they likely to act on these hallucinations?
Do you observe the client responding to unheard sounds/voices or unseen people/objects?
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?
106 B3: Identifying co-occurring conditions

Table 24: Assessment of mental state (continued)

Cognition

Level of consciousness

Is the client alert and oriented to time, place, person?

Is the client attentive during the interview (drowsy, stuporous, distracted)?
Does the client’s attention fluctuate during the interview?
Does the client present as confused?
Is the client’s concentration impaired (can they count from 100 or say the months of the year backwards)?

Orientation

Does the client know:

Who they are? Who you are?
Where they are?
Why they are with you now?
The day of the week, the date, the month, and the year?

Memory

Can the client remember:

Why they are with you? (Immediate)
What they had for breakfast? (Recent)
What they were doing around this time last year? (Remote)
Are they able to recall recent events (memory and simple tasks; e.g., calculation)?

Insight and judgement

How aware is the client of what others consider to be their current difficulty?
Is the client aware of any symptoms that appear weird/bizarre or strange?
Is the client able to make judgements about their situation?

Adapted from NSW Department of Health [431] and Stone et al. [389].
B3: Identifying co-occurring conditions 107

Source of referral and current health care providers

Clients may have various sources of referral to treatment. For example, they may be referred by their GP,
family or friends, or corrective services. In general, the most common form of referral is self-referral [432].

In addition to identifying the source of referral, it is important to identify all care and treatment 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, the AOD worker should, with the client’s permission, liaise with these providers
regarding the person’s treatment to ensure care coordination and continuity of care (see Chapter B5).

Presenting issues
Ascertain what the client perceives to be their biggest issues and the reasons why they are in treatment.
This is usually broader than the AOD issue (e.g., psychological, social, health, legal, accommodation,
financial).

AOD use history

It is important to gain an understanding of the range of substances currently used, the quantity and
frequency of use, age of first use, duration of use, previous AOD-related problems, circumstances of
use, risk behaviours related to use, and previous treatment/attempts to change (and why these were
successful or unsuccessful). Clinicians should also gain an understanding of the development of the
client’s AOD use over time, including periods of abstinence, and how these were supported [389].

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 [433]).

It can be useful to ask the client to describe a normal day, in order to help the client evaluate the ways in
which their AOD use affects their 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.

Personal, medical, and family history

Exploring and discussing the client’s background, from birth to the present, can help both the client and
AOD worker to understand the beginnings of AOD use and mental health symptoms, and the impact on
the client’s life, as well as help the client develop self-compassion [389]. Enquire about:
108 B3: Identifying co-occurring conditions

• Family context (including family history of AOD use and mental 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.

Risk factors for CVD and other health conditions

As described in Chapter B1, clients of AOD treatment services are at increased risk of physical health
problems, with higher mortality rates than the general population. Identifying the presence of risk factors
and behaviours of CVD and other health conditions, including, but not limited to sleep, diet, smoking, and
physical activity is important to ensure that a client’s holistic health needs are addressed.

Trauma history
It is important to identify whether the client has experienced any traumatic events in their life [389], as
many clients presenting for AOD treatment report a history of trauma [137, 138, 378, 434]. As described in
Chapter A4, the word trauma is widely used and can mean different things to different people. In these
Guidelines, we use the word trauma to refer to an extremely threatening or horrific event, or a series
of events, 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, life or safety is at risk [10, 11]. Examples of potentially traumatic
events include, but are by no means limited to, being involved in a road traffic accident; experiencing or
being threatened with physical or sexual assault; being in a life-threatening car or other form of accident;
combat exposure or being in a place of war or conflict; or witnessing any of these events. The most
important factor in understanding a person’s experience of an event is whether or not they perceived it to
be a traumatic event; events that may be traumatic to some people may be perceived as relatively minor
to others, and vice versa.

As described in Chapter B2, 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 ‘block out’ or reduce the thoughts and feelings they have had since the trauma
[30]. 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).
B3: Identifying co-occurring conditions 109

Recognition and identification of past trauma is an important component of providing trauma-

informed care (see Chapter B2). 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. Each AOD worker
must use their judgement and expertise in determining when it is clinically appropriate to ask trauma-
related questions based on a client’s presentation. 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 [389].

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.

Before questioning the client, the AOD worker should:

• Seek the client’s permission to ask them about exposure to traumatic events, and advise the client
that they do not have to talk about these experiences or provide any detail if they do not want to.
Clearly communicate the reasons for asking about past trauma, and begin with general questions
that become more specific as client comfort increases [156]. It may not be readily apparent
to the client that their current situation may be related to their past [435, 436]. For example,
clearly explaining to the client that the questions relating to trauma will help contextualise
their substance use, and will also help gain a better understanding of the interplay between AOD
use and trauma symptoms [389]. Ensure that the client has the opportunity to say if they feel
uncomfortable.

• Advise the client that talking about traumatic events can be distressing; even clients who want to
talk about their trauma history may underestimate the level of emotion involved [437]. It should
be noted that studies have found that while some people may become upset when talking about
these events, talking about the trauma does not overwhelm or re-traumatise the majority of people.
On the contrary, even in the context of distress, most people describe the process as a positive,
validating experience [402, 438, 439].

• Advise the client of any restrictions on confidentiality, for example, in relation to the mandatory
reporting of children at risk or serious indictable offenses.

When broaching the subject of trauma, ask the client if they have 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, or 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?’ [400,
440]. Standardised screening tools such as the Life Events Checklist (described later in this chapter)
may be used to assess for a history of trauma exposure. Some clients find it easier to complete a self-
report screening tool than to say aloud to the assessor that they have, for example, been raped [437], and
research suggests that verbal disclosure of trauma via interview evokes more distress than completing
a written questionnaire [402]. However, such screening tools should always be completed with an AOD
worker present and should never be given to the client to complete at home.
110 B3: Identifying co-occurring conditions

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 [390, 391]. Clients may also fail to
disclose their trauma due to an inability to recall it, feelings of loyalty towards their perpetrators, and
dissociative responses in reaction to any inquiry about trauma [436].

During the trauma assessment it is essential that the AOD worker questioning the client does not ‘dig’
for information that is not forthcoming, as doing so may result in destabilisation [395, 437, 441]. 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. As described in Chapter B2, there is an inherent power imbalance in the helper–helped
relationship and AOD workers must do their best to reduce this inequity [390, 394, 395]. Trauma and AOD
use are both characterised by the loss of control, and it is important that the client feels able to regain a
sense of control. In line with this, it can be useful to periodically check in with the client and make sure
they are comfortable to continue the discussion [390].

The following are some additional guidelines on discussing traumatic experiences with clients during
assessment and at other times during their treatment [442]:

• Display a comfortable attitude if the client describes their trauma experience. Some
clients will have had experiences when people did not want to hear their account, especially when
details of the experience are gruesome or horrific. The client should know that they can tell you
anything.

• Recognise the client’s courage in having talked about what happened. The client needs to
know that you appreciate how difficult it is for them to talk about their trauma. Make it clear to the
client that you respect and admire their strength in coming through the traumatic experience and
in seeking help, but do not patronise them.

• 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 may help to normalise their experience, and also alleviate possible shame or guilt about
not recovering sooner [443].

• Utilise grounding and other techniques as necessary. If a client is having a very strong
emotional reaction to talking about their trauma, consider the use of techniques outlined for the
management of trauma symptoms provided in Chapter B7 and Appendix CC.

Psychiatric history
Enquire as to whether the client has any current mental health symptoms (such as depression, anxiety,
psychosis), whether they have experienced these in the past, whether they have ever been diagnosed
B3: Identifying co-occurring conditions 111

with a mental disorder, and whether they have ever received any treatment. If the client has experienced
mental health symptoms or has been diagnosed with a mental 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 mental health conditions?

• 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 [444, 445], and will resolve with a period of abstinence without the need for any direct
intervention [35, 37, 102]. It is nonetheless important for symptoms to be managed to prevent the client
from relapsing in the early stages (see Chapter B6). The duration of abstinence may vary depending on
substances used; however, most people should start to experience considerable improvement over a
period of one month [39, 418, 421].

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 their AOD use.

Criminal history
Enquire about past and present criminal behaviour, arrest history, any impending court cases or
outstanding warrants.

Strengths and weaknesses

A client’s strengths and weaknesses can usually be deduced from other information collected during the
assessment process. Some examples of strengths may include good social support, high self-esteem,
and insight. Some weaknesses may be unemployment, risk-taking behaviour, or negative self-image.

Readiness for change

It may be helpful to ascertain how motivated the client is to change their current AOD use. This process
involves an exploration of the client’s perception of the positive and negative aspects of continued AOD
use. Prochaska and DiClemente [446] suggest that clients fall into one of six stages of change, which
clients cycle through dynamically rather than in an ordered linear manner [389], indicating that the focus
of treatment for people in the earlier stages of change should incorporate motivational interviewing/
motivation enhancement techniques to assist the person in progressing to further stages. In general,
clients in the later stages of change have better AOD use and mental health treatment outcomes than
112 B3: Identifying co-occurring conditions

clients in earlier stages [447]. Table 25 summarises these stages and outlines some useful interventions
and motivational strategies for each stage of change. The choice of treatment type can be informed in
part by the client’s readiness to change; for example, harm reduction may be an appropriate treatment
for someone in the pre-contemplation stage, whereas goal setting or relapse prevention may be more
suitable for someone in later stages (e.g., preparation or action stages) [389].

The stages of change model is also relevant in assessing the client’s motivation to receive treatment
for co-occurring mental health conditions. Just because a person has presented for treatment for their
AOD use, this does not necessarily mean that they have 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 they are also ready to deal with the trauma-related symptoms they experience
due to abuse experienced as a child. Appendix H provides a useful matrix for assessing motivation for
both AOD and mental health treatment.

Table 25: Readiness for change

Stage Description Interventions Motivational

strategies

Pre- Not yet considering Aim to raise doubt Establish rapport, build
contemplation behaviour change. about perceptions. trust, ask permission.
Little awareness of, or Link behaviour with Raise concern in the
concern for negative consequences. client about their
consequences. Reduce harm. behavioural patterns
(feedback).
Highlight negative
E.g., ‘I get out of breath, but
consequences.
I feel fine, so I don’t think
there’s a problem with my Build confidence and
smoking’. hope.

Contemplation Considers change but Motivational Normalise ambivalence

rejects it. interviewing can (reflect).
Ambivalence remains. assist in resolving Elicit change talk,
Wavers between reasons ambivalence. self-motivational
to change and reasons Elicit reasons for statements.
to stay the same. change and risks of not
E.g., ‘I see it would be better changing.
for me if I quit smoking,
but it’s the only time of the
day I have for myself’.
B3: Identifying co-occurring conditions 113

Table 25: Readiness for change (continued)

Stage Description Interventions Motivational

strategies

Preparation or Balance tips towards Goal setting, problem- Clarify goals and
determination change. solving, match to strategies for
Window of opportunity needs. Identify risks behaviour change
where client is for relapse, including (affirm).
preparing for change. triggers. With the client’s
E.g., ‘I really want to quit Build self-efficacy. permission, offer
smoking, I just don’t Discuss treatment information and
know how I would do it’. options. guidance.

Action Engage in behaviours Support self-efficacy. Reinforce the

designed to bring Assist with coping and importance of
about change. education. changing.
May occur with or Reinforce positive
without assistance. behaviour.
E.g., ‘After my last Avoid exposure to AOD
appointment, I bought use environment.
some NRT patches’.

Maintenance Sustain change. Reinforce positives Affirm the client’s

Prevent relapse. and assist with lapses. determination and
Self-help groups. self-efficacy.
E.g., ‘I’ve felt great the
last few months, but Provide relapse
I’m wondering if I still prevention techniques.
need to be using the NRT Emphasise client
patches’. alertness. Work
towards longer-term
goals.

Lapse/recurrence Not so much a stage Avoid demoralisation Explore meaning.

in itself, but rather a or judgement.
normal and expected Remain positive.
part of the process.
Normalise the process
Any slip or lapse into of lapsing.
any of the previous
Help re-start the
stages.
stages of change and
E.g., ‘I slipped over the avoid being stuck in
New Year’s break and this stage.
had a few ciggies while
Help the client to learn
watching the fireworks’.
from mistakes.

Adapted from Clancy and Terry [448], Fullerton [449], Figlie and Caverni [450], and Stone et al. [389].
114 B3: Identifying co-occurring conditions

Beliefs about self, others, and the world

Beliefs about how the client sees themselves and the world can provide insight into the client’s self-
esteem, sociability, and trust [389]. Client responses to questions about their worldview can also identify
core maladaptive beliefs, such as emotional deprivation or defectiveness. Assessing early maladaptive
schemas can assist with this process (e.g., Young and Brown [451]).

Standardised screening and assessment

The informal assessment process can be aided by a range of standardised screening and assessment
tools. Standardised tools can be a useful means of gathering data by providing a reliable and valid
view of the client’s difficulties and current life situation [452, 453]. Furthermore, when conducted
appropriately, the process of standardised assessment can be a source of rapport building [454, 455].

Groth-Marnat [425, 456] 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 is an ongoing process, but should be completed upon entry into and exit
from treatment, as well as at follow-up [102, 389]. 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 [457, 458]. Some helpful screening tools have been included in Appendices J – Y.
Standardised tools cover a range of areas that may be relevant to AOD services, including global health,
general health and functioning, and specific mental health conditions. Table 26 lists the standardised
screening and assessment tools discussed in this section.
B3: Identifying co-occurring conditions 115

Table 26: Standardised screening and assessment tools

Instrument Measures Number Administration Where to

of items access
General health and functioning

Camberwell Comprehensive 22 Self or clinician Appendix J

Assessment of assessment and
Need (CAN) outcome of needs
in 22 areas
Client Version
(CANSAS-P)

General mental health instruments

Depression Screening and 21 or 42 Self Appendix K

Anxiety Stress outcomes for
Scale (DASS) depression,
anxiety, stress
and general
psychological
distress
Indigenous Risk AOD problems and 13 Clinician Appendix L
Impact Screen mental health risk
(IRIS)
Aboriginal and
Torres Strait
Islander specific
Kessler Screening for 10 Self or clinician Appendix M
psychological psychological
distress scale distress
(K10)
PsyCheck Screening for 25 or 29 Mixed Appendix N
general mental
health, suicide/
self-harm,
symptoms of
depression and
anxiety
116 B3: Identifying co-occurring conditions

Table 26: Standardised screening and assessment tools (continued)

Instrument Measures Number Administration Where to access

of items
Specific mental health instruments

Adult ADHD Self- Symptoms of 18 Self or clinician Appendix O

Report Scale ADHD
(ASRS)
The Eating Past month Semi- Clinician http://www.credo-
Disorder eating disorder structured oxford.com/7.2.html
Examination psychopathology interview
(EDE)
The Eating Past month 31 Self http://www.credo-
Disorder eating disorder oxford.com/7.2.html
Examination psychopathology
Questionnaire
(EDE-Q)
International PTSD and Complex 18 Self or clinician Appendix P
Trauma PTSD
Questionnaire
(ITQ)
Iowa Personality Personality 11 Self https://help.
Disorder Screen disorder valant.com/79967-
(IPDS) measures/ipds-
iowa-personality-
disorder-screen
Life Events Lifetime exposure 17 Self Appendix Q
Checklist for to traumatic
DSM-5 (LEC-5) events
Primary Care Probable DSM-5 5 Self or clinician Appendix R
PTSD for DSM-5 PTSD
(PC-PTSD-5)
PTSD Check List PTSD symptoms 20 Self Appendix S
for DSM-5 (PCL-
5)
Psychosis Psychosis 7 Clinician Appendix T
Screener (PS) symptoms
B3: Identifying co-occurring conditions 117

Table 26: Standardised screening and assessment tools (continued)

Instrument Measures Number Administration Where to access

of items
Standardised Personality 8 Self https://hal.archives-
Assessment disorder ouvertes.fr/hal-
of Personality 01419303
– Abbreviated
Scale (SAPAS-
SR)

General AOD instruments

Alcohol, Screening for 8 Clinician https://www.who.

Smoking and AOD use and int/publications/i/
Substance risk (lifetime item/978924159938-
Involvement and recent use, 2
Screening Test specific AOD
(ASSIST) use, frequency,
dependence,
abuse, intravenous
use)

Alcohol Use Screening and 10 Self or clinician Appendix U

Disorders outcome of
Identification alcohol use (use,
Test (AUDIT) dependence and
related problems)

CAGE Screening 4 Self or clinician Appendix V

Questionnaire to identify
problematic
alcohol use

Drug Abuse Screening and 10 Self or clinician Appendix W

Screening Test assessment
(DAST-10) to identify
problematic drug
use over past
12-months
118 B3: Identifying co-occurring conditions

Table 26: Standardised screening and assessment tools (continued)

Instrument Measures Number Administration Where to access

of items
Drug Use Screening and 11 Self or clinician Appendix X
Disorders outcome of
Identification drug use (use,
Test (DUDIT) dependence and
related problems)

Michigan Screening and 24 Self or clinician Appendix Y

Alcohol assessment to
Screening Test identify lifetime
(MAST) problematic
alcohol use

Timeline Follow Assessment and Dependent Varied https://www.nova.

Back (TLFB) outcome tool to on time edu/gsc/forms/
collect information period timeline-followback-
on the quantity/ forms.html
frequency/
duration of AOD
use over specific
time period

General health and functioning

Camberwell Assessment of Need (CAN)

The Camberwell Assessment of Need (CAN) is one of the most widely used needs assessment and
treatment outcome tools [459] and has evidence to support its use among people with mental health
conditions [460–462]. It has also been validated for use in Australian populations [463], 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 [459, 464]. Several versions of the CAN exist, including:

• Camberwell Assessment of Need Short Appraisal Schedule (CANSAS): For use in clinical
work. The CANSAS allows the perspective of staff, clients and carers to be separately recorded.
However, due to discrepancies in clinician and client assessments of need, a client rated short-
form measure has been developed and evaluated (CANSAS-P).
B3: Identifying co-occurring conditions 119

• CANSAS-P: A two-page version for clients to complete. Evaluation of the CANSAS-P found it was
able to better identify the needs of clients, particularly unmet needs [459].

• CAN-Clinical (CAN-C): Detailed 22-page assessment, measuring the need rating, help received,
and action plan for each domain.

• CAN-Research (CAN-R): Detailed 22-page assessment, measuring the need rating, help received
and satisfaction for each domain [459].

The CANSAS-P has been recommended as the preferred needs assessment measure for client completion
[459], and is available in Appendix J. Further information about each version can be obtained through the
CAN webpage: https://www.researchintorecovery.com/measures/can/.

General mental health instruments

There is 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 I. It should be noted that some of these tools require specialist training,
or else mislabelling, misinterpretation, or inappropriate use may occur [389, 425, 465]. Some tools are
copyright protected and need to be purchased, and/or require the worker to have specific qualifications.
The requirements of each tool described here (and in Appendix I) 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 [466] comprehensive review of screening tools for use in
AOD settings. This document is available online at http://www.nada.org.au/.

As mentioned earlier in this chapter, screening is designed only to highlight the existence of symptoms,
not to diagnose clients. The possible presence of disorders needs to be assessed by a health professional
who is qualified and trained to do so (e.g., a registered psychologist, or psychiatrist). Most of the
measures described are those of self-report (i.e., they may be self-completed by the client). Others,
however, need to be administered by the AOD worker.

The Depression Anxiety Stress Scale (DASS)

The Depression Anxiety Stress Scale (DASS) [467] has been shown to be a valid and reliable measure
of the dimensions of depression, anxiety, and stress separately but also taps into a more general
dimension of psychological distress [468, 469]. The DASS is available in two forms: the DASS-21 and the
DASS-42. The use of either test is sufficient in the screening process (i.e., the use of both is unnecessary).
The two forms have 21 and 42 items respectively and are each rated on a 4-point scale of how much each
particular statement applies to the person. The DASS is a self-report instrument, and no special skills
are required to administer or score it. However, decisions based on particular score profiles should be
made only by experienced clinicians who have carried out an appropriate clinical examination [467].
Nevertheless, it is a useful tool for screening and assessment and the DASS-21 is included in Appendix K.

For all questions, the client circles the answer truest to them in the past week. Scores are summed for
each scale (D = Depression, A = Anxiety, S = Stress), and the total for each scale multiplied by 2. A guide to
interpreting DASS scores is provided in Table 27.
120 B3: Identifying co-occurring conditions

Currently, no studies have been conducted to validate the DASS as a measure of anxiety among people
with AOD use disorders. However, one study has shown that the DASS can reliably screen for depression
symptoms among people seeking treatment for AOD use [470]. Similarly, another study has shown that
the DASS can be used as a reliable screen for symptoms of PTSD among people with AOD use disorders
[471].

Table 27: Interpreting DASS scores

Depression Anxiety Stress

Normal 0-9 0-7 0-14

Mild 10-13 8-9 15-18

Moderate 14-20 10-14 19-25

Severe 21-27 15-19 26-33

Extremely severe 28+ 20+ 34+

Adapted from Lovibond and Lovibond [467].

The Indigenous Risk Impact Screen (IRIS)

The Indigenous Risk Impact Screen (IRIS) [472] was developed by an expert group of Indigenous and
non-Indigenous researchers in Queensland to assist with the early identification of AOD problems and
mental health risks. This screening tool has been shown to be reliable, simple, and effective [473]. It has
also been validated for use in Indigenous prison populations [474, 475]. The IRIS consists of 13 items
which are asked by the AOD worker. The IRIS is made up of two sets of questions, with items 1–7 forming
the ‘AOD risk’ component and items 8–13 forming the ‘mental health and emotional wellbeing risk’
component. The items assessing mental health and emotional wellbeing focus on symptoms of anxiety
and depression. The client chooses the answer from a list of response options which best describes
their current situation. After tallying up the corresponding numbers, a score of 10 or greater on the AOD
component indicates problematic use of AOD is likely, while a score of 11 or greater indicates the need for
further assessment or brief intervention regarding mental health and emotional wellbeing [473]. The IRIS
is included in Appendix L.

Kessler psychological distress scale (K10)

The Kessler psychological distress scale (K10) [476] is a widely used, simple self-report measure
of psychological distress which can be used to identify those in need of further assessment for anxiety
and depression (Appendix M). This measure was designed for use in the general population; however, it
may also serve as a useful clinical tool. The K10 comprises 10 questions that are answered using a five-
point scale (where 5 = all of the time, and 1 = none of the time). For all questions, the client circles the
B3: Identifying co-occurring conditions 121

answer truest for them in the past four weeks. Scores are then summed with the maximum score of 50
indicating severe distress, and the minimum score of 10 indicating no distress. A guide to interpreting
K10 scores is provided in Table 28.

A number of studies have been conducted to test the reliability and validity of the K10, and its brief
version, the K6. Good reliability and validity have been found when these measures have been used
among people with AOD use disorders, as well as in the general population [477–480].

Table 28: Severity of psychological distress according to K10 score

K10 score Level of psychological distress

10-15 Low

16-21 Moderate

22-29 High

30-50 Very high

Adapted from Andrews and Slade [481].

PsyCheck
The Australian PsyCheck screening tool (Appendix N) has been shown to be a valid and useful resource
for clinicians [482]. The screening tool has three sections:

• A general mental health screen, including history of treatment.

• Suicide/self-harm risk assessment.

• The Self Reporting Questionnaire (SRQ) [483], a 20-question screening tool that assesses for
current symptoms of depression and anxiety. Clients are asked to indicate which symptoms they
have experienced in the past 30 days, and of those, which have been experienced when not using
AOD. The clinician should count the number of ticks and put the total number at the bottom of the
page.

The PsyCheck manual [482] 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 symptomatology, further assessment may be warranted.
The PsyCheck screening tool has been shown to have good test-retest reliability among people using
AOD services [484]. More information on the PsyCheck screening tool is available at https://www.
turningpoint.org.au/treatment/clinicians/screening-assessment-tools.
122 B3: Identifying co-occurring conditions

Specific mental health instruments

Brief descriptions of selected instruments for specific mental health conditions are provided below.
Further disorder-specific assessment measures can be found on the DSM-5 website: https://www.
psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures.

Adult ADHD Self-Report Scale (ASRS)

The World Health Organisation developed the Adult ADHD Self-Report Scale (ASRS) as a means of
assessing symptoms of ADHD in adults. The full version of the scale contains 18 items, but the short
screener version contains 6 items and has been shown to outperform the original 18-item scale [485].
The 6-point scale involves respondents assessing the frequency of ADHD symptoms over the past
six months, on a 5-item scale ranging from ‘never’ to ‘very often’. The 6-item screening tool has been
validated for use in AOD populations [486–488], demonstrating that it is an appropriately sensitive tool
for screening for the presence of ADHD among people with co-occurring conditions. The ASRS is included
in Appendix O.

The Eating Disorder Examination (EDE) and Questionnaire (EDE-Q)

The Eating Disorder Examination (EDE) [489] is a diagnostic interview. The EDE-Q is the
questionnaire form of the EDE, and both are considered the ‘gold standard’ measures of ED
psychopathology [490, 491]. As an interview, the EDE is designed to be administered by a clinician, and the
developers recommend clinician training to ensure that all concepts being assessed are well-understood
[492]. However, the EDE-Q is a self-report measure, which can be completed individually, or with the help
of a clinician (explaining concepts such as binge eating).

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) [493]. A number of shorter
versions of the EDE-Q have been validated for ED psychopathology [494–497]. The EDE-Q has been
validated for use among people with AOD use disorders [498]. Both instruments are available for free
download from https://www.credo-oxford.com/7.2.html.

The International Trauma Questionnaire (ITQ)

The International Trauma Questionnaire (ITQ) is a brief measure used to identify possible PTSD
and CPTSD [499] as defined by ICD-11. An indicative diagnosis of PTSD requires that a person must
endorse having experienced at least one symptom from each of the three core symptom clusters (re-
experiencing in the here and now, avoidance, or sense of current threat) as ‘moderately’, ‘quite a bit’, or
‘extremely’ in the past month, as well as functional impairment associated with these symptoms. An
indicative diagnosis of CPTSD requires that in addition to meeting criteria for a diagnosis of PTSD, a
person must endorse having experienced at least one symptom from each of the three disturbances in
self-organisation clusters (affective dysregulation, negative self-concept, disturbances in relationships).
A person can receive an indicative diagnosis of either PTSD or CPTSD – not both (i.e., if criteria for CPTSD
B3: Identifying co-occurring conditions 123

is met, the person does not also receive an indicative diagnosis of PTSD [499]). At the time of writing, no
studies have been conducted to validate the ITQ as a measure of PTSD or CPTSD among people with AOD
use disorders. The ITQ is included in Appendix P.

The Iowa Personality Disorder Screen (IPDS)

The Iowa Personality Disorder Screen (IPDS) is a brief 11-item screen originally administered
alongside a brief interview [500], but has since been adapted into a self-report measure [502]. The
screening tool asks people to indicate whether or not they identify with common traits found among
people with personality disorders, including both general personality disorder criteria as well as specific
criteria. Research suggests that identifying with five or more of these traits is indicative of a probable
personality disorder among people attending AOD treatment [503]. The IPDS has demonstrated good
diagnostic accuracy, sensitivity, specificity, concurrent validity, and internal consistency among people
attending AOD treatment [503, 504], as well as good psychometric properties among people attending
mental health treatment [505]. A comparison of screening tools for personality disorders found that
the IPDS is one of the most reliable and valid screening instruments for personality disorders [506]. The
IPDS is available to download from https://help.valant.com/79967-measures/ipds-iowa-personality-
disorder-screen.

Life Events Checklist for DSM-5 (LEC-5)

The Life Events Checklist (LEC-5) for DSM-5 is a self-report measure designed to screen for
lifetime exposure to 17 potentially traumatic event types [507]. There is no formal scoring protocol or
interpretation, other than identifying whether a person has experienced one or more of the events listed.
For each event type, respondents indicate whether they experienced the event themselves, witnessed it,
learned about it and/or experienced it as part of their job. The LEC-5 is commonly administered with the
PTSD Checklist for DSM-5 (PCL-5). At the time of writing, no studies have been conducted to validate the
LEC-5 among people with AOD use disorders. The LEC-5 is included in Appendix Q.

The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)

The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) [508] is a very brief 5-item screening tool
designed for use in primary care and other medical settings to identify probable PTSD [508]. The tool
includes an introductory sentence to cue respondents to traumatic events; however, the tool does not
include a list of potentially traumatic events. While the PC-PTSD-5 has not yet been validated for use
among people with AOD use disorders, the reliability and validity of its predecessor (used to screen for
PTSD based on DSM-IV criteria) has been established among people with AOD use disorders [509, 510].
This scale is included in Appendix R.

PTSD Checklist for DSM-5 (PCL-5)

The PTSD Checklist for DSM-5 (PCL-5) is a 20-item self-report measure that assesses the 20 DSM-
5 symptoms of PTSD [511]. Responses for each symptom are answered using a five-point scale (where
4 = extremely, and 0 = not at all). The PCL-5 can be administered in three formats: without Criterion A
124 B3: Identifying co-occurring conditions

(overview of instructions and items only), which is appropriate when trauma exposure is measured
by some other method; with a brief Criterion A assessment; or with the LEC-5 and extended Criterion A
assessment.

DSM-5 symptom cluster severity scores can be obtained by summing the scores for the items within
a given cluster; that is, cluster B (items 1-5), cluster C (items 6-7), cluster D (items 8-14), and cluster E
(items 15-20). These scores can be summed to obtain a total PTSD symptom severity score out of 80.
Initial research suggests that a PCL-5 cut-off score between 31-33 is indicative of probable PTSD across
samples [512]. A provisional PTSD diagnosis can be made by treating each item rated as 2 = ‘Moderately’
or higher as a symptom endorsed, then following the DSM-5 diagnostic rule which requires at least: 1 B
item (questions 1-5), 1 C item (questions 6-7), 2 D items (questions 8-14), 2 E items (questions 15-20). At
the time of writing, no studies have been conducted to validate the PCL-5 among people with AOD use
disorders. The PCL-5 is included in Appendix S.

The Psychosis Screener (PS)

The Psychosis Screener (PS) [513] is an interview-style questionnaire rather than self-report and is
therefore administered by the AOD worker (Appendix T). It uses elements of the Composite International
Diagnostic Interview (CIDI) to assess the presence of characteristic psychotic symptoms. The PS has
been shown to have a moderate ability to discriminate between those who meet diagnostic criteria for
psychotic disorders and those who do not in community and prison samples [513, 514]. The PS consists of
seven items; the first six items cover the following features of psychotic disorders: delusions of control,
thought interference and passivity, delusions of reference or persecution, and grandiose delusions. The
final item records whether a respondent has ever received a diagnosis of schizophrenia. While there is
no official cut-off score, the screener may be useful as a guide in assessing for possible symptoms of
psychosis. More information about the interpretation of scores can be found:
https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/TR.210.pdf.

The Standardised Assessment of Personality – Abbreviated Scale (SAPAS-SR)

The Standardised Assessment of Personality – Abbreviated Scale (SAPAS-SR) is a brief screen
originally administered alongside a brief interview [515], but has since been adapted into a self-report
measure [501]. People are asked to indicate whether or not they identify with eight traits commonly
found among people with personality disorders (e.g., dependence on others), with a score of three or
higher indicating a likely personality disorder. The SAPAS-SR demonstrates good diagnostic accuracy,
sensitivity, specificity, and internal consistency among people attending AOD treatment [503], as well as
among people attending mental health treatment [516]. A comparison of screening tools for personality
disorders determined that the SAPAS-SR is one of the most reliable and valid screening instruments for
personality disorders [506]. The SAPAS-SR is available to download from https://hal.archives-ouvertes.
fr/hal-01419303.
B3: Identifying co-occurring conditions 125

General AOD instruments

Although AOD workers are likely to be familiar with the range of tools available for screening and
assessing for AOD use, we have included a brief overview for others who may be less familiar with these
tools. As with the screening and assessment of mental health conditions, the screening process for AOD
is not diagnostic, but can be useful for identifying those in need of further assessment and treatment
[466].

Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)

The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is an 8-item clinician
administered tool to assess for problematic use of tobacco, alcohol, cocaine, cannabis, amphetamine-
type stimulants, sedatives, inhalants, hallucinogens, opioids and other drugs [517]. The ASSIST was
developed for the World Health Organisation to assess the frequency and recency of use, dependence and
use-related problems, with a risk score for each substance indicating low, moderate or high risk [518].
The level of risk category determines the need for, and most appropriate intervention depending on level
of use (none, brief or referral). The ASSIST tool and manual can be freely accessed https://www.who.int/
publications/i/item/978924159938-2.

Alcohol Use Disorders Identification Test (AUDIT)

The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item screening instrument developed
by the World Health Organisation, which can be either self or clinician administered, and is designed to
assess harmful alcohol use, abuse and dependence [519]. No specific training is required to administer or
score the AUDIT. Scores on each of the 10 items are summed (questions 1 to 8 are scored on a 0 to 4 scale
and 9 and 10 are scored 0,2,4), with a score of 8 or more indicating hazardous or harmful alcohol use [519].
The maximum score is 40. The AUDIT is included in Appendix U.

The CAGE Questionnaire

The CAGE questionnaire is a widely used screening tool to identify problematic alcohol use among
adults [520]. The CAGE consists of 4-items which can be self-completed, or clinician administered. ‘CAGE’
refers to the four questions contained in the measure: Cut down, Annoyed, Guilty, Eye-opener, with items
scored 0 (no) or 1 (yes), and then summed. Higher scores in general indicate possible problematic alcohol
use [520]. The CAGE is included in Appendix V.

The Drug Abuse Screening Test (DAST)

The Drug Abuse Screening Test (DAST-10) is a brief, 10-item version of the 28-item DAST measure.
The DAST-10 can be self or clinician administered and is designed to identify problematic substance use
over the past 12-months in a similar style to the MAST [521]. In addition to the original 28-item and 10-
item DAST, a 20-item version has also been made available. In the 10-item instrument, ‘Yes’ responses are
scored as 1, with the total summed apart from question 3, which is reverse scored (i.e., scored 1 for ‘no’)
[521]. The DAST-10 is included in Appendix W.
126 B3: Identifying co-occurring conditions

The Drug Use Disorders Identification Test (DUDIT)

The Drug Use Disorders Identification Test (DUDIT) is an 11-item tool, which can be self or clinician
administered, developed as a parallel to the AUDIT to identify problematic past year AOD use [522]. As
with the AUDIT, items 1 to 9 are scored on a 0 to 4 scale, with the final two questions scored 0, 2, 4. The
maximum score is 44. Scoring guidelines suggest that a score of 6 or more among men, and 2 or more
among women, may be indicative of drug-use-related problems. A score of 25 points or more, regardless
of sex, is strongly indicative of dependence [522]. The DUDIT is included in Appendix X.

The Michigan Alcohol Screening Test (MAST)

The Michigan Alcohol Screening Test (MAST) is a 24-item self-report tool designed to identify
lifetime problems with alcohol use [523]. Several modified versions of the MAST have been developed,
varying in length (e.g., the Short MAST or SMAST, containing 13-items; the Brief MAST or bMAST, containing
10-items), and for use in different population groups (e.g., MAST-Geriatric version, MAST-Adolescent
version). The MAST can either be scored using a weighted scoring system or by assigning one point
per item, with higher scores indicative of more problematic alcohol use in both methods. Treatment
recommendations are based on weighted scores, with scores from 0 to 4 indicating no need for further
action; 5 to 6 indicating a need for further evaluation by a healthcare professional; and 7 to 53 indicating
a need for comprehensive AOD use evaluation by a healthcare professional [524]. The MAST is included in
Appendix Y.

The Time Line Follow Back (TLFB)

The Time Line Follow Back (TLFB) is designed for collecting self-reported, retrospective estimates
of AOD use and is extensively used to assess daily AOD use in research and practice [525]. The TLFB can
be used as a weekly tool to assess daily AOD use during treatment, as well as assisting people identify
patterns in their daily routines and relationships between AOD use and other areas of their lives [526].
When using the TLFB, a designated period of time, such as a week or several months, is specified with the
use of a calendar. Respondents are asked to fill out the amount of AOD used each day of the calendar in
the specified time frame (e.g., if asking about alcohol, the number of standard drinks each day). To assist
with recall, respondents are encouraged to use diaries or appointment books, and reflect on AOD use
during different times of the week (e.g., weekday vs weekend). Sample calendars and instructions can be
freely accessed for clinical purposes: https://www.nova.edu/gsc/forms/timeline-followback-forms.
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 [389, 527]:

• Focus first on the client’s strengths.

• Gently and tactfully outline the client’s difficulties.

B3: Identifying co-occurring conditions 127

• Phrase the assessment in terms that are appropriate for the client.

• Focus on the pattern of results rather than just an overall score.

• Interpret the results in the context of the client’s personal history.

• Pull the assessment results together and offer hope for the future by discussing a treatment plan.

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 this has been made by a
suitably qualified mental health professional (e.g., a registered 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 they reduce or stop AOD use. As discussed
in Chapter A4 and Chapter B7, if symptoms are substance-induced, they are likely to dissipate if the
person reduces or stops their use. On the other hand, the client’s mental health symptoms may increase
when they reduce or stop using, particularly if they have been using to self-medicate their symptoms. It
is important that the client knows that you will be monitoring these symptoms to determine whether
further treatment may be required. AOD workers may find the wellbeing plan located in the Worksheets
section of these Guidelines useful for helping clients identify strategies for managing their triggers and
warning signs. In addition, the wellbeing plan may help clients identify things that are important to them,
trusted people they can talk to, and what professional support they can access.
B4: Assessing risk
B4: Assessing risk 129

B4: Assessing risk

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 co-occurring 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 and 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.

Risk assessment
It is important to assess the risk a client poses to themselves or others in the informal assessment
interview (described in Chapter B3) and to monitor this throughout treatment. This chapter focuses on
two areas of risk: suicide and domestic or family violence. It should be borne in mind, however, that there
are several other areas of risk that should be assessed and monitored throughout treatment, including
self-harm, homicidal thoughts/attempts, and child welfare, as well as the evaluation of safety regarding
sexual practices, injecting practices, and other high-risk behaviours as appropriate. In any situation
where the risk of harm to self or others is perceived to be significant, other services may need to be
enlisted (e.g., police, ambulance, crisis teams).

Suicidality
The term ‘suicide’ is used in reference to any self-inflicted injury resulting in death, where death was the
deliberate intention [528]. 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). The term ‘commit’ suicide is a remnant from when the act of
suicide was a criminal offence and also has religious associations (i.e., to ‘commit’ a crime or a sin). The
last Australian jurisdictions to decriminalise suicide were the Australian Capital Territory in 1990 and the
130 B4: Assessing risk

Northern Territory in 1996 [529]. Just as non-stigmatising language should be used when referring to a
person with an AOD use disorder or a mental disorder (e.g., not using the terms ‘addict’ or ‘schizophrenic’),
it is important that discussions involving suicide remain non-stigmatising. Clients of AOD treatment
services are at high-risk of suicide [530–532]. The presence of co-occurring mental disorders further
increases this risk [533–537]. A thorough assessment of suicide risk should take place in the initial
consultation phase. However, suicide risk should also be assessed and monitored throughout treatment,
particularly at pivotal points in treatment and at times of increased risk (e.g., during periods of instability,
when experiencing additional stressors), as suicide risk is a dynamic process that is subject to change
over time [389]. If a person presenting to treatment is not at risk of suicide at intake, it should not be
assumed their low level of risk will remain the same. How to assess for suicide risk, and appropriate
responses to varying levels of risk, is explained in depth below. Table 29 outlines the dos and don’ts in
regard to the management of suicidality.

Table 29: Dos and don’ts of managing a client who is suicidal

Do:

Ensure the client has no immediate means of self-harm; remove weapons and potentially
dangerous objects.

Talk to the client alone – without any family or friends present.

Allow sufficient time to discuss the issue.

Discuss limits of confidentiality.

Introduce suicide in an open, yet general way (e.g., ‘sometimes people feel so overwhelmed they
think about suicide, is this something you’ve thought about?’).

Ask the client about suicide directly. An indirect question may be misunderstood.

Use clear unambiguous language that is non-threatening (e.g., ‘thinking about suicide’, ‘killing
yourself’).

Be non-judgemental and empathetic.

Emphasise that there is help available.

Validate the client’s feelings and emphasise the fact that speaking with you is a positive thing.

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).

Contact the local mental health crisis team if the client appears to be at high-risk.
B4: Assessing risk 131

Table 29: Dos and don’ts of managing a client who is suicidal (continued)

Don’t:

Invalidate the client’s feelings (e.g., ‘All you have to do is pull yourself together’, ‘Things will work
out’).

Panic if someone starts talking about their suicidal feelings. These feelings are common and
talking about them is an important, encouraging first step.

Be afraid of asking about suicidal thoughts. Most clients are quite happy to answer such
questions.

Worry that questions about suicide may instil the idea in the client’s mind or embarrass the client.

Leave a high-risk client unattended.

Adapted from NSW Department of Health [431] and Stone et al. [389].

The assessment of suicide risk is a process through which an AOD worker directly enquires about
suicidal thoughts (frequency, intensity, plans, intent), history of suicidal behaviour and self-harm,
current stressors, hopelessness, and protective factors (e.g., family, friends, other services). While self-
harming behaviour is a risk factor for suicide, it should be noted that self-harm may not always be
indicative of suicide risk. For some people, self-harm may function as a mechanism for coping with
distress without there being an intention to die. Irrespective of intention, it is important to consider the
lethality of self-harm behaviours in assessing risk.

Discussing suicide with clients is vital and does not increase the risk of suicidal behaviour [389,
538, 539]. Rather, sensitive questioning by a healthcare worker can be a relief for clients who have
been harbouring thoughts of self-harm or suicide, and provides an opportunity to manage this risk
appropriately, either within the AOD service, or in collaboration with mental health and emergency
services [540, 541].

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 [542, 543].

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 [544, 545]. The SAK is a
comprehensive assessment and policy package, specifically developed to help AOD services assess and
manage suicide risk. It contains four key resources for AOD staff and managers (see Table 30):

• A suicide risk screener.

• A suicide risk formulation template.

• A safety plan.

• A suicide policies and procedures pro forma.

132 B4: Assessing risk

Table 30: Suicide Assessment Kit key resources

Resource Purpose

Suicide risk screener Designed for use at specific time points in treatment (i.e.,
admission, transition points, discharge), or when the client is
suspected to be at increased risk of suicide.

Suicide risk formulation template Designed to help AOD workers develop a comprehensive
picture of background factors that may contribute to a client’s
risk of suicide, as well as strengths and protective factors
that can be incorporated into management and treatment.

Safety plan Designed to help AOD workers develop a plan with a client on
how to manage suicidal thoughts when they occur.

Suicide policies and procedures pro Designed to help agencies develop policies and procedures
forma for the assessment and management of suicide risk, as well
as documentation regarding file and 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 Z) rely on AOD workers incorporating their
knowledge, judgement, expertise, and skill in the assessment of risk. Figure 13 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.
B4: Assessing risk 133

Figure 13: Shared risk assessment space between AOD workers and AOD clients

Suicide Risk Screener

As mentioned, the Suicide Risk Screener was developed as part of the SAK in response to research that
highlighted the need for improved assessment and management of suicide risk in AOD residential
rehabilitation programs Australia-wide [543]. It can be used to assist in assessing clients’ level of risk,
determining what intervention and management strategies are required, and in developing a safety plan
to reduce risk [545]. The Suicide Risk Screener, scorer, and interpretation are located in Appendix Z.

When to complete the Suicide Risk Screener

It is vital that suicide risk assessment be conducted at various points throughout treatment, and
should not be viewed as a one-off event. Assessing risk should be conducted at particularly significant
transition points within treatment (e.g., intake, discharge), as well as times when crisis is clearly visible
[389, 545]. In addition to conducting risk assessments at fixed points throughout treatment, it is
important that AOD workers respond to their own informal assessment and conduct additional screening
depending on a client’s presentation, behaviour, personal situation and/or circumstances, or ominous
statements [545].
134 B4: Assessing risk

Warning signs for suicide

Research has identified the importance of both warning signs and risk factors for suicide in conducting
suicide risk assessments [546, 547]. Warning signs for suicide are specific to the current state of the
person (e.g., behaviours preparing for suicide), and indicate a heightened risk in the near-term (e.g.,
minutes, hours, or days). In contrast, risk factors are often long-lasting and increase suicide risk over
time (e.g., lifetime psychiatric diagnoses, past suicide attempts) [546, 547].

Warning signs may be immediately apparent at intake or may arise during treatment. The presence of
warning signs indicates that screening and information gathering regarding suicidality is required.
Warning signs can be either direct, requiring immediate attention, or indirect, which are less identifiable
[546–548]. Direct signs include [545, 549]:

• Suicidal communication: A client threatening to hurt or kill themselves or talking about wanting
to do so. Suicidal communication 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 themselves by seeking access to pills,
rope, or other means.

• Making plans: A client talking or writing about death, dying, or suicide, when these behaviours 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 [545, 546]. Any
changes in normal thoughts, emotions, or behaviours can indirectly indicate that a client is in crisis
[389, 548], but the most common of these changes are sleep disturbances, anxiety, agitation, and
hopelessness [548]. These factors are critical in assessing level of suicide risk. The mnemonic ‘IS PATH
WARM’ (see Table 31) may be useful in assisting AOD workers remember common warning signs [550],
with each letter corresponding to a specific warning sign experienced or reported in the last few months
[551].

Table 31: IS PATH WARM model for common suicide warning signs

Mnemonic Warning sign Explanation

I Ideation Has the client expressed a desire to kill themselves, with

a method that they have access to, or can access (e.g.,
weapon, pills), or an intention to obtain a method for the
purpose of killing themselves?

S Substance use Has the client recently relapsed?

P Purposelessness Does the client express a lack of purpose in life, or reason

for living?
B4: Assessing risk 135

Table 31: IS PATH WARM model for common suicide warning signs (continued)

Mnemonic Warning sign Explanation

A Anger Does the client express feelings of rage, uncontrolled

anger, or revenge-seeking?

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?

W Withdrawal Does the client indicate a desire to withdraw from

significant others, or have they already begun
withdrawing?

A Anxiety Does the client feel anxious, agitated, unable to relax,

and/or report disturbances in sleep?

R Recklessness Does the client act recklessly without thinking or

considering the consequences?

M Mood changes Does the client report dramatic shifts in emotions?

Adapted from Juhnke et al. [551] and Deady et al. [545].

Other mnemonics that AOD workers may find useful include ‘SIMPLE STEPS’, for assessing the severity
of suicide ideation [552, 553], and ‘SHORES’, for assessing protective factors [554]. These mnemonics are
illustrated in Table 32 and Table 33.

Table 32: SIMPLE STEPS model for assessing severity of suicidal ideation

Mnemonic Warning sign Explanation

S Suicidal Is the person expressing suicidal ideation?

I Ideation What is their suicidal ideation?

M Method How detailed is the person’s suicidal method and is their

method accessible?

P Perpetuation How intense is their emotional pain?

136 B4: Assessing risk

Table 32: SIMPLE STEPS model for assessing severity of suicidal ideation (continued)

Mnemonic Warning sign Explanation

L Loss Have they experienced actual or perceived losses (e.g.,

relationships or material objects)?

E Earlier attempts Have there been previous suicide attempts? What did
they involve? What happened afterwards?

S Substance use Is the person currently using substances or have they

recently relapsed?

T Trouble shooting (lack Are they able to see any alternatives or options other than
of) suicide?

E Emotions and diagnosis Assessment of emotional factors and diagnoses

commonly associated with suicide (e.g., hopelessness,
helplessness, worthlessness, loneliness, depression).

P Protective factors (lack Internal or external factors that might reduce the risk
of) of suicide (e.g., individual resilience, family/community
support).

S Stressors and life events Evaluation of current and previous stressors.

Table 33: SHORES model for assessing protective factors

Mnemonic Factor Explanation

S Skills and strategies to Emotional regulation, adaptive thinking, engaging in

cope interests or hobbies.

H Hope Hope and goals for the future, in addition to a sense of

purpose to obtain those goals.

O Objections Moral, cultural or spiritual beliefs that may protect

against suicide.

R Reasons to live and Reasons to stay alive include family or carer

Restricted means responsibilities (e.g., to a person’s children). Restricted
means refers to reducing access to methods which
might be used in suicide (e.g., medications, poisons).
B4: Assessing risk 137

Table 33: SHORES model for assessing protective factors (continued)

Mnemonic Factor Explanation

E Engaged care Active engagement in a therapeutic relationship.

S Support Involvement in supportive relationships, including

family, community, friends.

The risk of suicide can increase during times of significant events, stress, upheaval, or trauma. It is likely
that warning signs will be more pronounced during such times. These risk factors might include [389,
545, 550]:

• Relationship break-up/significant relationship problems.

• Trauma.

• Impending legal event.

• Child custody issues.

• Past history/family history of suicide or suicide attempt, or recent suicide of friend.

• Loss of a loved one.

• Financial crisis, job loss, employment set back.

• Family conflict or breakdown.

• Chronic pain or illness.

• AOD relapse.

• AOD intoxication.

• Recent discharge from treatment service.

• Social isolation.

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 [389, 538,
539]. 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 their 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 [555].
138 B4: Assessing risk

Protective factors
In conducting a suicide risk assessment, it is also important to consider protective factors [556].
Protective factors can be any values, beliefs, supports or reasons that a person may have for living.
Protective factors can vary, but their existence offers protection against suicide, with more stable factors
offering greater protection than fewer unstable factors [545]. For example, a person with hopeful plans for
the future, with good physical health and a stable daily routine may be less likely to attempt suicide than
an isolated, physically unwell person with no social support. It is critical to note, however, that no single
protective factor is a reliable indicator that a person is completely safe [545]. The mnemonic ‘SHORES’
(see Table 33) may be useful in assisting AOD workers remember protective factors.

Some examples of protective factors include [545]:

• Strong social connections (i.e., one or more people that a person feels comfortable confiding
in) which may be family, a partner, peers or a community a person feels part of. For this to be an
effective protective factor, the person must be willing to seek help from their social supports if
needed (i.e., their existence alone is not protection).

• Stability across multiple areas of a person’s life, such as housing, employment, daily routine,
physical health, religious or cultural values.

• Hopeful plans for the future.

• Personal skills and attributes which may offer protection against suicidal thoughts and
behaviours, such as resilience, problem solving skills, strong self-esteem, self-worth, optimism,
and empathy.

Safety plan
As described in the SAK, a safety plan is a strategy put in place between a healthcare practitioner and
client on how to manage suicidal thoughts [545]. Some strategies that might be included in a safety plan
are:

• Identifying warning signs.

• Preparing safety strategies, including identifying protective factors.

• Strategies for staying safe.

• Names and emergency contacts of supportive people, AOD workers, other key agencies involved in
treatment.

Responding to chronic suicidality

An additional challenge for AOD workers is managing and responding to chronic suicidality, which is
experienced by some clients, particularly those who have experienced complex trauma [135, 389, 557].
Chronic suicidality may vary in intensity over time, and the difficulty for clinicians is to determine when
to intervene. It is important for clinicians to be able to identify and distinguish the differences between
acute and chronic suicidality, as chronic suicidality is managed slightly differently [135, 389]. The NHMRC
B4: Assessing risk 139

[555] suggests:

• 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 [555]:

• Changes in the usual pattern or type of self-harm.

• Significant change in mental state (e.g., sustained and severe depressed mood, worsening of a
major depressive episode, severe and prolonged dissociation, appearance of psychotic states).

• Worsening of AOD use disorder.

• Presentation to health services in a highly regressed, uncommunicative, or withdrawn state.

• Recent discharge from psychiatric facility (within last few weeks).

• Recent discharge from psychiatric treatment due to breach of treatment contract.

• Recent adverse life events (e.g., loss or breakdown of significant relationship, legal, employment or
financial problems).

Figure 14 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).

Figure 14: Estimating the probable level of suicide risk

HIGH ACUTE
CHRONIC HIGH-RISK
HIGH LETHALITY
METHOD OF
SELF-HARM

CHRONIC
NEW PATTERN
PATTERN OF
OF SELF-HARM
SELF-HARM
BEHAVIOUR
BEHAVIOUR

LOW-LETHALITY
METHOD OF
SELF-HARM
CHRONIC NEW
LOW-RISK EMERGING
RISK

Source: NHMRC [555], adapted from Spectrum: http://www.spectrumbpd.com.au/

140 B4: Assessing risk

In terms of responding to the differing levels of risk presented in Figure 14 [555]:

• If a client is at chronic low-risk (the bottom left-hand quadrant of Figure 14), 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 left-hand quadrant of Figure 14). 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 14), 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
14), 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.

Domestic and family violence

AOD use has been associated with both the perpetration and victimisation of domestic and family
violence including physical, sexual and emotional abuse [558–563]. There has also been increasing
recognition of coercive control as a form of domestic and family violence.

Evidence suggests that up to two thirds of women attending AOD treatment have experienced violence
[564]. Although domestic and family violence is commonly characterised as males using violence
against females, this is not the only form of family violence. Other relationships can experience family
violence, including same-sex, non-spousal, and carer relationships, and can involve children [563, 565,
566].

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 34.
B4: Assessing risk 141

Table 34: Key issues in domestic and family violence and implications for AOD workers

Key factor Significance Implication for AOD worker

AOD use The relationship between AOD use and family Attempt to identify power and control
violence is thought to be bi-directional (i.e., strategies employed by those using
AOD use can increase the risk of violence violence, whilst supporting and
and vice versa) [567–569]. preserving the abused person’s safety
[570, 571].

Gender In general, women and children are Family violence also occurs in
victimised more than men, and men are non-spousal, same-sex, and carer
more likely than women to use violence in relationships, and can involve
relationships. Women are also more likely children [565, 566]. Risk assessment
than men to be injured through family is warranted for all clients, which
violence, and therefore express fear [572– should include exposure to, and use
574]. of, violence in relationships [563, 565,
575].

Co-occurring Not all families with AOD and mental health Responding to AOD and mental
conditions conditions have family violence, but families health conditions needs to be broad,
with AOD and mental health conditions comprehensive, and involve multiple
and family violence are at increased risk services in a cohesive, coordinated
of experiencing other problems, such response (see Chapter B5).
as co-occurring psychiatric conditions,
physical health problems, housing and/
or employment problems, socioeconomic
disadvantage, and social isolation [563, 576].

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 reasons
include [577, 578]:

• 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.

• Grief for loss of partnership.

142 B4: Assessing risk

• Feelings of guilt and self-blame.

• Fear of losing children or having children removed.

Additionally, some people may have difficulty recognising that they are in a violent relationship, may
have maladaptive internal beliefs about relationships, or may fear reinforcing negative racial stereotypes
[579]. Domestic violence may also be normalised within some cultures, which can make it difficult for
those involved to recognise the behaviours as abuse [577]. It is also important to recognise that many of
these internal beliefs may not fall within a person’s conscious awareness. For all of these reasons, leaving
a violent relationship has been described as a process that takes time, rather than being a one-off event
[579].

The strategies listed in Table 35 may be helpful for AOD workers managing clients experiencing
domestic or family violence. It should be noted that clients may be reluctant to disclose issues relating
to domestic or family violence for a number of reasons, such as a desire for privacy, anxiety about the
consequences of disclosure (e.g., from the perpetrator or society), anxiety about the impact of disclosure
on parental custody, new services being intimidating, and lack of trust in practitioners [580]. 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 35: Dos and don’ts of managing a client experiencing domestic and family
violence

Do:

Be open, approachable, and trustworthy.

Take the client seriously. Tell them you believe them and emphasise that it is not their fault.

Affirm the perpetrator’s responsibility for their violence, even in the presence of AOD use. Let the
client know how much you appreciate how difficult it is to talk about.

Seek to build the client’s confidence and empower them – it takes courage and strength to survive
violence.

Let the client dictate the pace and encourage their progress.

Listen to what the client says about what they want, and how they view their level of danger. Most
people only reveal a small amount of the abuse they have endured – only they know how much
danger they are in.

Explore options and choices, including ways of increasing the client’s safety and the safety of any
children – whether they choose to leave the situation or not.

Establish ways to maintain contact safely.

B4: Assessing risk 143

Table 35: Dos and don’ts of managing a client experiencing domestic and family
violence (continued)

Don’t:

Undermine the client by making them feel inadequate for not seeking help earlier. Remember they
may have sought help earlier or may not have been able to.

Patronise or speak down to the client.

Give your own opinion, be judgemental, or decide who in the relationship is to blame.

Rush the client or tell them what they should do.

Give up or display frustration 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.

Adapted from the Stella Project [578], ATODA [581], and Heward-Belle et al. [570].

Safety plan
Safety planning is an essential component of assisting people who experience domestic or family
violence. As having a physical copy of a safety plan could be risky for a person experiencing violence,
a copy of the plan should be kept in the client’s files and reviewed regularly [581, 582]. The safety plan
should:

• Include emergency contact numbers.

• Identify a friend/neighbour/family member who can provide assistance.

• Identify one or more places of safety, means of getting there safely, as well as secure locations to
store valuables, emergency items, and documents.

• Identify safe ways to access finances in an emergency.

• Encourage the client to establish a distress code to be used with trusted friends/family members
that will trigger them to call emergency services.
B5: Coordinating care
B5: Coordinating care 145

B5: Coordinating care

Key points
• People with co-occurring 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, and family issues).
• 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.

There has been increased recognition of the need for a holistic approach to health care, which is better
able to incorporate services that reflect a person’s need for housing, employment, education, training,
community, justice, and other support services in the delivery of appropriate mental health care [583,
584]. As described in Chapter B1 and Chapter B3, people with co-occurring mental health and AOD use
disorders often present to treatment with numerous additional issues that need to be addressed during
the course of treatment, including physical health, housing, employment, education and training, legal,
and family issues. These issues can often be interrelated, such as difficulty obtaining employment due
to a lack of secure housing and/or childcare [585]. It can be extremely difficult for a person to maintain
progress in relation to their mental health or AOD use if they do not know where they are going to live, or
how they are going to feed themselves or their family. Therefore, addressing these fundamental issues as
part of treatment is essential, and is also in line with the approach of ‘treating the person, not the illness’
[9, 389, 586].

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
146 B5: Coordinating care

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 their
situation differently – the key is to support and guide clients and facilitate treatment and access to
services as required.

Peer workers also play an important role in supporting clients with AOD and mental health conditions.
Peer support can facilitate program engagement, and the delivery of programs by peers has been
found to enhance treatment outcomes [587]. Data from qualitative interviews conducted among
people attending treatment for their co-occurring disorders also suggests that peer support provides
opportunities for community integration, aids in building social confidence, provides a safe space,
improves feelings of being accepted, and helps people to not feel alone [124, 125, 588]. Figure 15 illustrates
some of the services that may need to be incorporated into a coordinated approach to clinical care.

Figure 15: Services that AOD workers may need to engage in client care
B5: Coordinating care 147

Coordinated care increases the likelihood that clients will receive specialised assistance where it
is needed and facilitates client engagement in treatment. There is evidence to suggest that care
coordination is effective in increasing treatment engagement and retention, increasing treatment
satisfaction, improving quality of life, increasing the use of community-based services, and decreasing
the cost of healthcare [589–595]. Treatment retention has been consistently associated with better
treatment outcomes among people with AOD use disorders [594, 596–598].

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 [599]. 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 [599]. Superior
treatment outcomes have similarly been associated with coordinated care when there is frequent in-
person contact, close interaction between primary care providers and case managers, and culturally
responsive practices [600, 601]. 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 [599].

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 [602]. In turn, many people with mental health conditions experience a lack of coordinated care, or
service integration, and consequently fall ‘between the gaps’ [102, 602].

What is coordinated care?

Innovative models of health care are not only focused on providing physical or mental health care,
but seek to incorporate services that are reflective of a person’s broader needs (e.g., employment,
housing, education, training, community, and justice health services) [603–605]. The actual definition
of coordinated care can vary between services, and can include case management, collaborative care,
shared care, team coordination, and multidisciplinary care. In practice, coordinated care should involve
the coordinated delivery of individual services across multiple sectors, which is perceived as a seamless
service system by clients, and results in overall improved client outcomes [102, 599, 602, 605, 606].
Despite differences in terminologies, the core elements remain the same. Figure 16 illustrates the core
elements of care coordination.

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 [389]. The challenge for a holistic health care approach to co-
occurring conditions is in the active engagement of multiple services and service providers, with a
mixture of professional and non-professional support [605, 607]. AOD workers in particular are in primary
148 B5: Coordinating care

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 13 illustrates the continuation of case
study K, following Con’s story after one of his mental health workers suspected Con was hearing voices.

Figure 16: Core elements of coordinated care

Assessment
Comprehensive
assessment of the
client’s needs

Delivery Shared understanding

The right services to Common goals, clear
the right person at understanding of roles
the right time and responsibilities

Client-centred
Organisation
Interdisciplinary
Agency staff and
approach to responsive
resources necessary to
integrated health care
carry out client care
and social support

Facilitation
Coordination Care coordinator
Clear communication and manages engagement
information exchange with appropriate services,
between care providers, follows evidence-based
including family and care standards, assesses
friends client’s needs and
preferences
Development
Comprehensive care
plan

Adapted from McDonald et al. [608], Ehrlich et al. [609], Brown et al. [610], and NSW Mental Health Coordinating Council [611].
B5: Coordinating care 149

Box 13: Case study K: Managing co-occurring physical, mental, and AOD use disorders:
Con’s story continued

Case study K: Con’s story continued

It was apparent to the mental health outreach workers that Con was experiencing a relapse of symptoms
of psychosis, and Con was readmitted to an inpatient mental health unit. During Con’s admission, the
social worker assigned to him applied for a National Disability Insurance Scheme (NDIS) package to
provide Con with an increased level of support to assist with maintaining his living in the community.
The increase in support provided enough for a cleaner and support worker who visited Con every day
and took him to his medical appointments, all of which was overseen by a care coordinator. With the
additional support, Con was able to reduce his drinking and keep his house clean. Con’s support team
were also able to ensure his nutritional needs were being met and provided additional social contact
by taking him to and from the shops. Con’s community mental health team continued to visit him and
manage his psychotic disorder.

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 adherence 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.

Barriers to effective coordinated care

Despite the need for holistic approaches to complex problems, there are several practical barriers that
prevent effective care coordination between services. These include structural barriers, geographic
barriers (e.g., working with rural/remote services), difficulty reconciling treatment approaches between
services, lack of clear communication, and competition between traditionally separate services, all of
which make collaboration difficult [612, 613]. Moreover, both primary care providers and insurers currently
identify the lack of a viable financial model as one of the major barriers to widespread coordinated care
[614].
150 B5: Coordinating care

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 [615, 616], 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 [605]. For some services, this working environment may foster
creativity; others may find their collaborative efforts stifled, and the associated difficulties overwhelming
[605].

An additional barrier that may prevent effective collaboration between services is the lack of an existing
model to follow [617]. Some common principles that can be incorporated into care coordination include
[389, 600, 607, 618, 619]:

• Cross-disciplinary training and involvement of external service providers in case review meetings.

• Effective communication between services and service providers.

• Culturally responsive practices.

• Clear roles and accountability within and across services and service providers.

• Shared respect for the client and their health needs, and a common work culture that incorporates
collaboration as a key aim.

• Routine evaluation of client care outcomes, including adherence.

• Centralised access to care, including designating a single point of contact to coordinate care for
clients. If a single point of contact is not possible, clear communication with the client about who
to contact for varying aspects of their care.

• Recognition that co-location alone does not result in effective service coordination or increase
communication.

• Recognition of barriers to referral pathways, which include staff turnover, client confidentiality,
and competition between services and service providers, which in turn requires dedication and
commitment to overcome.

Stigma and discrimination

Stigma and discrimination can be barriers to coordinated care. Stigma is usually based on stereotypes,
assumptions or misconceptions, that discriminate, disparage, or devalue a person or a group of people
[620, 621]. Stigma and discrimination are particularly evident in relation to both mental health and AOD
use and can result in people being excluded from or denied health services [622]. Some people view those
with AOD use conditions as being personally responsible for their problems and therefore less deserving
of sympathy and treatment. Although some headway has been made in relation to societal attitudes
toward other mental health conditions, some people continue to view people with AOD use disorders as
immoral [623–626]; or potentially dangerous, violent, or manipulative [627, 628].
B5: Coordinating care 151

There is evidence that stigma and discrimination are commonly experienced across healthcare settings
by people with co-occurring AOD and mental health conditions and are significant barriers to people
accessing health services [622, 624]. Those who have experienced stigma or discrimination, or perceive
that stigma exists, are less likely to access treatment services or seek help [624]. Unfortunately, these
negative experiences can deter or delay future help-seeking [629].

Stigma and the attitudes of some providers can also impact the quality of healthcare provided,
particularly among clinicians who believe people with co-occurring conditions are responsible for their
own problems and are therefore less deserving of treatment than other people. For example, a person
experiencing co-occurring conditions in need of a liver transplant may be perceived as less deserving
than a person without co-occurring conditions [630]. These biases may also impact upon clinicians’
interactions with clients, insofar as clinicians with these attitudes may be more likely to patronise, scold
or blame clients, provide opinion-based (as opposed to evidence-based) advice and care [631], or deny
treatment altogether [624, 632].

Lack of practitioner knowledge, discriminatory workplace policies, practices, and structures may also
intentionally or unintentionally deter people from seeking help [632, 633]. For example, workplace
cultures that normalise stigmatising language or behaviours can impact whether clients are treated with
dignity and respect [634].

As described in Chapter A3, Chapter B3 and Chapter B4, the language used when working with co-
occurring conditions is vitally important; equally important is the use of respectful, person-centred,
non-judgemental language when discussing clients with other healthcare providers, family members,
or members of the public. Useful language guides developed by NADA and NUAA, in collaboration with
people with lived experience, provide suggestions for non-stigmatising language, and examples of how
such language can be utilised in clinical practice. More information about the Language Matters resource
is available via NADA: https://nada.org.au/resources/language-matters/. There is preliminary evidence
for organisational interventions aimed at reducing stigma among service providers [635, 636], which
should include the identification of structural factors within workplaces and organisations that may
contribute to the perpetuation of stigma, and consultation with the workforce [634, 637, 638].

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 [389]. 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 [389].

Referrals can involve transferring a client temporarily, permanently, or sharing client care [389].
Whenever possible, 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
152 B5: Coordinating care

rehabilitation who has been identified as having a bipolar disorder may be retained in AOD treatment, but
it may be useful to obtain an appointment with a psychiatrist who can undertake an assessment, provide
a diagnosis, and prescribe medications; the client’s condition can then be managed while they are 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 co-occurring conditions in
particular often have difficulty navigating their way through the available services, and many are lost
during the referral process [389]. 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 [85].
Therefore, it is crucial that the referral process focuses on linking the client with services as smoothly as
possible. This process 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., not requiring urgent medical or psychiatric attention), the referral
process may be passive, facilitated, or active (see Table 36). In the case of clients with co-occurring
conditions, active referral is recommended over passive or facilitated referral. Active and timely referrals
have been associated with improved AOD and mental health outcomes [639, 640], whereas passive
referrals are considered to be one of the reasons for low engagement in continuing care [641].

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). With clients’ permission, families and
carers should be involved in the referral process wherever possible, as they will often need to facilitate
clients’ access to other services. Families and carers should also be informed of services available to
them in the form of advocacy and support groups (e.g., Family Drug Support, SMART Family and Friends).

Table 36: Referral processes

Passive referral

Passive referral occurs when the client is given the details of the referral agency in order to make their
own appointment. This method is almost never suitable for clients with co-occurring conditions.
B5: Coordinating care 153

Table 36: Referral processes (continued)

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 their 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 their 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 co-occurring conditions.

Adapted from Clemens et al. [642] and Rastegar [643].

Communicating with other services

Good communication and sharing information between all health professionals involved in the care of
people with co-occurring conditions is essential to adequate care. Ensure that:

• You obtain the client’s consent before sharing any information.

• The client is kept informed during this process.

• Confidentiality is maintained (e.g., obtain client’s written permission for release of case notes and
avoid faxing confidential information).

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 [389]:

• 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…; Andrew’s 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.

154 B5: Coordinating care

A pro forma which may be useful in the referral process is included in Appendix BB.

In an attempt to increase communication, teamwork, and safety, a model of standardised

communication has been introduced in various healthcare settings, modelled on aviation approaches
to standardised safety processes [644]. The model, ISBAR, is a standardised cross-professional tool
for enhancing communication, organised in a clear and concise format (see Figure 17) [645]. Although
commonly used in clinical handover, ISBAR may also be useful in referral and discharge, with clinicians
communicating with other services and agencies about client care.

Figure 17: ISBAR model of effective communication

Adapted from Scotten et al. [646] and SA Health [647].

B5: Coordinating care 155

South Australia Health has developed an ISBAR toolkit to assist with the safe transfer 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 [647].

Some examples of how to modify ISBAR to your clinical practice include [647]:

• 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 [648, 649].

Communicating with the client about referral

Referral to other services should involve the client’s informed consent, and openness regarding the
reasons for referral. To assist the client in attending a referral appointment, it can be useful to discuss
issues such as:

• Name, phone number, and address of the referral service.

• Directions and transportation to and from the service appointment.

• What the client can expect upon arrival at the service, along with the nature, purpose, and value of
the referral.

• Written material about the service (if available).

• A method of contacting the AOD worker.

• Any other concerns the client has about the referral.

Continue to provide support to the client until an appointment with the new clinician or agency has been
arranged. If the client expresses reservations about working with a new clinician or agency, it may be
useful to treat the client in collaboration with the new clinician for a period of time, where appropriate
[389].
156 B5: Coordinating care

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. Clients being discharged from residential
AOD services in particular can struggle to find housing, employment, and engage with outpatient
services [650]. It is important to involve clients in their discharge planning and make them fully aware of
their options [234]. While it may be useful to arrange or plan follow-up consultations to monitor how well
the client is maintaining the progress made during therapy, a client has the right to refuse further follow-
up; if this situation occurs, note the refusal in the client’s record and avoid judgemental reactions [234].

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 [651]. 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 [652, 653].
Challenges for busy health care staff include [654, 655]:

• Multitasking.

• Shift changes.

• Gaps in information transfer.

• Interruptions.

• Previous handover lacks detail or is 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 [389, 656, 657]. 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 B6 provides useful information
regarding relapse prevention, support and self-help groups, and other management techniques that
clients may benefit from. Appendix BB and Appendix CC provide useful CBT and anxiety management
strategies.
B6: Approaches to co-occurring
conditions
158 B6: Approaches to co-occurring conditions

B6: Approaches to co-occurring

conditions

Key points
• Four models of care have been identified in the treatment of co-occurring conditions:
sequential treatment, parallel treatment, integrated treatment, and stepped care.
• Integrated treatment presents a number of advantages over other treatment approaches;
however, there is limited evidence to suggest that any one model is better than another.
• Both psychological and pharmacological interventions have been found to have some benefit
in the treatment of many co-occurring conditions.
• When pharmacotherapy is used, this should be accompanied by supportive psychosocial
interventions.

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 B7, we discuss
the evidence regarding the efficacy of these approaches in relation to the management and treatment of
specific co-occurring 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 co-occurring conditions. Four approaches have been suggested (see Table
37):

• Sequential treatment.

• Parallel treatment.

• Integrated treatment.

• Stepped care.

There has been much discussion of models of care for clients with co-occurring conditions, but very little
research is available to determine which models may be better suited for which conditions. AOD workers
may need to make pragmatic decisions as to which model is most appropriate for individual clients.

It should be noted that there are several ways in which the term ‘integrated’ is used with regard to
AOD and mental health. In these Guidelines, we use the term ‘integrated treatment’ to refer to the
simultaneous treatment of a person’s AOD use and mental health by a single provider or service, which
is distinct from the concept of ‘integrated services’ (combining different services such as mental health
and AOD) and ‘integrated systems’ (combining service policies, funding, budgets or administrations)
[111]. The idea of integrated treatment for two disorders has considerable intuitive appeal and presents
B6: Approaches to co-occurring conditions 159

a number of advantages over other treatment approaches. Integrated treatment by a single provider or
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 [658].

While applying an integrated approach to the treatment of co-occurring conditions is appealing, there
has been very little research undertaken directly comparing this approach to parallel or sequential
models [659, 660]. Many studies examining the efficacy of integrated treatments compare them to
‘treatment as usual’ or other forms of treatment for either the AOD use or the mental health condition
alone. Although the findings from these studies are promising, these designs cannot establish the
efficacy of integrated treatment relative to parallel or sequential treatment [659, 661–669]. Similarly, while
there is intuitive appeal to applying a stepped-care approach to co-occurring conditions, few studies
have examined stepped-care interventions for co-occurring conditions and these approaches have not
been compared to other models. More research is needed to guide treatment approaches in this space.

Table 37: Models of care for co-occurring 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 their 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. Of note, stepped care models can include
sequential, parallel, and/or integrated treatment approaches.
160 B6: Approaches to co-occurring conditions

Approaches to co-occurring conditions

This section provides a brief introduction to different approaches to the treatment of co-occurring
AOD use and mental disorders. It does not attempt to provide detailed information relating to the
implementation of these approaches, but rather, an overview of the options available. Where appropriate,
readers are referred to existing literature and resources for more detail about the use of particular
interventions.

AOD workers are likely familiar with traditional psychological and pharmacological approaches to
the treatment of co-occurring conditions. Other approaches include ECT, 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 disorders [102]. These approaches have predominantly been delivered face-to-face, but
delivery via telehealth (e.g., telephone or videoconferencing) has expanded considerably in response to
the COVID-19 pandemic. Psychological approaches include:

• Acceptance and commitment therapy (ACT).

• Behavioural activation.

• Cognitive behavioural therapy (CBT).

• Contingency management.

• Dialectical behavioural therapy (DBT).

• Exposure therapy.

• Mindfulness training.

• Motivational interviewing (MI).

• Psychosocial group therapy.

• Relapse prevention.

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).
B6: Approaches to co-occurring conditions 161

Acceptance and commitment therapy (ACT)

ACT is a behavioural approach, which has been referred to as one of the ‘new wave’ or ‘third generation’
cognitive behavioural therapies [670]. ACT applies six core processes (acceptance, cognitive defusion,
being present, self as context, values, and committed action) to develop psychological flexibility – that
is, the ability to remain in the present moment; be mindful of experiences, thoughts, emotions and
sensations; and consciously behave in ways that align with chosen values [671]. Using mindfulness
techniques, ACT is focused on addressing the reluctance to feel negative experiences, thoughts,
emotions, and sensations, and accepting negative thoughts and feelings rather than striving to
change or eradicate them. Strategies such as cognitive defusion ultimately help clients commit to and
pursue their goals by encouraging clients to adopt a more non-judgemental and mindful approach to
themselves and their surroundings [670].

ACT has been shown to be effective at reducing the quantity and frequency of AOD use [672–674], as
well as associated stigma and shame [675]. It has been found to reduce psychiatric symptoms among
people with single disorder anxiety [676, 677], OCD [678], depression [677, 679, 680], psychosis [681, 682],
ADHD [683], and PTSD [684, 685]. Although evidence for ACT among people with co-occurring disorders is
limited, ACT has been shown to improve abstinence among people with co-occurring affective disorders
and AOD use [686], improve PTSD symptoms, and reduce frequency and quantity of AOD use among
people with co-occurring PTSD and AOD use [687]. It has also been successfully adapted into e-health
interventions [676, 679].

Behavioural activation
Originally developed in the 1970s, behavioural activation is a manualised approach based entirely on
behavioural strategies [688]. Behavioural activation aims to improve mood and resilience by enabling a
person to focus on their core values and increase engagement in activities that align with those values
[689]. 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.

Behavioural activation has been shown to be effective at reducing the quantity and frequency of AOD
use as well as depressive symptoms, among people with co-occurring depression and AOD use [690];
effective at improving abstinence from AOD use among those with single disorder AOD use [691, 692], and
as effective as CBT [693] and antidepressants [694] at treating depressive symptoms among those with
depression as a single disorder.

Cognitive behavioural therapy (CBT)

CBT emphasises the important role of thinking in how we feel and how we behave. CBT aims to identify
and modify maladaptive thought processes and behaviours through cognitive restructuring and
behavioural techniques to achieve change. There is considerable evidence supporting the use of CBT for
the treatment of depressive, anxiety, and AOD use disorders [695–697] delivered in a variety of formats
162 B6: Approaches to co-occurring conditions

(e.g., in-person, multimedia, online) [696, 698]. Appendix BB describes a number of CBT techniques that
may be used in the management and treatment of mental health and AOD use 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 [699] and Graham [700]. A
number of the interventions designed for specific co-occurring disorders, such as Seeking Safety (for PTSD
and substance use [701, 702]) and Dual Focus Schema Therapy (for personality disorders and AOD use [703,
704]), are in part based on these CBT techniques. Interventions for specific co-occurring conditions are
discussed in more detail in Chapter B7.

Contingency management
Contingency management may be used as part of a treatment approach for people with AOD use
disorders, that involves rewarding or reinforcing desired behaviour in the client in a supportive manner
[705]. Examples are providing vouchers for negative urine samples, for treatment attendance, or for
medication adherence. There is evidence that contingency management techniques can be used
successfully to facilitate AOD treatment goals, such as reduced use or abstinence [706–709]. Studies have
also found contingency management to be effective in promoting abstinence from cannabis among
people with co-occurring psychosis [710, 711]; cocaine and opiates among buprenorphine-maintained
clients with co-occurring major depression [712]; cocaine among homeless clients [713]; as well as
reducing substance use [714], and substance use and psychiatric symptoms, among people using
stimulants with serious mental illness [715].

Dialectical behavioural therapy (DBT)

DBT combines behaviour-change strategies from CBT and acceptance strategies from Zen philosophy
into an approach that focuses on client validation and behavioural change [716, 717]. 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 [716, 718, 719]. The primary principles
underpinning DBT are increasing interrelatedness, synthesising acceptance and change, and teaching
coping skills to deal with change [720]. 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. A strong
therapeutic alliance and improvements in emotion regulation skills appear to be particularly important
for positive treatment outcomes [721, 722]. DBT has been found to be efficacious in treating personality
disorders (including those co-occurring with AOD use) [723, 724], AOD use disorders (including those co-
occurring with personality disorders) [723, 725], and there is emerging research supporting its use for ED
that are co-occurring with AOD use disorders [726, 727] (see Chapter B7).

Exposure therapy
Exposure therapy involves repeated, prolonged, and systematic confrontation with certain objects or
situations that trigger anxiety or fear responses, and learning to tolerate the anxiety associated with
these triggers without engaging in avoidance or safety behaviours (i.e., behaviours which reduce the
anxiety) [728, 729]. The triggers that induce anxiety can be objects (e.g., food), situations (e.g., open
B6: Approaches to co-occurring conditions 163

spaces), cognitive (e.g., memories, intrusive thoughts), or physiological (e.g., dizziness) [730]. The nature
of the exposure therapy can be in vivo (e.g., physically touching a light switch), in the imagination (e.g.,
confronting images of loved ones dying), or recalled (e.g., details of a specific memory). In cases where in
vivo is not possible or feasible, due to either a lack of access to the situations associated with anxiety or
safety concerns, exposure via virtual reality may be used [729].

There are different types of exposure therapy which have been tailored for the treatment of specific
disorders, such as exposure response therapy (ERP) for OCD and prolonged exposure (PE) for PTSD [729].
Regardless of the type of exposure therapy, this technique concurrently weakens the association between
triggers and anxiety arousal, and avoidance or safety behaviours and anxiety reduction (i.e., exposure
therapy seeks to weaken the idea that anxiety will only reduce once avoidance or safety behaviours are
performed [731–733]). Exposure therapy aims to help people tolerate the distress associated with triggers
without engaging in avoidance or safety behaviours (e.g., AOD use; repetitive behaviours), and provides
corrective feedback to challenge the fear response [730–732]. Common elements of exposure therapies
include psychoeducation, building a stimulus or fear hierarchy (i.e., rating anxiety-provoking stimuli
based on the amount of anxiety generated), and using this hierarchy to guide treatment intensity [730,
732].

Exposure therapy can be used to successfully treat OCD [731, 734], ED [735, 736], anxiety disorders
(including those co-occurring with AOD use [737, 738]), and PTSD (including those co-occurring with
AOD use [739–741]). Exposure therapy has also been used successfully to reduce relapse and cravings
among people with alcohol dependence [742, 743], and reduce cravings among people who use cannabis
[744], methamphetamines [745], and opiates [746]; however, this evidence is mixed and often limited
by methodological factors (e.g., lack of active control groups [742, 743]). Clinicians wishing to deliver
exposure therapies require specialised training before implementing.

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 co-
occurring conditions, 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) [747, 748]. Regular practice of mindfulness allows a person to develop the capacity to interrupt
automatic thought patterns, and be accepting, open, and curious of that experience [749]. Although
mindfulness can be a useful practice for everyone, it can be particularly helpful for people with co-
occurring AOD and mental disorders by assisting with the development of greater awareness of
automatic thinking patterns which can often maintain the mental-health-AOD-use cycle [109, 750]. 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-
164 B6: Approaches to co-occurring conditions

based stress reduction and mindfulness-based cognitive therapy are two specific group therapies based
on mindfulness techniques [751]. For a more detailed discussion of mindfulness, readers are referred to
Ostafin and colleagues [748].

There is evidence of the efficacy of mindfulness for assisting with relapse prevention in AOD use [752],
as well as reducing cravings, AOD-related problems, the quantity and frequency of AOD use [753], and
avoidance-based coping strategies among people with AOD use disorders [754]. There is also evidence of
the efficacy of mindfulness in the treatment of mental disorders [755, 756].

Motivational interviewing (MI)

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 co-occurring mental disorder (see Chapter B3 for a discussion of readiness to change).
MI may be used to increase the client’s motivation in this regard [757]. MI is a directive client-centred
counselling process that assumes equity in the client-AOD worker relationship and emphasises a client’s
right to define their problems and choose their own solutions. It is, in this sense, a counselling style (as
opposed to a set of techniques) based on collaboration rather than confrontation, evocation rather than
education, and autonomy instead of authority [757–759], that aims to increase a person’s motivation and
commitment to change [758, 759].

The strategy involves a non-confrontational conversation seeking out the ambivalence in the client’s
attitudes that can be used as encouragement for them to think about further change. For example, a
client may say they are not really interested in dealing with their social anxiety but agree that it is a
problem. Probing around this ‘problem’ and exploring ambivalence may lead to the client contemplating
further ways to address the problem. The strategy is to use available openings to help the client advance
towards a decision to make changes that will benefit their mental health. There is considerable evidence
supporting the use of MI for treating mental and AOD use disorders [760–763]. Examples of MI strategies
and techniques are provided in Appendix E, along with a number of useful resources for MI.

Psychosocial group therapy

Psychosocial groups within the AOD treatment setting are also much appreciated by clients with co-
occurring conditions [764]. Evidence suggests that clients who attend groups consistently and for a
longer time period (e.g., for a year) achieve the best results, although positive outcomes can nonetheless
be achieved by attending shorter-term groups [765, 766]. Similarly, incorporating creative elements into
group interventions, with multiple activities conducted within shorter group sessions, appear to improve
treatment outcomes among people with mental health conditions [767]. 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 co-occurring conditions [162, 768]. 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 [769, 770]. Readers are referred to Mueser and colleagues [770] for a more detailed
discussion on the use of group interventions for co-occurring disorders.
B6: Approaches to co-occurring conditions 165

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 and AOD
use disorders [771]. As such, the goal of relapse prevention is to enable clients to recognise the factors
which increase their own risk of relapse, and intervene at earlier points in this process [102].

Relapse prevention strategies that are already used in AOD treatment can also be used to reduce risk of
relapse of the mental health condition. For example, relapse prevention for AOD use has been shown to be
effective in reducing PTSD symptom severity [772], and the quantity, frequency, and severity of AOD use
among people with co-occurring PTSD and AOD use [772, 773]. Some simple strategies that can be useful
in helping a client reduce the risk of relapse include [102, 774–777]:

• 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 pattern presents the risk of complete relapse. To avoid this
situation, it can be useful to normalise lapses and explore the events that led to a lapse, and how it
could be avoided.

• Encourage the client to practise and use any of the strategies they have learnt about managing
their mental health condition.

• Identify and plan for high-risk situations – including emotions, thoughts, places, events, and people
which are likely to make the client vulnerable to mental distress or substance use; plan ahead to
anticipate these situations, monitor warning signs and triggers, and develop coping strategies to
deal with them.

• Consider social factors and support – relapse is more likely when social factors are difficult and
support levels are low. Support the client in making changes in their life to develop healthy and
protective environments. It can be useful to discuss supports with the client and plan for any
foreseeable issues (e.g., housing, family, relationship). It may also be useful to provide the client
with information on services and organisations that can assist in such situations.

Pharmacological approaches
The use of pharmacotherapies is common practice in the treatment of both AOD use and mental
disorders. It is recommended, however, that when pharmacotherapy is used, it should be accompanied
by supportive psychosocial interventions [778–781]. Symptoms are less likely to return on completion
166 B6: Approaches to co-occurring conditions

of psychological treatment compared to pharmacotherapy, where relapse upon cessation is common

[782]. 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 B3). When prescribing medications, the following should be taken into
account:

• Possible interaction effects with other prescribed and non-prescribed substances.

• The possible presence of medical problems such as liver dysfunction related to long-term AOD use
or hepatitis.

• The abuse potential of the medication being prescribed.

• Potential contraindications.

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 co-occurring mental disorder will likely have been
prescribed medication for that disorder (such as antidepressants, mood stabilisers, anti-anxiety
agents, or antipsychotics). Medications can be extremely helpful in managing mental health symptoms;
however, their effectiveness relies upon them being taken as prescribed. There are many factors that may
facilitate medication adherence including having strong social supports, a strong therapeutic alliance
with healthcare providers, and insight and understanding of one’s mental health condition [783–785].
Conversely, factors that may adversely impact upon medication adherence include experiencing negative
side effects and cognitive deficits [783–785].

Some people experience unpleasant and distressing side effects of varying levels of severity from
psychiatric medications. These side effects may lead to reduced adherence, and some people will choose
to live with some symptoms of the mental disorder rather than take medication [786]. 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 their needs. Finding the best fit is particularly important
for people with severe mental disorders such as psychotic, bipolar, and severe depressive disorders, as
psychosocial interventions alone may not be sufficient.

When medications have been prescribed, it is important to assist the client adhere to medication
scheduling, irrespective of whether a person experiences memory problems or other cognitive difficulties.
In other illnesses such as diabetes and hypertension, medication adherence 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 they need to take their medication. MI, contingency management and cognitive
B6: Approaches to co-occurring conditions 167

behavioural techniques have been shown to be particularly useful in improving medication adherence,
as have medication regime management and pharmacist consultations [787–789]. Community
pharmacists may be able to assist in the preparation of dosage administration aids (e.g., Webster-paks),
which may be especially useful for clients who have trouble remembering what medications/dosages
should be taken and when. The SIMPLE model [790] is a useful tool for remembering different evidence-
based interventions that can enhance medication adherence:

S Simplifying regimen characteristics. Adjust timing, frequency, and dosage. Match regime to
client’s daily activities (e.g., mealtimes). Use adherence aids (e.g., pill boxes, alarms).

I Imparting knowledge. Clearly discuss the medication as appropriate with the client using
simple everyday language. Do not overwhelm the client with information or instructions.
Supplement verbal information with written materials or pamphlets.

M Modifying patient beliefs. Assess the client’s beliefs, intentions, and perceived ability to
adhere to the medication regime. Encourage behaviour change by ensuring that the client
perceives their condition to be serious, believes in the positive effects of the treatment,
perceives themselves to have the skills required to stick to the medication regime, and has
channels to express fears or concerns.

P Patient and family communication. Include the client in decisions about treatment. With
the client’s consent, send reminders via mail, e-mail, or telephone. Actively listen to the client
and avoid interrupting them. Involve family or social networks where appropriate.

L Leaving the bias. Studies have found small or no relationships between medication
adherence and race, sex, education, intelligence, marital status, occupation, income, and ethnic
or cultural background.

E Evaluating adherence. Ask the patient simply and directly, without judgement, about their
medication adherence. Pill counting, measuring serum or urine drug levels can also be used.

Adapted from Atreja et al. [790].

Medication interactions
It is important for AOD workers to be aware of the complex and dynamic relationship between AOD
use, mental disorders, and prescribed medication (i.e., the potential interactions between AOD use and
prescribed medications and the ways in which AOD use and prescribed medication can affect each
other). During the assessment phase, workers should explore the influence of prescribed medication on
AOD use and vice versa. This clarification will contribute to a comprehensive management and treatment
plan, with appropriate goals [389].

Table 38 provides some of the interactions between AOD and prescription medication, but this list is not
exhaustive. 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
168 B6: Approaches to co-occurring conditions

of fluvoxamine associated with opiate withdrawal [791]. In cases where withdrawal is unexpected, it
is possible that the client may engage in other AOD use (or decrease treatment adherence) 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 [792]. As described in Chapter B1, the
compounds found in tobacco smoke can increase the rate some psychiatric medications, such as
olanzapine and clozapine, are metabolised. This means people who smoke may need to be prescribed
higher doses to achieve the required therapeutic dose of these medications, while those who are
intending to reduce or quit smoking need to be carefully monitored and their doses reduced to avoid
potential toxicity [230–232].

Interactions are also possible with other non-psychiatric medications. For example, alcohol increases
the potential for stomach ulcers and bleeding when combined with steroids or other anti-inflammatory
medications due to the combined toxic effects on the stomach lining [793]. Interactions with dietary
supplements are also possible: as mentioned in Chapter B7, 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, immunosuppressants, and some cardiac medications [794].

Table 38: Drug and medication interactions

Potential medication
Drug type Implications
interaction
Depressants

Central nervous system TCAs The likelihood of overdose is

depressants MAOIs significantly increased.
• Alcohol The sedative effects of
SSRIs
• Benzodiazepines benzodiazepines are increased
• Opiates with concurrent use of alcohol.
• Antipsychotics
Possibility of reduced effects of
prescribed medications.

Alcohol intoxication or Lithium carbonate Potential for electrolyte

withdrawal imbalances. Potential for lithium
toxicity.

Benzodiazepine or alcohol Antipsychotics Lowered seizure threshold with

withdrawal Antidepressants increased potential for seizures.
B6: Approaches to co-occurring conditions 169

Table 38: Drug and medication interactions (continued)

Potential medication
Drug type Implications
interaction
Stimulants

Stimulants (e.g., MAOIs Can lead to hypertension (high

amphetamines, tobacco, blood pressure) crisis.
caffeine, cocaine, 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 [431].

As such, when managing and treating clients with co-occurring AOD and mental health conditions, AOD
workers need to take into account the level and type of AOD used (especially alcohol), as these may [795]:

• Alter the metabolism of prescribed medication.

• Decrease the effectiveness and/or increase the potential for side effects.

• Warn the client about potential interactions between substances of misuse and prescribed
medication.

• Discuss the problems and potential dangers of using non-prescribed AOD to counteract the effects
or side effects of prescribed medication.

It is important to note that polydrug use, and the variation in compounds contained in drugs that are
manufactured illegally, may make it difficult to clarify and assess potential drug interactions [431, 796,
170 B6: Approaches to co-occurring conditions

797]. In instances where workers are unable to determine if a medication will interact with AOD use,
medication should be titrated, starting with a low dose [798].

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) has long been associated with a history of cruelty, fear, and
stigmatisation, despite evidence of its efficacy for many people with severe mood and psychotic
disorders. Although the exact mechanisms as to why ECT is effective are not well understood,
contemporary ECT remains a safe and effective approach, that does not need to be a treatment of
last resort [799]. During ECT treatment, an electric current stimulates seizure activity in the brain via
electrodes applied to the scalp. Throughout treatment, the person receiving treatment is anaesthetised
and given muscle relaxants to prevent body spasms [800]. There are notable adverse effects associated
with ECT, which are most commonly related to executive function, attention, and memory [799]. Memory
loss (including forgetting past information, or retrograde amnesia, as well as difficulty retaining new
information, or anterograde amnesia) is typically greater with longer courses of ECT. There is evidence
that the majority of adverse cognitive effects are temporary, although there is variability in how different
people respond and recover [799]. Other adverse effects are associated with general anaesthesia and are
less common (e.g., cardiac events), or other neurological events (e.g., stroke) [801]. More contemporary
approaches to ECT, including electrode placement, have substantially reduced these risks [799]. The
number of ECT sessions depends on a client’s progress but is usually between six and twelve sessions
[800]. Clinicians may wish to refer to patient accounts and experiences with ECT for more information; for
example, Wells and colleagues [802], where patients describe both positive and negative experiences.

The effectiveness of ECT in the treatment of depression, catatonia, mania, and schizophrenia is well
documented [799, 803–806], but ECT remains underutilised [807]. There is evidence supporting the use
of ECT for treatment resistant depression, mania, and schizophrenia [799], as well as a potential first-
line treatment when rapid improvement in clinical symptoms is required (e.g., for clients at high risk of
medical complications or suicide risk) [808].

Self-help groups
Reviews of the research literature suggest that some clients of AOD services will benefit from joining a
self-help group such as Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery, or alternative
self-help groups [725, 809, 810]. ‘Dual diagnosis’ support groups are also an option, specifically for people
with co-occurring mental and AOD use disorders [811, 812]. One recent Cochrane review concluded that
there is high quality evidence to suggest that manualised forms of self-help groups (such as Alcoholics
Anonymous and 12-step facilitation) are more effective than established treatments, such as CBT,
at increasing abstinence [809]. As with other psychosocial groups, there is also evidence that longer
attendance at self-help groups and higher levels of social support have a positive impact on outcome
[813–817].

As with all interventions, it may take a few attempts to find the group that suits a person’s needs and
it is possible that one group may not suit the client but the next will—even in the same type of self-help
B6: Approaches to co-occurring conditions 171

group. 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 [769]. It should be noted that some groups, particularly those that adopt a
12-step philosophy, may be disapproving of the use of any medication [818]; yet clients with co-occurring
mental disorders are often prescribed medication to help treat their mental health condition [819]. Some
clients with co-occurring conditions, particularly those who experience religious delusions, may also
have difficulty with the strong spiritual focus of many self-help groups [820].

E-health and telehealth interventions

E-health is the provision of health services and/or information via the Internet or associated
technologies [821]. Examples of e-health interventions include those delivered online or via smartphone,
programs with multimedia components, text message-support, gaming, virtual reality, biofeedback
and wearable devices [822]. Since its relatively recent appearance, e-health has been referred to as one
of the most important revolutionary additions to modern healthcare [821, 823]. Telehealth on the other
hand, refers to the delivery of healthcare via online or other telecommunication methods. Telehealth is
particularly important for those in rural and remote areas, and for people who have difficulty attending
or accessing local services. The uptake of digital mental health services in Australia increased by over
100% for most services (e.g., online courses, clinician registrations) during the recent COVID-19 pandemic
[824, 825]. Telehealth service consultations in Australia have similarly increased by up to 34% since the
introduction of telehealth items to the Medicare Benefits Schedule [826].

E-health interventions overcome many of the 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 [827–829]. E-health
interventions also have the capacity to overcome difficulties associated with face-to-face treatment,
including gender differences [827, 830], the inclusion of more marginalised socioeconomic and cultural
groups [831], and reducing the costs and increasing the standardisation of traditional treatments [832–
835]. Despite their benefits, e-health interventions are often underutilised by mental healthcare services
in Australia, which is partly driven by clinician reluctance [836].

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 and wearable devices,
social media, virtual reality, biofeedback, and gaming [837, 838]. 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 [833, 839]. 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 [840–843]. A number of e-health
interventions have been developed for AOD and specific mental disorders, and a systematic review of
the efficacy of computer-based interventions at improving AOD use and mental health outcomes found
that relative to baseline, several programs were effective at reducing AOD use, anxiety, social phobia,
depression, stress, and improving quality of life [844]. Interventions that were CBT-based were found to
172 B6: Approaches to co-occurring conditions

be particularly effective, demonstrating significantly greater improvements in alcohol use, anxiety, and
quality of life compared to waitlist and psychoeducation controls [844].

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 [845], all of which
have been associated with unhealthy lifestyles (e.g., smoking, obesity, lack of exercise, poor diet) [846,
847]. As such, treatment interventions that are either based on nutrition, exercise, or include these as
adjunctive interventions, are promising approaches for addressing co-occurring physical conditions
[848]. Research has found that people with psychiatric conditions who engage in regular exercise report
better health-related quality of life [849] and benefits have been demonstrated across a wide range of
activities (e.g., frisbee, tennis, cycling, aerobic/gym activities, tai chi, yoga [850]).

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, bipolar, panic disorder, agoraphobia, social anxiety, specific phobia, and AOD use disorders
[310, 851–853]. People who engaged in regular physical activity were more likely to experience symptom
improvement over a three-year follow-up study [852].

Although the mechanisms of action are not entirely clear, research findings indicate that exercise
induces changes in neurotransmitters (e.g., serotonin and endorphins) [854, 855] which relate to mood,
and can improve reactions to stress [856, 857]. There is also some indication that exercise reduces
chronic inflammation, which is commonly found among people with mental disorders [858]. 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 [859,
860]. A number of physical health interventions for AOD and specific mental disorders are described in
Chapter B7.

Complementary and alternative therapies

Complementary and alternative therapies are practices and products that are traditionally outside the
realm of conventional medicine, but are more natural and economical than traditional pharmacotherapy,
sometimes with fewer side effects [861]. They include, but are not limited to, acupuncture, dietary
and nutritional supplements, and herbal remedies. Research has indicated that there has been an
increase in the use of complementary and alternative therapies, particularly among people seeking
to treat their depression or anxiety, often in combination with conventional medication [862]. The use
of complementary and alternative therapies may be rising in popularity due to their ability to fill a
major gap in mental health service delivery, particularly in areas with reduced rates of services [863].
It is beyond the scope of these Guidelines to provide an extensive and comprehensive list of available
complementary and alternative therapies; however, attention is drawn to some promising interventions
for which there is emerging evidence (see Chapter B7).
B7: Managing and treating specific
disorders
174 B7: Managing and treating specific disorders

B7: Managing and treating specific

disorders

Key points
• Symptoms of co-occurring 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 co-occurring conditions;
however, these interventions have generally not been well researched.
• Where there is an absence of research on specific co-occurring 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 co-occurring conditions.
• 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.

This chapter provides a discussion of current best practice and evidence regarding the management
and treatment of the more common co-occurring mental disorders seen among clients of AOD services.
Symptoms of mental disorders may be identified through screening and assessment processes
(described in Chapter B3), or they may arise spontaneously during the client’s treatment. There is a
distinction between the management of co-occurring mental health conditions and their treatment. 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. Without further treatment, these techniques on their own may not provide long-term relief
from symptoms; however, they may allow the client’s AOD use to be treated in the interim. One advantage
of managing mental health symptoms is that no diagnosis is required prior to their use (i.e., symptoms
are managed rather than disorders being treated). Readers are encouraged to read Chapter A4 of these
Guidelines to familiarise themselves with the signs and symptoms of mental disorders.

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
B7: Managing and treating specific disorders 175

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 co-occurring mental disorders [97–99, 102, 864, 865]. 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 [866–868]. 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 their AOD use, which may require treatment [869].

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 people with more
severe mental disorders (or cognitive impairment) as even low-level substance use may be problematic
[132]. 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 drugs. Although abstinence is favoured, many people with co-occurring 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 [133, 134].

It is fundamentally important to discern the client’s preferences regarding treatment for their mental
health. Just because the client has sought treatment for their AOD use does not necessarily mean that
they are ready to address their mental health condition. It is important that the client is not forced to
undergo treatment for their mental health if they are not ready to, as this may jeopardise the therapeutic
relationship. Ultimately, it is up to the client to decide whether they want to address the issue and how
they 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 disorders. Some interventions have been designed for the treatment of
specific co-occurring conditions; however, these interventions generally have not been well researched.
In the absence of specific research on co-occurring 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 on trials of treatments for mental disorders (see Chapter A4 for disorder descriptions);
however, these treatments may also be useful for those who do not meet diagnostic criteria but
experience symptoms that cause significant distress or impairment.

Psychological and pharmacological interventions have been found to have some benefit in the treatment
of many co-occurring mental disorders. As mentioned in Chapter B6, it is recommended that when
pharmacotherapy is used, this should be accompanied by supportive psychological interventions
[870, 871]. Symptoms are less likely to return on completion of psychological treatment compared to
pharmacotherapy, where relapse upon cessation is common [782]. Pharmacotherapies are beneficial,
176 B7: Managing and treating specific disorders

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 B3). AOD workers should also be aware of:

• Possible interaction effects between prescribed and non-prescribed substances.

• The presence of medical problems such as liver dysfunction related to long-term AOD use or
hepatitis, which may be exacerbated by certain medications.

• The abuse potential of medications prescribed.

• Potential contraindications.
ADHD
178 B7: Managing and treating ADHD

Attention-deficit/hyperactivity disorder (ADHD)

ADHD and AOD use frequently co-occur, and there is evidence to suggest that the presence of ADHD
is a primary risk factor for the development of AOD use disorders [872, 873]. Research suggests that
untreated ADHD is associated with a more problematic course of AOD use disorder, with clients less likely
to gain benefits from treatment, adhere to treatment, and achieve and maintain abstinence [874–876].
ADHD is also associated with an earlier age of first substance use, higher rates of poly-substance use,
greater substance dependence, and increased risk of relapse [873, 877–879]. However, evidence suggests
that responding early to ADHD through the provision of appropriate evidence-based treatments can
prevent the development of AOD use disorders among adolescents, and reduce the risk of AOD relapse
among adults [877, 880].

Difficulties can be faced when assessing and screening for the presence of co-occurring ADHD, as
symptoms can be masked or even resemble those of intoxication or withdrawal (see Chapter A4) [878,
881, 882]. Although some experts recommend an abstinence period of one month or more to assist with
diagnosis [102, 883, 884], this strategy is not supported by the broader evidence base, or the majority of
experts [883, 885–887].

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 [884].

Clinical presentation
ADHD represents a persistent pattern of developmentally inappropriate levels of inattention,
hyperactivity, and/or impulsivity [10, 11]. Although estimates vary, research conducted in the last decade
indicates that, on average, 55% of children and adolescents diagnosed with ADHD in childhood will
continue to have the disorder in adulthood [888]. Attentional difficulties in particular are more likely
to persist into adulthood, whilst impulsivity and hyperactivity tend to diminish over time [889]. Adult
symptoms are expressed differently to the way in which they are expressed in childhood, and may
include [10, 11]:

• Difficulties paying close attention to detail.

• Difficulties maintaining focus.

• Easily distracted.

• Difficulties completing tasks or projects.

• Disorganisation.

• Procrastination.

• Lack of motivation.

• Difficulties concentrating or studying (which may present as academic underachievement).

• Occupational or workplace difficulties.

B7: Managing and treating ADHD 179

• Forgetfulness, including the frequent loss of possessions.

• Restlessness.

• Difficulties with time management.

• Difficulties sleeping, and/or fatigue.

• Irritability, frustration, or anger.

• Problems forming and maintaining relationships.

• Difficulty obtaining and/or maintaining stable employment.

• History of imprisonment or frequent contact with police.

Some symptoms which clients may present with, such as problems sleeping, irritability and fatigue, are
not unique to ADHD, but are common to many mental disorders.

Managing ADHD symptoms

Research indicates that people diagnosed with ADHD in adulthood may require additional psychosocial
support to assist them to come to terms with their diagnosis, and reframe their past [890]. The
techniques outlined in Table 39 can help AOD workers manage clients with ADHD symptoms.

Table 39: Dos and don’ts of managing a client with symptoms of ADHD

Do:

Reduce or remove distracting stimuli.

Consider using visual aids to convey information.

Assist the client plan activities and encourage the use of appropriate tools (e.g., smartphone,
activity journal) to organise prompts, reminders, and important information.

Encourage stress-reduction methods, such as progressive muscle relaxation.

Encourage physical exercise.

Involve family members and friends – educating them about the condition and treatment will
provide long-term benefits.

Offer to help the client engage with education courses or training, which can assist with attention
training.
180 B7: Managing and treating ADHD

Table 39: Dos and don’ts of managing a client with symptoms of ADHD (continued)

Don’t:

Get visibly upset or angry with the client.

Confuse the client by conducting unstructured, unfocused sessions.

Overwhelm the client by conducting lengthy meetings or verbal exchanges.

Adapted from Gournay [891], SAMHSA [102], and Zulauf [892].

Treating ADHD
There are several 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 co-occurring ADHD and AOD
use should use an integrated multimodal approach, with components of individual and/or group
psychotherapy, psychoeducation, as well as peer and family support, to enhance the effect of treatment
[9, 884, 893–895]. In general, evidence suggests that treatments focusing on either ADHD or AOD use
in isolation are not effective at treating both disorders [896]. However, there is some recent evidence to
suggest that reducing AOD use, or maintaining abstinence following AOD treatment, may improve ADHD
symptoms [897, 898]. Evidence from the broader ADHD literature suggests that an approach combining
psychotherapy and pharmacotherapy may result in better outcomes for ADHD symptoms than either
psychotherapy or pharmacotherapy alone [781, 886, 892, 899–901], however, this approach has yet to be
rigorously evaluated among people with co-occurring ADHD and AOD use.

Psychotherapy
Psychotherapy is recommended as a critical component of a multimodal approach targeted towards
co-occurring ADHD and AOD use [884, 894, 902]. Evidence suggests that CBT is the most effective
psychological approach for ADHD, when delivered in conjunction with pharmacotherapy [781, 884, 892,
903]; however, positive outcomes have also been associated with the use of other approaches, such as
meta-cognitive group therapy [904, 905], structured skills training [906, 907], virtual remediation therapy
[908], and cognitive remediation, both as therapist-led programs [909] and self-directed interventions
[910].

Common therapeutic elements include psychoeducation, a focus on problem solving and planning,
strategies to improve attention, impulsivity management, and cognitive restructuring [893, 903].
Evidence suggests that a structured format of repetitive skills practising and reinforcement of coping
strategies for core ADHD symptoms are key components for the effective treatment of ADHD [911, 912].
However, these interventions have yet to be evaluated among people with co-occurring AOD use. DBT-
based skills training may be a promising treatment for co-occurring ADHD and AOD use. In a small
B7: Managing and treating ADHD 181

feasibility study conducted among Swedish men in compulsory care for severe AOD use disorders, self-
reported ADHD symptoms, general wellbeing, and externalising behaviours improved after six weeks of
manualised, structured skills training groups [913]. While the lack of control group and low treatment
acceptability and feasibility suggest more research is needed, these findings are encouraging.

To date, only one integrated psychotherapeutic approach for co-occurring ADHD and AOD use has been
rigorously evaluated, which compared CBT for AOD use with an integrated CBT program for ADHD and
AOD use [914]. The integrated CBT program consisted of motivational therapy, coping skills training and
relapse prevention for AOD use, planning and problem-solving skills, and dealing with emotions; whereas
the CBT for AOD use focused only on AOD use. While those in the integrated CBT group demonstrated
greater reductions in ADHD symptoms compared to those who received CBT for AOD use alone, there
was no difference between groups in relation to AOD use or other outcomes [914]. While more research is
needed to support conclusive recommendations, these findings are promising.

Lastly, there is preliminary evidence to support the use of behavioural interventions focused on academic
training for adolescents with ADHD and AOD use disorders, but further research is needed [875].

Pharmacotherapy
There are two main types of pharmacotherapies used in the treatment of ADHD: psychostimulants
and non-stimulants. Table 40 lists some of the pharmacological treatments for ADHD. For ADHD
as a single disorder, the first line pharmacotherapies are the psychostimulants lisdexamfetamine
and methylphenidate [885, 915]. Despite robust findings regarding the effectiveness of these
pharmaceuticals among people with ADHD alone, findings among people with co-occurring AOD use
disorders have been less promising. While these medications have been associated with modest
reductions in ADHD symptoms, few studies have found them to demonstrate superiority over placebos
[916, 917]. Nonetheless, psychostimulants, in combination with psychotherapy, are safe, are associated
with reductions in ADHD symptoms, and remain the first line recommendation for the treatment of ADHD
among people with AOD use disorders [884, 916, 917]. Some trials also indicate that more meaningful
reductions in ADHD symptoms among people with AOD use disorders may be achieved with higher
doses of psychostimulants [884, 918]. Irrespective of dose, it is essential that a medical assessment
be conducted prior to the prescription of psychostimulants to ensure that the person does not have
cardiovascular or other conditions that may contraindicate psychostimulant prescription [919].

While there has been some concern regarding the use of psychostimulants among people with AOD use
disorder due to their potential for misuse and diversion [920], it is important to note that this view is
not supported by the evidence. Psychostimulant medications, particularly longer acting formulations
such as lisdexamfetamine or extended-release methylphenidate, have low abuse potential [884, 921].
Nonetheless, it has been suggested that prescribers may wish to consider the use of non-stimulants if
extra-medicinal use of psychostimulants is of great concern [916]. In view of the fact that non-stimulants
are less efficacious than psychostimulants 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 [922].

Atomoxetine, a non-stimulant noradrenaline reuptake inhibitor, is recommended for those who

182 B7: Managing and treating ADHD

cannot tolerate, or do not respond to, lisdexamfetamine or methylphenidate [885]. As is the case
with psychostimulants, it appears that atomoxetine may not be as effective among people with AOD
use disorders compared to those with single disorder ADHD, but this body of research is small [916].
Close monitoring for signs of any depressive symptoms during the first few months of atomoxetine
administration is recommended (including agitation, self-harm behaviours, and suicidal ideation) as
there have been some reports of increased risk among children [919]. Preliminary research has also
been conducted on the non-stimulants bupropion (norepinephrine reuptake inhibitor), guanfacine and
clonidine (alpha 2- adrenoceptor agonists); but conclusions regarding their efficacy cannot be made at
this time [884, 916].

Table 40: Pharmacotherapy medications for ADHD

Drug name Brand name Drug type

Methylphenidate Artige, Concerta, Psychostimulant
Ritalin

Dexamphetamine Aspen Psychostimulant

Lisdexamfetamine Vyvanse Psychostimulant

Atomoxetine Strattera Noradrenaline

reuptake inhibitor

Adapted from Zalauf et al. [892], Pérez de los Cobos et al. [886] and the Better Health Channel [923]. For a full list of generic
brands available, see the Therapeutic Goods Administration website (https://www.tga.gov.au).

E-health and telehealth interventions

Emerging e-health programs combine 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
[924, 925]. 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 organisational skills [925]. The course, delivered
with therapist support, teaches participants how to effectively use their smartphone applications to
better organise their lives. Compared to a 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 co-occurring ADHD and AOD use, the findings from this RCT are
promising.
B7: Managing and treating ADHD 183

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, and more beneficial effects on some treatment outcomes compared to
psychotherapies such as CBT [926, 927]. Research indicates that exercise interventions (frequent aerobic
exercise in particular) may assist with the management of ADHD symptoms, particularly intrusive
thoughts, worry, and impulsivity [928]. One meta-analysis has suggested that moderate-intensity aerobic
exercise may reduce symptoms of hyperactivity, impulsivity, anxiety, and inattention, and improves
executive functioning among young boys aged 8 to 13 years with ADHD [929]. As such, exercise may be a
useful adjunct to pharmacotherapy and psychotherapy for ADHD; however, this approach has yet to be
rigorously evaluated in adults with co-occurring ADHD and AOD use [928].

Complementary and alternative therapies

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 [930, 931]. Moreover,
another study has reported that omega-3 and omega-6 fatty acids have similar benefits to, and may
improve the tolerability of, methylphenidate in single disorder ADHD [932]. In contrast, however, an RCT
examining the role of omega-3 and omega-6 supplementation over 12 weeks in children with ADHD
did not find any significant treatment effects on aggression, impulsiveness, depression, or anxiety
symptoms relative to placebo [933]. Findings from these studies suggest that intervention length may
moderate treatment effects, and that omega-3 and omega-6 supplements may require dosing durations
of up to 6 months before any symptom benefits become evident [933]. While these findings have yet
to be replicated among adults, and among people with co-occurring ADHD and AOD use, they point to
potential avenues of future research.

Mindfulness

Mindfulness interventions for single disorder ADHD have been evaluated in three meta-analyses, which
found reductions in ADHD and depressive symptoms, and improvements in executive functioning
among children, adolescents, and adults, with larger effects for adults than children [934–936]. Some
research suggests that, among adults, mindfulness exerts similar effects to other established treatment
strategies (e.g., structured skills training [906]). However, this research is yet to be conducted among
people with co-occurring ADHD and AOD use.

Summary
For those with co-occurring ADHD and AOD use, reviews of the evidence recommend an integrated,
multimodal approach, with components of individual and/or group psychotherapy, psychoeducation,
as well as peer and family support [9, 884, 893–895]. The use of structured psychotherapies, including
CBT with a focus on goals, with active AOD worker involvement and effective social support, is likely to
184 B7: Managing and treating ADHD

be the most beneficial [884, 892] and, as with the treatment of other co-occurring disorders, treating
both conditions concurrently is more likely to produce a positive treatment outcome than treating either
disorder alone [102, 896, 922]. Box 14 illustrates such a multimodal approach through the continuation of
case study A, after Sam's ADHD was identified.

Box 14: Case study A: Treating co-occurring ADHD and AOD use: Sam’s story continued

Case study A: Sam’s story continued

Based on Sam’s symptoms, the AOD worker thought it would be beneficial for her to see a psychiatrist
who specialised in adult ADHD, and asked Sam if she would be willing to see a psychiatrist who would be
able to assess her further and help develop a treatment plan. The AOD worker told Sam that they would be
happy to keep seeing her and liaise with both her GP and the psychiatrist. Sam thought this was a good
plan and consented to the sharing of information between these services.

The AOD worker helped Sam make an appointment to see the psychiatrist and her GP, and helped Sam
put these appointments into her phone calendar, setting reminders. Sam also organised a follow-up
appointment to see the AOD worker after her appointments with the GP and psychiatrist. With Sam’s
permission, the AOD worker invited Sam’s partner into the consultation room and let them know about
the upcoming appointments so they could remind Sam and help her arrive on time. Sam had agreed
to the AOD worker discussing her condition with her partner, as she understood they would be able
to provide additional information about her condition and be helpful and supportive of her ongoing
treatment.

The psychiatrist who assessed Sam diagnosed her with ADHD, and noted the range of inattention,
hyperactivity and impulsivity symptoms that were present. The psychiatrist also mentioned that the
way Sam responded to her use of Ritalin and methamphetamines, where she did not experience a ‘high’
but instead felt calm and relaxed, was significant. The psychiatrist explained that psychostimulants
are one of the primary treatments for ADHD, which are carefully prescribed and monitored. After Sam’s
GP conducted a thorough medical assessment, the psychiatrist prescribed her with psychostimulant
medication and advised Sam that it was important for her not to use any other substances, because
of the possibility of interactions between drugs. The AOD worker told Sam she would be available for a
phone or Zoom call every day during Sam’s first week taking the psychostimulants, to see how she was
going.

Sam continued with her treatment and recommenced NRT. In addition to regular monitoring and some
minor adjustments to the psychostimulant dosage, Sam attended individual sessions with her AOD
worker, where she was provided with a range of evidence-based interventions to help her with her alcohol,
methamphetamine and cannabis use. These began with psychoeducation and information about the
substances Sam had been using, focusing on the way in which they affected her ADHD and how her ADHD
symptoms impacted on her substance use. The AOD worker also suggested some relaxation exercises for
occasions when she became tense, that Sam began to practice and enjoy.
B7: Managing and treating ADHD 185

Box 14: Case study A: Treating co-occurring ADHD and AOD use: Sam’s story
(continued)

Sam also re-enrolled in a part-time TAFE course, and started working part-time in a fabric shop, which
aligned well with her studies in design. An important component of her treatment plan was helping
Sam organise activities which were part of her everyday life. The AOD worker helped Sam set up a daily
calendar, and use different functions on her smartphone (i.e., setting alarms for important events,
scheduling meetings and appointments). Sam’s partner also helped her keep a schedule and maintain
reminders and appointments in her phone.

Key points:
• Treatment for ADHD and AOD use should be concurrent and multimodal.
• Providing education about the nature of the ADHD, AOD use and their relationship, is
essential – for both the client, friends and family.
• Treatment requires long-term planning and follow-up and more general efforts at
rehabilitation, including further education.
Psychosis
B7: Managing and treating psychosis 187

Psychosis

Clinical presentation
Acute psychosis represents one of the most severe and complex presentations, and one of the most
intrusive when attempting to treat co-occurring AOD use [937]. During an acute episode of psychosis, a
person’s behaviour is likely to be disruptive and/or peculiar. Symptoms of psychosis include [938]:

• Delusions – false beliefs that are held with conviction. They are often bizarre and may 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 [541].

People in AOD settings commonly present with low-level psychotic symptoms, particularly as a result of
cannabis or methamphetamine use. These clients may display a range of low-grade psychotic symptoms
such as [541]:

• Increased agitation, severe sleep disturbance.

• Mood swings.

• A distorted sense of self, others, or the world.

• Suspiciousness, guardedness, fear, or paranoia.

• Odd or overvalued ideas.

• Illusions and/or fleeting, low-level hallucinations.

• Erratic behaviour.

Co-occurring AOD use adds to diagnostic uncertainty in presentations where there are symptoms
of psychosis. For many people who experience psychotic symptoms as a direct effect of intoxication
(auditory or visual hallucinations, paranoia) these experiences will resolve when the drug has left the
body. These experiences may be considered by people who use AOD as a ‘bad trip’. If symptoms persist
188 B7: Managing and treating psychosis

for periods beyond intoxication, however, it is important to consider whether they may be part of an
emerging or underlying psychotic episode. This becomes likely where symptoms are persistent and
distressing for at least one week (see Chapter B3). Although approximately one third of psychotic
disorders are initially diagnosed as substance-induced [939], 25% are later revised to schizophrenia [38,
940]. Substance-induced psychosis may be virtually indistinguishable from an independent psychotic
disorder at initial presentation [941], and longitudinal observation under abstinence conditions may be
necessary to distinguish between them [102, 942]. The identification, management and treatment of
substance-induced disorders are described in more detail later in this chapter. Irrespective of whether a
person’s psychotic symptoms are substance-induced or not, early identification and intervention is key
to optimal outcomes [943–945].

Managing symptoms of psychosis

Table 41 presents some strategies for managing acute psychotic symptoms. Some clients may be
aware that they are unwell and will voluntarily seek help; others may lack insight into their symptoms
and refuse help. If the active-phase psychosis is putting the client or others at risk of harm, it may be
necessary to contact mental health services. It is also true that many people with psychotic illness are
vulnerable to manipulation, including interpersonal violence, financial and sexual exploitation.

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 co-occurring psychosis and AOD use are frightened of being
imprisoned, forcibly medicated, or having their children removed [778, 795]. 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 [795].

Table 41: Dos and don’ts of managing a client with symptoms of psychosis

Do:

Ensure the environment is well lit to prevent perceptual ambiguities.

Ensure discussions take place in settings where privacy, confidentiality, and dignity can be
maintained.

Try to reduce noise, human traffic, or other stimulation within the person’s immediate
environment (e.g., reduce clutter).

Ensure the safety of the client, yourself, and others.

Allow the person as much personal space as possible.

Be aware of your body language – keep your arms by your sides, visible to the client.

Ignore strange or embarrassing behaviour if you can, especially if it is not serious.

Listen attentively and respectfully.

B7: Managing and treating psychosis 189

Table 41: Dos and don’ts of managing a client with symptoms of psychosis (continued)

Do:

Appear confident, even if you are anxious inside – this will increase the client’s confidence in your
ability to manage the situation.

Be empathic. Psychotic experiences are typically frightening and distressing.

Speak clearly and calmly, asking only one question or giving only one direction at a time.

Present material in simple and concrete terms, with examples.

Use a consistently even tone of voice, even if the person becomes aggressive.

Limit eye contact as this can imply a personal challenge and might prompt a hostile, protective
response.

Point out the consequences of the client’s behaviour. Be specific.

Ensure both you and the client can access exits – if there is only one exit, ensure that you are
closest to the exit.

Have emergency alarms/mobile phones and have crisis teams/police on speed dial.

If psychosis is severe, arrange transfer to an emergency department for assessment and

treatment by calling an ambulance on 000.

Don’t:

Get visibly upset or angry with the client.

Confuse and increase the client’s level of stress by having too many workers attempting to
communicate with them.

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?’

Use ‘no’ language, as it may provoke hostility and aggression. Statements like ‘I’m sorry, we’re not
allowed to do that, but I can offer you other help, assessment, referral…’ may help to calm the client
whilst retaining communication.

Use overly clinical language without clear explanations.

Crowd the client or make any sudden movements.

Leave dangerous items around that could be used as a weapon or thrown.

Adapted from NSW Department of Health [431], Canadian Guidelines [778], Jenner et al. [541], SAMHSA Guidelines [102], and UK
NICE Guidelines [795].
190 B7: Managing and treating psychosis

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 supported to maintain an adequate diet, relaxation, and sleep
patterns because stress can trigger some psychotic symptoms [946].

Despite the risk of further psychotic episodes, some people may continue using substances that can
induce psychosis. In such cases, the following strategies may be helpful [541]:

• Talk to the client about ‘reverse tolerance’ (i.e., increased sensitivity to a drug after a period of
abstinence) and the increased chance of future psychotic episodes.

• Try and understand whether there is a pattern between AOD use and psychotic symptoms. Some
people may use AOD to block out distressing symptoms; others may continue to use for the
positive effects of substances despite the knowledge they will also experience the negative effects
such as psychotic symptoms.

• Encourage the client to avoid high doses of drugs and riskier administration methods (e.g.,
injecting in the case of methamphetamine).

• Encourage the client to take regular breaks from using and to avoid using multiple drugs.

• Help the client recognise early warning signs that psychotic symptoms might be returning
(e.g., feeling more anxious, stressed or fearful than usual, hearing things, seeing things, feeling
‘strange’), and encourage them to immediately stop drug use and seek help to reduce the risk of a
full-blown episode.

• Inform the client that the use of AOD can make prescribed medications for psychosis ineffective.

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,
childcare, 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 B5 for strategies on how
to incorporate other service providers in a coordinated response to clients’ care.

Treating psychotic spectrum disorders

In general, if a person is well maintained on medication for their psychotic disorder, then management
for AOD use should proceed as usual. Although AOD workers may feel daunted at the prospect of treating
this often severe and complex clinical group, it is crucial to remember that treatment and care should
reflect a person’s needs and preferences, whilst taking into account the evidence base.

People with co-occurring psychotic spectrum and AOD use disorders should have the opportunity to
participate and make informed choices about their treatment, in consultation and partnership with their
health care providers [778]. UK and Canadian guidelines on the management of co-occurring psychosis
and AOD use recommend that, when planning treatment, workers take into account the severity of both
disorders, the person’s social and treatment context, and their readiness to change [778].
B7: Managing and treating psychosis 191

There are several options available for the treatment of co-occurring psychotic disorders and AOD
use, including psychotherapy, pharmacotherapy, ECT, e-health interventions, physical activity, and
complementary and alternative therapies. Clinical guidelines in Australia and internationally currently
recommend the use of integrated treatment programs addressing both psychosis and AOD use, and
suggest that a combination of antipsychotic pharmacotherapy with psychosocial interventions focused
on AOD use may produce the best outcomes [444, 778, 779, 942]. The evidence base surrounding each of
these approaches is discussed below.

Psychotherapy
A Cochrane review [947] of RCTs examining 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 any one approach to psychological treatment over standard care, with
many studies reporting mixed findings. The authors note, however, that it is difficult to draw any firm
conclusions from the current evidence base due to methodological differences between studies. The only
clear finding was an association between MI and greater reductions in alcohol use relative to standard
care [947].

Barrowclough and colleagues [948] 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:

• Make use of more frequent and shorter reflections to clarify meaning.

• Use frequent and concise summaries to draw together information.

• Avoid emotionally salient material that is likely to increase thought disorder.

• Provide sufficient time for the client to respond to reflections and summaries.

• Ask simple open questions and avoid multiple choices or complicated language.

While acknowledging the lack of robust evidence, in addition to MI, the Royal Australian and New Zealand
College of Psychiatry (RANZCP) guidelines for the management of schizophrenia and related disorders
nonetheless recommend the use of integrated therapies that combine CBT, lifestyle interventions and
case management for the treatment of co-occurring schizophrenia and AOD use [444].

CBT for psychosis is a well-recognised evidence-based treatment for symptoms of psychosis [444].
Several studies have examined the efficacy of CBT on symptoms of psychosis and AOD use [949, 950];
again, evidence regarding the efficacy of CBT in treating co-occurring psychotic disorders and AOD
problems is mixed. Naeem and colleagues [950] 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 [949] found no significant differences between the
CBT and psychoeducation groups for the key outcomes of cannabis use or psychopathology.
192 B7: Managing and treating psychosis

Recent research has identified assertive community outreach as one integrated approach that may
be particularly beneficial for clients with co-occurring psychosis and AOD use. Assertive community
outreach utilises specialised outreach teams to provide integrated and intensive treatment within a
community setting (e.g., the client’s home), and includes mental health treatment, housing support,
and rehabilitation [951]. Several studies examining the effectiveness of assertive community outreach
for people with co-occurring psychosis and AOD use have found improvements in psychotic symptoms
[952, 953], reduced frequency of AOD use [954], improved housing stability [952, 955, 956], fewer hospital
readmissions [952, 957], improved psychological wellbeing [955], and general functioning [956] relative to
baseline and treatment as usual control conditions.

Recent research has also demonstrated that, relative to standard care for psychosis and co-occurring
AOD use, skills-based training and peer supported social activities delivered alongside standard care,
leads to improved outcomes in relation to symptoms of psychosis, AOD use, as well as functional
outcomes [958]. Cognitive remediation therapy has also been found to be beneficial in addressing
cognitive and functional deficits (e.g., relating executive function, attention, memory, social cognition)
among people with psychotic disorders [959] and shows promise as an adjunctive treatment for people
receiving AOD treatment [960]; however, research among people experiencing both conditions is in its
infancy [961].

Contingency management may also be a useful adjunct to other treatments for psychotic spectrum
disorders and AOD use. As discussed in Chapter B6, contingency management involves the use of
reinforcement to encourage particular behaviours (and discourage undesired behaviours). A meta-
analysis examining the effect of contingency management for people with co-occurring psychotic
and AOD use disorders concluded that contingency management improves abstinence from AOD use,
although effects on psychotic symptoms were not examined [962]. These findings are consistent with a
review of earlier research [963].

The popularity of mindfulness-based interventions has increased in recent years. To date, however, no
studies have evaluated mindfulness in the context of co-occurring psychosis and AOD use. Studies
of single disorder psychosis have found mindfulness beneficial in reducing both negative [964, 965]
and positive psychotic symptoms [965]; and mindfulness has been found to reduce the frequency and
amount of AOD use, AOD-related problems [966], cravings [754, 966], and depressive symptoms [754],
relative to control groups (which included treatment as usual, CBT, and support groups), among people
with AOD use disorders as single disorders. Together these findings suggest that mindfulness may be
beneficial for people experiencing both conditions.

Pharmacotherapy
Despite the high rates of AOD use among people with psychosis, most trials of pharmacotherapy for
psychotic spectrum disorders have excluded people with AOD use disorders [779]. International clinical
guidelines typically conclude that there is limited evidence to recommend the use of one antipsychotic
over another among people with co-occurring AOD use disorders [778]; however, growing literature and
corresponding reviews indicate that some antipsychotics show more promise than others. Most of
the research to date has focused on those with a diagnosis of schizophrenia, but some studies have
B7: Managing and treating psychosis 193

included people experiencing first-episode psychosis or diagnosed with other psychotic disorders (e.g.,
schizoaffective disorder, psychosis in the context of bipolar disorder, substance-induced psychosis).

Two main findings can be drawn from the research to date. Firstly, ‘atypical’ second generation
antipsychotics appear to be more effective relative to ‘typical’ first generation antipsychotics (e.g.,
haloperidol), with reference to both psychiatric and AOD-related outcomes [967, 968]. It has been
theorised that the increased AOD use found among those with psychotic disorders relates to dopamine
dysfunction which is better addressed by the newer atypical antipsychotic agents than the older typical
agents [969]. Atypical antipsychotics may also be preferred by clients as they are associated with fewer
extrapyramidal side effects such as involuntary movements [778]. Furthermore, there has been some
suggestion that typical antipsychotics may actually increase AOD use and craving [968]. Table 42 lists the
names of some of the more common antipsychotics.

There is some evidence to suggest that clozapine [779, 942, 968, 970–972], paliperidone [973–976],
and aripiprazole [967, 976–978] are most promising with respect to a variety of outcomes, including
improvements in symptoms of psychosis and/or AOD use. AOD use has not been found to influence the
efficacy of quetiapine, olanzapine, risperidone, or ziprasidone, for people with psychotic disorders [979].
Preliminary evidence suggests that ziprasidone shows similar efficacy relative to other antipsychotics,
though may be more tolerable with fewer side effects [972].

The second main finding that can be drawn from studies to date is that the use of long-acting
injectables (LAI), also refered to as depot medication, appear to produce better treatment outcomes
among people with AOD use disorders relative to oral antipsychotics. Specifically, LAIs are associated
with a lower rate of relapse to psychosis and longer time to relapse [980]. Paliperidone, aripiprazole and
risperidone are specific medications where there is some evidence to suggest that the LAI form may
be more effective (with respect to producing improvements in severity of psychosis and/or AOD use)
relative to their corresponding oral preparation [973, 974, 976, 978, 981, 982]. People receiving monthly
paliperidone LAI have also been shown to demonstrate greater treatment adherence, have lower rates of
inpatient days, outpatient visits, long-term stays, and lower medical costs; relative to people receiving a
range of other oral atypical antipsychotics [973–975]. While both paliperidone LAI and aripiprazole LAI have
been linked with reductions in the severity of psychotic symptoms, aripiprazole has also been found to
produce improvements in AOD cravings and quality of life [976].

There is also some evidence to suggest that some medications may be more effective than others
depending on the type of AOD used. For example, olanzapine, risperidone and haloperidol may be
particularly effective in improving symptoms of psychosis and reducing cannabis use among people
with cannabis use disorder, while haloperidol and olanzapine have been recommended for those with
cocaine use disorders [983]. For those with polydrug use disorder, atypical antipsychotics, in particular,
olanzapine, may be more effective than typical antipsychotics [983]. It should be noted, however, that
head-to-head comparison studies are rare and tend to be conducted over relatively short follow-up
periods. A good approach to management is to tailor the choice of antipsychotic to the individual based
on response, side-effect profile, and means of administration (oral versus LAI).

Regarding amphetamine-induced psychosis specifically, findings have been mixed. A review of

aripiprazole, haloperidol, quetiapine, olanzapine, and risperidone concluded that they were safe and
194 B7: Managing and treating psychosis

effective in reducing both positive and negative symptoms of psychosis, but found no clear evidence
for the superiority of one antipsychotic over another [984]. However, a subsequent review and meta-
analysis of the efficacy of these drugs and paliperidone extended-release concluded that olanzapine
and quetiapine are more efficacious than risperidone; and olanzapine, quetiapine, haloperidol, and
paliperidone extended-release are more efficacious than aripiprazole, at reducing symptoms of
amphetamine-induced psychosis [985].

Table 42: Antipsychotic medications

Newer (atypical) antipsychotics Traditional (typical) antipsychotics

Drug name Brand names Drug name Brand names

Amisulpride Amipride, Amisolan, Solian, Chlorpromazine Largactil

Sulprix

Aripiprazole Abilify, Abyraz, Tevaripiprazole Droperidol Droleptan

Asenapine Saphris Flupentixol Fluanxol

Brexpiprazole Rexulti Haloperidol Serenace

Carbamazepine Tegretol Periciazine Neulactil

Cariprazine Reagila Zuclopenthixol Clopixol

Clozapine Clopine, Clozaril, Versacloz

Olanzapine Olanzacor, Ozin, Pryzex, Zypine,

Zyprexa

Lithium Lithicarb, Quilonum

Lurasidone Latuda

Paliperidone Invega

Quetiapine Delucon, Kaptan, Quetia,

Seroquel, Syquet, Tevatiapine

Risperidone Ozidal, Rispa, Risperdal,

Rispernia, Rixadone

Sodium Epilim, Valprease, Valpro

valproate

Ziprasidone Zeldox, Ziprox

Adapted from the Australian Government Department of Health [986] and the Therapeutic Goods Administration [987]. For a full
list of generic brands available, see the Therapeutic Goods Administration website (https://www.tga.gov.au).
B7: Managing and treating psychosis 195

Electroconvulsive therapy (ECT)

ECT has long been used as an adjunctive treatment for people who do not have an adequate response to
antipsychotics [808]. A Cochrane review that examined the efficacy of ECT among people with treatment-
resistant schizophrenia as a single disorder concluded that, when combined with standard care, ECT
may lead to greater improvements compared with antipsychotics alone; however, the available evidence
was too weak to determine whether ECT is superior or inferior to other controls for the management of
treatment resistant schizophrenia [988].

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 [989]. 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 and expert moderation; web-based CBT; personalised advice based on clinical monitoring; and
text messaging interventions.

Physical activity
To date there is no evidence about the use of exercise for psychotic disorders other than schizophrenia, or
co-occurring psychosis and AOD use disorder, though results of a meta-review suggest physical activity
is a promising adjunctive treatment for people with either schizophrenia or AOD use disorders [990].
Research conducted among people with single disorder schizophrenia has found that physical exercise
may be useful in terms of improving cognitive functioning (e.g., short-term memory), promoting healthy
lifestyles, managing medication side-effects [991–996], as well as reducing symptoms of psychosis [997–
999]. Studies that have examined the efficacy of exercise interventions among people with schizophrenia
have included a range of physical activities, including basketball [1000], aerobic exercise [992, 998, 1001],
cycling [997], and yoga [995, 1002, 1003]. Based on the evidence to date, aerobic activity has the most
support [992, 994, 998, 1004–1009], but there is also some support for resistance training as an adjunct
to other exercise [996, 1001, 1010, 1011]. In particular, endurance programs of at least 12-weeks, 3 sessions
per week, of general aerobic endurance training lasting at least 30 minutes in duration are recommended
[1012].

Complementary and alternative therapies

Research examining complementary therapies for co-occurring psychosis and AOD use is rare. One RCT
has examined the effects of auricular acupuncture as an adjunct to antipsychotics among people with
co-occurring schizophrenia and AOD use [1013]. In this study, auricular acupuncture (which involves
the placement of acupuncture needles in the ears) was given 4-6 times a week, for 20-40 minutes a
session, for up to 20 sessions. Relative to people who received antipsychotics alone, those also receiving
196 B7: Managing and treating psychosis

acupuncture showed improved treatment adherence to antipsychotics after 10 sessions. Relative to

baseline levels, all participants also showed decreases in AOD cravings after 10 sessions, and further
decreases in AOD cravings after 20 sessions. However, there were no differences in psychiatric symptom
severity from baseline for either group and psychotic symptoms were not examined. These findings
require replication to be sure of their effectiveness.

While there has been little research examining complementary and alternative therapies for people with
co-occurring psychosis and AOD use, there have been some promising treatment outcomes for people
with single disorder psychotic disorders for horticultural therapy [1014], music therapy [1015], yoga [1016],
and a gluten-free diet [1017]. It should be noted however, that the majority of participants in these studies
were also receiving antipsychotic medication and as such, the utility of these complementary and
alternative approaches as standalone therapies for people with single disorder psychotic disorders has
not been established.

Summary
In summary, existing research suggests that there is no ‘one size fits all’ approach for treating co-
occurring psychotic spectrum and AOD use disorders [1018], and that 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 15 illustrates the continuation of case study B,
following Amal’s story after his psychotic symptoms appeared to worsen.

Box 15: Case study B: Treating co-occurring psychosis and AOD use: Amal’s story
continued

Case study B: Amal’s story continued

The inpatient detoxification team immediately organised for Amal to have an assessment by the
team psychiatrist, who admitted Amal to the inpatient mental health unit for further assessment and
stabilisation. Amal’s AOD team continued to provide advice and support for his ongoing detoxification
during his inpatient mental health stay. During this time, Amal’s family were asked to meet with the
treating team and provide additional information. Amal’s father told the team that Amal had experienced
previous episodes of hallucinations and delusions; he did not think these had all occurred when Amal
had used methamphetamines but couldn’t be sure. Amal’s mother said that her mother had experienced
‘mental health problems’ and been hospitalised many times when she was younger, but she didn’t know
the exact nature of her condition.

Amal stayed at the mental health unit for a period of time, during which it was established that while
his substance use may have contributed to and exacerbated his symptoms, it was likely that he had an
independent psychotic disorder. He was stabilised on antipsychotics, started receiving psychotherapy
and began working with a case manager who liaised with the outpatient AOD team and made a plan for
his discharge. It was explained to Amal that his methamphetamine use would likely exacerbate or cause
a relapse in his psychotic disorder. As such, an important part of his discharge plan included relapse
B7: Managing and treating psychosis 197

Box 15: Case study B: Treating co-occurring psychosis and AOD use: Amal’s story
(continued)

prevention strategies and the provision of ongoing support from the AOD service. Amal also had a longer-
term goal of wanting to move out of his parents’ house and live independently, which his case manager
worked into his treatment goals.

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.
• Involvement of family, carers or friends is often critical to providing a full picture but
also needs to be carefully and sensitively managed.
• Medication adherence needs long-term attention.
• A holistic approach, assessing a person’s accommodation and employment needs in
addition to their mental, physical, and AOD use disorders, is vital.
Bipolar disorders
B7: Managing and treating bipolar disorders 199

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 [133]. 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 may appear to be completely well. People
with bipolar disorder predominantly present to services during the depressive phases of the disorder
rather than during 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 adherence.

Managing symptoms of bipolar

In general, if the client presents during a depressive episode, management of symptoms should follow
the guidelines for the management of depressive symptoms (see Table 43). As previously mentioned,
low mood is often a trigger for relapse to AOD use and addressing depressive symptoms is an important
component of relapse prevention [1019]. If, however, 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.

The techniques outlined in Table 44 may assist in the management of a person experiencing symptoms
of mania or hypomania. Some clients may be aware that they are unwell and will voluntarily seek help;
others may lack insight into their symptoms and refuse, or not perceive the need for, 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.
200 B7: Managing and treating bipolar disorders

Table 43: Dos and don’ts of managing a client with depressive symptoms of bipolar

Do:

Encourage and emphasise successes and positive steps (even just coming in for treatment).

Take everything they say seriously.

Maintain eye contact and sit in a relaxed position – positive body language will help you and the
client feel more comfortable.

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.

Constantly monitor suicidal thoughts and talk about these thoughts openly and calmly.

Encourage the client to express their feelings.

Be available, supportive, and empathetic.

Offer realistic hope (i.e., that treatment is available and effective).

Encourage regular sleep, exercise and eating patterns.

Keep language clear, specific, and simple.

Assist the client to identify early warning signs that they may become unwell.

Provide contact details of counselling services and offer to make referrals if required (many
depressed people struggle to do this alone).

Encourage participation in healthy, pleasurable, and achievement-based activities (e.g., exercise,

hobbies, work).

Don’t:

Make unrealistic statements or give unrealistic hope, like ‘everything will be fine’.

Invalidate the client’s feelings.

Be harsh, angry, or judgemental. Remain calm and patient.

Lose hope or become frustrated.

Act shocked by what the client may reveal.

Adapted from Scott et al. [1020], Clancy and Terry [448] and Headspace [1021].
B7: Managing and treating bipolar disorders 201

Table 44: Dos and don’ts of managing a client experiencing mania/hypomania

Do:

Ensure the safety of the client, yourself, and others.

Assist the client identify early warning signs that they may become unwell.

Help to reduce triggers that aggravate the person’s symptoms (e.g., reduce stimulation such as
noise, clutter, caffeine, social gatherings).

Speak clearly and calmly, asking only one question or giving only one direction at a time.

Answer questions briefly, quietly, calmly, and honestly.

Use a consistently even tone of voice, even if the person becomes aggressive.

Encourage regular sleep, exercise and eating patterns.

Be cautious about becoming swept up by the person’s elevated mood.

Point out the consequences of the client’s behaviour. Be specific.

If the person is well enough, discuss precautions they can take to prevent risky activities and
negative consequences (e.g., give their credit cards and/or car keys temporarily to a trusted family
member or friend to prevent reckless spending and driving).

If promiscuity or socially inappropriate behaviour is a problem, encourage the person to avoid

situations in which their behaviour may lead to negative consequences.

Encourage the person to postpone acting on a risky idea until their mood is stable.

Ensure both you and the client can access exits – if there is only one exit, ensure that you are
closest to the exit.

Have emergency alarms/mobile phones and have crisis teams/police on speed dial.

If the person is placing themselves at risk, or they are experiencing severe symptoms of psychosis,
arrange transfer to an emergency department for assessment and treatment by calling an
ambulance on 000.
202 B7: Managing and treating bipolar disorders

Table 44: Dos and don’ts of managing a client experiencing mania/hypomania

(continued)

Don’t:

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.

Get visibly upset or angry with the client. Remain calm and patient.

Confuse and increase the client’s level of stress by having too many workers attempting to
communicate with them.

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.

Leave dangerous items around that could be used as a weapon or thrown.

Laugh (or let others laugh) at the person.

Act horrified, worried, or panic.

Treating bipolar disorders

There are several options available for the treatment of bipolar disorders, including psychotherapy,
pharmacotherapy, ECT, e-health and telehealth interventions, as well as complementary and alternative
therapies (e.g., dietary supplements). The evidence base surrounding each of these treatments is
discussed below. Despite a small evidence base regarding the treatment of bipolar disorder in the
context of co-occurring AOD use disorders, most of which has focused on pharmacological treatments,
experts recommend an integrated multidisciplinary approach to treating these conditions [1022, 1023].

Psychotherapy
Research on psychological treatments for co-occurring bipolar disorder and AOD use is minimal and
has largely been limited to small studies of CBT approaches. In line with Australian and international
guidance on the treatment of bipolar disorder [1024–1027], these studies have examined the use of
psychotherapies as adjuncts to pharmacotherapy, not as monotherapies. The intervention that has
received most investigation to date is Integrated Group Therapy (IGT), an integrated, 12- or 20-session
psychosocial group treatment program that focuses on similarities between recovery and relapse
processes in bipolar disorder and AOD use disorder. One pilot non-randomised trial and two small
RCTs have shown more positive findings in relation to AOD use outcomes relative to group counselling
control conditions, but not in relation to mood [1028–1030]. It has been suggested that the consistent
B7: Managing and treating bipolar disorders 203

superiority of IGT over group drug counselling indicates that the efficacy of drug treatment for people with
co-occurring bipolar disorder is enhanced when treatment is provided in the context of mood disorder
treatment, but additional strategies may be needed for mood management [871].

Preliminary studies have also been conducted on several other integrated treatments delivered as
adjuncts to pharmacotherapy, but again, these have been limited to small RCTs with mixed findings.
Schmitz and colleagues [1031] compared an individual integrated CBT treatment for bipolar and
AOD use delivered in combination with medication monitoring to medication monitoring alone. No
significant differences were found in relation to AOD use; findings in relation to mood were mixed but
appeared promising. A further two intensive 6-month long programs that involved clients’ families, the
Integrated Treatment Adherence Program based on ACT for adults [1032] and the Family Focused Treatment for
adolescents [1033], have also undergone preliminary evaluations with promising findings in relation to
symptoms of bipolar disorder, but not in relation to AOD use.

Other integrated interventions that have undergone preliminary evaluation and found to be acceptable,
feasible, and potentially efficacious in reducing either AOD use and/or symptoms of bipolar disorder
include HABIT, a manualised integrated group therapy that combines CBT with mindfulness-based
relapse prevention [1034], and an integrated individual therapy that combines CBT and MI [1035]. Further
research is needed to determine their effectiveness.

Pharmacotherapy
Pharmacotherapy is the first-line approach to treating bipolar disorders as single disorders [1024–1027].
It is therefore not surprising that the vast majority of research regarding the treatment of co-occurring
bipolar and AOD use disorders has focused on pharmacotherapies. Nevertheless, the evidence base
is limited making it difficult to draw firm conclusions. Most studies have been conducted with a
small number of people, lacked comparison groups, and involved the use of a variety of concomitant
medications, making it difficult to clearly attribute effects to the medication examined [1023, 1036].
Multiple medications are often used to treat each specific disorder, such as the use of mood stabilisers
(see Table 45), antipsychotics (see Table 42), and/or antidepressants (see Table 47) for the bipolar
disorder, in conjunction with medication specifically to treat the AOD use disorder (e.g., naltrexone for
alcohol use disorder) [1037], but care should be taken to avoid unnecessary polypharmacy due to the
potential for interaction effects.
204 B7: Managing and treating bipolar disorders

Table 45: Mood stabiliser medications

Drug name Brand names Drug name Brand names

Aripiprazole Abilify, Abyraz, Quetiapine Delucon, Kaptan, Quetia,

Tevaripiprazole Seroquel, Syquet, Tevatiapine

Asenapine Saphris Risperidone Ozidal, Rispa, Risperdal,

Rispernia, Rixadone

Carbamazepine Tegretol Sodium valproate Epilim, Valprease, Valpro

Lamotrigine Lamictal, Lamidus, Ziprasidone Zeldox, Ziprox

Lamitan, Lamotrust,
Logem, Reedos, Torlemo

Lithium Lithicarb, Quilonum

Olanzapine Olanzacor, Ozin, Pryzex,

Zypine, Zyprexa

Paliperidone Ivenga

Adapted from Khoo [1038]. For a full list of generic brands available, see the Therapeutic Goods Administration website
(https://www.tga.gov.au).

Research to date has largely focused on the use of quetiapine among people with co-occurring bipolar
and alcohol use disorders. Although initial open-label uncontrolled trials largely found quetiapine to have
a positive impact on both psychiatric symptoms and AOD use, most RCTs have demonstrated that these
improvements tend to be no greater than those achieved with a placebo [1036]. A similar pattern has
been observed for sodium valproate among people with co-occurring bipolar and alcohol, cocaine and/or
cannabis use disorders; although findings from one RCT suggest that greater reductions in alcohol use
may be obtained by adding sodium valproate to lithium and individual counselling [1039].

Lithium itself has been examined in a small RCT conducted among adolescents which found
significantly greater reductions in AOD use and depressive symptoms among those who received lithium
relative to those who received placebo [1040]. A further study demonstrated that lithium had an impact
on reducing cannabis and cocaine use among people with co-occurring 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 [1041].

Lamotrigine has been shown to have mixed results in uncontrolled trials with regard to symptoms of
bipolar, cocaine and alcohol use, but the only RCT conducted to date found no significant differences
in outcomes for those who received lamotrigine compared to those who received a placebo medication
[1036]. Topiramate has also been examined in an RCT and was not found to be superior to placebo
B7: Managing and treating bipolar disorders 205

with respect to reductions in AOD use and mood [1036]. Aripiprazole, olanzapine, and asenapine have
all undergone preliminary testing, and all have been associated with reductions in cravings and
improvements in bipolar symptoms but are yet to be examined in controlled trials [1036]. Over the past
several years, studies have widened their focus to include non-traditional pharmacotherapies, such as
memantine (an NMDA-receptor agonist typically used in the treatment of Alzheimer’s disease) [1042] and
ondansetron (an antiemetic usually used in the treatment of nausea) [1043]. Although this is an area that
is still developing, some promising findings have emerged.

It is also important to bear in mind that people with a co-occurring bipolar disorder may be less likely
to take their medication if they lack insight, do not recognise their manic episodes, or enjoy their manic
episodes. Measures to increase medication adherence may be particularly pertinent (discussed in
Chapter B6). Other strategies to promote medication adherence among clients with co-occurring bipolar
disorder include the Integrated Treatment Adherence Program described earlier in this chapter, which is an
adjunctive psychosocial approach designed to improve treatment adherence [1032].

Electroconvulsive therapy (ECT)

While ECT has been suggested as a second-line treatment option for single disorder bipolar in very severe
cases (e.g., treatment-resistant or acute mania, depression, suicidality) [1026, 1027], to date, few research
studies have assessed the efficacy of ECT in treating co-occurring bipolar and AOD use disorders.

Of the research that has been conducted, one study conducted a retrospective analysis of Swedish
medical records of people with bipolar and depression, both as single disorders and co-occurring with
AOD use, who had previously received ECT [1044]. ECT was found to improve remission rates from baseline
for people with single disorder bipolar, at a similar rate to people with unipolar depression (35% for
bipolar vs. 45% for unipolar depression). However, people with co-occurring mood disorders and AOD use
had lower remission rates compared to people without co-occurring AOD use (26% to 29% vs. 42% to 47%
respectively) [1044].

In a second study conducted among 190 adolescents and young people aged 16 to 25 with depressive,
psychotic and bipolar disorders, a course of five ECT treatments was found to reduce AOD use outcomes,
such as cravings and problematic behaviour associated with substance use, relative to baseline [1045].
Following these treatments, people also demonstrated reductions in the frequency of depressive and
psychotic symptoms, as well as self-harm ideation [1045]. However, it should be borne in mind that
bipolar disorders made up only a very small subsample of this study (14%). While these studies may be
promising, more conclusive evidence for the use of ECT among people with co-occurring bipolar and AOD
use is needed.

E-health and telehealth interventions

There are several online interventions to support the mental health of people with bipolar disorders,
including MoodSwings [1046, 1047], Living With Bipolar [1048], Beating Bipolar [1049], the Bipolar Education
Programme [1050], HealthSteps for Bipolar Disorder [1051], LiveWell [1052], ORBIT [1053], ERPonline [1054], and
OpenSIMPLe [1055]. However, only some of these have been, or are in the early stages of being, evaluated.
Feasibility and preliminary studies of Living With Bipolar [1048], Bipolar Education Programme [1050], and
OpenSIMPLe [1055] are promising.
206 B7: Managing and treating bipolar disorders

One online program, Therapeutic Education System (TES), developed for people with AOD use was recently
evaluated among 95 people, a subsample of whom were experiencing co-occurring bipolar disorder
[1056]. TES comprises 65, 15-minute modules, covering substance use-related topics, such as problem
solving and drug-refusal skill training. Compared to those in the treatment as usual control group, those
enrolled in TES reported greater perceived usefulness of treatment and better emotional regulation,
although the groups did not differ in subsequent enrolment rates in AOD treatment programs, self-
reported cravings, number of drug-related dreams, or satisfaction with treatment. Outcomes related to
bipolar symptoms were not examined.

Physical activity
A small number of studies with relatively small samples have examined the effect of exercise on bipolar
disorders. Ng and colleagues [1057] conducted a small, retrospective chart review, and found that
depression and anxiety improved among people with bipolar disorder who participated in a voluntary
40-minute, supervised group walking activity whilst in a psychiatric facility, every weekday morning,
compared to non-walkers. However, there was no clinical difference in overall improvement between
walkers and non-walkers [1057]. 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
people with bipolar disorder [1058]. 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 [1059]. In a systematic review of the literature, it was similarly concluded that
physical activity is associated with reduced depressive symptoms among people with bipolar, as well as
improved quality of life [1060]. The optimal dose for exercise among people with bipolar has not yet been
determined; however, guidelines for mood disorders from the RANZCP suggest that exercise should be
regular (two to three times per week) and vigorous (requiring sustained effort) to maximise the chance
of deriving health benefits [1027]. Similarly, although the optimal dose and exercise type for people with
bipolar have yet to be determined, aerobic and resistance-based exercises are recommended for people
with mood disorders in general [1027].

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 [1060–1062]. Although exercise may be beneficial
in redirecting excess energy for some, others found their manic symptoms were aggravated, potentially
risking a cycle of manic and hypomanic symptoms [1063]. It has been suggested that the exacerbation
of manic symptoms may be due to direct effects on mood, or indirectly on excessive goal-focused
activities, which can be a risk pathway for bipolar disorder [1064, 1065]. However, these preliminary
findings originate from a small qualitative study and require further empirical evidence, with some
participants in the study finding exercise calming [1061]. No research has been conducted to examine the
efficacy of exercise among people with co-occurring bipolar and AOD use; however, given the unknown
and potentially risky relationship with mania, physical activity among people with co-occurring disorders
should be closely monitored.
B7: Managing and treating bipolar disorders 207

Complementary and alternative therapies

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 and -6 supplementation, icariin, citicoline [1066–1070]), and mania
symptoms (e.g., magnesium supplementation [1071–1073]), many therapies have the potential to induce
mania or interact with pharmacotherapies (e.g., St John’s Wort [1074–1077]); 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 these co-occurring disorders. Box 16 illustrates the continuation
of case study C, following Scott after his initial visit with the AOD worker.

Box 16: Case study C: Treating co-occurring bipolar disorder and AOD use: Scott’s story
continued

Case study C: Scott’s story continued

During the comprehensive assessment with the AOD worker, Scott described other periods where he had
felt elated. His girlfriend said that he would sometimes come home after two weeks at work and start a
new project in a ‘frenzy’, often staying up all night or only coming to bed at 2 or 3am, but rarely finished
any of them before moving on to something new. During these periods, Scott’s girlfriend said he was like
a different person - he was full of energy, talked non-stop, would do all the housework and didn’t seem to
need much sleep. Scott excitedly told the AOD worker that he just started rebuilding a motorbike in his
garage. Scott’s girlfriend expressed her frustration that their house was full of half-completed projects,
with ‘stuff everywhere’.

Recognising a probable bipolar disorder, the AOD worker organised for Scott to see a psychiatrist, who
confirmed this diagnosis. Scott’s AOD worker told him that if he wanted to work on his AOD use, they
would work together with his psychiatrist to manage both conditions together. Scott agreed this was
a good idea and was prescribed a mood stabiliser by his psychiatrist. A concurrent approach to Scott’s
mental health and AOD use began, which involved regular meetings with Scott and the professionals
involved in his mental health care and AOD treatment.

In addition to psychotherapy and medication, the team helped Scott with financial management and
provided him with some strategies to help with his spending. They also discussed Scott’s lifestyle and
in particular, the nature of his fly-in-fly-out employment. The first time this was raised, Scott became
extremely angry. Refusing to believe there was any problem or connection between the long shift work,
numerous consecutive working days, his AOD use and mental health symptoms, he told the treatment
208 B7: Managing and treating bipolar disorders

Box 16: Case study C: Treating co-occurring bipolar disorder and AOD use: Scott’s story
(continued)

team to ‘butt out’ and stormed out of the meeting. Very late that evening, Scott’s girlfriend was contacted
by a friend who had found Scott passed out in a local park – he was naked and his feet were bare and
bloodied. It appeared that he had consumed a large quantity of alcohol and had been wandering around.
His girlfriend picked Scott up and she and the friend took him to emergency, where he was admitted
overnight.

Over the next few days, Scott’s mood had settled, and he started to think more about his life and work,
and the things that were important to him. In the next treatment team meeting, he listened to the
concerns raised, and said he loved his job but could see why the type of work he had been doing may be
contributing to making things worse and would think about it some more. He was grateful that his team
was being patient with him, listening to him think things through without judging him. Scott started
going to the gym again and joined the local soccer team.

Key points:
• In cases of bipolar disorder co-occurring with AOD use, treatments need to be
coordinated and carefully integrated. Strategies to address medication adherence,
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
210 B7: Managing and treating 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).

Managing depressive symptoms

Negative mood is often a trigger for relapse, and therefore addressing depressive symptoms is also
an important part of relapse prevention [1078, 1079]. The techniques outlined in Table 46 may help AOD
workers to manage clients with depressive symptoms. A number of simple strategies based on CBT may
also be useful for clients in managing depressive symptoms, including [482, 1080, 1081]:

• Cognitive restructuring.

• Pleasure and mastery events scheduling.

• Goal setting.

• Problem solving.

These techniques are discussed in greater detail in Appendix BB.

It is important to note that many depressive symptoms (and many anxiety symptoms) will subside
after a period of abstinence and stabilisation [1082–1084]. 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 [1082, 1083, 1085]. 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 depressive episodes in circumstances when they are not intoxicated or
withdrawing, they 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.

Table 46: Dos and don’ts of managing a client with depressive symptoms

Do:

Encourage and emphasise successes and positive steps (even just coming in for treatment).

Take everything they say seriously.

B7: Managing and treating depression 211

Table 46: Dos and don’ts of managing a client with depressive symptoms (continued)

Do:

Maintain eye contact and sit in a relaxed position—positive body language will help you and the
client feel more comfortable.

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.

Constantly monitor suicidal thoughts and talk about these thoughts openly and calmly.

Encourage the client to express their feelings.

Be available, supportive and empathetic.

Offer realistic hope (i.e., that treatment is available and effective).

Provide contact details of counselling services and offer to make referrals if required (many
depressed people struggle to do this alone).

Encourage participation in healthy, pleasurable, and achievement-based activities (e.g., exercise,

hobbies, work).

Don’t:

Make unrealistic statements or give unrealistic hope, like ‘everything will be fine’.

Invalidate the client’s feelings.

Be harsh, angry, or judgemental. Remain calm and patient.

Act shocked by what the client may reveal.

Adapted from Scott et al. [1020] and Clancy and Terry [448].

Treating depressive disorders

There are several options available for the treatment of depressive disorders, including psychotherapy,
pharmacotherapy, ECT, e-health, physical activity, as well as complementary and alternative therapies
(e.g., omega-3). The evidence base surrounding each of these treatments is discussed below.
212 B7: Managing and treating depression

Psychotherapy
Research on psychological therapies provides support for the use of integrated psychological treatments
for co-occurring depression and AOD use disorders [228, 665, 1086, 1087]. However, the small number
of studies, methodological limitations (e.g., lack of randomisation to treatment conditions), variation
in study results, and small sample sizes used in these studies highlight the need for larger trials to be
conducted in this area [665, 1088].

The majority of studies to date have examined the use of integrated treatments that adopt a CBT
approach [122, 665, 1089]. Reviews of the literature have shown that integrated CBT approaches yield
superior results for depression and AOD use when compared to no treatment or treatment as usual
comparison groups [1088, 1090], but there is insufficient evidence demonstrating that any one
psychological therapy is more effective than another for these co-occurring conditions [1091].

In a 2019 Cochrane review, Hides and colleagues [1091] identified there was limited evidence to suggest
that integrated CBT (ICBT) results in higher rates of abstinence at 6- to 12-months follow-up compared
to 12-step facilitation therapy. Both approaches appeared to be similarly effective in terms of depressive
symptoms at follow-up, however, reductions appeared more quickly with 12-step facilitation therapy
than ICBT and Hides and colleagues [1091] caution that these findings are based on low-quality
evidence. As a way of enhancing CBT, it has been suggested that CBT be combined with other evidence-
based psychological strategies, such as contingency management (see Chapter B6). The addition of
contingency management to CBT-based approaches has been shown to lead to superior outcomes in
terms of AOD abstinence and depressive symptoms relative to CBT-based approaches alone [1092, 1093].

Another approach showing promise in the treatment of co-occurring AOD use and depression is
behavioural activation (described in Chapter B6). There is empirical evidence illustrating that
behavioural activation is as effective in treating depression as cognitive and behavioural techniques
(with or without antidepressants) and more effective than antidepressant medication alone [693,
694, 1094]. The efficacy of behavioural activation in treating co-occurring AOD use and depression has
been examined in several RCTs across a variety of AOD treatment settings (community-based clinics,
residential treatment, specialist addiction clinics). A systematic review of these trials concluded that,
although the research to date is promising, further research is needed [690].

Lastly, although still in the early stages, there is preliminary support for the use of mindfulness-based
approaches in the treatment of co-occurring depression and AOD use. These approaches include
mindfulness-based relapse prevention [1095, 1096] and mindfulness-based cognitive therapy [1097],
which have been associated with greater reductions in depressive symptoms and AOD craving relative to
treatment as usual for AOD.

Pharmacotherapy
There is consensus amongst experts that pharmacotherapy (i.e., antidepressants; see Table 47) for co-
occurring depression and alcohol use disorders can be effective, provided an individualised approach is
used [1098, 1099]; however, it has been suggested that using pharmacotherapy to treat only depression or
only AOD use is not likely to be sufficient to achieve improvements for both conditions [1100].
B7: Managing and treating depression 213

A number of systematic reviews have examined the effectiveness of antidepressant medication among
people with co-occurring AOD use disorders and depression [1100–1103]. Most studies to date have
focused on alcohol use disorders, but other AOD use disorders examined include cocaine use disorder,
opiate use disorder, and nicotine use disorder [1101].

Systematic reviews and meta-analyses have shown that, while their effect on AOD has been mixed,
the effect of antidepressants on depression among people with AOD use disorders is comparable to
that observed among people with single disorder depression [34, 1100–1102]. There is some evidence to
suggest that their effectiveness may vary depending on the type of AOD use disorder a person presents
with. For example, although studies of co-occurring alcohol dependence and major depression support
the use of antidepressants [1102], most studies of cocaine and opiate dependent clients do not [1101].

The majority of studies to date have examined the use of SSRIs and few have directly compared the
effectiveness of different types of antidepressants among people with AOD use disorders. As such,
there is insufficient evidence to recommend the use of one over another [1102]. Despite a lack of
comparative research, there is some evidence to suggest that particular antidepressants may be more
effective in treating depression among people with AOD use disorders than others. In a systematic
review of pharmacotherapy among people with co-occurring AOD use and depressive disorders (either
major depressive disorder or dysthymia), Stokes and colleagues [1101] found that imipramine (a
tricyclic antidepressant, TCA) improved depressive symptoms among people with co-occurring alcohol
dependence and opiate dependence, however, SSRIs showed no effects on depression. The lack of
effects for SSRIs was observed both when SSRIs were used alone and in combination with other relapse
prevention medications (e.g., naltrexone). Consistent with these findings, the addition of citalopram to
naltrexone and case management has not been shown to confer any added benefit over naltrexone and
case management among people with either independent or substance-induced depression and alcohol
dependence [1104]. Antidepressants that do not come under the umbrella of SSRIs or TCAs have been
found to be effective in single studies, with improvements observed on outcomes such as depression,
alcohol consumption, cravings, and time to relapse [1100].

It has also been suggested that different types of antidepressants seem to be suitable for different
types of substance use disorders [1105]. In particular, people with AOD use disorders tend to respond
better to antidepressants that have a similar direct or side effect profile to their substance use. Hence,
the more sedating antidepressants such as doxepin or paroxetine are more effective among people
who use alcohol, heroin, and sedatives, and the more stimulating antidepressants such as desipramine
and bupropion have greater efficacy among those with depression who use stimulants and nicotine. As
there is insufficient evidence for the use of antidepressants for treating depression among people who
use psychostimulants such as amphetamines and ecstasy [1106, 1107], the use of the more stimulating
antidepressants for these clients provides the best guidance at this time.

As with any medication, the choice of antidepressant used should be made with the client and take into
consideration the safety and tolerability of the medication, and any potential contraindications. SSRIs
and other atypical antidepressants are typically better tolerated, associated with fewer adverse effects,
and are safer in overdose relative to TCAs [1102, 1108, 1109]. For all AOD clients, extreme caution should
be taken when prescribing monoamine oxidase inhibitors (MAOIs). These medications are potentially
214 B7: Managing and treating depression

dangerous because of the dietary and medication restrictions involved [1105, 1106]. 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) [1110, 1111]. Further MAOIs have a number of possible/theoretical interactions with alcohol
(tyramine in some wines/beers) and other drugs of abuse [1105]. For these reasons, MAOIs should only be
used when other antidepressant medication options have failed.

Esketamine, an NMDA-receptor antagonist recently approved for the treatment of depression by the
Australian Therapeutic Goods Administration, is another pharmacotherapy that may be considered
for people who have not demonstrated an adequate response to at least two other antidepressants
[1112]. Caution should be used however, due to its abuse potential and significant adverse effects (e.g.,
dizziness, nausea, dissociation) [1113–1116]. Relative to placebo, people are more likely to discontinue
esketamine due to the intolerability of these side effects [1116].

Suicide risk should be carefully monitored when a person commences any antidepressant, given
ongoing uncertainty and controversy regarding initiation of antidepressants and increased suicide risk;
in particular, suicide attempts within the first three to four weeks of acute treatment [1117, 1118]. Thus,
although it is suggested that the benefits of antidepressant use outweigh the risks, and appropriate use
actually protects depressed patients from suicide, it is important to maintain appropriate monitoring of
suicidality [1098, 1109].

It is important to note that it can take up to four weeks for an antidepressant to reach therapeutic
levels. Responses to antidepressants are typically noticeable within two to four weeks, with continued
improvement in symptoms for up to 12 weeks [1098]. With these issues in mind, early follow-ups after
initiation of an antidepressant medication are recommended [1098]. 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 (usually a minimum of three weeks), 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 [1098].

Thase and colleagues [1099] 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 most of the newer antidepressants such as SSRIs, such caution as waiting for
a minimum number of weeks of abstinence cannot be justified. This would particularly apply where a
client has a history of depression during periods of abstinence, or where the person has had successful
antidepressant intervention in the past.

Some clients may be reluctant to take SSRIs due to the misconception that they are ‘addictive’. SSRIs are
not habit-forming; however, people may experience a discontinuation syndrome if medication is stopped
abruptly [1109]. Symptoms typically appear within three to four days of stopping and are similar to some
of those experienced during alcohol and opiate withdrawal (e.g., flu-like symptoms, light-headedness,
headache, nausea) [1109]. When discontinuing SSRIs, the dose should be gradually tapered.
B7: Managing and treating depression 215

Table 47: Antidepressant medications

Drug type and name Brand names

Tricyclic antidepressant (TCA):

Amitriptyline Endep, Entrip, Lupin

Clomipramine Anafranil, Placil

Dosulepin (dothiepin) Dothep, Mylan

Doxepin Deptran

Imipramine Tofranil

Nortriptyline Allegron, NotriTABS

Monoamine oxidase inhibitor (MAOI):

Phenelzine Nardil

Tranylcypromine Parnate

Reversible inhibitor of monoamine oxidase A (RIMA):

Moclobemide Amira, Aurorix, Clobemix

Selective serotonin reuptake inhibitor (SSRI):

Citalopram Celapram, Cipramil, Talam

Escitalopram Cilopam, Escicor, Esipram, Lexam, Lexapro, Loxalate

Fluoxetine Fluotex, Lovan, Prozac, Zactin

Fluvoxamine Faverin, Luvox, Movox

Paroxetine Aropax, Extine, Paxtine, Roxtine

Sertraline Eleva, Sertra, Setrona, Zoloft

Serotonin and noradrenaline reuptake inhibitor (SNRI):

Desvenlafaxine Desfax, Desven, Pristiq

Duloxetine Cymbalta, Depreta, Duloxecor, Dytrex, Tixol

Venlafaxine Efexor, Elaxine, Enlafax

216 B7: Managing and treating depression

Table 47: Antidepressant medications (continued)

Drug type and name Brand names

Noradrenaline and specific serotonergic agent (NaSSA):

Mirtazapine Avanza, Axit, Mirtanza, Mirtazon

Tetracyclic antidepressant:

Mianserin Lumin

Noradrenaline reuptake inhibitor (NRI):

Reboxetine Edronax

Melatonergic antidepressant:

Agomelatine Domion, Valdoxan

N-methyl-D-aspartate (NMDA) receptor antagonist:

Esketamine Spravato

Adapted from Australian Government Department of Health [1119]. For a full list of generic brands available, see the Therapeutic
Goods Administration website (https://www.tga.gov.au).

Naltrexone and acamprosate, medications commonly used in the treatment of alcohol use disorders,
have shown moderately positive outcomes in depression as a single disorder [1120]. However, in a 2019
review of trials examining the use of alcohol medications among people with co-occurring alcohol
dependence and depression, naltrexone and acamprosate produced mixed findings. As such, the authors
concluded that their efficacy for alcohol use disorder and depression together remains unclear [1100].
More promising results have been found in relation to the use of disulfiram in this population, which has
been associated with improvements in both depression and alcohol-related outcomes in some studies
[1100, 1103]. 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.
B7: Managing and treating depression 217

Recent reviews have noted emerging evidence of the efficacy of anticonvulsants/antiepileptics for
alcohol abstinence in people with co-occurring depression [1100, 1103], and recent trial results have
demonstrated that a single high-dose of buprenorphine may rapidly reduce depression and suicidal
ideation in people with opiate dependence and co-occurring depression [1121, 1122]. These findings
suggest that buprenorphine may prove to be an especially useful pharmacotherapy for this sub-group,
however, further research is needed.

Electroconvulsive therapy (ECT)

The 2019 RANZCP clinical practice guidelines for the treatment of depression note that ECT is a highly
efficacious treatment with a strong evidence base, particularly for patients with severe or psychotic
depression, catatonia, high risk of suicide, or who have not responded to adequate trials of medication
or psychotherapy [808]. However, only one study to date has assessed the efficacy of ECT in treating co-
occurring depression and AOD use disorders [1123]. This study, a retrospective chart review comparing
depressed patients with and without co-occurring AOD use disorders, found that patients with co-
occurring alcohol use disorders experienced similar improvements in their depressive symptoms
following ECT as those with mood disorders alone [1123]; however, patients with both co-occurring alcohol
and drug use disorders experienced smaller improvements post-ECT than those with mood disorders
alone [1123].

E-health interventions
Research examining e-health interventions based mostly on CBT strategies has found evidence for
modest, yet positive effects on depression outcomes [833, 1124], and their use as a low-intensity, initial
treatment for adults experiencing mild symptoms of depression has been recommended by the RANZCP
guidelines [1098]. A small number of e-health interventions specifically designed to treat co-occurring
depression and AOD use have been developed and evaluated in Australia.

The SHADE program, consisting of nine sessions of interactive exercises based on MI and CBT, has
been associated with moderate to large reductions in alcohol consumption and significant reductions
in depression scores over 12-month follow-up [1125, 1126]. More recently, a brief (four-session) early
intervention program called the DEAL Project was developed, targeting young people experiencing
depression with harmful patterns of alcohol use [110]. The program is undertaken entirely online with
no clinician support. In evaluating the intervention, Deady and colleagues [1127] 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. At the time of writing,
both SHADE and the DEAL Project are freely available via the eCliPSE portal http://www.eclipse.org.au.

There are also several Australian-based online programs for depression as a single disorder, including
MindSpot Wellbeing Course, moodgym, myCompass, and This Way Up Depression Course [1128, 1129]. The
majority have been evaluated in clinical trials, and demonstrated small to moderate positive effects on
symptoms of depression [833, 1124, 1130–1132]. The ReachOut website includes a comprehensive list of
apps recommended by clinicians https://au.reachout.com/tools-and-apps.
218 B7: Managing and treating depression

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 [1133–1135]; and,
conversely, more physical inactivity found among people who are depressed [1136]. As mentioned
previously, exercise is relatively low-risk, associated with a wide range of physical health benefits,
and research has demonstrated exercise to be as effective in reducing depressive symptoms as
psychotherapy and antidepressants [272, 1137]. A Cochrane review examining the effect of exercise on
depressive symptoms 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 [1138]. The UK NICE Guidelines for mild to moderate
depression recommend 45 minutes to 1 hour duration of structured, supervised physical activity
programs, three times a week over 10 to 14 weeks [1139].

A number of systematic and meta-analytic reviews have examined the effects of physical exercise on
elevated symptoms of depression and/or diagnosed depressive disorders among people with AOD use
disorders. A systematic review by Giménez-Meseguer and colleages [306] found that both physical
fitness and body-mind interventions have positive effects on depression, quality-of-life, and cravings
among people with an alcohol use or other drug use disorder. Similarly, a meta-analysis of 22 studies
examining the use of physical exercise of varied intensity (from light to vigorous, aerobic-based
activities, mind-body practices such as Tai chi, qigong) as a treatment for AOD use disorders found
improvements in abstinence rates, withdrawal symptoms, and depression [305]. However, some reviews
have pointed toward differential effects depending on the type of activity. Specifically, among people
with alcohol use disorders, aerobic exercise or strength training has been found to result in reduced
depressive symptoms but not a reduction in daily alcohol consumption, compared to control conditions
[1140]. Among people with AOD use disorders more broadly, another review found highly mixed outcomes
in relation to depression and AOD use with anaerobic exercise (i.e., high intensity, interval training) [1141].

Yoga

Yoga is a complex mind–body intervention involving spiritual practice, physical activity, breathing
exercises, mindfulness and meditation [1142, 1143]. 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 [1142–1144]. 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 [1144].

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 (as opposed to exercise-based practice)
[1145–1148]. Further, yoga has been shown to result in similar remission rates compared to ECT, and
similar short-term improvements in symptoms compared to antidepressant medication [1145]. However,
the current evidence base is hampered by the limited number of RCTs comprising small samples.
B7: Managing and treating depression 219

Reviews of yoga efficacy among people with various standalone AOD use disorders have highlighted
equivalent or superior improvements in AOD use and psychosocial outcomes when compared to
controls (e.g., attention, waitlist, physical exercise). There is also evidence to suggest that it may enhance
the effects of other evidence-based psychological treatments, such as CBT [1149, 1150]. However, only
one study to date has examined the effect of yoga breathing (Sudarshana Kriya Yoga) on depressive
symptoms among people with alcohol dependence [1151]. 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 co-occurring AOD and depressive disorders needs
further investigation, these findings indicate that yoga may be considered as an additional treatment for
clients with co-occurring AOD use and depression.

Complementary and alternative therapies

Omega-3

There has been much research conducted examining the relationship between omega-3 and depressive
disorders, with some limited evidence that omega-3 fatty acids (primarily found in fish and seafood)
have antidepressant effects [1152–1154]. Although there are some indications that omega-3 fatty acids
have a beneficial role in reducing dependence, cravings, and stress among people with AOD use disorders
[1153], findings are inconsistent and most research to date has been conducted on animals [1152, 1154].
Further, the role of omega-3 fatty acids among people with co-occurring AOD use and depression has not
been rigorously examined.

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 antidepressant medication [1155]. Systematic reviews 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, and equivalent reductions compared to antidepressant
medications [1156, 1157]. However, the long-term side effects, particularly among pregnant women, are
unknown.

Although there is some evidence of efficacy in mild to moderate depression, as described in Chapter
B6, 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 [794].

Although the use of St John’s Wort among people with co-occurring AOD and depressive disorders has
not been examined, 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.
220 B7: Managing and treating depression

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 17 illustrates the continuation of case
study D, following Sheryl after the identification of her co-occurring depressive and AOD use disorder.

Box 17: Case study D: Treating co-occurring depression and AOD use: Sheryl’s story
continued

Case study D: Sheryl’s story continued

When Sheryl’s GP received her blood test results, they showed Sheryl had an underactive thyroid, for
which her GP immediately organised medication. Sheryl’s GP contacted the local addiction medicine
specialist to advise on the most appropriate method of benzodiazepine titration and withdrawal and
organised an appointment for Sheryl. One of Sheryl’s daughters accompanied her to the appointment.
Through the AOD service, Sheryl heard about a group therapy that is run on Tuesday evenings that didn’t
sound too bad, and with the encouragement of her daughter, started attending.

After a few weeks taking thyroxin medication, Sheryl’s energy increased but she continued experiencing
very low mood. Upon telling her GP of her continued periods of depression, they discussed treatment
options including psychological therapy and medications. Sheryl was reluctant to take another
medication and preferred to see a psychologist. She was referred to a clinical psychologist who began
CBT. Sheryl’s GP began organising regular case management meetings between herself, Sheryl, the
addiction medicine specialist, the clinical psychologist and Sheryl’s daughters. It was decided in the
first meeting that given Sheryl’s medical condition her GP was the appropriate person to take on the
role of the primary case manager. At one of these meetings, Sheryl asked to revisit the idea of taking
antidepressants. Although she was making progress, Sheryl was still feeling very low and was having
trouble fully engaging in therapy.

As part of Sheryl’s psychotherapy, Sheryl was encouraged to rediscover things she was genuinely
interested in and re-establish a sense of purpose. Over time, she reconnected with her friends and
enrolled in some online classes through her local community college.

Key points:
• People with co-occurring disorders may not necessarily present in obvious ways. The
need for careful history taking regarding AOD use cannot be overemphasised.
• Underlying medical conditions may resemble or disguise symptoms of mental
disorders, and it is vital to conduct comprehensive medical assessments.
• It is common for symptoms of both AOD and mental health conditions to be
exacerbated by major life events.
Anxiety
222 B7: Managing and treating anxiety

Anxiety

Clinical presentation
Anxiety is a normal reaction to stress, and in moderation, can help to improve performance [1158].
Anxiety can become problematic however, when the fear or worry is excessive, or a person has difficulty
controlling their worry, and/or repetitive intrusive thoughts or actions. Symptoms of anxiety include poor
concentration, an 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.

Managing symptoms of anxiety, panic, or agitation

The presence of an anxiety disorder can significantly increase the risk of relapse to AOD use [1159, 1160].
Techniques for managing clients with symptoms of anxiety are outlined in Table 48. Clients may also be
encouraged to try relaxation techniques to manage the distressing and distracting symptoms of anxiety
[103, 1161, 1162].

Some useful relaxation methods include:

• Progressive muscle relaxation.

• Controlled or abdominal breathing.

• Calming response.

• Visualisation and imagery.

• Grounding.

Each method works best if practiced daily for 10–20 minutes; however, not every technique may be
appropriate for every client. These techniques are described in detail in Appendix CC. Some of the
cognitive behavioural techniques described in Appendix BB (i.e., cognitive restructuring, structured
problem solving, and goal setting) may also be useful in managing symptoms of anxiety [1163–1166], but
again, no one strategy is effective for everyone. If the client experiences unpleasant effects from any
strategy, they should discontinue its use.

As with depressive symptoms, many anxiety symptoms will subside after a period of abstinence and
stabilisation [777, 866–868]. It may be 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. If the client has a history of anxiety in circumstances when they are not intoxicated
or withdrawing, they 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.
B7: Managing and treating anxiety 223

Table 48: Dos and don’ts of managing a client with symptoms of anxiety

Do:

Approach the client in a calm, confident, and receptive way.

Move and speak at an unhurried speed.

Be patient in order to allow the client to feel comfortable to disclose information.

Minimise the number of staff present and attending to the client.

Minimise surrounding noise to reduce stimulation.

Reassure the client frequently (e.g., ‘This won’t take much longer’).

Explain the purpose and structure of interventions.

Remain with the client to calm them down.

Don’t:

Crowd or pressure the client.

Get frustrated or impatient.

Panic. The more relaxed you are, the more relaxed the client is likely to feel.

Act shocked by what the client may reveal.

Adapted from NSW Department of Health [431], SAMHSA [102], and Clancy and Terry [448].

Treating anxiety disorders

As with depression, much of the anxiety exhibited by clients entering AOD treatment will subside
following a period of abstinence and stabilisation without the need for any direct attention [866–868],
but some may require further treatment. Research relating to co-occurring anxiety and AOD use is sparse
[1158, 1167]; however, there are several options available for the treatment of anxiety disorders as single
disorders, including psychotherapy, pharmacotherapy, e-health interventions, physical activity, and
complementary and alternative therapies (e.g., dietary supplements). The evidence base surrounding
these treatments in relation to each of the different anxiety disorders is discussed below.

Broadly speaking, the RANZCP clinical practice guidelines for the treatment of GAD, panic disorder, and
SAD recommend an approach that begins with psychoeducation and lifestyle advice, followed by CBT,
pharmacotherapy (SSRIs or SNRIs) augmented with graded exposure, or a combination of CBT and
pharmacotherapy [1158].
224 B7: Managing and treating anxiety

There is also growing evidence suggesting that integrated treatment approaches may be effective at
reducing symptoms of anxiety [669, 1168, 1169], depression, stress [1168], and AOD use [669, 1168–1171],
as well as improving quality of life [669], among people with co-occurring anxiety and AOD use; but the
evidence is mixed.

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 co-
occurring anxiety and AOD use is scarce [1172], it would be reasonable to draw similar conclusions for
these co-occurring groups as for those experiencing co-occurring depression and AOD use – namely,
use of a medication such as an 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 [1110, 1173]. Commonly prescribed anti-anxiety medications include some of the SSRIs (and other
antidepressants, e.g., venlafaxine) listed in Table 47, and those listed in Table 49.

Despite their proven effectiveness in relieving anxiety, the use of benzodiazepines is not recommended
due to their abuse liability [1158, 1174, 1175]. 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, and monitoring for misuse is in place. If benzodiazepines are used, the client should only be
prescribed the lowest possible dose for only a short period of time (no more than one month [1110]).

Table 49: Anti-anxiety medications

Drug name Brand names

Selective serotonin reuptake inhibitor (SSRI):

Citalopram Celapram, Cipramil, Talam

Escitalopram Cilopam, Escicor, Esipram, Lexam, Lexapro, Loxalate

Fluoxetine Fluotex, Lovan, Prozac, Zactin

Fluvoxamine Faverin, Luvox, Movox

Paroxetine Aropax, Extine, Paxtine, Roxtine

Sertraline Eleva, Sertra, Setrona, Zoloft

Serotonin and noradrenaline reuptake inhibitor (SNRI):

Duloxetine Cymbalta, Depreta, Duloxecor, Dytrex, Tixol

Venlafaxine Efexor, Elaxine, Enlafax

B7: Managing and treating anxiety 225

Table 49: Anti-anxiety medications (continued)

Drug name Brand names

Benzodiazepines:

Alprazolam Alprax, Kalma

Clobazam Frisium

Clonazepam Paxam, Rivotril

Diazepam Antenex, Ranzepam, Valium, Valpam

Lorazepam Ativan

Oxazepam Alepam, Murelax, Serepax

Tricyclic antidepressant (TCA):

Amitriptyline Endep, Entrip, Lupin

Clomipramine Anafranil, Placil

Imipramine Tofranil

Monoamine oxidase inhibitor (MAOI):

Phenelzine Nardil

Antipsychotics:

Quetiapine Delucon, Kaptan, Quetia, Seroquel, Syquet, Tevatiapine

Adapted from Lampe [1176], the Australian Government Department of Health [1119], and the Therapeutic Goods Administration
[987]. For a full list of generic brands available, see the Therapeutic Goods Administration website (http://www.tga.gov.au).

Generalised anxiety disorder (GAD)

Psychotherapy

There is very little evidence regarding the effectiveness of psychological therapies for co-occurring
GAD and AOD use disorders [1086]. Kushner and colleagues [1169] developed an integrated group CBT
program for co-occurring 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 co-occurring
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
226 B7: Managing and treating anxiety

relaxation training, and both groups demonstrated a reduction in anxiety symptoms. However, only
38% of the sample had a principal diagnosis of GAD. Buckner and colleagues [1171] similarly developed
an individual integrated CBT program for people with co-occurring anxiety and cannabis use disorders.
In an RCT evaluating this program, people who received the integrated intervention were more likely
to be abstinent from cannabis and reported greater reductions in anxiety severity following treatment
compared to a control group receiving motivation enhancement therapy, and both groups used less
cannabis, and reported fewer cannabis-related problems. However, only 25% of the sample had a principal
diagnosis of GAD. Mindfulness-based interventions, comprising elements addressing relapse prevention,
non-reactivity, and non-judgemental awareness have also shown promise among people with stimulant
dependence and GAD [1178].

Based on a large body of evidence, the RANZCP guidelines recommend 8-12 sessions of face-to-face
or guided digital CBT as the first-line treatment for GAD [1158]. Individual or group therapy have been
found to be equally effective, but there is evidence to suggest that individual therapy is associated
with greater treatment adherence, and greater and faster gains in worry reduction. Although other
psychological therapies have been tested (e.g., applied relaxation, cognitive therapy, mindfulness and
acceptance-based interventions, meta cognitive and psychodynamic therapies) there is insufficient
evidence to recommend their use in the treatment of GAD at this time. For those experiencing moderate
or severe GAD, or those who do not demonstrate sufficient improvement in response to CBT, the use of
pharmacotherapies may be considered as an alternative or adjunctive treatment [1158].

Pharmacotherapy

As with CBT for GAD, there is a strong evidence base to support the use of SSRIs (in particular, sertraline,
escitalopram, and paroxetine) and SNRIs (venlafaxine and duloxetine) in the treatment of GAD [1158]. The
RANZCP guidelines suggest that SSRIs or SNRIs may be considered as an alternative to CBT for cases
in which the response to CBT has been inadequate or if the person has a preference for medication.
Similarly, the combined use of CBT and an SSRI or SNRI may be considered in cases of severe GAD, or
where the response to either CBT or pharmacotherapy alone has been insufficient. SSRIs have been found
to be associated with reductions in alcohol use among people with anxiety and depression [1179].

Other pharmacotherapies that have demonstrated some effectiveness in treating GAD as a single
disorder include pregabalin, agomelatine, buspirone, and imipramine; however, both buspirone and
imipramine are associated with significant side effects and therefore only recommended when
alternatives have been ineffective [1158]. Of these medications, only buspirone has been found to be
effective in producing improvements in anxiety, drinking outcomes and treatment retention in people
with GAD and alcohol use disorders [1172, 1180]. However, it should be noted that at the time of writing,
buspirone was not listed by the Australian Register of Therapeutic Goods nor in the MIMS Australia.

The RANZCP guidelines provide guidance on dose titration and switching within- and between- classes
of anti-depressants and other medications depending on treatment response. It is important to note
however, that treatment response is typically slow (at least four weeks) and it is therefore important
to allow time for appreciable effects to be discerned, which may be difficult for clients who are seeking
immediate relief from their symptoms.
B7: Managing and treating anxiety 227

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 RANZCP guidelines recommend a stepped-care
approach that begins with psychoeducation and lifestyle advice (e.g., in relation to healthy eating,
sleep, exercise patterns and limiting the use of caffeine, tobacco and alcohol), followed by either CBT,
pharmacotherapy (SSRIs or SNRIs) augmented with graded exposure, or a combination of CBT and
pharmacotherapy as necessary, depending on the severity of symptoms [1158].

Psychotherapy

Based on a large body of evidence, the RANZCP guidelines recommend 8-12 sessions of face-to-face
or guided digital CBT as the first-line treatment for panic disorder [1158]. Outcomes for individual or
group therapy appear to be comparable, and the effects have been shown to be long-lasting. Although
other psychological therapies have been tested (e.g., mindfulness, ACT, and psychodynamic therapies)
there is insufficient evidence to recommend their use in the treatment of panic disorder at this time.
For those experiencing moderate or severe panic disorder, or those who do not demonstrate sufficient
improvement in response to CBT, the use of pharmacotherapies may be considered as an alternate or
adjunctive treatment [1158].

The small amount of literature relating to the treatment of both panic disorder and AOD use has
concentrated on CBT and should be regarded as preliminary. In an RCT of people with panic disorder
receiving inpatient treatment for alcohol dependence, Bowen and colleagues [1181] 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. Kushner and colleagues [1169] similarly evaluated an integrated group CBT
program for co-occurring anxiety and alcohol use disorders in a RCT of individuals in a residential
treatment program for alcohol use disorders with co-occurring 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. However, as only 17% of the sample had a principal diagnosis of panic
disorder, the degree to which the findings reflect this client population is uncertain. In a third RCT,
Buckner and colleagues [1171] similarly evaluated an individual integrated CBT program for people with
co-occurring anxiety and cannabis use disorders which was delivered as an outpatient treatment. People
who received the integrated intervention were more likely to be abstinent and report greater reductions
in the severity of anxiety symptoms following treatment compared to the control group (who received
motivation enhancement therapy), and both groups used less cannabis, and reported fewer cannabis-
related problems. However, only 18% of the sample had a principal diagnosis of panic disorder.

Pharmacotherapy

There is a dearth of research exploring the pharmacological treatment of co-occurring panic and AOD use
disorders; however, there is a large body of evidence demonstrating the efficacy of SSRIs, SNRIs, TCAs,
228 B7: Managing and treating anxiety

and benzodiazepines for the treatment of panic disorder as a single disorder [1158, 1182, 1183]. Although
SSRIs, TCAs and benzodiazepines are considered to be equally effective, SSRIs and SNRIs (in particular,
venlafaxine) are recommended by the RANZCP as first-line pharmacotherapies due to their superior
safety and side-effect profiles relative to TCAs and benzodiazepines. As mentioned previously, TCAs are
poorly tolerated, potentially lethal in overdose, and cause significant adverse effects when combined with
other central nervous system depressants. Current evidence does not support the use of one SSRI over
another [1158].

The RANZCP guidelines suggest that SSRIs or SNRIs may be considered as an alternative to CBT for cases
in which the response to CBT has been inadequate or if the person has a preference for medication.
Similarly, the combined use of CBT and an SSRI or SNRI may be considered in cases of severe panic
disorder, or where the response to either CBT or pharmacotherapy alone has been insufficient. As
mentioned previously, it is important that practitioners explain to clients who are prescribed SSRI or SNRI
antidepressants, that they may experience an initial exacerbation of anxiety, particularly where there is a
history of panic attacks [1158]. To reduce the likelihood of this occurring, it is recommended that clients
start with a low dose and titrate slowly to a required therapeutic dose.

The RANZCP guidelines provide guidance on dose titration and switching within- and between- classes
of anti-depressants and the other previously mentioned medications depending on treatment response.
It is important to note however, that treatment response is typically slow (at least four weeks) and it
is therefore important to allow time for appreciable effects to be discerned, which may be difficult for
clients who are seeking immediate relief from their symptoms.

Social anxiety disorder (SAD)

There has been more research conducted on the treatment of co-occurring SAD and AOD use disorders
than any other anxiety disorder, but it is nonetheless limited to a small number of studies among people
with alcohol use disorders and findings have been mixed. For social anxiety as a single disorder, the
RANZCP guidelines recommend a stepped-care approach that begins with psychoeducation and lifestyle
advice (e.g., in relation to healthy eating, sleep, exercise patterns and limiting use of caffeine, tobacco and
alcohol), followed by either CBT, pharmacotherapy (SSRIs or SNRIs) augmented with graded exposure, or a
combination of CBT and pharmacotherapy as necessary, depending on the severity of symptoms [1158].

Psychotherapy

Three RCTs have examined the effectiveness of CBT-based therapies for SAD among people with alcohol
use disorders with mixed findings. The first, conducted by Randall et al. [1184], compared the efficacy of
CBT for alcohol use alone with CBT for both alcohol use and social anxiety. The latter was delivered in the
same session but not in an integrated fashion (i.e., the first half of the session was dedicated to alcohol,
the second half to social anxiety). Contrary to expectations, this study found that although both groups
demonstrated improvements in relation to alcohol use and social anxiety, the combined condition did
not demonstrate greater improvements in social anxiety, and in fact demonstrated poorer alcohol-
related outcomes.
B7: Managing and treating anxiety 229

The second study by Schadé et al. [1185] examined the efficacy of providing CBT for social anxiety as an
adjunct to relapse prevention. Alcohol-related outcomes were comparable to those found among people
who only received relapse prevention for alcohol use, but those who received the adjunctive CBT for social
anxiety were found to have greater improvements in relation to anxiety. More recently, an Australian study
examined the efficacy of an integrated program comprised of CBT and motivational enhancement for
alcohol and social anxiety relative to CBT for alcohol use alone [669]. This study similarly found that while
both groups demonstrated improvements in relation to both drinking and social anxiety, the integrated
treatment was found to produce greater improvements in social anxiety and quality of life.

A third study by Kushner and colleagues [1169] examined an integrated group CBT program for co-
occurring anxiety (GAD, panic disorder, or SAD) and alcohol use disorders among people in a residential
treatment program (45% of whom had a principal diagnosis of SAD). Those randomised to receive the
integrated 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.

In a further RCT, Buckner and colleagues [1171] examined an outpatient treatment involving an individual
integrated CBT program for people with co-occurring anxiety and cannabis use disorders (67% of whom
had a principal diagnosis of SAD). People who received the integrated intervention were more likely to be
abstinent and experienced greater reductions in the severity of anxiety symptoms following treatment
compared to the control group (who received motivation enhancement therapy), and both groups used
less cannabis, and reported fewer cannabis-related problems.

Collectively, this research suggests that either integrated or adjunctive treatment of social anxiety and
alcohol use disorder may be of greater benefit than treatment for alcohol use alone, but further research
is needed. Further research is also needed regarding the efficacy of other types of psychotherapy which to
date, has concentrated on CBT. This focus is not surprising however, as there is a strong evidence-base
for the use of CBT for social anxiety as a single disorder, but little evidence to support the use of other
psychotherapies [1158].

Pharmacotherapy

There is 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 [1184, 1186, 1187]. 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 [1186, 1187].

There is a large body of evidence demonstrating the efficacy of SSRIs, SNRIs, and MAOIs (in particular,
phenelzine) for the treatment of SAD as a single disorder [1158]. Although comparative research is lacking,
SSRIs and SNRIs are recommended by the RANZCP as first-line pharmacotherapies due to their superior
safety and side-effect profiles relative to MAOIs. As mentioned previously, MAOIs may cause significant
adverse effects and the person must adhere to strict dietary restrictions [1158]. Other medications that
have demonstrated some level of effectiveness include pregabalin and gabapentin. It is recommended
that beta blockers, buspirone and antipsychotics should be avoided [1158].
230 B7: Managing and treating anxiety

The RANZCP guidelines suggest that SSRIs or SNRIs may be considered as an alternative to CBT for cases
in which the response to CBT has been inadequate or if the person has a preference for medication.
Similarly, the combined use of CBT and an SSRI or SNRI may be considered in cases of severe SAD,
or where the response to either CBT or pharmacotherapy alone has been insufficient. As mentioned
previously, it is important that practitioners explain to clients prescribed SSRI or SNRI antidepressants
that they may experience an initial exacerbation of anxiety [1158]. To reduce the likelihood of this
occurring, it is recommended that clients start with a low dose and titrate slowly to a required
therapeutic dose.

The RANZCP guidelines provide guidance on dose titration and switching within- and between- classes
of anti-depressants and the other previously mentioned medications depending on treatment response.
It is important to note however, that treatment response is typically slow (at least four weeks) and it
is therefore important to allow time for appreciable effects to be discerned, which may be difficult for
clients who are seeking immediate relief from their symptoms.

E-health and telehealth interventions

As noted in previous sections, there has been an expansion of research into e-health and telehealth
interventions, with growing evidence to support their use in managing and treating various disorders.
Many smartphone apps exist for the treatment of anxiety as a single disorder and have been shown
to be effective at reducing symptoms compared to waitlist or online peer support controls [1188]. A
systematic review and a meta-analysis found no differences between videoconferencing or face-to-face
therapy in the treatment of anxiety as a single disorder [1189, 1190]. Further, a systematic review and
meta-analysis examining e-health interventions for GAD found significant post-treatment improvements
for generalised anxiety and pathological worry [1191]. Indeed, the efficacy of e-health interventions
was found to be equivalent to that of CBT interventions delivered face-to-face. For these reasons, the
RANZCP guidelines recommend either face-to-face or digital CBT as first line treatment options for GAD,
panic disorder, and SAD [1158]. The Richards et al. [1191] review further concluded that online CBT-based
interventions have a stronger evidence-base and greater efficacy compared to online psychodynamic-
based interventions.

Wolitzky-Taylor and colleagues developed a group-based computerised CBT program for people with co-
occurring anxiety and AOD use disorders [1192]. Evaluated among a small sample of people with GAD, SAD,
panic disorder, agoraphobia or specific phobia attending AOD treatment, those randomised to receive
six-sessions demonstrated greater reductions in anxiety symptoms and substance use compared to
those attending AOD treatment only, with reductions in anxiety maintained up to six-months [1192].

With the exception of Wolitzky-Taylor and colleagues [1192], only one other e-health intervention has
been developed for addressing co-occurring anxiety and AOD use. Stapinski and colleagues [1193]
developed Inroads, based on an integrated evidence-based CBT program for social anxiety and alcohol
use (previously discussed in relation to SAD [1194]). Inroads is a five-module web-based integrated
intervention for young adults aged 17 to 24 years, with personalised weekly therapist support provided in
addition to two optional text/phone sessions following modules one and four [1194]. Evaluated among a
small community-based sample of young adults with moderate to severe anxiety symptoms and high
B7: Managing and treating anxiety 231

levels of alcohol use, those randomised to receive Inroads demonstrated significantly greater reductions
in relation to social anxiety symptoms, as well as binge and hazardous drinking, which were sustained
to the six-month follow-up compared to those receiving information about alcohol and safe drinking
guidelines. The completion of more modules was associated with greater improvements in all outcomes
[1194].

An Australian program called Mental Health Online (formerly Anxiety Online) provides psychoeducation
about AOD use [1195]. Mental Health 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,
preliminary findings from two naturalistic studies show promise, reporting that participation in Mental
Health Online was associated with reductions in severity of all five disorders, and increased confidence
in managing one’s own mental health care [1195, 1196]. Significant improvements in quality of life were
also consistently observed for GAD, SAD, and PTSD e-therapy programs, but not the OCD or panic disorder
program [1195, 1196]. Overall, treatment satisfaction was good across all five e-therapy programs [1195].

Physical activity
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 [1158, 1175, 1197]. In particular, exercise is thought to help manage the physical symptoms of
anxiety by reducing overall arousal [1158]. Aerobic and non-aerobic exercise have been found to be as
effective as CBT [1198], with reductions in anxiety, tension, and irritability observed among those with GAD
who participated in resistance training and aerobics [1199, 1200]. Regular walking has also been found
to enhance the efficacy of CBT across different anxiety disorders [1201]. Regular exercise has been found
to produce greater reductions in anxiety than relaxation for those with panic disorder [1202], but is less
effective than pharmacotherapy [1203] or group delivered CBT [1204]. The RANZCP guidelines recommend
that people with anxiety disorders exercise three times a week, for 30 minutes at a time [1158].

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 [272, 307].
Findings indicate that both aerobic and anaerobic training may be effective, over an optimal duration
of nine weeks [1205]. An additional meta-analysis concluded that aerobic exercise effectively decreases
AOD-related withdrawal symptoms and reduces anxiety among people with AOD use [305]. However,
there is mixed evidence regarding the optimal intensity, with some studies finding support for light to
moderate exercise, and others finding larger effects with higher intensity training [307].

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 [1206] or mindfulness-based meditation
[1207], but two systematic reviews concluded that meditative therapies reduced anxiety symptoms [1208,
1209]. No research has evaluated yoga for people with co-occurring anxiety and AOD use.
232 B7: Managing and treating anxiety

Complementary and alternative therapies

Acupuncture

Several studies have examined the efficacy of acupuncture for people with co-occurring anxiety and AOD
use, with mixed findings. Auricular acupuncture (inserting acupuncture needles into the ears [1210–1212])
and electroacupuncture (inserting acupuncture needles into fatty tissue [1213]), have both involved
manual or electrical stimulation of the needles, and have been examined as monotherapies [1210–1212]
or combined with pharmacotherapy (escitalopram [1213]). Relative to baseline, one study reported that
20 sessions of auricular acupuncture delivered over 10 weeks reduced symptoms of anxiety and AOD
cravings, equally as well as a relaxation control [1210]. Similarly, four weeks of electroacupuncture was
found to reduce anxiety symptoms and AOD cravings at post-treatment relative to baseline, with greater
reductions observed among those in the treatment group compared to those in control [1213]. However,
two further studies examining auricular acupuncture have not found any effect on symptoms of anxiety
or AOD cravings relative to baseline [1211, 1212].

Repetitive Transcranial Magnetic Stimulation (rTMS)

Two studies have examined rTMS as a treatment for people with co-occurring anxiety and cocaine use
disorder [1214, 1215]. rTMS involves receiving repeated electrical pulses to specific areas of the brain (the
dorsolateral prefrontal cortex) for 20 sessions delivered over two to eight weeks, and was combined with
exposure to AOD-related cues in one study [1215]. Relative to baseline, rTMS significantly reduced anxiety
symptoms and cocaine cravings, and improved abstinence from cocaine use in both studies.

Biofeedback

The results of a single study suggest that receiving heart rate variability feedback training may be an
effective treatment for people with co-occurring anxiety and AOD use disorders [1216]. In this study,
biofeedback training involved participants being provided with visual feedback (in the form of a balloon)
about heart rate variability while receiving breathing instructions, with additional regular signals
indicating whether they achieved pre-set breathing targets. Relative to people receiving usual care at
an inpatient rehabilitation centre, people who received biofeedback experienced greater reductions in
anxiety and AOD cravings, as well as more improved vasomotor function, following the intervention.

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 [1217–1219]. Despite its popularity, there is no convincing evidence supporting the use of
homeopathy in the treatment of anxiety disorders [1220]. Further, none of these supplements have been
evaluated among people with co-occurring anxiety and AOD use disorders.
B7: Managing and treating anxiety 233

Summary
While research concerning both psychological and pharmacological treatments for co-occurring anxiety
and AOD use disorders is sparse [1172, 1221], there is increasingly promising evidence for integrated
treatments that target both disorders [669, 1169, 1171, 1222]. In the absence of research examining
treatments for co-occurring 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 co-
occurring disorders. Box 18 illustrates the continuation of case study E, following Declan’s story after his
heart attack.

Box 18: Case study E: Treating co-occurring anxiety and AOD use: Declan’s story
continued

Case study E: Declan’s story continued

Declan started seeing a psychologist at his local AOD service, who diagnosed him with social phobia with
panic attacks. Declan also started seeing a cardiologist. A treatment plan was developed in consultation
with Declan, and his psychologist suggested that they try CBT for the treatment of his anxiety and
AOD use. In addition to CBT, Declan started using a mindfulness app, which he found annoying at first,
but after a few weeks started to incorporate into his physical fitness routine and started to find more
beneficial.

Declan’s CBT helped him understand the reasons for his panic and fear. His psychologist also organised
for Declan to attend weekly sessions of a local relapse prevention program run by their AOD service. His
psychologist helped him address avoidance behaviours with a program of gradual exposure to situations
that he had previously found anxiety provoking. While Declan continued to respond well to treatment, he
and his psychologist agreed that he should remain in contact with the psychologist over the long-term,
but 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.
• The use of apps or other e-health interventions can be a useful adjunct to
psychotherapy.
OCD
B7: Managing and treating OCD 235

Obsessive compulsive disorder (OCD)

Clinical presentation
As mentioned in Chapter A4, previously classified as an anxiety disorder, OCD (and related disorders) is
now a separate category of disorder in the DSM-5-TR and ICD-11.

A person with OCD may be significantly distressed by their symptoms, and their ability to function may
be impaired. They may be plagued with persistent thoughts or impulses that are intrusive and unwanted
(referred to as obsessions or ruminations) and they may feel compelled to perform repetitive, ritualistic
actions that are excessive and time consuming (referred to as compulsions or rituals). A person with
OCD may present with either obsessions or compulsions alone, or a combination of both. Symptoms of
obsessions may include:

• Fear of germs, dirt, or poisons.

• Harm from illness or injury to self or others.

• Intrusive thoughts about sex or sexual acts.

• Excessive concerns with symmetry or orderliness.

• Needing to know or remember things.

• Hoarding or saving and collecting things.

Anxiety about obsessions may lead to vigilance about possible threats, and a compelling need for
control. A person may feel annoyed, discomforted, distressed, or panicked about their obsessions,
and may feel driven to perform repetitive mental or physical acts in response to alleviate their anxiety.
Symptoms of compulsions may include:

• Excessive hand washing, showering, tooth brushing.

• Excessively checking locks, appliances, other safety items.

• Repeating activities or routines (e.g., opening a door, switching a light on and off).

• Repeating mental acts (e.g., counting, and repeating words silently).

• Applying rules to the placement of objects.

• Inability to throw out excessive collections of items (e.g., newspapers, clothes).

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 recognition of OCD, and a lack of disclosure by clients who may
experience shame or embarrassment and be intent on hiding their symptoms [1223–1226].

Managing symptoms of OCD

Many people may have mild symptoms that are associated with stressful life events or situations
which often improve without the need for specific treatments. It should also be noted that many people
experience some obsessions or compulsions, but these do not interfere with functioning. However, those
236 B7: Managing and treating OCD

who experience the severity, distress and impairment associated with more chronic and enduring OCD
may benefit from some form of treatment [1227].

The techniques outlined in Table 50 may help AOD workers to manage clients with obsessive-compulsive
symptoms, whether they are transient or more entrenched.

Table 50: Dos and don’ts of managing a client with obsessive compulsive symptoms

Do:

Ignore strange or embarrassing behaviour if you can, especially if it is not serious.

Approach the client in a calm, confident and receptive way.

Move and speak at an unhurried speed.

Be patient in order to allow the client to feel comfortable to disclose information.

Minimise the number of staff present and attending to the client.

Minimise surrounding noise and distractions to reduce stimulation.

Explain the purpose of interventions.

Remain with the client to calm them down.

Don’t:

Crowd or pressure the client.

Become frustrated or impatient.

Laugh (or let others laugh) at the person.

Act horrified, worried, embarrassed or panic.

Confuse and increase the client’s level of stress by having too many workers attempting to
communicate with them.

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 anxious; how can I help you?’

Use ‘no’ language, as it may provoke hostility and aggression. Statements like ‘I’m sorry, we’re not
allowed to do that, but I can offer you other help, assessment, referral…’ may help to calm the client
whilst retaining communication.

Use overly clinical language without clear explanations.

Adapted from NSW Department of Health [431], Clancy and Terry [448], Jenner and Lee [541], Arch and Abramowitz [1228], and
Davis et al. [1229].
B7: Managing and treating OCD 237

Treating OCD
Despite evidence from the general population indicating that roughly one in ten people with an AOD use
disorder have co-occurring OCD (see Chapter A2), the treatment of these co-occurring disorders has
not been rigorously investigated. Whether or not a person is in need of treatment will largely depend on
the intensity and duration of symptoms, the impact of symptoms on their everyday life, whether or not
there are any other co-occurring conditions (e.g., depressive or anxiety disorders), and whether there have
been any other treatment attempts in the past. As with all treatment decisions, this decision should be
informed by the relevant evidence-base, and decisions made in partnership with the client.

Although there is very little evidence regarding the treatment of co-occurring OCD and AOD use, the
evidence which does exist suggests that treating both OCD and AOD use leads to better treatment
outcomes than treating AOD use alone [1230]. There are several 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. Although the evidence is mixed, there is some evidence to suggest that the combination
of psychotherapy and pharmacotherapy may be more effective than either approach in isolation,
particularly among those with severe OCD [1227, 1231, 1232].

Psychotherapy
Evidence regarding the treatment of OCD among people with AOD use disorders is lacking, with most
studies of OCD treatment excluding people with AOD use disorders [102]. Only one RCT has examined the
concurrent treatment of OCD and AOD use. In this study, Fals-Stewart and Schafer [1233] examined the
efficacy of CBT with exposure response therapy (ERP), for the treatment of OCD among people attending
residential rehabilitation for their AOD use.

CBT incorporating ERP has long been considered an evidence-based treatment for OCD as a single
disorder and continues to be recommended as a first-line treatment option [731, 1234, 1235]. Evidence-
based psychological treatments should be given an adequate trial before pharmacological treatments
are considered. ERP involves repeated, prolonged and systematic exposure with certain objects or
situations that trigger obsessional responses (exposure) and resisting the compulsive urges that
arise in response to the triggers (response prevention) [728]. The nature of the exposure therapy can
be in vivo (e.g., physically touching a light switch) or in the imagination (e.g., confronting images of
loved ones dying). In this way, ERP can teach people to tolerate the distress associated with obsessions
without engaging in maladaptive behaviours like compulsions, and can provide corrective feedback that
challenges the fear response [731, 732]. Fals-Stewart and Schafer [1233] found that clients who received
concurrent CBT with ERP for their OCD remained in treatment longer, and had lower OCD symptom
severity and higher abstinence rates during treatment and at the 12-month follow-up, compared to those
who received AOD treatment alone or AOD use plus progressive muscle relaxation.

Based on the limited evidence regarding the treatment of co-occurring OCD and AOD use [1233], and
evidence pertaining to the treatment of OCD and AOD use as single disorders, Klostermann and Fals-
Stewart [1230] recommend five steps for treating people with co-occurring OCD and AOD use. The five
steps include:
238 B7: Managing and treating OCD

• 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 fear or stimulus hierarchy.

• Treatment: Concurrent delivery of ERP and AOD use treatment.

Although these findings and recommendations 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 [1236, 1237]. Stewart and O’Connor
[1237] 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 [1237].

There is also a need to investigate alternative approaches to ERP. While ERP continues to be
recommended as the first line psychotherapy for OCD as a single disorder, recent reviews have
demonstrated that other approaches including behavioural and cognitive therapies may be equally
effective [1231, 1232, 1238]. Other approaches that show promise for single disorder OCD include ACT and
EMDR [1236].

Psychotherapy has consistently been found to be more effective than pharmacotherapies for treating
single disorder OCD; however, it should be noted that most psychotherapy trials have included patients
who were taking stable doses of antidepressants [1232]. Furthermore, the superiority of psychological
therapies is marginal when compared to adequate doses of pharmacotherapy for OCD [1238].

Pharmacotherapy
There has been little research examining the efficacy of pharmacotherapy interventions among people
with co-occurring OCD and AOD use. A Cochrane review of pharmacotherapy for anxiety and co-occurring
alcohol use disorders found no rigorously conducted trials of medication treatment for co-occurring OCD
and alcohol use [1172]. In view of the lack of evidence for pharmacological interventions for co-occurring
OCD and AOD use, clinicians may be guided by the body of research that has been conducted for single
disorder OCD.

Evidence from systematic reviews and meta-analyses examining RCTs of pharmacotherapies for single
disorder OCD have found that the SSRIs citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine,
and sertraline; the SNRI venlafaxine; and the TCA clomipramine, to be associated with reductions in
symptom severity and improvements in health-related quality of life [1227, 1232, 1239–1247]. There is some
evidence that the use of the second-generation antipsychotics are associated with reductions in OCD
B7: Managing and treating OCD 239

symptoms [1248]; however, adverse side effects may limit their utility.

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, particularly among
those with severe OCD [1227, 1232]. Research has found a positive dose-response relationship for SSRIs,
with greater symptom improvements found among those who are taking higher doses of SSRIs [1238].
Table 51 provides a list of SSRIs for the pharmacological treatment of single disorder OCD. It should
be noted that there is commonly a delay in the onset of effect of up to 12 weeks, although depressive
symptoms improve more quickly [1235].

Table 51: Selective serotonin reuptake inhibitor (SSRI) medications

Drug name Brand names

Citalopram Celapram, Cipramil, Talam

Escitalopram Escicor, Esipram, Lexam, Lexapro, Loxalate

Fluoxetine Fluotex, Lovan, Prozac, Zactin

Fluvoxamine Faverin, Luvox, Movox

Paroxetine Aropax, Extine, Paxtine, Roxtine

Sertraline Eleva, Sertra, Setrona, Zoloft

Adapted from Australian Government Department of Health [1119] and the Therapeutic Goods Administration [987]. For a full list
of generic brands available, see the Therapeutic Goods Administration website (http://www.tga.gov.au).
240 B7: Managing and treating OCD

E-health and telehealth interventions

Although there have yet to be any e-health interventions developed specifically for co-occurring OCD
and AOD use, there have been several e-health interventions developed for OCD as a single disorder,
some of which include CBT and ERP-based videoconferencing and telehealth programs, smartphone,
internet, computer, and virtual reality-based interventions [1249]. A meta-analysis examining remote CBT
programs for OCD symptoms delivered via telephone, videoconference, computer and the internet found
evidence of effectiveness [1250], with effects similar to those found in clinician-delivered CBT sustained
up to four months [1250–1254].

There is evidence to suggest a dose-response relationship with regards to computerised CBT programs,
with greater symptom improvements found among those who have completed more homework [1255].
However, studies have found that clinician-assisted programs are associated with greater adherence,
lower dropout rates, and better outcomes than computerised programs with no human contact [1256].
There are also a number of self-guided CBT-based programs which have been developed for single
disorder OCD, including smartphone applications and internet-based programs [1257]. Although there is
limited evidence suggesting that some self-guided programs may reduce OCD symptoms from baseline
to post-completion [1258–1261], the evidence-base underpinning many of these programs remains
unclear.

Several self-help and therapist-delivered e-health programs based on ERP have also been developed;
however, the findings from studies examining the efficacy of computerised ERP interventions are 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 [1255]. 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 [1236]. Given these findings, the UK
NICE Guidelines recommend that BT Steps/OC Fighter should not be used in the treatment of OCD [1262].

Another ERP program, iCBT, has been found to be more efficacious in reducing OCD and depressive
symptoms, and improving general functioning compared to both an active control (online, non-directive
supportive therapy) [1252], and baseline symptoms and functioning [1263]. Data from a further two
trials assessing LiveOCDFree and nOCD also found that ERP-based smartphone applications significantly
decreased symptoms of OCD compared to baseline, among those with single disorder OCD [1264, 1265].
Evidence from a randomised trial similarly suggests that using either of two smartphone applications
targeting cognitive flexibility for a week reduced OCD symptoms relative to a control, among people
with single disorder OCD [1266]. Additional research suggests that virtual reality may be a promising
avenue for treatment, with significant reductions in OCD symptoms evident after engaging in 12 virtual
ERP sessions relative to pre-treatment, and effects sustained up to four months post-treatment [1267].
Although encouraging, further research is needed.

Physical activity
There is preliminary evidence to suggest that physical exercise may be beneficial for people with single
disorder OCD. Several pilot studies have demonstrated that the combination of a six to 12-week moderate
aerobic exercise program with psychotherapy or pharmacotherapy reduced OCD symptom severity,
B7: Managing and treating OCD 241

which was maintained up to six months follow-up [1268–1270]. One study found that significantly lower
OCD symptoms, anxiety and negative mood levels were reported immediately following each 20-40
minute exercise session [1271]. Similarly, another RCT found that a 12-week aerobic exercise program was
effective at reducing compulsions, mood and anxiety, to a greater extent than psychoeducation, though
obsessions did not change, among adults with single disorder OCD [1272]. Further, the severity of OCD
symptoms did not significantly differ between groups directly following the intervention [1273]. While
promising, more rigorous research is necessary to evaluate the benefits of physical exercise, and there
is no evidence to date on the efficacy of physical exercise for the treatment of co-occurring OCD and AOD
use disorder specifically.

Complementary and alternative therapies

As mentioned previously, SSRIs are associated with various dose-dependent side effects, including
nausea, diarrhoea, dizziness, headaches, insomnia, sedation, anxiety, sexual dysfunction, and decreased
libido [1274, 1275]. 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 [1276, 1277]. As such, several studies have examined alternative
therapies in the treatment of single disorder OCD.

In systematic reviews of complementary and alternative approaches, there is some evidence that health-
based games [1278], art therapy, sports therapy, recreational therapy [1279], mindfulness meditation,
electro-acupuncture, yoga, nutrient glycine, borage, and milk thistle may have a positive impact on OCD
symptoms [1280]. 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 co-occurring OCD and AOD
use.

Neurofeedback

Neurofeedback involves providing auditory or visual feedback for suppressing or producing certain brain
waves, enabling people to self-regulate their brain activity. One systematic review and meta-analysis
suggests that neurofeedback effectively reduces OCD symptoms among those with single disorder OCD
compared to control conditions [1281]. While promising, it should be noted that included studies varied
in terms of their design and validity, and drawing conclusions is therefore difficult. Further, the effects of
neurofeedback are yet to be evaluated among people with co-occurring OCD and AOD use.

Deep brain stimulation

Deep brain stimulation is a neurosurgical procedure which involves embedding microelectrodes in brain
areas involved in single disorder OCD treatment, and using an electric current to directly stimulate the
embedded microelectrodes and associated brain regions [1282]. Several reviews provide evidence that
deep brain stimulation effectively reduces OCD symptoms by 20-46% [1282–1284] compared to control
conditions. Deep brain stimulation may be particularly useful for people with treatment resistant OCD
[1282]. However, one-third of people who receive deep brain stimulation experience serious adverse side
effects such as brain haemorrhage and infection [1283], and to date there is no evidence on the efficacy
of deep brain stimulation among people with co-occurring OCD and AOD use.
242 B7: Managing and treating OCD

Summary
There are currently no evidence-based integrated treatments for co-occurring OCD and AOD use
disorders, and evidence from only one RCT among people with co-occurring OCD and AOD use favouring
the concurrent treatment of these disorders [1233]. Although there is limited evidence for the treatment
of co-occurring OCD and AOD use, results from single disorder OCD studies suggest there is strong and
consistent evidence to recommend the use of ERP, behavioural and cognitive therapies as the first line
of treatment in single disorder OCD. Box 19 illustrates the continuation of case study F, following Ayla’s
story.

Box 19: Case study F: Treating co-occurring OCD and AOD use: Ayla’s story continued

Case study F: Ayla’s story continued

The AOD worker conducted a suicide risk assessment and although Ayla spoke of ending her life, she
was not at immediate risk for suicide. The AOD worker organised for Ayla to see a clinical psychologist
who specialised in ERP, along with a psychiatrist who specialised in OCD. Ayla’s AOD worker coordinated
the treatment approach, and together with Ayla’s GP, the clinical psychologist, psychiatrist, Ayla and
her parents devised a treatment plan. Ayla’s treatment consisted of concurrent pharmacotherapy and
CBT with ERP, which addressed her OCD and cannabis use. Ayla’s treatment took place over several
months, with long-term plans for ongoing monitoring and support put in place to ensure Ayla was able to
maintain her treatment gains.

Key points:
• Symptoms of OCD 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 is a need to monitor ongoing physical health complications of co-occurring
OCD.
Trauma, PTSD and complex PTSD
244 B7: Managing and treating trauma, PTSD and complex PTSD

Trauma, post traumatic stress disorder (PTSD), and complex

PTSD

Clinical presentation
As described in Chapter A4, trauma is a term that is widely used and may mean different things to
different people. It can include a myriad of extremely threatening or horrific events, or a series of events,
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, life or safety is at risk [10, 11].

Most people will experience some emotional or behavioural reactions following exposure to a traumatic
event such as anxiety or fear, aggression or anger, depressive or dissociative symptoms. These emotional
and behavioural responses are to be expected and are a completely normal response to an adverse event.
For the majority of people, these emotional and behavioural reactions will subside and/or reduce in
intensity over time without the need for any intervention; for some people however, these reactions may
be prolonged, leading to significant distress, as well as impairment in social, occupational and other
areas of functioning [102, 156, 157]. Symptoms may be especially long-lasting or complex when the trauma
is interpersonal and intentional (e.g., torture, sexual violence), and if the trauma occurred in childhood
[157, 1285].

Approximately one in ten Australians who experience a traumatic event develop PTSD [157] (described in
Chapter A4). Symptoms of PTSD include:

• 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 alterations in cognitions and mood, including guilt and hopelessness; feeling
a distorted sense of blame of self or others; feeling detached from others; a persistent inability to
experience positive emotions; and reduced interest in activities.

• Persistent symptoms of increased physiological arousal and reactivity, including hypervigilance

towards distressing cues, sleep difficulties, exaggerated startle response, irritability, increased
anger, and concentration difficulties.

Some people develop a more complicated form of PTSD referred to as complex PTSD, in which they also
experience pervasive difficulties with emotional regulation, self-concept, and relationship difficulties
across a variety of contexts (described in Chapter A4). Research among people with AOD use disorders
indicates that 85% of those who meet criteria for PTSD experience it in this more complex form [1286].
Although complex PTSD may arise in relation to any trauma, it is typically associated with prolonged or
repeated interpersonal traumas that occur during childhood [158].
B7: Managing and treating trauma, PTSD and complex PTSD 245

Managing trauma-related symptoms

The provision of trauma-informed care in AOD treatment settings is essential and described in more
detail in Chapter B2. Given that substances are often used to self-medicate trauma-related symptoms
[30], it is not surprising that many people report experiencing an increase in trauma-related symptoms
when they reduce or stop using substances [380]. Evidence to date however, indicates that, as with
symptoms of depression and anxiety, on average, PTSD symptoms also decline in the context of well
managed withdrawal [381–383].

As described in Chapter B2, it is important to note that avoidance symptoms, rather than re-
experiencing symptoms, have been associated with the perpetuation of trauma-related symptoms [398,
1287–1291]. It is therefore crucial that if a person does experience an exacerbation of trauma-related
symptoms, that they are not encouraged to avoid or suppress these thoughts or feelings. Telling a person
not to think or talk about what happened may also intensify feelings of guilt and shame. For those who
have experienced abuse, it may closely re-enact their experience of being told to keep quiet about it [136].
This does not mean that clients should be pushed to revisit events or disclose information if they are not
ready to do so. Rather, it means that it is understandable that the person may be upset by these thoughts
and feelings that may arise, and they should be allowed to engage with these feelings in order to help
process the trauma emotionally.

Chapter B3 provides guidance on how to discuss trauma with clients. As mentioned previously, 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 [136]. In-depth discussion of a person’s trauma experiences should
only be conducted by someone who is trained in dealing with trauma responses [135].

Even without knowing the details of a client’s trauma, AOD workers can use the techniques outlined in
Table 52 to help clients manage their symptoms. Encouraging clients for their resilience in the face of
adversity is important even if past adaptations and ways of coping are now causing problems (e.g., AOD
use). Understanding AOD use as an adaptive response reduces the client’s guilt and shame and provides
a framework for developing new skills to better cope with symptoms [384].

Table 52: Dos and don’ts of managing a client with trauma-related symptoms

Do:

Give the client your undivided attention, empathy and unconditional positive regard.

Use relaxation and grounding techniques where necessary.

Display a comfortable attitude if the client chooses to describe their trauma experience.

Normalise the client’s response to the trauma and validate their feelings.
246 B7: Managing and treating trauma, PTSD and complex PTSD

Table 52: Dos and don’ts of managing a client with trauma-related symptoms
(continued)

Recognise the client’s resilience in the face of adversity.

Recognise the client’s courage in talking about what happened.

Let the client know what to expect if they undergo detoxification (e.g., possible changes in trauma-
related symptoms).

Maximise opportunities for client choice and control over treatment processes.

Monitor depressive and suicidal symptoms.

Don’t:

Rush or force the client to reveal information about the trauma.

Engage in an in-depth discussion of the client’s trauma unless you are trained in trauma
responses.

Judge the client in relation to the trauma or how they reacted to the trauma.

Abruptly end the session.

Encourage the client to suppress their thoughts or feelings.

Engage in aggressive or confrontational therapeutic techniques.

Be afraid to seek assistance.

Use overly clinical language without clear explanations.

Adapted from Ouimette and Brown [1292], Elliot et al. [384], SAMHSA [102], Marsh et al. [135], and Mills and Teesson [136].

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 [1293]. 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 people who have experienced trauma 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 CC useful for managing trauma-
related symptoms. Many common procedures and practices may re-trigger trauma reactions. For
example, aggressive or confrontational group techniques can trigger memories of past abuse. Such
B7: Managing and treating trauma, PTSD and complex PTSD 247

techniques are counterproductive; those who have been exposed to abuse in particular may revert to
techniques used to cope during the trauma such as dissociating or shutting down emotionally. Engaging
in these strategies may then lead to the client being labelled as ‘treatment resistant’ and, consequently,
feelings of self-blame. Chapter B2 also provides guidance on other aspects of service provision to
consider in providing a trauma-informed approach to care.

As discussed in Chapter B8, it is also essential that workers attend to their own responses to working
with traumatised clients through self-care. Hearing the details of others’ trauma can be distressing,
and in some cases may lead to vicarious traumatisation or secondary traumatic stress [404, 1294].
By attending to one’s own self-care and engaging in clinical supervision, the likelihood of developing
secondary traumatic stress may be reduced. Chapter B8 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 can benefit from a variety of treatments. It is important to
emphasise that while there is a strong evidence base for certain treatments, the need for individualising
a treatment plan to suit the particular client is of paramount importance.

Due to the inter-relatedness of PTSD and AOD use, experts recommend that these conditions be treated
in an integrated fashion [102, 141, 739, 1295, 1296]. Some clinicians maintain the view that the AOD use
must be treated first, or that abstinence is necessary before PTSD diagnosis and management can be
attempted. In practice, however, this approach can lead to clients being passed between services with
little coordination of care [1297]. Moreover, clients express a preference for integrated interventions that
treat both disorders concurrently [141, 1298]. Ongoing AOD use may impede therapy, but it is not necessary
to achieve abstinence before the commencement of PTSD treatment [1299]. Improvements can be
obtained even in the presence of continued substance use [1300, 1301].

There are several 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.

As complex PTSD is a new diagnosis there is no direct evidence about how to treat it; however, given
the high prevalence of complex PTSD [1286], it is likely that a high proportion of participants in the PTSD
treatment trials described in this section were experiencing PTSD in its complex form. A meta-analysis
that retrospectively assessed PTSD psychotherapy trials to determine if they included patients with
complex PTSD has also found beneficial effects of standard trauma-focused treatments in reducing
PTSD symptoms as well as some symptoms specific to complex PTSD (i.e., negative self-concept,
disturbances in relationships) [1302]. Given that complex PTSD is comprised of a greater number and
diversity of symptoms, its treatment may nonetheless require additional treatments and/or treatment of
a longer duration compared to those with PTSD [1303].
248 B7: Managing and treating trauma, PTSD and complex PTSD

Psychotherapy
A number of psychotherapeutic interventions have been developed for the treatment of co-occurring
PTSD and AOD use, and an increasing number are undergoing evaluation. Although there is some
contention regarding the naming conventions, existing approaches may be divided into two types: i)
past-/trauma-focused therapies; and ii) present-/non-trauma-focused therapies [1304–1306]. The main
distinction is that the former involves the revisiting of trauma memories and their meaning, while the
latter focus on the development of coping skills in the present.

Several reviews have concluded that there is support for individual past-/trauma-focused psychological
interventions that utilise exposure-based approaches, particularly in relation to PTSD outcomes, but
that there is very little evidence to support the use of non-trauma-focused individual or group-based
interventions over treatment as usual for AOD use [739, 1296, 1307, 1308].

It should be noted that there are diverging views as to whether or not psychotherapy for PTSD, and
complex PTSD in particular, should be undertaken using a phase-based approach [1309]. A phase-
based approach proposes that it is necessary for a person to undertake interventions that focus on
stabilisation in the first phase of treatment (i.e., establishing safety, symptom management, improving
emotion regulation and addressing current stressors) prior to moving on to processing the trauma
memory, followed by reintegration (i.e., re-establishing social and cultural connection and addressing
personal quality of life) [1310]. However, the evidence to date suggests that this approach is neither
necessary nor recommended, as it may lead to unnecessary delays or restrictions in access to effective
past-/trauma-focused therapy [1309, 1311, 1312]. Indeed, studies comparing the efficacy of a phased-
based approach relative to past-/trauma-focused treatment have found that recovery may be faster for
those who receive past-/trauma-focused treatment [1311, 1312]. That is not to say that the components
incorporated in phase one are not important, but rather, that they can be integrated throughout the
treatment process alongside the past-/trauma-focused work [1313]. The vast majority of past-/trauma-
focused therapies described in this chapter incorporate phase one components in their programs.

Past-/trauma-focused therapies

Past-/trauma-focused therapies are typically delivered individually and involve various exposure-based
techniques in which the client revisits, and seeks to make meaning of, the traumatic events they have
experienced and their consequences. Of these, prolonged exposure (PE) has received the most empirical
attention. Alongside other past-/trauma-focused therapies, including cognitive processing therapy (CPT),
and EMDR, PE is considered a first-line treatment for PTSD in the absence of AOD use [1303, 1308].

Prolonged exposure (PE)

Similar to exposure for phobias, PE for PTSD involves exposure to the feared object or situation; in this
case, traumatic memories (imaginal exposure) and physical reminders of the trauma (in vivo exposure).
Traditionally, PE for PTSD was considered inappropriate for use with people experiencing AOD use
disorders based on concerns that the emotions experienced may be overwhelming and could lead to
relapse or further deterioration [1314]. However, the evidence suggests that this is not the case; PE does
not lead to an exacerbation of AOD use, cravings, or increase the severity of the AOD use disorder [741,
B7: Managing and treating trauma, PTSD and complex PTSD 249

1314]; in fact, it may be protective against relapse [1315]. Trials examining the efficacy of PE (in its original
form, as well as modified or enhanced versions) delivered alongside treatment-as-usual for AOD use
report positive outcomes including significant reductions in PTSD symptoms [741, 1316, 1317]. Contingency
management has also been shown to be an effective adjunct to PE among people with opioid use
disorders, leading to greater treatment retention and greater reductions in PTSD symptoms [1318]. One
RCT has also examined the efficacy of PE 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 to alcohol use at 6-month follow-up
[1315].

A number of clinical researchers have investigated the efficacy of integrated exposure-based programs
that address PTSD and AOD use simultaneously. Typically these programs involve psychoeducation
regarding each disorder and their interrelatedness, coping skills training, relapse prevention, and
exposure to traumatic memories and/or reminders; and they are sometimes delivered in combination
with other therapeutic techniques [739]. Support for these programs is growing, with an increasing
number of studies providing evidence for their safety and efficacy, including two Australian trials
[1300, 1301]. 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 [739, 1296, 1307].

The majority of research in this area has focused on the efficacy of an integrated treatment called
Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) [442]. Since the first
RCT of this intervention was completed in Australia [1300], a further three have been undertaken in the
United States [772, 1319, 1320]. Collectively, these studies have found that, while decreases in substance
use are comparable to control conditions, with respect to PTSD symptom reduction, COPE outperforms
treatment-as-usual for AOD use, relapse prevention, and a present-/non-trauma focused therapy
(Seeking Safety). A modified version of the COPE program is currently being examined among Australian
adolescents [1321, 1322]. Another integrated exposure-based program for adolescents that has shown
promise in reducing PTSD symptoms, AOD use and risk behaviours is Risk Reduction Through Family Therapy
(RRFT), which combines trauma-focused CBT and multisystemic therapy [1323, 1324].

Cognitive processing therapy (CPT)

CPT focuses on challenging and modifying unhelpful trauma-related beliefs (e.g., beliefs surrounding
safety, trust, power, control, esteem, and intimacy) that are having a negative impact on a person’s life
via written exposure and cognitive restructuring. Despite CPT being a first line treatment for PTSD, few
studies have examined its effectiveness for people with co-occurring AOD use disorders. CPT, and CPT
integrated with CBT for substance use, have shown promise among people with AOD use disorders;
however, the predominance of this research has been conducted on veteran samples. Studies comparing
outcomes of CPT for veterans with and without co-occurring AOD use disorders have found no significant
differences between groups [1325, 1326]. Subsequent open label trials of CPT combined with CBT for
substance use have also reported reduced PTSD symptoms, depressive symptoms, and AOD-related
outcomes [1327–1329].
250 B7: Managing and treating trauma, PTSD and complex PTSD

Eye movement desensitisation and reprocessing (EMDR)

In EMDR, a person focuses on the imagery of a trauma, negative thoughts, emotions and body sensations
whilst following guided eye movements led by a therapist. Although EMDR is a first line treatment for
PTSD only a small number of studies have examined its effectiveness for people with co-occurring
AOD use disorders. Two small pilot trials have found that EMDR, alongside treatment-as-usual for AOD
use, produces significantly greater reductions in PTSD symptoms compared to treatment-as-usual for
AOD use alone [1330, 1331]. Although case series have described benefits in relation to AOD use as well
[1332], these trials did not find any between-group differences [1330, 1331]. There is some very preliminary
evidence to suggest that EMDR combined with schema therapy for PTSD and AOD use disorders may be
effective in reducing both PTSD and AOD use [1333]. Two additional studies of EMDR for people with either
PTSD or a history of trauma and co-occurring AOD use are currently underway [1334, 1335].

Present-/non-trauma-focused therapies

Present-/non-trauma-focused therapies are typically integrated CBT-based treatments which focus on

providing clients with coping skills to live in the present without revisiting the traumatic event [1336].
These interventions are typically delivered in individual or group formats. As mentioned previously,
three reviews have concluded that there is little evidence to support the use of present-/non-trauma-
focused individual or group-based interventions relative to providing treatment-as-usual for AOD use
[739, 1296, 1307]. They are, nonetheless, an important treatment option for clients who are not wishing to
undergo past-/trauma-focused therapies. Several present-focused treatments have, and continue to be,
developed [1336–1339], but the program which has undergone the most extensive evaluation is Seeking
Safety [702, 1340].

Seeking Safety focuses on examining the impact of trauma without delving into the trauma narrative
[1341]. The treatment has been conducted in group and individual formats in a variety of settings (e.g.,
outpatient, inpatient, residential, prisons) and populations (e.g., women, veterans, adolescents). RCTs
and meta-analyses have found that, while PTSD and AOD use treatment outcomes for people who receive
Seeking Safety are better than those who receive no treatment, they are comparable to those who receive
alternate treatments such as relapse prevention, treatment-as-usual for AOD use, or health education
[773, 1342–1344].

An emerging alternative present-centred therapy is integrated CBT (ICBT). ICBT addresses PTSD, substance
use, and their interaction through three core components: cognitive restructuring, centring and
breathing retraining, and psychoeducation [1345]. Two RCTs have examined the efficacy of ICBT relative
to usual care and individual addiction counselling. Neither reported significant differences for PTSD
outcomes [667, 1346], but one reported better AOD-related outcomes [667].

Mindfulness-based programs have also shown promise in early pilot studies [1347–1349] and one RCT
which found greater improvements in PTSD symptoms, AOD cravings, and negative affect among those
randomised to receive Mindfulness Oriented Recovery Enhancement relative to Seeking Safety [1177]. Research
examining the efficacy of ACT for PTSD and AOD use is in its early stages, but has been associated with
improvements in PTSD symptoms and alcohol-related outcomes among veterans [687].
B7: Managing and treating trauma, PTSD and complex PTSD 251

Pharmacotherapy
Pharmacotherapies are not a recommended first line treatment for PTSD due to their limited efficacy.
There is also little evidence to suggest that combining psychological and pharmacological interventions
leads to improved outcomes. Nonetheless, Australian and international guidelines for the treatment
of PTSD [1308, 1350] recommend that pharmacotherapies be used as an adjunct to trauma-focused
psychotherapy if the person has not gained benefit from psychological treatment, or if they express a
preference for pharmacotherapy [1308, 1350–1352]. When pharmacotherapies are considered, SSRIs are
the recommended first line option, particularly fluoxetine, paroxetine, and sertraline [1303, 1308], followed
by the SNRI venlafaxine (see Table 47).

Trials of pharmacotherapy for PTSD co-occurring with AOD use disorders have examined the use of
sertraline and paroxetine (SSRI antidepressants), desipramine (TCA), prazosin (alpha1-adrenergic receptor
agonist), aprepitant (neurokinin-1 receptor antagonist), topiramate and zonisamide (anticonvulsants),
N-acetylcysteine (mucolytic agent), naltrexone (opioid antagonist), and disulfiram (alcohol antagonist).

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 [1353,
1354]. More recently, Hien and colleagues [780] 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, though improvements in alcohol use and
dependence were equivalent between groups.

Petrakis and colleagues [1355] conducted an RCT comparing the efficacy of desipramine and paroxetine
with and without adjunctive naltrexone among veterans with 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 greater reductions in cravings but did not provide any advantage over placebo in terms of alcohol
use.

The limited research that has been conducted among people with co-occurring PTSD and AOD use
disorders in relation to prazosin and aprepitant suggests that these agents are no more effective
than placebo in relation to either PTSD or alcohol-related outcomes [1356], whereas topiramate [1357],
zonisamide (as an adjunct to CPT) [1358], and N-acetylcysteine (as an adjunct to CBT for substance
use) [1359] have been associated with greater reductions in PTSD symptom severity and alcohol-
related outcomes relative to placebo [1357]. Naltrexone, disulfiram, and the combination of these two
medications have been associated with greater reductions in alcohol-related outcomes but not PTSD
symptoms, relative to placebo; however, unwanted side effects were more common among people who
received the combination of naltrexone and disulfiram [1315, 1360].

In recent years there has been growing interest in the use of psychedelic substances such as MDMA,
psilocybin, and ketamine to enhance psychotherapy for the treatment of PTSD and AOD use disorders
(alcohol in particular) as single disorders. Despite there being considerable enthusiasm about
the potential of these substances bringing a long-awaited breakthrough in psychiatry, to date the
predominance of research is limited to small, uncontrolled trials [1361–1364]. Further research is needed
to determine clinical efficacy and safety for single, as well as co-occurring conditions.
252 B7: Managing and treating trauma, PTSD and complex PTSD

E-health and telehealth interventions

Currently, there are two e-health programs which have been developed to target co-occurring AOD
use and PTSD among veterans. Thinking Forward is a self-directed online CBT program, comprising 12
interactive modules, developed for people with PTSD engaging in hazardous alcohol use. Findings to date
have been mixed with one RCT reporting an association between Thinking Forward and reductions in heavy
drinking but not PTSD symptoms, and another finding reductions in PTSD symptoms but not alcohol
use [1365, 1366]. Similarly, VetChange, a CBT and MI-based online program for veterans with clinical levels
of PTSD and at-risk alcohol use, has demonstrated significant post-treatment reductions in alcohol
use and PTSD symptoms relative to baseline [1367–1369]. These reductions were more pronounced for
VetChange participants compared to those randomised to a waitlist control [1367]. VetChange has also been
adapted into a mobile app (https://mobile.va.gov/app/vetchange), which is yet to be evaluated.

Although there are few internet programs targeting co-occurring PTSD and AOD use, many evidence-
based interventions exist for PTSD as a single disorder. Two meta-analyses support the benefit of
e-health interventions, finding that they lead to greater improvements in PTSD symptoms compared to
usual care, waitlist, and active controls [1370, 1371]. Improvements were observed regardless of whether
individualised feedback was provided alongside the e-health intervention [1370]. Programs shown to have
moderate treatment effects often incorporated CBT techniques, in the form of psychoeducation, exposure
(e.g., writing about one’s trauma experience), anxiety management, and cognitive restructuring [1350].

Two promising internet programs – PTSD Online and The PTSD Course – have been developed in Australia
and provide psychoeducational resources about AOD use [1195, 1372]. PTSD Online is a 10-week therapist-
assisted program incorporating psychoeducation and CBT-based components. Several uncontrolled
studies have found promising results, including high levels of treatment satisfaction and significant
post-treatment improvements in PTSD symptoms, psychological distress, and quality of life relative to
baseline [1195, 1196, 1373, 1374]. Similarly, The PTSD Course (formerly PTSD Program) is an online intervention
including seven lessons based on elements of psychoeducation, CBT, and exposure therapy. People
accessing the program are able to discuss relevant issues in forums moderated by therapists and
message clinicians. One small RCT found significantly greater reductions in PTSD symptom severity
among people randomised to receive PTSD Course compared to a waitlist control [1372]. People who
accessed PTSD Course also reported high levels of satisfaction with the treatment.

There are several smartphone apps designed to treat PTSD as a single disorder. PTSD Coach, developed
by the US Department of Veterans Affairs, is based on CBT and incorporates psychoeducation, self-
assessment, treatment and referral resources, and social support tools, which can together be used as a
stand-alone or supportive app during therapy [1375]. An online version of the app is also available (http://
www.ptsd.va.gov/apps/PTSDCoachOnline). When compared to a waitlist control, Kuhn and colleagues
[1376] found people accessing PTSD Coach reported greater reductions in PTSD symptoms [1376]. Miner and
colleagues [1377], on the other hand, found no difference in post-treatment PTSD symptom scores [1377].
PTSD Coach has also been adapted into PTSD Coach Australia for Australian veterans [1378]. Qualitative
feedback from participants provided promising support for this adaptation [1379].
B7: Managing and treating trauma, PTSD and complex PTSD 253

Physical activity
A number of uncontrolled pilot studies have found aerobic exercise to be associated with improvements
in PTSD symptoms [1380–1384]. Promising findings were also provided by a small controlled trial which
found greater reductions in PTSD symptoms among people randomised to receive exposure therapy with
exercise augmentation compared to those randomised to receive exposure therapy alone [1385]. Another
small controlled trial reported greater reductions among people with PTSD as a single disorder following
12 weeks of aerobic and resistance exercises, compared to people randomised to a wait-list control [1386].
A more rigorous evaluation of the impact of exercise on PTSD symptoms was completed in Australia.
Rosenbaum and colleagues [1387] 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. People randomised to receive the exercise
program demonstrated significantly greater reductions in PTSD symptom severity compared to those
randomised to receive inpatient care alone.

In a more recent RCT, veterans with PTSD as a single disorder participated in 12 weeks of supervised
exercise training, including aerobic, balance, strength, and flexibility exercises, three days a week [1388].
Relative to veterans randomised to a wait-list control, those who received the exercise intervention
reduced their PTSD symptoms by an average of 16% (compared to 7% in the control group), and
also reported greater decreases in negative cognitions, negative mood, depressive symptoms, and
improvements in sleep quality. While further research is needed examining the optimal dose, frequency
and intensity of exercise, these findings provide preliminary support for the use of exercise as an adjunct
to evidence-based PTSD treatments. Research has yet to examine the impact of physical exercise in
people with co-occurring PTSD and AOD use disorders.

Yoga

A review of the literature concluded that yoga appears to have benefits for people with PTSD, particularly
in relation to hyperarousal symptoms [1389]. The predominance of research to date has consisted of
small, uncontrolled pilot studies; however, one RCT provides stronger evidence in support of yoga as
an alternative therapy for PTSD. Van der Kolk and colleagues [1390] 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 people by helping them to tolerate physical and sensory experiences
associated with fear and helplessness and to increase emotional awareness and affect tolerance [1390].
A long-term follow-up of this trial illustrated that the benefits of yoga relative to a control group were no
longer evident 18 months after study completion, though an increased frequency of yoga practise was
associated with reduced PTSD symptoms in both conditions [1391]. These findings are similar to those
from a more recent RCT, which compared a holistic yoga intervention to a wellness lifestyle program
among veterans and civilians with PTSD as a single disorder [1392]. People randomised to the yoga
254 B7: Managing and treating trauma, PTSD and complex PTSD

intervention experienced greater decreases in PTSD symptom severity directly following the intervention
relative to people randomised to the lifestyle program, but these differences were no longer significant
seven months after the study.

Studies examining the efficacy of yoga among people with co-occurring PTSD and AOD use disorders
are lacking; however, there is some evidence to suggest that yoga may be beneficial among people with
these co-occurring disorders. 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 [1393]. 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 [1394]. One further qualitative study examined yoga
among women in AOD treatment, most of whom reported a history of trauma [1395]. Women included
in this study reported a wide variety of benefits for yoga, including improved mental health, emotional
expression, improved sleep, and increased strength. Further research among people with co-occurring
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.

Complementary and alternative therapies

Music therapy

A single study examined the efficacy of music-therapy as an adjunct to outpatient AOD treatment among
12 people with PTSD and AOD use disorders, where music therapy involved psychoeducation, breathing/
singing exercises, and attentional control training. In this trial, Hakvoort and colleagues [1396] found that
six, one-hour sessions of music therapy reduced PTSD symptoms relative to before treatment. Moreover,
83% of people remained abstinent at the end of treatment, with no reports of relapse or AOD cravings,
although 50% of people dropped out of the study.

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 co-occurring PTSD and AOD use. The evidence to date suggests that individual past-/
trauma-focused psychological interventions delivered alongside AOD treatment are more efficacious
than those that are present-/non-trauma focused. It is, however, important that both options be
considered in the context of tailoring a person’s treatment to their individual needs and preferences.
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, yoga and music therapy also appear to convey benefit; however,
further research is needed to determine efficacy in PTSD populations and people with co-occurring AOD
use disorders in particular. Box 20 illustrates the continuation of case study G, following Julie’s story after
identification of her PTSD disorder was made.
B7: Managing and treating trauma, PTSD and complex PTSD 255

Box 20: Case study G: Treating co-occurring PTSD and AOD use: Julie’s story continued

Case study G: Julie’s story continued

The AOD worker organised for Julie to speak with one of the team’s psychologists. Over a series of
sessions with her treating psychologist, Julie began to talk more about how the traumatic events in her
life had affected her. She reported a mix of re-experiencing, avoidance and hyperarousal symptoms in
relation to both the physical and sexual assaults she had experienced as a child and as an adult and
became visibly upset - at times shaking - when she discussed the events. It also became apparent that
Julie felt a great deal of guilt, shame and self-blame surrounding the events.

Throughout treatment, the psychologist continued to normalise Julie’s symptoms, providing

psychoeducation and self-management techniques, and was able to explore the relationship between
Julie’s trauma-related symptoms and her substance use. Julie was also able to recognise how these
events had played a deciding role in how she viewed herself and others, and her relationships. Although
distressing, over time Julie recognised that addressing these issues would be an important part of
her treatment and worked with her psychologist on deciding on an evidence-based approach that
she felt comfortable with. Julie struggled to reduce her substance use during this time and with the
support of the psychologist, decided to commence opiate substitution therapy to further support her
in reducing her substance use whilst still undertaking sessions with her psychologist. Both Julie and
her psychologist were aware that it may take time, but they would both work together to help her work
through the traumatic events she had experienced to achieve her long-term treatment goals.

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
B7: Managing and treating ED 257

Eating disorders (ED)

EDs (i.e., anorexia nervosa, bulimia nervosa, binge eating disorder) and AOD use frequently co-occur
[1397]. 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 [1398]. Assessment can be made even more difficult as the
minimisation or denial of symptoms can form part of some eating disorder presentations; either due to
a lack of self-awareness, shame, or as a result of some EDs being experienced by the person as ‘valuable’
to them and something they must protect [428, 1399]. It is however, important that co-occurring ED
and AOD use is identified; the consequences of ED and AOD use are severe, and can include medical
complications [1400, 1401], additional severe psychiatric conditions [1402–1404], suicidal ideation and
attempts [1405, 1406], and mortality [1407].

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
EDs are characterised by disturbances in eating behaviours and food intake that impair psychosocial
functioning and/or physical health. These disturbances may involve:

• Food restriction (e.g., limiting the amount of food eaten each day by reducing portion size, going
long periods of time without food [>4 hours at a time], eliminating food types such as fats or
carbohydrates, or not eating at all).

• Compensatory behaviours in reaction to consuming food (e.g., overexercising, vomiting and/or

purging, laxative use).

• 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 physical symptoms associated with ED are related to the effects of starvation, bingeing,
purging, and/or overexercising [1408–1410]. People with ED, particularly bulimia nervosa, may show few
outward signs of their disorder [1411, 1412], and may also hide symptoms of their ED (e.g., by wearing
loose fitting clothing) [428]. Any visible physical signs of the ED may be complicated by AOD use. For
example, AOD use can influence features that are usually associated with the assessment of ED, such
as weight, appetite and food restriction [1412]. 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 [10]. Further, for some with ED and AOD conditions, alcohol may serve as the main source
of nutrition. 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) [1413]. The level of care required will depend on illness severity,
the presence of any medical complications, dangerousness of behaviours, and any other psychiatric
comorbidities (e.g., depression, anxiety) [1408, 1414]. In more complex presentations of ED, consultation
with additional interdisciplinary professionals may be required, including dieticians, exercise therapists,
social workers, family therapists, and psychiatrists [1408].
258 B7: Managing and treating ED

AOD workers should also be aware of the potential interactions between co-occurring ED and AOD use
and consider this interplay 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
suppress appetite [1400]. 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 [1415].

Symptoms of ED

Anorexia nervosa
The most profound clinical feature of anorexia nervosa is extreme caloric restriction to induce weight
loss. People can have anorexia nervosa even when at normal weights; it is the restriction and the weight
loss rather than actual body weight that are the key features. Anorexia nervosa can be conceptualised as
a disorder of control and denial where low body weight is mistakenly perceived to be normal or excessive
and is central to a person’s self-worth [11]. In many instances, the rigid control of food intake and weight
can be best thought of as an attempt to cope with, cause or prevent a life event or mood (e.g., prevent
puberty, reduce anxiety, deter abuse) [423]. Although not all physical symptoms will be noticeable, AOD
workers should be aware of the potential for medical complications, many of which may improve or be
reversed with early intervention [1409]. Physical signs a person may present with may include [1409, 1414,
1416]:

• Bradycardia (slowed heart rate).

• Low blood pressure.

• Abdominal pain, discomfort and/or constipation.

• Peripheral oedema (swelling of lower legs or hands).

• Bruising and/or broken blood vessels.

• Loss of menstruation (in females), and low testosterone levels (in males).

• Fatigue.

• Lethargy or hyperactivity.

• Cold sensitivity or intolerance.

• Loss or thinning of hair.

• Acne.

• Xerosis (dry skin).

• Lanugo hair on the body (fine hairs on the back, face, arms).

• Dehydration.

Other complications may include neurological abnormalities, changes in cardiac structure (e.g.,
ventricular atrophy), decreased bone density or osteoporosis, hypoglycaemia or diabetes, liver enzyme
abnormalities, and elevated cortisol levels.
B7: Managing and treating ED 259

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 [1414, 1417].

Bulimia nervosa
Bulimia nervosa is characterised by a cycle of binge eating and purging behaviours. Binge eating involves
a discrete time period where a person feels a loss of control over their eating, as they consume more or
different food than usual, and do not feel able to stop eating or limit their intake [10, 11, 1408]. Bingeing
is often followed by compensatory behaviours designed to prevent weight gain (e.g., vomiting, use of
laxatives, fasting or excessive exercising). As with anorexia nervosa, a person’s perception of their value
and self-worth is disproportionately influenced by their body weight, size, and shape [10].

The cycle of bingeing and purging is maintained by the belief that control over one’s eating, weight, and
shape will increase a person’s self-worth, and that by restricting and compensating after a binge they are
effectively managing weight. However, restricting food intake leads to binge eating which then results
in compensatory behaviours [1414]. Negative mood states such as sadness, frustration, anger, fear, or
loneliness, can exacerbate this cycle [1418, 1419].

As described in Chapter A4, people with bulimia nervosa may present with symptoms of extreme dietary
restrictions and/or exercise plans without purging behaviours [1408]. Further, people with bulimia
nervosa are often ashamed of their eating behaviours, and attempt to hide or conceal their symptoms
[428, 1420]. Some people even report deliberately selecting certain compensatory behaviours, such as
vaping, because they are easy to conceal [1421]. As such, bulimia nervosa can be an isolating disorder
[1414]. As with anorexia nervosa, the outward symptoms can be difficult to observe, particularly as people
with bulimia nervosa may not display the same dramatic loss in weight. Physical signs a person may
present with may include [1410, 1414, 1422]:

• Fatigue.

• Bloating and constipation.

• Gastric acid reflux, which can lead to difficulty swallowing or indigestion.

• Abdominal pain and distension.

• Calloused knuckles.

• Hoarse voice.

• Delayed digestion.

• Electrolyte abnormalities, such as hypokalaemia (low potassium).

• Muscle spasms.

• Heart palpitations.

• Nausea.

• Poor kidney function.

260 B7: Managing and treating ED

• Dental erosion.

• Enlarged glands.

• Poor colon function.

Binge eating disorder

Binge eating disorder is characterised by recurrent episodes of binge eating which occur without
compensatory weight control methods. As with bulimia nervosa, an episode of binge eating occurs within
a discrete time period during which a person feels a loss of control over their eating, where they consume
more or different food than usual, and do not feel able to stop eating or limit their food intake [10, 11, 1408].
As described in Chapter A4, binge eating disorder differs from bulimia nervosa as episodes of binge
eating are not regularly followed by compensatory behaviours to prevent weight gain (e.g., strenuous
exercise, self-induced vomiting, misuse of laxatives). 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 and can co-occur. Symptoms include [1414]:

• Obesity.

• Hyperlipidaemia (elevated lipids in the blood).

• Type 2 diabetes.

Common to anorexia nervosa, bulimia nervosa, and binge eating disorder is a dysfunctional and
distressing 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
[159, 160, 1423]. People with bulimia nervosa and binge eating disorder are distressed by the loss of
control over their eating, and the perception of overeating, and are at increased risk of additional
psychiatric comorbidities [1408]. In bulimia nervosa, binge eating is thought to come about from severely
restricting food intake as well as a mechanism for emotion regulation, but those with binge eating
disorder do not illustrate the same intake restrictions between episodes of binge eating [1414].

Managing ED
Despite the differences between ED in terms of clinical characteristics and observable symptoms, there
are common 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 [1424, 1425]. The techniques outlined in
Table 53 may help AOD workers to manage clients with ED symptoms.
B7: Managing and treating ED 261

Table 53: Dos and don’ts of managing a client with symptoms of eating disorders

Do:

Encourage and emphasise successes and positive steps (even just coming in for treatment).

Take everything the client says seriously.

Approach the client in a calm, confident and receptive way.

Be direct and clear in your approach.

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.

Constantly monitor suicidal thoughts and talk about these thoughts openly and calmly.

Encourage the client to express their feelings.

Focus on feelings and relationships, not on weight and food.

Be available, supportive, and empathetic.

Encourage participation in healthy, pleasurable, and achievement-based activities (e.g., exercise,

hobbies, or work).

Encourage, but do not force, healthy eating patterns.

Assist the client to set realistic goals.

Involve family or friends in management or treatment strategies.

Be patient in order to allow the client to feel comfortable to disclose information.

Explain the purpose of interventions.

Don’t:

Act shocked by what the client may reveal.

Be harsh, angry, or judgemental. Remain calm and patient.

Use statements that label, blame or shame the client.

Invalidate the client’s feelings.

Make comments (either positive or negative) about body weight, appearance, or food – these will
only reinforce their obsession.

Express any size prejudice or reinforce the desire to be thin.

262 B7: Managing and treating ED

Table 53: Dos and don’ts of managing a client with symptoms of eating disorders
(continued)

Engage in power struggles about eating.

Criticise the client’s eating habits.

Trick or force the person to eat.

Get frustrated or impatient.

Adapted from NSW Department of Health [431], Clancy and Terry [448], and World Health Organisation; Collaborating Centre for
Evidence in Mental Health Policy [1410].

Treating ED
EDs are complex psychiatric illnesses that impair psychological, social, and physical functioning.
It has been argued that the treatment of co-occurring 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 [726, 1415, 1426]. 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 and urine tests) to identify complications that may need immediate attention and/or
hospitalisation for medical stabilisation [1414, 1415, 1427, 1428].

There are several options available for the treatment of ED alone, including psychotherapy,
pharmacotherapy, e-health and telehealth interventions, physical activity-based interventions, as well
as complementary and alternative therapies. The evidence base surrounding each of these treatments
is briefly discussed below, with regards to each ED. A detailed summary of the evidence relating to each
disorder is also provided in a systematic review undertaken by the Australian National Eating Disorders
Collaboration [1429].

There is limited evidence about the treatment of co-occurring ED and AOD use disorders specifically,
due to the exclusion of people with AOD use disorders from the majority of ED treatment trials [1430].
The preliminary evidence that does exist, however, suggests that structured programs incorporating
elements of established psychotherapies such as CBT, family-based treatment (FBT), and DBT, including
individual psychotherapy sessions, family therapy, group therapy, and nutritional planning, may
effectively reduce symptoms of ED among people with co-occurring AOD use in ED treatment programs
[1404, 1431, 1432]. There is also some evidence to suggest that treating a person’s AOD use disorder may
lead to improvements in ED symptoms [1430].

Treating anorexia nervosa

The treatment of anorexia nervosa should begin with a comprehensive assessment, evaluating a
person’s nutritional, medical and psychological needs [1424]. This process should be ongoing throughout
treatment, as clinical needs and priorities of the client may change [870]. Clinical practice guidelines
on the treatment of ED from the RANZCP [870, 1424, 1433] recommend that the initial assessment of
anorexia nervosa incorporate the following information:
B7: Managing and treating ED 263

• 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, kidney function).

• Co-occurring psychiatric conditions.

• 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).

It is suggested that these assessment factors be incorporated into a case formulation (discussed
in Chapter B3), with treatment priorities based on a thorough risk assessment. Clinical guidelines
recommend that treatment priorities follow client engagement (including psychoeducation, with
family involvement, and MI), medical stabilisation, reversal of the cognitive effects of starvation, and
psychological treatment [870, 1427]. Where possible and practicable, it is recommended that people with
anorexia nervosa requiring admission be treated at specialist ED units, or by professionals specialising
in ED.

Psychotherapy

To date, there are no evidence-based psychotherapies for treating co-occurring anorexia nervosa and
AOD use specifically. Australian and international clinical practice guidelines for single disorder ED
recommend the inclusion of psychotherapy as an essential component of treatment for anorexia nervosa
[870, 1434]; however, it is recommended that, where indicated, more intense psychological therapies be
initiated only after medical stabilisation and the cognitive effects of starvation have improved [870].

The effectiveness of existing psychotherapies is moderate at best, which may be due, in part, to high
rates of treatment dropout and poor treatment retention [1429, 1435]. Regardless of the approach used,
strategies to engage the client and maintain the therapeutic relationship throughout treatment may be
beneficial to address high rates of treatment dropout. The interventions with the most theoretical and
empirical support include family-based therapy (i.e., Maudsley family therapy), particularly among young
people; CBT and CBT-enhanced (CBT-E). Other treatments with some evidence of low to moderate effect
include focal psychodynamic therapy; interpersonal psychotherapy (IPT); cognitive analytic therapy;
specialist supportive clinical management (SSCM); the Maudsley model of anorexia nervosa treatment
for adults (MANTRA), MI, and psychodynamic approaches [870, 1429, 1435]. Table 54 provides a brief
description of these approaches.

Research comparing different approaches has been limited and findings mixed (e.g., [1436–1443]);
as such, there is no clear guidance for clinicians to suggest that one therapeutic approach is better
than the other [1435, 1436, 1444]. In general, for children and adolescents with single disorder EDs, the
best evidence is for Maudsley FBT and, for adults, the best evidence is for CBT or psychotherapy of a
longer duration. As such, Australian clinical guidelines suggest that specialist-led manualised-based
approaches (e.g., CBT approaches) that have the strongest evidence-base should be first line options, but
do not stipulate any specific therapies as a first line treatment option [870].
264 B7: Managing and treating ED

Table 54: Brief description of psychotherapy approaches to ED

Cognitive behavioural therapy – enhanced (CBT-E)

CBT-E is an extension of CBT focused on educating clients about being underweight, starvation and 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 [1440]. CBT-E also
addresses other features that often co-occur with eating disorders, including low self-esteem, clinical
perfectionism, mood intolerances, and interpersonal difficulties [1423, 1445].

Integrative cognitive-affective therapy (ICAT)

ICAT is focused on the relationship between emotions and bulimic symptoms as well as adaptive eating
[1446]. The relationship between symptoms and factors that maintain bulimic behaviours are addressed
in four phases of treatment: treatment ambivalence and emotions; adaptive coping strategies; problem
areas believed to maintain bulimic symptoms; healthy lifestyle and relapse prevention.

Focal dynamic therapy

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 [1440].

Cognitive interpersonal therapy (MANTRA)

MANTRA (Maudsley model of Anorexia Nervosa Treatment for Adults) is a social-cognitive interpersonal
treatment that draws on MI, cognitive remediation, and the involvement of family and carers. It focuses
on addressing intrapersonal and interpersonal processes that are thought to be fundamental to the
maintenance of the disorder [1429].

Family-based treatment (FBT/Maudsley therapy)

FBT, first developed at the Maudsley Hospital in London, is a treatment program for anorexia nervosa in
young people. In Maudsley Therapy, the family is actively involved in treatment, which is primarily focused
on weight gain, and families are encouraged to take control over refeeding. Later stages of treatment
involve handing back control over eating to the young person, and addressing other issues [1429].

Specialist supportive clinical management (SSCM)

SSCM combines 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.
Clients are provided with information on a range of strategies to promote normalisation of eating and
restoration of weight [1429].
B7: Managing and treating ED 265

Table 54: Brief description of psychotherapy approaches to ED (continued)

Interpersonal psychotherapy (IPT)

IPT targets interpersonal issues which are believed to contribute to the development and maintenance of
ED. Four interpersonal problem areas are addressed: grief, relationship difficulties and deficits, and role
transitions [1429].

Adapted from Peckmezian et al. [1429]. Note this is not an exhaustive list of all psychotherapies available for the treatment of ED.
For a more comprehensive overview of approaches, see the Peckmezian and colleagues [1429] Evidence Review.

Pharmacotherapy

To date, there are no evidence-based pharmacotherapies for treating co-occurring anorexia nervosa
and AOD use. Guidelines suggest that pharmacotherapy alone should not be the primary treatment
for single disorder anorexia nervosa, and there is little consistency between guidelines with regard to
recommendations relating to specific medications [870, 1428, 1434].

Although atypical antipsychotics and SSRIs (olanzapine and fluoxetine in particular) have been used
in clinical settings, research indicates that there is no conclusive evidence of any effect on the primary
psychological features of anorexia nervosa or weight gain, but they may assist in treating other
psychological symptoms (e.g., depression) that may co-occur with anorexia nervosa [1414, 1429, 1447, 1448].
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 [1449, 1450]. A
comprehensive review of pharmacotherapy for single disorder anorexia nervosa found that olanzapine
increased weight gain and improved depression, anxiety, aggression and obsessive-compulsiveness
[1451]; however, the evidence remains weak and there is the possibility of adverse side effects [870].

Treating bulimia nervosa

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 [870]:

• Enquiry 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 hypokalaemia, cardiac issues, obesity, Type 2
diabetes, and hypertension, makes physical assessment among those with suspected bulimia nervosa
essential [1424]. As with the physical assessment of those with anorexia nervosa, this assessment
should include weight, height, pulse rate, blood pressure and BMI. Additional tests should be undertaken
266 B7: Managing and treating ED

to assess for hypokalaemia and dehydration (associated with purging behaviours), cardiac function
(e.g., electrocardiogram), glucose levels, and kidney function, as indicated [870, 1424]. 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 [870].

Psychotherapy

There is very little evidence about the concurrent treatment of AOD use and bulimia nervosa. There is,
however, some evidence to suggest that treating a person’s AOD use disorder may lead to improvements
in bulimia nervosa [1430, 1452].

There are currently several evidence-based treatments available for bulimia nervosa as a single disorder,
including CBT and CBT-E; IPT; FBT; DBT; and integrative cognitive-affective therapy (ICAT); in addition to
multidisciplinary and combined therapies [1453]. Unlike anorexia nervosa, overall, these treatments have
been shown to produce moderate to large reductions in symptomology [1454]. On average, an estimated
30-40% of people treated with these psychotherapies attain binge-purge abstinence, and effects appear
to be maintained over the longer term after treatment has ceased [1453, 1454].

Most psychotherapy research to date has been conducted in relation to CBT [1444]. There is robust
evidence supporting CBT treatment approaches (in particular those that are specific to ED, such as
CBT-E [1453–1455]), with both national and international clinical guidelines recommending the use of CBT
approaches as the first line of treatment [870, 1428, 1429, 1434, 1456]. These typically comprise of 16–20
clinician-led sessions. There is some evidence to suggest that self-guided CBT is effective, but less so
than clinician-led CBT [1453].

Pharmacotherapy

Unlike psychotherapy, the impacts of pharmacological treatments for bulimia nervosa are small to
moderate and have not been found to continue after cessation of medication [1454]. However, studies
that have examined the combined use of pharmacotherapies (mostly SSRIs) and psychotherapies
(mostly CBT), have generally found this combined approach to demonstrate similar effectiveness to
psychotherapy alone, but results are not consistent [1454].

Most treatment guidelines for single disorder bulimia nervosa recommend the use of SSRIs (specifically
fluoxetine) in combination with psychotherapy [1434, 1457]. Although meta-analyses and other reviews
have found that SSRIs appear to be less effective than TCAs and MAOIs (such as those listed in Table 47)
[1454, 1458, 1459], their side effect profile is often more tolerable [1449]. As mentioned previously, extreme
caution should be used when prescribing TCAs and MAOIs.

In addition to antidepressants, Australian guidelines for the treatment of ED recommend the use of the
antiepileptic topiramate when psychological treatment is not available [870]. There is also some evidence
from open label trials of lamotrigine, a mood stabiliser, showing positive outcomes on ED symptoms
when given in conjunction with DBT [1460].
B7: Managing and treating ED 267

Treating binge eating disorder

The Australian clinical practice guidelines for single disorder ED recommend the same comprehensive
assessment for binge eating disorder as described for bulimia nervosa [870].

Psychotherapy

To date, there are no evidence-based psychotherapies for treating co-occurring binge-eating disorder
and AOD use. Similar to bulimia nervosa, the first line of recommended treatment for addressing
single disorder binge eating disorder is CBT [870, 1429, 1461]. CBT has been found to outperform most
comparison therapies and has been found to be more effective than pharmacological interventions for
the treatment of binge eating disorder [1462, 1463]. Other psychological therapies found to be effective in
the treatment of binge eating disorder include IPT, psychodynamic therapy, and DBT [1429, 1464].

Pharmacotherapy

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 [870]. Although
there are no current evidence-based pharmacotherapies for treating co-occurring binge-eating disorder
and AOD use, there is emerging evidence suggesting that pharmacotherapy may be beneficial for some
people with binge eating disorder as a single disorder [1461, 1465]. RCTs examining the efficacy of SSRIs
(fluoxetine, citalopram, escitalopram, fluvoxamine, and sertraline [1464]), SNRIs (duloxetine [1466]), mood
stabilisers (topiramate [1467]), anticonvulsants (lamotrigine [1468]), antiobesity medications (orlistat
[1464]), and psychostimulants (lisdexamfetamine [1464]), have found reductions in the frequency of binge
eating episodes, BMI decreases, and overall clinical improvement.

Five RCTs to date have evaluated lisdexamfetamine for single disorder binge eating disorder, with
findings demonstrating strong evidence in support of its safety and efficacy [1469–1473]. These studies
found that compared to placebo, lisdexamfetamine was associated with significant improvements in
binge-eating symptoms, reduced frequency of binge-eating episodes, and reduced body weight [1474].
The anticonvulsants topiramate and lamotrigine have also been evaluated for efficacy and safety for
single disorder binge eating disorder in several RCTs [1467, 1468, 1475, 1476]. 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. The antiobesity
medication Orlistat has been examined for efficacy in four RCTs to date [1463, 1477–1479]. These trials
found that, although weight loss was enhanced with Orlistat, the frequency of binge eating was not
reduced.

There is also some evidence to support the use of pharmacotherapies which target AOD use, such as
baclofen, acamprosate, and bupropion, for the treatment of binge-eating disorder as a single disorder
[1480, 1481]. Two narrative reviews concluded that, while baclofen reduces the frequency of binge-eating
episodes [1480, 1481], depressive symptoms may increase [1481] relative to baseline. In these reviews,
268 B7: Managing and treating ED

bupropion also reduced the frequency of binge-eating episodes relative to baseline, and improved
weight goals relative to both a placebo and sertraline, although the findings for binge-eating episodes
were somewhat mixed [1480, 1481]. In one RCT, acamprosate also reduced the frequency of binge-eating
episodes, as well as related factors such as food cravings and compulsive eating, relative to before
treatment, but not relative to placebo [1482].

E-health and telehealth interventions

Although there are no e-health or telehealth interventions for co-occurring ED and AOD use disorders,
there has been some research conducted into the use of e-health interventions for single disorder ED.
Systematic reviews of internet-based interventions for single disorder ED have found that ED symptoms,
including bingeing and purging episodes, reduced significantly with the use of an internet-based therapy
[1483, 1484]. In contrast, however, several studies reported poorer outcome, or no difference, for e-health
interventions relative to waitlist and treatment-as-usual control groups [1485]. Notably, though, some
studies that did not report significant findings are likely limited by methodological factors, such as
small sample sizes.

There is no clear evidence as to which e-health intervention has the most empirical support for single
disorder ED, although self-help CBT has been highlighted as an effective, accessible, time and cost
effective alternative to clinician delivered CBT [1455, 1485, 1486]. The majority of studies have focused on
internet-based CBT, with the online components ranging from e-mail-based therapy, adjunctive internet-
based guidance, to online CBT. One review found that internet-based therapies that were bolstered
by face-to-face contact via assessment and clinician support were associated with higher rates of
therapeutic adherence and lower attrition from internet-based treatment [1484].

Guided self-help and self-help CBT for single disorder ED in particular have been shown to be effective in
reducing the frequency of bingeing and purging, and improving ED psychopathology, but less effective
than face-to-face psychotherapy in achieving abstinence [1453, 1455, 1483, 1486–1488]. These findings
provide some support for the use of guided e-health interventions in the treatment of ED as an adjunct to
other treatments [1487]. Unguided self-help initiatives do not appear to be effective at treating ED [1483,
1487].

A systematic review of smartphone applications for ED identified up to 20 interventions currently

available for ED treatment [1487], with varying levels of empirically supported content. These apps mostly
provide educational content, but some incorporate additional features such as self-assessment tools
and referral infrastructure. In another systematic review, smartphone applications improved abstinence
rates from bingeing and purging behaviours from baseline [1483]. Moreover, the increasing popularity and
widespread use of smartphone applications suggests they could be an effective medium for delivering
treatment once their clinical utility is established [1487]. However, most experts agree that the evidence
for smartphone applications as treatment for ED is limited, as these applications are not necessarily
founded on evidence-based principles [1487, 1489].

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 co-occurring ED and AOD use, in terms of treatment,
B7: Managing and treating ED 269

recovery, and relapse prevention [990]. The benefits associated with exercise in ED include the promotion
of physical activity and healthy weight control, as well as the potential prevention and/or restoration
of medical conditions such as reduced bone mass, cardiovascular disease, and diabetes [1490, 1491].
However, as excessive exercise can also be an illness feature in ED, and further 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 [1492]. There
is also the potential that physical activity may lead to compulsive ‘overexercising’ [1493]. As such, some
current international guidelines discourage offering clients with EDs physical therapies [1428], despite
evidence to suggest its effectiveness. Other guidelines recommend its use under the supervision of a
skilled exercise professional with ED experience [1434, 1494, 1495].

Although physical activity has not been evaluated among people with co-occurring ED and AOD use,
two reviews have examined exercise in people with single disorder ED and found moderate physical
activity to be associated with reduced ED cognitions (e.g., food preoccupation), frequency of bingeing and
purging episodes, and ED psychopathology [990, 1496]. One small pilot study examined 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 [1497].
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 [1498]. The exercises included stretching, yoga, Pilates,
strength training, balance, exercise balls, aerobic exercise (e.g., walking or skipping), recreational games,
or other enjoyable activities [1498]. It is suggested that moderate physical activity facilitates weight gain
by improving emotional wellbeing, increasing appetite, and reducing body-image and appearance-related
distress [1492].

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 [1492]. One systematic
review identified 11 therapeutic elements that appear to be essential to the success of exercise
interventions within ED treatment, including the use of positive reinforcement, beginning with mild
intensity exercise, using a graded program, including psychoeducation, including nutritional advice, and
debriefing following exercise sessions [1494].

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 [1492, 1499],
and thus, hinder potential positive outcomes.
270 B7: Managing and treating ED

Complementary and alternative therapies

Research into complementary and alternative therapies for co-occurring ED and AOD use disorders has
examined yoga, acupuncture, therapeutic massage, hypnosis, herbal medicine, light therapy, spiritual
healing, and art therapy [1500]. Despite the breadth of research, no intervention has been identified
as an effective, evidence-based treatment for co-occurring ED and AOD use. While the research in
this area continues to develop, there are promising preliminary findings relating to the use of yoga
[1501], acupuncture [1502], hypnosis [1503–1505], relaxation [1506], brain stimulation [1507], bright light
phototherapy [1506], and therapeutic massage [1502, 1508].

Summary
Despite much research, there is little evidence upon which to provide clear guidance on the treatment of
co-occurring 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, with strongest evidence in support of CBT-based approaches [1400]. 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 [870]. Box 21 illustrates the continuation of Kai’s
case study, following their story after their ED was identified.

Box 21: Case study H: Treating co-occurring ED and AOD use: Kai’s story continued

Case study H: Kai’s story continued

The AOD worker consulted with an ED specialist, who arranged with Kai and their mother to attend
an assessment. Kai was moderately underweight (with a BMI of 16) and the specialist arranged for a
complete physical assessment, including heart rate, blood pressure, temperature, metabolic tests,
assessments for any cognitive changes, and contributing factors. Kai’s family were encouraged to
maintain involvement with their ongoing treatment, and the specialist devised a plan with Kai that
included their family’s involvement, with a focus on medical stabilisation, psychoeducation with MI,
reversal of the cognitive effects of starvation, and psychological treatment.

Kai continued working with the AOD service who provided ongoing support in relation to their goal of
reducing their use of alcohol and non-prescribed opioids, but Kai said they were not ready to give up
smoking. The AOD worker made a note of this and planned to explore it further using MI in a future
appointment. During one follow-up appointment, the AOD worker asked Kai to take a urine test. Kai
refused and left the appointment. Assuming Kai had used non-prescribed opioids between appointments
and did not want them to show up in a urine test, Kai’s AOD worker called Kai and told them that it was
normal to experience lapses and they would work through the process together. The AOD worker asked
Kai to please come back so they could discuss Kai’s reasons for leaving, and also so she could give Kai
some additional relapse prevention strategies. Kai agreed to come back.
B7: Managing and treating ED 271

Box 21: Case study H: Treating co-occurring ED and AOD use: Kai’s story (continued)

During their next appointment, Kai told the AOD worker that they were sexually assaulted in a public
toilet when they were 14, and since that time had experienced a lot of difficulty going into any public
toilets, even when accompanied. The AOD worker asked Kai whether their food restriction also started
around this time and thinking about it, Kai thought it may have. Kai said they had not used any opioids.
The AOD worker organised a case management meeting with everyone involved in Kai’s care to reassess
Kai’s treatment plan. The ED specialist was able to start addressing the underlying trauma which was
recognised as a contributing factor to the ED. Kai also agreed to an inpatient stay at a specialised ED
facility to stabilise their weight gain and was provided with ongoing support from their AOD worker, who
was also involved in discharge planning and relapse prevention.

Key points:
• It can be difficult to identify ED in people with AOD use disorders.
• Once identified, it is vital that a person experiencing ED 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 disorders
B7: Managing and treating personality disorders 273

Personality disorders
As described in Chapter A4, personality disorders are highly stigmatised conditions, even within mental
health and healthcare more broadly. As such, it is crucial that any communication regarding clients
with potential personality disorders – whether that communication involves the client directly or is with
healthcare providers on behalf of the client – remains respectful, non-judgemental, compassionate, and
client-centred.

Clinical presentation
People with personality disorders display patterns of thinking, behaving and emotional expression
that lead to frequent and enduring problems across multiple areas of a person’s life and, in particular,
problems forming long-term, meaningful, and rewarding relationships with others. Symptoms can
include:

• Behaviour that may be considered manipulative or deceitful.

• Impulsivity.

• Difficulties in relating to others.

• Unstable relationships.

• Difficulty showing remorse for their behaviour or empathy for other people.

• Suspiciousness.

• Difficulty accepting responsibility or accommodating others.

• Emotional instability and hypersensitivity.

• Pervasive and persistent irritation, anger, or aggression.

• Being overly self-involved.

• Excessive dependence on others.

It is important to remember however, that symptoms of personality disorders such as difficulties with
emotion-regulation, self-control, and impulsivity, are often present to varying degrees in many clients
and do not necessarily indicate a personality disorder.

Managing symptoms of personality disorders

Strategies for managing the symptoms of personality disorders are outlined in Table 55. The development
of coping skills (e.g., breathing retraining, meditation, cognitive restructuring described in Appendix
BB and Appendix CC) to regulate emotions is considered fundamental in the treatment of co-occurring
personality and AOD use disorders [102]. Coping strategies have been found to mediate the relationship
between personality disorder and AOD use [1509] and deficits in emotion regulation are considered core
to maintaining symptoms of BPD [1510].
274 B7: Managing and treating personality disorders

AOD workers may find it difficult to manage symptoms of personality disorders which are some of
the most challenging conditions to treat [1511, 1512]. Establishing a positive therapeutic relationship is
essential, but often difficult due to the inherent relational difficulties that are experienced by people
with these conditions. These difficulties often arise from insecure attachment during childhood and
frequently surface in the context of a therapeutic relationship [121]. Other challenges include strong
countertransference reactions including anger, frustration or indifference; as well as often needing to
manage the heightened risk that is presented with chronic suicidal thinking and AOD use [121, 162]. Some
personality characteristics, impulsivity in particular, place clients at extremely high risk for suicide, and
require increased levels of monitoring the risk of suicide and self-harm.

Engagement and rapport building form an intensely important part of treatment and clients with
personality disorders may require more time and attention than other clients [121]. Clients with
personality disorders may have trouble developing positive therapeutic relationships 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 [948]. Structure and firm boundaries are very important components of
the therapeutic process when managing clients with symptoms of personality disorders.

Progress may also be slow and uneven as many people with personality disorders have trouble
integrating change-oriented feedback [102]. Donald and colleagues [121] note the importance of striking
the right balance between validation (i.e., empathetic acceptance of the client and their difficulties),
which has typically been lacking from this client group’s experiences and is often responded to well, and
change-oriented interventions focused on changing current behaviours (such as developing alternative
coping strategies to replace self-harm or AOD use). It may also be helpful to highlight aspects of the
client’s personality that may be viewed as strengths, and enhance their prospects of achieving the
outcomes they are working towards [162].

Table 55: Dos and don’ts of managing a client with symptoms of personality disorders

Do:

Place strong emphasis on engagement to develop a good client–worker relationship and build
strong rapport.

Set clear boundaries and expectations regarding the client’s role and behaviour. Some clients may
seek to test these boundaries.

Establish and maintain a consistent and reliable approach to clients and reinforce boundaries.

Anticipate difficulties with adhering to treatment plans and remain patient and persistent.

Plan clear and mutual goals and stick to them; give clear and specific instructions.

Help with the current problems the client presents with rather than trying to establish causes or
exploring past problems.
B7: Managing and treating personality disorders 275

Table 55: Dos and don’ts of managing a client with symptoms of personality disorders
(continued)

Assist the client to develop skills to manage negative emotions (e.g., breathing retraining,
progressive muscle relaxation, cognitive restructuring).

Maintain a calm environment, as significant stress may exacerbate symptoms.

Take careful notes and monitor the risk of suicide and self-harm.

Avoid judgement and seek assistance for personal reactions (including frustration, anger, dislike)
and poor attitudes towards the client. Remember that challenging aspects of behaviour often
have survival value in the context of past experiences.

Listen to and evaluate the client’s concerns.

Accept but do not confirm the client’s beliefs.

Don’t:

Reward inappropriate behaviour (such as demanding, aggressive, suicidal, chaotic, or seductive

behaviour).

Display frustration or anger with the client. Remain firm, calm and in control.

Assume a difficult client has a personality disorder; many do not, and many clients with these
disorders are not difficult.

Adapted from NSW Department of Health [431], Project Air [1513], Davison [1514], and Fraser et al. [162].

Treating personality disorders

As discussed in Chapter A2, the most common personality disorders seen in AOD services are BPD and
ASPD and research regarding the treatment of co-occurring personality and AOD disorders has largely
focused on these two conditions [162]. Experts suggest that treating both the personality and AOD
use disorder simultaneously, using a combination of psychotherapy and pharmacotherapy to support
reductions in, or the cessation of, AOD use may be the best approach, although research comparing this
with other approaches is lacking [162, 1515]. Donald and colleagues [121] recommend a staged approach,
in which the early phases of treatment concentrate on the stabilisation of AOD use and self-harming
behaviours using a transdiagnostic approach that focuses on emotion regulation and impulsivity,
followed by interventions that focus on issues relating to identity and the self.

Treatment options available include psychotherapy and pharmacotherapy, which may be supplemented
by other interventions including e-health and telehealth interventions, physical exercise and
complementary and alternative therapies (e.g., omega-3). The evidence base surrounding each of these
treatment options with regards to the treatment of BPD and ASPD is discussed below.
276 B7: Managing and treating personality disorders

Borderline personality disorder (BPD)

Psychotherapy

Psychotherapy is regarded as the most effective treatment for BPD as a single disorder [1516] and is the
recommended first-line of treatment for BPD in Australian and international guidelines [555, 1517–1519]. A
Cochrane review of psychotherapies for BPD concluded that psychotherapy is an effective treatment for
reducing BPD symptom severity, depression, and suicidality in people with BPD, but the vast majority of
studies reviewed excluded people with co-occurring AOD use disorders [1516].

Although a large number of treatments have been developed for BPD, Dialectical Behaviour Therapy (DBT)
and Mentalisation Based Treatment (MBT) are the most researched to date [1516]. DBT is a complex, skills-
based, psychological intervention and has been modified for people with co-occurring BPD and AOD use
disorders (DBT-S). In this model, the symptoms of BPD and AOD use are viewed as attempts to regulate
emotions [162]. Using some of the same principles as CBT, the client is supported with strategies to
promote abstinence and is more likely to remain engaged in treatment. Although research to date
is limited to a small number of studies, DBT-S is the preferred treatment approach to date, having
demonstrated improvements in relation to both BPD symptoms and AOD use [724, 1520].

MBT is an evidence-based treatment for BPD that focuses on mentalising, rather than cognitions or
behaviours [1516, 1521]. Mentalising, or mentalisation, is a general term used to describe how we make
sense of ourselves and the world around us. Although difficulties with mentalisation may be associated
with many mental health conditions, people with BPD in particular may be more limited in their capacity
to mentalise [1521]. In targeting mentalisation, MBT aims to improve some of the core characteristics of
BPD, such as impulsivity, emotional instability, impaired interpersonal functioning, fractured identity,
and chronic emptiness [1522]. Philips and colleagues [1523] conducted a feasibility study comparing the
effectiveness of MBT provided in combination with AOD treatment, to AOD treatment alone among people
with co-occurring BPD and AOD use disorders. No significant differences were found between groups with
regard to changes in BPD symptom severity or substance use, but a trend towards a reduced number of
suicide attempts among those who received MBT was found relative to AOD treatment alone. It should be
noted, however, that therapist adherence to the treatment manual in this study was low.

Another promising treatment is Dynamic Deconstructive Psychotherapy (DDP) [1524, 1525]. DDP is a modified
form of psychodynamic psychotherapy, and was initially developed for particularly challenging cases
of BPD, including those with co-occurring AOD disorders [1525]. In a systematic review of the literature,
Lee and colleagues [724] 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 [1524, 1526, 1527]. DDP also effectively reduces some secondary treatment
outcomes related to personality disorders, such as suicidal behaviour [1515].

Several other treatments have also been developed and undergone preliminary examinations for co-
occurring BPD and AOD use but require further research [1528, 1529]. One treatment that does not appear
to be of benefit in the treatment of co-occurring BPD and AOD use is Dual Focus Schema Therapy (DFST) [704,
1530], a combination of relapse prevention and therapy focused on early maladaptive schemas (such
B7: Managing and treating personality disorders 277

as continuing negative self-beliefs, negative beliefs about others or events), as well as coping styles
[724, 1531]. DFST has only been examined in a single study to date, but appeared to be of limited benefit,
and greater reductions in AOD use were found among those in the control condition (individual drug
counselling) [724].

Pharmacotherapy

Although somewhat dated, current Australian and international guidelines on the management
of BPD suggest pharmacotherapies only be used as an adjunct to psychotherapy [555, 1517–1519].
Pharmacotherapies that support a reduction in, or the cessation of, AOD use (e.g., naltrexone and
disulfiram) in particular may be helpful in facilitating stabilisation that will allow the client to make
further gains in psychotherapy [121, 1532]. Concerns have been raised with regard to the potential for
dangerous interaction effects of medications and AOD use in the context of impulsivity and self-harming
behaviours [1240]. As such, although disulfiram has been found to be safe and effective among people
with BPD and alcohol use disorders [1532], caution is advised due to the potential risk [1515].

No pharmacotherapies have been approved for the treatment of BPD as a single disorder, and there is
little evidence to support their efficacy in the context of BPD as a single disorder, and none in the context
of co-occurring AOD use disorders [162]. Nonetheless, off label prescribing of antidepressants, mood
stabilisers, antipsychotics and anticonvulsants to address primary or secondary symptoms of BPD is
common, with medications often chosen to target specific symptoms such as affect dysregulation or
impulsivity [1240, 1533]. This targeted approach to prescribing has been the subject of considerable
debate and concerns have been raised regarding the use of polypharmacy. There is consensus in the
literature, however, that prescribing should be kept to a minimum [1240] and polypharmacy avoided
whenever possible [1515, 1533, 1534].

E-health and telehealth interventions

Several mobile phone applications have been developed for people with BPD, mostly for use as adjuncts
to DBT. Research examining their acceptability, feasibility and preliminary effectiveness appear
promising, but none have undergone rigorous evaluation. Only one, DBT Coach, has been examined among
people with co-occurring AOD use disorders.

DBT Coach is a mobile phone application designed to improve the generalisation of specific skills taught
in DBT. In a pilot study of the feasibility, acceptability, and effectiveness of DBT Coach among people with
co-occurring BPD and AOD use disorders, participants found the application to be helpful and easy to
use, and over the course of the study, there was a decrease in depression, emotion intensity, and urges
to use AOD [1535]. A second study that evaluated DBT Coach among people with single disorder BPD also
found reductions in subjective ratings of distress and urges to self-harm, but borderline symptoms and
emotional regulation did not improve [1536].

Other mobile phone applications developed for BPD include EMOTEO, mDiary and Monsenso’s mHealth for
Mental Health module for BPD. EMOTEO targets emotion regulation through engagement with mindfulness
or distraction exercises that are matched to the user’s level of distress. An initial pilot study found that
people using the app reported high levels of satisfaction, and that the application reduced aversive
278 B7: Managing and treating personality disorders

tension over time [1537]. mDiary and Monsenso’s mHealth for Mental Health BPD modules provide the
opportunity for mood, symptom, medication, and skills monitoring, alongside changes in BPD symptoms
[1538, 1539]. Although interviews with people who have used these apps found that users viewed the
app as being user-friendly [1538], and helped in facilitating access to, and helping them implement, DBT
strategies [1539], outcomes related to psychopathology were not assessed.

In addition to apps based on DBT, one e-health program, Priovi, a schema-therapy based intervention
designed as an adjunct to individual psychotherapy, has been evaluated among people with single
disorder BPD [1540]. Compared to baseline, using Priovi over 12 months was found to reduce BPD
symptoms; however, some exercises provoked mild anxiety.

The use of telehealth interventions has yet to be examined among people with co-occurring BPD and
AOD use specifically. However, an evaluation of the use of telehealth among people with BPD as a single
disorder during the recent COVID-19 pandemic suggests that the delivery of treatments such as ACT and
DBT is as effective when conducted over the phone as treatment in person [1541].

Physical activity

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 [1542, 1543]. BPD has been associated with chronic health problems later in
life, such as arteriosclerosis, hypertension, heart disease, CVD, stroke, liver disease and arthritis [1544,
1545]. Although there has been no research examining the effect of physical activity on symptoms of BPD,
one study recommended that initial interventions include improved sleep and scheduled exercise. It
should be noted however, that this recommendation is based on theory, and lacks supportive evidence
[1546]. 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.

Complementary and alternative therapies

Although there has been some preliminary research with promising results for the use of omega-3
[1534, 1547], at present there is very little research examining the use of complementary or alternative
approaches in the management or treatment of BPD, either as a single disorder or co-occurring with AOD
use. However, one study found that ear acupuncture provided within the context of a modified 3-month
therapeutic community for AOD use disorders that included comprehensive psychotherapy (including
DBT) was positively associated with successful program completion [1548].

Antisocial personality disorder (ASPD)

There is a dearth of research regarding the psychological and pharmacological treatment of both ASPD
as a single disorder, as well as co-occurring with 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 [1549]. Further, many studies focus on changes to symptoms
and behaviour of ASPD, rather than changes to personality [1549].
B7: Managing and treating personality disorders 279

Psychotherapy

A Cochrane review of psychotherapies for ASPD was unable to draw firm conclusions from the available
evidence [1550]. Of the 19 studies included in the review, eight were conducted among people with co-
occurring ASPD and AOD use disorders [1551–1558]. No study found significant changes to specific ASPD
behaviours (e.g., offending, aggression, impulsivity); however, several found significant reductions in
AOD use following treatment [1553, 1554, 1556, 1557]. The addition of contingency management and/or
CBT to standard methadone maintenance was found to be superior compared to standard methadone
maintenance alone [1553]. 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 [1555].

A driving whilst intoxicated program plus incarceration has also been shown to produce greater
improvements compared to incarceration alone [1557]. This intervention utilised principles of MI and
Fraser and colleagues [162] suggest that this may be indicative of a benefit of non-confrontational
approaches over confrontational approaches in enhancing outcomes for people with ASPD.

There is some evidence supporting the use of brief psychoeducation interventions and cognitive
remediation among people with co-occurring ASPD and AOD use. Impulsive Lifestyle Counselling is a brief
psychoeducation intervention which aims to foster awareness about behavioural difficulties, increase
personal accountability, and support clients to develop alternative coping strategies [1559]. Several RCTs
have found that, relative to treatment as usual, four sessions of Impulsive Lifestyle Counselling delivered
over four weeks with a booster session delivered 8 weeks later [1559], significantly reduces AOD use,
improves abstinence from AOD use, increases self-rated help for ASPD symptoms at 3 months post-
treatment [1560] and reduces AOD treatment dropout at 10 months post-treatment [1561]. Moreover, self-
rated help for ASPD symptoms has been associated with improvements in abstinence from AOD use and
treatment retention [1560].

Cognitive remediation aims to improve cognitive functioning by targeting factors such as attention
and memory. Four weeks of cognitive remediation provided to people with an AOD use disorder, 25-35%
of whom also had a lifetime diagnosis of ASPD, was associated with improvements in impulsivity, self-
control, quality of life, and AOD use cravings relative to treatment as usual [961].

Pharmacotherapy

Although several studies have examined pharmacological interventions among people with ASPD as a
single disorder, a Cochrane review concluded that the limited evidence available does not provide enough
support for strong recommendations [1562]. These studies have investigated the use of antiepileptics
(carbamazepine, phenytoin, sodium valproate, divalproex sodium and tiagabine); antidepressants
(desipramine, fluoxetine and nortriptyline); dopamine agonists (bromocriptine and amantadine); central
nervous system agonists (methylphenidate); and opioid antagonists (naltrexone).

Despite the limited evidence, there has been some research conducted among people with co-occurring
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 co-occurring conditions [1562]. Compared to placebo, those with
280 B7: Managing and treating personality disorders

ASPD and AOD use disorder who were taking nortriptyline illustrated a greater reduction in alcohol
use and dependence [1563]. In the same study, the use of bromocriptine was found to reduce anxiety
symptoms for those with depression/anxiety and AOD use disorders [1563]. However, no changes to ASPD
symptoms were observed. An additional study found that people with antisocial traits demonstrated
greater reductions in alcohol use when administered naltrexone relative to people low on antisocial traits
[1564].

Based on the lack of consistent evidence, the UK NICE Guidelines do not recommend treating ASPD, nor
co-occurring ASPD and AOD use disorders, with pharmacological interventions. They also advise against
treating underlying behavioural symptoms with pharmacotherapy [1565].

E-health and telehealth interventions

At the time of writing, there were no e-health or telehealth treatments for ASPD either as a single disorder
or co-occurring with AOD use.

Physical activity

At the time of writing, no research has examined the effects of exercise interventions among people with
co-occurring ASPD and AOD use or ASPD as a single disorder.

Complementary and alternative therapies

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. However, limited evidence suggests that
meditation may improve secondary outcomes related to the treatment of ASPD as a single disorder, such
as self-control and empathy [1566].

Summary
In general, there is relatively little research to guide treatment for co-occurring personality disorders and
AOD use disorders. The first line of treatment for those with co-occurring BPD and AOD use should be
psychotherapy, with several interventions having been examined among people with co-occurring BPD
and AOD use. Similarly, psychological interventions should be the first line of treatment for those with co-
occurring ASPD and AOD use, although the available evidence is less well-developed. Without evidentiary
support, pharmacological intervention is not recommended for the treatment of either co-occurring
BPD and AOD use, or ASPD and AOD use, highlighting the need for further well-conducted studies to be
undertaken in this area.

Box 22 illustrates the continuation of case study I, following Mira’s story. As illustrated, it may be
necessary to plan treatment over the long-term and coordinate between multiple services in the delivery
of care to a person with co-occurring personality disorders and AOD use disorders.
B7: Managing and treating personality disorders 281

Box 22: Case study I: Treating co-occurring BPD and AOD use: Mira’s story continued

Case study I: Mira’s story continued

The AOD worker immediately noted Mira’s high risk of overdose and organised for Mira to have naloxone
training, which she had never had previously, as well as several take-home naloxone kits. The AOD worker
also liaised with probation and parole. As part of the new program, Mira underwent comprehensive
medical and psychological assessment, where she was also diagnosed with Hepatitis C. Mira
immediately began direct-acting antiviral treatment.

As Mira’s medical needs were being addressed and she began to physically feel better, she told her AOD
worker that she didn’t want to keep going the way she has been and end up back in prison – she wanted
to change. The AOD worker organised for Mira to be put on the wait list for a local DBT-S program. Mira
initially didn’t attend, but using MI techniques, the AOD worker helped Mira remember why attending was
so important to her, and she started attending her appointments regularly. Mira’s AOD worker continued
to provide support along with strategies on emotion regulation and relapse prevention. While there were
several setbacks, Mira remained committed to her treatment plan.

Key points:
• Both the BPD and AOD use 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 co-occurring disorders, interventions need to be planned over months
and years rather than weeks.
Substance-induced disorders
B7: Managing and treating substance-induced disorders 283

Substance-induced disorders

Clinical presentation
It can be difficult to distinguish substance-induced disorders from independent mental disorders at
initial presentation. As described in Chapter A4, substance-induced disorders are those that occur
as a direct physiological consequence of AOD intoxication or withdrawal, and usually abate following
a period of abstinence [10]. Symptoms of mood, anxiety, psychotic, obsessive-compulsive, sleep, and
neurocognitive disorders, as well as sexual dysfunction and delirium, may all be substance-induced. It
is also possible that people may present to treatment with a combination of substance-induced and
independent mental disorders [1567].

More information about identifying substance-induced disorders is described in Chapter B3. While
distinguishing between substance-induced and independent mental disorders can be difficult, it is
crucial that people experiencing mental health symptoms who are currently using substances, or with
a history of AOD use, are not automatically assumed to have a substance-induced disorder [1568]. Such
assumptions may lead to the person not being provided with appropriate and timely treatment.

Managing substance-induced symptoms

Symptoms of substance-induced disorders tend to reduce over hours to days with a period of abstinence
[171]. With respect to amphetamine-induced psychosis, however, some people report experiencing
symptoms of psychosis for months [170]. Substance-induced symptoms can have a dose-response
relationship with AOD use, such that the heavier a person’s AOD use is, the more intense their symptoms
are likely to be [1569, 1570]. Heavier AOD use is associated with an increased likelihood of progressing to a
substance-independent disorder [1570].

In relation to symptom-management, workers should be guided by the management strategies outlined

in the earlier sections of this chapter for managing symptoms of substance-induced disorders, in
relation to the predominant symptoms experienced by the client. It may also be useful to explain
to clients that substance-induced symptoms will likely subside after a period of abstinence and
stabilisation. Providing clients with simple strategies to manage their emotions and stress may also
be useful, as psychosocial stressors can cause a recurrence of substance-induced symptoms [1571].
Appendix CC describes some relaxation methods which clients may find useful.

Ongoing symptom monitoring and assessment is crucial in the management of a person who is
suspected of having a substance-induced disorder, both during and after discharge, as a significant
proportion of people who receive a diagnosis of a substance-induced disorder are later diagnosed with
independent mental disorders. It is estimated that between 25-32% of clients who receive a diagnosis
of substance-induced major depressive disorder are diagnosed with major depressive disorder one year
later [1078, 1572]. Similarly, a systematic review and meta-analysis examining the transition of substance-
induced psychosis to schizophrenia found that 25% of those with substance-induced psychosis
transitioned to schizophrenia. The risk of transitioning to schizophrenia was highest for cannabis-
induced psychosis (34%), followed by hallucinogens (26%), amphetamines (22%), opioids (12%), sedatives
284 B7: Managing and treating substance-induced disorders

(10%), and alcohol (9%) [38]. Findings suggest that half of all cases who transition to a diagnosis of
schizophrenia do so within two-to-three years [36, 1573]; 80% within five years [1573]. A similar proportion
of people diagnosed with substance-induced psychosis are later diagnosed with bipolar disorder (24%),
50% within four years of their diagnosis of substance-induced psychosis [36].

Treating substance-induced disorders

As symptoms of substance-induced disorders are likely to reduce with abstinence, abstinence is
generally recommended as a treatment approach, with careful monitoring of mental health symptoms
[35]. Workers are referred to previous sections of this chapter for evidence in relation to the treatment
of specific mental disorders; as, in general, evidence for the treatment of substance-induced disorders
beyond abstinence is lacking.

Summary
Symptoms of substance-induced disorders will typically reduce following a period of abstinence. During
this time, it is critical to monitor mental health symptoms and provide ongoing support, being mindful
of the possibility of the substance-induced disorder progressing to an independent mental disorder.
Other conditions
286 B7: Managing and treating other conditions

Confusion, disorientation or delirium

On occasion a client may present with no specific symptoms but is generally confused or disorientated.
The client’s confusion or disorientation may be the result of intoxication, or a physical or mental health
condition. In such cases, the AOD worker should [1574–1576]:

• 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.

• Attempt to maintain a regular schedule for the client.

• Explain any procedures the staff are applying (e.g., physical exams, treatment).

• Encourage mobility.

The UK NICE Guidelines for the diagnosis and management of delirium [1576] recommend that, if the
client is considered a risk to themselves, AOD workers should de-escalate the situation using verbal and
non-verbal strategies. If these techniques are ineffective, haloperidol can be administered for up to a
week. If delirium does not resolve, underlying causes, such as possible dementia, should be investigated.

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, with impairments
in executive functioning and goal-directed behaviour often the most commonly observed cognitive
impairments in AOD settings [389].

Cognitive difficulties often bear no relation to mental illness and are sometimes the result of heavy AOD
use or intoxication, or as a consequence of traumatic/acquired brain injury [1577]. There can, however, be
a tendency for cognitive difficulties to be misattributed or minimised as being exclusively related to AOD
use, leading to lack of further investigation, treatment, and subsequently further harm. While cognitive
impairment is common among clients of AOD services, there are a multitude of medical, social, and
neurodevelopmental factors that may contribute to its development, many of which are undiagnosed
at service entry [1578]. Prescription medications and polypharmacy can also contribute to cognitive
impairment. Appendix I contains information on a screening measure that AOD workers may find useful
in identifying clients who may be at risk of cognitive impairment, and it is recommended that workers
consult with neuropsychologists where appropriate.
B7: Managing and treating other conditions 287

AOD workers may find the recently released Turning Point guidelines on managing cognitive impairment
in AOD treatment settings useful, which are available from: https://www.turningpoint.org.au/
treatment/clinicians/Managing-Cognitive-Impairment-in-AOD-Treatment-Guidelines

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 56 presents some simple techniques which can be useful in overcoming cognitive impairment
[389].

Table 56: Techniques for managing cognitive impairment

General techniques to address cognitive impairment

• Integrate strategies such as repetition, writing things down, and cues to recall important information,
into counselling.
• Provide structure during sessions, reduce the pace of sessions, and avoid overloading clients with
information.
• Encourage healthy behaviours such as social and leisure activities.
• Encourage or incorporate stress reduction strategies such as mindfulness.
• Support motivation and realistic hope by informing clients that cognitive impairment from AOD use
can improve with AOD reduction and targeted interventions.

Techniques to address attention problems

• Have a clear structure for each session.

• Consider shorter but more frequent sessions.
• Avoid overloading by limiting the content of each session.
• Keep sessions focused on relevant topics.
• Reduce session pace and provide breaks.
• Conduct sessions in a quiet, non-distracting environment.
• Provide written handouts of important information.

Techniques to address learning and memory problems

• 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.
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Table 56: Techniques for managing cognitive impairment (continued)

Techniques to address difficulties with mental flexibility, problem-solving, planning,

and organising

• Encourage routines and daily planning.

• Explain step-by-step problem solving and how to break goals into smaller, more manageable tasks.
• Discuss and practice responding to high-risk situations.
• For impulsive clients, encourage self-monitoring and use of cue cards with strategies to use.

Adapted from Stone et al. [389].

Preliminary research suggests that psychological interventions focusing on cognitive training, such
as cognitive enhancement and remediation, can improve cognitive functioning among clients in AOD
treatment settings [961, 1579, 1580]. Both cognitive remediation and cognitive enhancement therapies
utilise computerised games and tasks to enhance domains of cognitive functioning (e.g., attention,
memory), but cognitive enhancement therapy additionally targets holistic factors such as social skills
and vocational capabilities to improve overall functioning [1581].

However, training for a specific cognitive impairment may have limited transference to other cognitive
domains [1582]. There is preliminary evidence to suggest that pharmacotherapies such as galantamine
(an acetylcholinesterase inhibitor) and modafinil may be effective in improving working memory among
people with cocaine dependence [1583, 1584].

Grief and loss

There is a multitude of different sources of grief and loss, and clients in AOD settings are often highly
likely to experience these emotions for a variety of reasons. Feelings of grief or loss are often associated
with traumatic experiences. It is also common for AOD clients to have lost partners, family members, or
friends as a result of AOD use. Receiving treatment for AOD issues is likely to cause feelings of loss due
to the heavy role AOD use plays in the client’s life [389, 1585]. Other tangible losses may include the loss
of relationships, employment, finances, identity, spiritual beliefs, and physical health, but a person may
also experience intangible losses such as loss of hope, dignity, identity, self-worth, trust, or values [389,
1586].

Clients experiencing grief may report symptoms similar to those of major depression, such as sadness,
tearfulness, difficulty sleeping, and decreased appetite. However, it is unlikely that clients experiencing
feelings of grief and loss would also experience the cognitive symptoms of depression, such as feelings
of guilt, hopelessness, helplessness and worthlessness [1587]. Also, while some people impacted by
grief and loss may express a desire to be reunited with a lost loved one, they generally do not experience
the persistent suicidal ideation that may be experienced by some people with major depression.
Nevertheless, as discussed in Chapter B4, continued assessment should be undertaken, as well as a
thorough risk assessment for any client who may be at increased risk of suicide, as major depression
may develop following grief reactions.
B7: Managing and treating other conditions 289

Symptoms of grief and loss fall into a number of categories including [389, 1585, 1588]:

• 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 – gastro-intestinal complaints, decreased sex drive, tension, headaches, sleep/appetite

disturbances, fatigue, lethargy, or depersonalisation/dissociation.

• Behavioural/social – inappropriate behaviour (e.g., laughter), social withdrawal, avoidance of

objects or people related to grief/loss, sighing, restlessness, crying, absentminded behaviour,
obsessive behaviour, or hyperactivity.

The above symptoms are all normal responses to grief that tend to dissipate as a person adjusts to
the loss over time. For some people, however, these symptoms may persist for an extended period and
significantly impair their ability to function. In recognition of this experience, the most recent edition
of the DSM has introduced the new diagnosis of prolonged grief disorder. Prolonged grief disorder is
characterised by an intense longing for the deceased person or a preoccupation with thoughts and
memories of the person alongside other grief-related symptoms that occur most of the day, nearly every
day. Grief-related symptoms experienced as a result of the death include identity disruption (e.g., feeling
as though part of oneself has died); a marked sense of disbelief about the death; avoidance of reminders
that the person is dead; intense emotional pain; difficulty reintegrating into one’s relationships and
activities (e.g., problems engaging with friends, pursuing interests, or planning for the future); emotional
numbness; feeling that life is meaningless; and intense loneliness.

Managing grief and loss

Table 57 presents strategies for managing these symptoms. While symptoms of grief and loss may
resemble each other, clients may not recognise their response as grief if it is unrelated to death [389,
1589]. The main issue in grief management is to normalise the process for the client. That is, encourage
and support the grieving process, and remind the client that this process is natural [389, 1585]. Clients
in AOD settings may struggle resolving their grief, as this process usually requires the ability to tolerate
and express intense emotion [1586]. Everyone deals with grief and loss differently and therefore not all
approaches will work for everyone. It has been suggested that treatment for grief and loss in AOD settings
should target coping skills that can help clients process the emotions triggered by loss by [1586, 1590]: i)
accepting the reality of the loss; ii) processing the pain associated with the loss; iii) adjusting to a world
without the loss, and; iv) finding an enduring connection with the loss while moving on [389, 1588]. An
information sheet for clients on grief and loss reactions is provided in the Worksheets section of these
Guidelines.
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Table 57: Dos and don’ts of managing a client with symptoms of grief or loss

Do:

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.

Normalise the client’s emotional, psychological, physical, and behavioural reactions to the loss.

Help the client find a suitable way to remember, but also reinvest in life.

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).

Be aware and understanding of feelings associated with grief, including anger.

Give both practical and emotional support.

Give the client your undivided attention and unconditional positive regard.

Be aware that concentration may be affected, therefore repeat instructions, write down
instructions and so on.

Discuss emotions and behaviours related to the loss, including AOD use.

Encourage healthy avenues for the expression of grief (e.g., physical activity, relaxation, artistic
expression, talking, writing) rather than AOD use.

Encourage the client to seek social support. This may include bereavement services.

Don’t:

Avoid the reality of the situation or the feelings associated with it (e.g., use the name of deceased).

Judge or be surprised at how the client reacts – every person is different.

Time-limit the client when discussing grief, it can be a slow process and the story related to grief
may be retold many times.

Be afraid to seek assistance.

Adapted from Marsh et al. [1585], Stone et al. [389] and Horton et al. [1591].
B7: Managing and treating other conditions 291

Aggressive, angry, or violent behaviour

Problems relating to anger and aggression are not uncommon in AOD services and should be managed
appropriately [1592]. Anger and aggression may occur regardless of whether a person has a co-occurring
mental health condition. In general, episodes of aggression are usually triggered by a particular event,
which may involve circumstances that have led the client to feel threatened or frustrated.

The following signs may indicate that a client could potentially become aggressive or violent [431]:

• 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 58 outlines some general strategies for managing
aggressive clients. Beyond immediate responses that are described below, clients who have persistent
issues with anger may benefit from anger management programs that promote the development of
coping skills for anger regulation, problem-solving skills, and promote relaxation [1593, 1594].

Table 58: Dos and don’ts of managing a client who is angry or aggressive

Do:

Stay calm and keep your emotions in check.

Adopt a passive and non-threatening body posture (e.g., hands by your side with empty palms
facing forward, body at a 45-degree angle to the aggressor).

Approach the client from the front.

Move the client to a place without an audience if possible, and try to reduce environmental
stimulation.

Let the client air their feelings and acknowledge them.

Ask open-ended questions to keep a dialogue going.

Be flexible, within reason.

Use the space for self-protection (position yourself close to the exit, don’t crowd the client).
292 B7: Managing and treating other conditions

Table 58: Dos and don’ts of managing a client who is angry or aggressive (continued)

Do:

Structure the work environment to ensure safety (e.g., have safety mechanisms in place such as
alarms and remove items that can be used as potential weapons).

Make sure other clients are out of harm’s way.

Don’t:

Challenge or threaten the client by tone of voice, eyes or body language.

Say things that will escalate the aggression.

Yell, even if the client is yelling at you.

Turn your back on the client.

Rush the client.

Argue with the client.

Dismiss delusional thoughts. These thoughts are real for the client.

Stay around if the client doesn’t calm down.

Ignore verbal threats or warnings of violence.

Tolerate violence or aggression.

Try to disarm a person with a weapon or battle it alone.

Adapted from NSW Department of Health [431] and Stone et al. [389].

Phases of aggression
This section has been adapted from information provided by Sunshine Coast Mental Health Service
[1595] and NSW Department of Health [431]. 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 18 outlines these phases of aggression.
B7: Managing and treating other conditions 293

Phase 1: Triggering event

Phase 1 is the initial triggering event which elicits the aggression. This event 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:

• Allowing the client personal space of up to six metres if possible.

• Avoiding standing over the client (e.g., if they are sitting, sit as well).

• Maintaining minimal eye contact (direct eye contact is confronting).

• Informing the client of anticipated delays.

• Keeping the environment relaxed, non-stimulating and non-stressful.

• Keeping your own posture and body language non-threatening (e.g., open stance and palms).

• Allowing the client to talk and be empathetic to their concerns.

Figure 18: Phases of aggression

Source: NSW Department of Health [431].

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.
294 B7: Managing and treating other conditions

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.

A Acknowledge the problem/situation: validate the client’s feelings, empathise.

S Separate from others: to ensure the safety of others if escalation occurs.

S Sit down: symbolises readiness to negotiate.

I Indicate possible options: give alternatives to alleviate the situation.

E Encourage the client to try these options: assist the client to follow through.

The following strategies may also be useful in managing escalating aggression:

• Provide a safe environment for the client, yourself, and others.

• The presence of a familiar person may help to calm and reassure the client.

• Do not assume aggressive behaviour is necessarily associated with mental illness.

• Know your own limits and refer/seek help if necessary.

• Be warm, friendly, and non-judgemental; reassure the client.

• Stay focused on the current situation but anticipate problems.

• Carefully monitor the physical and psychological condition of the client.

• If the client’s behaviour escalates, withdraw and seek assistance immediately.

• Try to maintain a quiet, non-stimulating environment for the client (excessive noise or people may
contribute to aggression).

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 them. It is
important that workers be given the opportunity to debrief. Any violence should be documented in the
client’s file.
B7: Managing and treating other conditions 295

Phase 5: Post-crisis depression

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 clients with co-occurring conditions, if not in both disorders. Although
integrated treatments appear beneficial for some disorders, further investigation is needed [659, 666–
669, 954].

For most co-occurring conditions, 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. It is important to recognise that research demonstrating
the potential of other approaches to treating co-occurring conditions, such as mindfulness, contingency
management, ECT, and e-health interventions, is growing. For pharmacological interventions, an
important role for 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 adherence therapy.
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B8: Worker self-care 297

B8: Worker self-care

Key points
• Working directly with clients with co-occurring mental health and AOD 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 experiencing burnout,
compassion fatigue, and vicarious trauma.
• 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 can help AOD workers in managing
workplace stress and responding to workplace situations.
• Active coping strategies can help reduce the risk of clinical burnout, compassion fatigue,
and vicarious trauma, 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.
• Organisational factors, such as the provision of adequate clinical supervision, may also help
in preventing and assisting with the management of work-related stress.

Working with clients who have co-occurring mental health and AOD 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 some cases, burnout. Other stress-related reactions can include compassion fatigue and vicarious
trauma (also referred to as secondary traumatic stress). Stress is experienced when task demands
exceed a person’s available personal and social resources [1596]. As such, it is critically important that
AOD workers manage and pay attention to their self-care.

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 [389]. Components of burnout and active coping strategies are illustrated in Figure 19.
298 B8: Worker self-care

Figure 19: Components of clinical burnout

Components of Active coping

clinical burnout strategies

Physical self-care: Eat well,

Physical and emotional
sleep well, exercise, time
exhaustion from stress
for relaxation and leisure

Cynicism and detachment Emotional self-care: Take

Burnout
from work the time to talk and debrief

Professional self-care: Maintain

support, clinical supervision,
A sense of inefficiency
professional development,
address workplace concerns

While some stress has been found to enhance performance, this is only up to a point. As shown in
Figure 20, evidence suggests there is a ‘sweet spot’ of stress, which can enhance motivation and
optimise creativity, where workers are challenged and engaged by their tasks. On the other hand, a lack
of challenging and engaging work can result in boredom, disengagement and decreased productivity.
Beyond the sweet spot, too much stress can reduce performance and lead to fatigue, illness, irritability
and burnout [1597].

Figure 20: Performance stress model

Adapted from Yerkes and Dodson [1597].

B8: Worker self-care 299

Prior to the COVID-19 pandemic, more than one-third of AOD workers across Australia reported having
experienced some degree of burnout [7], but this rate is likely to be an underestimate of the current
situation as rates of burnout have since soared across healthcare professions [1598]. Typically these
feelings are associated with the pressure to meet the clinical demands of caring for a large volume of
clients, who often present with complex and challenging treatment needs and may be challenging to
engage and retain in treatment, as well as frequent staff shortages [399, 1599–1603]. Other workplace
stressors and risk factors include [389]:

• Excessive workload and time pressure.

• Role conflict from different job demands.

• Role ambiguity due to lack of resources and unclear goals.

• Lack of support from co-workers and supervisors.

• Lack of feedback about performance.

• Lack of control and involvement in decision-making.

• Concern about whether you are making a difference.

• Concern about whether you are doing your job effectively.

• Concern about whether you are valued and adequately remunerated.

• Distressing outcomes for clients.

• Workplace conflict.

• Lack of support for training or adequate clinical supervision.

• Job uncertainty.

Experiencing 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 [389,
431]. These feelings have also been found to predict whether workers will choose to continue working in
the AOD sector [1604].

It is important that AOD workers who believe they may be at risk of burnout approach their supervisors
and seek arrangements for support, including the use of relevant Employee Assistance Programs where
available. Active coping and holistic self-care strategies, described below, have also been associated with
reduced levels of stress and reduced likelihood of burnout [389, 1605].

Compassion fatigue
Compassion fatigue is a state of exhaustion resulting from prolonged exposure to another person’s
emotional pain whereby a person has difficulty maintaining empathy and compassion for others [1606]. It
is common not only among AOD workers, but healthcare providers more broadly [1607, 1608].

Compassion fatigue can lead to declines in job performance, productivity and efficiency and may lead
AOD workers to feel increasingly helpless, detached, and exhausted, with a reduced ability to empathise
300 B8: Worker self-care

with the people in their care. Cynicism, frustration, apathy, or judgemental responses may become
increasingly prevalent, and workers may question their beliefs in the context of witnessing significant
loss [1609]. Risk factors that have been associated with compassion fatigue include [1610, 1611]:

• Insufficient social support (at work and home).

• Insufficient staff resources, training, or supervision.

• High expectations for quality of care.

• Limited variety in work activities.

• Poor work/life balance.

• High workload or workload intensity.

• Professional isolation.

• Personal history of trauma.

• High level of empathy.

• Maladaptive coping style (e.g., self-criticism).

• Lack of emotional self-awareness.

As is the case for burnout and vicarious trauma, the use of active coping and holistic self-care strategies
(described later in this chapter) are important for preventing and managing compassion fatigue.

Vicarious trauma
As detailed in Chapter A2, a high proportion of clients of AOD services have experienced trauma, and it
is important that symptoms of trauma-related disorders such as PTSD be managed and, if appropriate,
treated while the person is undergoing AOD treatment. Clinicians who work with traumatised clients
describe their work as being extremely rewarding [1612, 1613]; however, hearing the details of clients’
trauma can be distressing and, in some cases, lead to vicarious traumatisation or secondary traumatic
stress. The majority of AOD workers are themselves trauma survivors and although this lived experience
may enable them to empathise with their clients, it also places them in a position to be triggered by
clients’ trauma [386, 404].

Consistent with international research [1614], a survey of AOD workers from across Australia found that
20% were suffering from secondary traumatic stress [404]. The symptoms of vicarious trauma are similar
to those that a person experiences with PTSD (described in Chapter A4). It can lead to negatively altered
perceptions of both the world and oneself, and make AOD workers feel hypervigilant, isolated, frustrated,
guilty, overprotective of loved ones, and desensitised or detached following repeated exposure to trauma
narratives [1615]. Other signs may include [1616, 1617]:

• Physical symptoms: fatigue, rapid pulse, unexplained aches.

• Emotional symptoms: anger, hypersensitivity, helplessness.

• Cognitive symptoms: preoccupation with clients, self-doubt, cynicism.

B8: Worker self-care 301

• Behavioural symptoms: isolation, hypervigilance, changes in sleep/appetite.

• Relational symptoms: minimising concerns, mistrust, projecting blame.

• Spiritual symptoms: loss of meaning, questioning of beliefs.

Although the primary cause of vicarious trauma is secondary exposure to trauma material, vicarious
trauma may be exacerbated by personal and work-related risk factors such as a personal history of
trauma exposure; having experienced a greater number of trauma types; personal stressors; maladaptive
coping behaviours; workload; organisational gaps; losses at work; and fewer hours of clinical supervision
[404, 1618]. Importantly, findings from an Australian study indicate that secondary traumatic stress may
be prevented by monitoring of workers’ caseloads and the provision of adequate clinical supervision
(described later in this chapter [404]). As in the case for burnout and compassion fatigue, the use of
active coping and holistic self-care strategies (described below) are also important for preventing and
managing vicarious trauma.

Holistic self-care: AOD workers

The importance of AOD worker self-care cannot be understated. Applying a holistic approach to self-care
and the use of active coping strategies may assist AOD workers in responding to distressing events,
lessen workplace stress, foster resilience, and increase their capacity to respond to workplace situations.
AOD workers have described the usefulness of both self-initiated and organisational strategies which
may include [389, 431, 1599, 1619–1624]:

• Physical self-care: Maintaining a balanced, healthy diet; sleeping well; allowing time every day for
lunch and physical exercise; making time for relaxation and leisure activities; being aware of one’s
own AOD use.

• Emotional self-care: Using relaxation techniques (such as those in Appendix BB and Appendix
CC); practising self-compassion; maintaining a balance between work commitments and family/
personal life; scheduling regular holidays and other breaks from work (e.g., conferences, education
seminars, clinical supervision); maintaining healthy supportive relationships; seeking help from
medical or mental health specialists when needed.

• Professional self-care: Creating and contributing to a physically and psychologically safe

working environment; ensuring opportunities to formally and informally debrief with co-workers;
maintaining contact with peers and avoiding professional isolation; engaging in peer support,
clinical supervision, and professional development activities; using time-management skills;
taking the opportunity to address work-related concerns, demands, unfairness, or inequity;
maintaining a feasible workload; diversifying work activities.

Clinical supervision
Clinical supervision can help reduce work-related stress by providing a mechanism of support for
staff, debriefing, and managing stress. Supervision may also provide opportunities for professional
development, skill enhancement, identifying new ways of working with clients, validating existing clinical
302 B8: Worker self-care

skills, and increasing job satisfaction [431]. Although definitions between workplaces differ, in general,
clinical supervision means [1625, 1626]:

• Quality assurance and clinical safety.

• A method of improving clinical practice, which involves the worker learning new skills, problem
solving effectively, and obtaining suggestions for improving practice (not line management).

• Professional support.

• Workforce development.

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
[1627–1630], confidence, and self-capacity [1628–1630]; greater perceived opportunities for personal and
professional growth [1631]; reduced staff turnover [1632]; improved development of complex clinical skills
and delivery of evidence-based practice [1625, 1633, 1634]; reduced stress and burnout [1629, 1635–1637];
reduced work-related frustration [1638]; better communication between staff [1628, 1630, 1631]; and
the transfer of newly acquired skills from training into practice [1639, 1640]. Further, less experienced
AOD workers can benefit from clinical supervision by receiving feedback on their interpersonal style,
counselling skills, and ongoing appraisal [1641]. Clinical supervision also enhances client care by
contextualising client experiences to other healthcare professionals [1642]. As such, clinical supervision
can improve the quality of client–AOD worker relationships and enhance treatment outcomes [1641].
These findings may explain why effective clinical supervision is associated with reduced burnout [1629],
compassion fatigue [1643], and vicarious trauma [404, 1644, 1645].

In 2018, NSW Health reviewed their 2006 clinical supervision guidelines for AOD services, which may 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 [1625]. These
guidelines are accessible via the NSW Health website: https://www.health.nsw.gov.au
Part C: Specific population groups
304 Part C: Specific population groups

Part C: Specific population groups

Part C of the Guidelines aims to provide workers with an overview of the available evidence for managing
and treating co-occurring AOD and mental conditions within specific population groups. Numerous
cultural and contextual factors need to be considered such as the client’s cultural background, gender
and sexual identity, stability of accommodation, whether they live in remote locations, and whether
treatment is being coerced. It is important that AOD workers are aware of specific factors that may
affect the management and treatment of people from these groups so that they may tailor treatment
appropriately. Although the available evidence for managing and treating co-occurring conditions is
described according to different population groups, workers should be aware that it is likely that people
attending AOD services will belong to more than one group.

The predominant approaches to treatment and service delivery for AOD use and co-occurring
conditions have been driven by research conducted on (and by) the dominant culture of urban-dwelling
Westernised adults. This is not to say that these techniques will not be effective for clients from different
backgrounds with diverse needs, but rather that approaches may need to be adapted depending on the
individual needs and characteristics of clients, in keeping with person-centred approaches.

Aboriginal and Torres Strait Islander people

Aboriginal and Torres Strait Islander people experience considerably poorer physical and mental health in
comparison to the wider Australian community. Research shows that, although there are proportionately
more Aboriginal and Torres Strait Islander people than non-Aboriginal and Torres Strait Islander people
who refrain from drinking [1646], those who do drink are more likely to do so at high-risk levels [1646,
1647]. Between 2014–2018, both Aboriginal and Torres Strait Islander men and women died from alcohol-
related causes at a rate four and a half times higher than their non-Aboriginal and Torres Strait Islander
counterparts [1646]. As a result, it is possible that heavy drinking may be normalised within some
communities, which may act as a barrier to people seeking treatment [1648].

However, alcohol is not the only substance that presents a major concern for Aboriginal and Torres
Strait Islander people. In 2012-13, 46% of Aboriginal and Torres Strait Islander people over the age of 15
years reported using an illicit substance in their lifetime; in 2018-2019, 29% reported use in the previous
12-months (37% of men; 22% of women) [1649]. Substances most commonly used in 2018-19 included
cannabis (25%), amphetamines (3%), and non-prescription analgesics (3%). d’Abbs and colleagues [1650,
1651] have also highlighted the devastating effects of volatile substance use and petrol-sniffing among
Aboriginal and Torres Strait Islander communities in Central Australia. Of concern, in 2019 the rate of
unintentional drug-related deaths (involving non-pharmaceutical opioids, stimulants, pharmaceutical
opioids, benzodiazepines, and cannabinoids) was three times higher among Aboriginal and Torres Strait
Islander (20 per 100,000 people) than non-Aboriginal and Torres Strait Islander (6 per 100,000 people)
people [1652]. Research has also found that Aboriginal and Torres Strait Islander people aged over 18 years
are three times as likely to be current daily cigarette smokers (43%) as non-Aboriginal and Torres Strait
Islander people (14%) [1653].
Part C: Specific population groups 305

Aboriginal and Torres Strait Islander people are also over-represented in inpatient mental health services,
with almost twice as many Aboriginal and Torres Strait Islander people than non-Aboriginal and Torres
Strait Islander people hospitalised for a mental illness between 2015–2017 [1654]. Across Australia, the
most common mental health conditions requiring hospitalisation between 2015-2017 were substance-
induced mental and behavioural disorders (40%), schizophrenia spectrum and other psychotic disorders
(23%), depressive and bipolar disorders (13%), and anxiety disorders (12%) [1655]. Further, in 2018–19,
Aboriginal and Torres Strait Islander people were almost three times more likely than non-Aboriginal and
Torres Strait Islander people to report high or very high levels of psychological distress [1646, 1656].

In 2014–2018, the suicide rate for Aboriginal and Torres Strait Islander people across all age groups was
almost double the non-Aboriginal and Torres Strait Islander rate, and highest among those aged 35-39
years [1646]. These rates are likely to underestimate actual suicide prevalence, as self-harm, suicidal
ideation, and suicidal attempts are underreported among Aboriginal and Torres Strait Islander people
[1657]. Aboriginal and Torres Strait Islander people were also hospitalised for self-harm at nearly three
times the rate of non-Aboriginal and Torres Strait Islander people [1646].

There is limited data regarding the population prevalence of AOD and mental health disorders, or their
co-occurrence, among Aboriginal and Torres Strait Islander communities; however, a landmark study
examining the prevalence of mental health and AOD use disorders among 544 Aboriginal and Torres
Strait Islander adults located in urban, regional and remote areas of Southern Queensland and two
Aboriginal Reserves located in New South Wales was conducted between 2014-2016 [1658]. This study
found that 67% of the sample had experienced a mood, anxiety, or AOD use disorder in their lifetime (73%
of men and 63% of women); a rate 30% higher than that observed in the Australian general population.
Among those who met diagnostic criteria for an AOD use disorder in the past 12-months, 28% of men and
71% of women also met criteria for a co-occurring mood or anxiety disorder. Table 59 presents the crude
prevalence estimates for each mental disorder.

Table 59: Crude prevalence of lifetime mental health disorders among Aboriginal and
Torres Strait Islander people

Men % Women % Total %

Mood disorders

Major depressive disorder 18.4 27.3 23.9

Dysthymic disorder 2.4 3.6 3.1

Bipolar disorders 0.9 3.3 2.4

Any mood disorder 31.9 38.9 36.2

Anxiety disorders

Panic disorder 7.2 15.1 12.1

Social phobia 9.7 12.2 11.2

306 Part C: Specific population groups

Table 59: Crude prevalence of lifetime mental health disorders among Aboriginal and
Torres Strait Islander people (continued)

Men % Women % Total %

Anxiety disorders

Specific phobia 9.7 13.6 12.1

Generalised anxiety disorder 5.7 6.2 6.1

Post-traumatic stress disorder 13.5 25.2 20.8

Obsessive-compulsive disorder 2.4 3.3 2.9

Any anxiety disorder 32.9 49.0 42.8

Substance use disorders

Alcohol abuse 25.6 15.4 19.3

Alcohol dependence 28.5 19.6 22.9

Substance abuse 15.9 4.2 8.6

Substance dependence 16.4 8.0 11.2

Any substance use disorder 54.6 33.5 41.5

Any mental disorder 72.9 63.2 66.9

Source: Nasir et al. [1658].

There is also little research regarding the prevalence of mental health conditions among Aboriginal
and Torres Strait Islander people engaged in AOD treatment; however, analysis of data from a remote
Aboriginal residential rehabilitation service in Western NSW revealed that 51% of clients had been
diagnosed with a mental health condition [1659]. A subsequent study conducted across other Aboriginal
and Torres Strait Islander residential rehabilitation services found that 78% of clients experienced
moderate to very high psychological distress, and 88% were categorised as being at risk of a mental
health condition [1660]. Other studies have also shown an association between depression, anxiety,
suicide, and alcohol dependence in Aboriginal and Torres Strait Islander communities [1661–1663], and
an association between the frequency of alcohol consumption and the experiencing of hallucinations,
paranoia, self-harm, and panic [1664–1666].

Moreover, as with the general population, Aboriginal and Torres Strait Islander people who experience
co-occurring disorders are more likely to experience a range of other difficulties than those with a mental
health or AOD use disorder alone [1667]. Aboriginal and Torres Strait Islander women accessing treatment
Part C: Specific population groups 307

for co-occurring mental health and AOD use disorders have reported that their co-occurring conditions
had led to severe and wide-ranging negative outcomes, such as general poor health, diminished social
networks, unemployment, and financial instability. These women also reported that their co-occurring
conditions 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) [1668]. Factors that contribute to
elevated rates of AOD use disorders and psychiatric morbidity in Aboriginal and Torres Strait Islander
communities include the long-term effects of intergenerational trauma linked to the stolen generations
and assimilation policies of the Australian Government; high rates of exposure to other traumas; the
destruction of social infrastructure; rapid urbanisation and poverty; cultural, spiritual and emotional
alienation; loss of identity; family dislocation; and increased AOD consumption [1669–1672]. Trauma
exposure, co-occurring PTSD and AOD problems are disproportionately high among Aboriginal and Torres
Strait Islander people [1668, 1673]. In a sample of people from remote Aboriginal and Torres Strait Islander
communities in Western Australia, 96% reported a history of trauma exposure, 55% met diagnostic
criteria for PTSD, and, of these, 91% also met diagnostic criteria for an alcohol use disorder [1673].
Aboriginal and Torres Strait Islander women accessing treatment services have reported a perceived
association between negative early life events (e.g., domestic violence, physical and sexual abuse) and
the onset of their AOD and mental health conditions, as well as their ability to trust and share personal
information with others, including health providers [1668, 1674]. These difficulties may be a significant
barrier to help-seeking.

The need for culturally appropriate tools for identifying co-occurring conditions (such as the IRIS,
described in Chapter B3), as well as culturally appropriate integrated services that are linked with
Aboriginal and Torres Strait Islander services and consultants is well recognised [1675, 1676]. Although
integrated treatment is recommended, research examining the efficacy of integrated treatments for
co-occurring AOD and mental health conditions among Aboriginal and Torres Strait Islander clients is
limited. However, findings from preliminary research suggest that culturally adapted brief interventions
may improve both wellbeing and substance dependence. In collaboration with Aboriginal medical health
workers from three remote communities in the Northern Territory, Nagel and colleagues [1677] developed
a brief intervention consisting of two one-hour treatment sessions delivered two to six weeks apart,
which integrated problem-solving, motivational therapy, and self-management principles. Compared
to treatment as usual, those randomised to the brief intervention demonstrated greater and sustained
improvements in both mental health and alcohol dependence, and a trend toward greater improvements
in cannabis dependence.

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 Aboriginal and Torres Strait Islander perspectives and needs. Workers should
also be aware of the cultural diversity within Aboriginal and Torres Strait Islander populations, which is
often overlooked [1678, 1679]. Differences in cultural identity extend to different languages, accessing
traditional lands, practising traditional culture, laws and governance, as well as family and kinship
structures [1679, 1680]. Recognising and responding to the complexities of Aboriginal and Torres Strait
Islander 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
308 Part C: Specific population groups

which determine the level of interaction between family and kin [1681]. The different forms of distress
experienced by Aboriginal and Torres Strait Islander people, as well as the different pathways to recovery,
need to be identified, which depend on a diverse range of beliefs and experiences [1682]. It is therefore
important that AOD workers try to familiarise themselves with more specific information regarding the
Aboriginal and Torres Strait Islander peoples in their community. These and other issues to be aware of
when working with Aboriginal and Torres Strait Islander clients are summarised in Table 60.

Recommendations for the provision of culturally appropriate services are provided in Table 61. Further
detail and resources that may assist AOD workers and services in providing culturally appropriate care
can be found in the Network of Alcohol and other Drugs Agencies AOD treatment guidelines for working
with Aboriginal and Torres Strait Islander People in non-Indigenous settings [1675]. These Guidelines
include Yarning about Mental Health training, which was also developed by the Australian Integrated
Mental Health Initiative to strengthen AOD workforce knowledge and skills in mental health approaches,
including culturally adapted strategies and tools for understanding mental health, promoting wellbeing,
and delivering brief interventions. An evaluation of the training found that trainees perceived the
program to be highly appropriate and helpful in their work with Aboriginal and Torres Strait Islander AOD
clients, as well as significant improvement in confidence and knowledge related to Aboriginal and Torres
Strait Islander mental health and wellbeing [1683].

Table 60: Considerations for AOD workers in working with Aboriginal and Torres Strait
Islander clients

• The concept of family (including extended family and relatives) and community in Aboriginal and
Torres Strait Islander 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 [1668]. Community and
Aboriginal and Torres Strait Islander support groups may also be useful services.

• Many Aboriginal and Torres Strait Islander people have a holistic concept of health, which is
often referred to as social and emotional wellbeing [1657]. This multifaceted concept reflects
the Aboriginal and Torres Strait Islander 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 a person’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 [108, 1668, 1684]. Nasir et al. [1658] point to the
importance of land and culture as a possible explanation for lower rates of AOD and mental health
disorders among Aboriginal and Torres Strait Islander people living in Reserve and remote areas
relative to those living in other settings. Men accessing AOD services have also reported that they
perceive traditional arts and crafts, culturally-focused talks, and connecting with the land to be the
most beneficial cultural activities [1685].
Part C: Specific population groups 309

Table 60: Considerations for AOD workers in working with Aboriginal and Torres Strait
Islander clients (continued)

• There are high rates of trauma, grief, and loss in Aboriginal and Torres Strait Islander
communities as Aboriginal and Torres Strait Islander people are faced with death and serious
illness within their extended family more often than non-Aboriginal and Torres Strait Islander
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 [1686].

• 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 Aboriginal and Torres Strait Islander clients with apparent psychotic symptoms,
it is important to clarify the cultural appropriateness of such symptoms. For example, it is not
uncommon for some Aboriginal and Torres Strait Islander 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
Aboriginal and Torres Strait Islander 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 Aboriginal
and Torres Strait Islander 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 Aboriginal and Torres Strait Islander 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.

• Watch the client’s body language and mirror it if possible. For instance, direct eye contact is
often viewed as impolite in Aboriginal and Torres Strait Islander communities and is often avoided.
Speaking softly with brief answers may be a sign of shyness or good manners.
310 Part C: Specific population groups

Table 60: Considerations for AOD workers in working with Aboriginal and Torres Strait
Islander clients (continued)

• Be respectful of cultural prohibitions such as:

• Referring to a deceased person by name.

• Referring to certain close relatives by name (e.g., a Torres Strait Islander male may not refer to
his brother-in-law by name).

• Appearing to criticise elders or family members.

• Confiding personal information to a member of the opposite sex – men’s and women’s business
are usually kept separate (this may require a same sex AOD worker).

• Consultation may take longer so set aside extra time.

• Be aware that levels of literacy may be low.

• It is important to be clear about your role and the types of things you would like to cover in the
consultation.

• Assessment of Aboriginal and Torres Strait Islander clients should occur within their own cultural
context.

• Act as an advocate for the client where necessary in guiding them through the health care system.

• Understand that developing relationships with clients and communities will take time and that
establishing these relationships is often necessary prior to engaging in treatment and learning
more about how to appropriately interact with clients.

• Be proactive in engaging with the local community rather than waiting for them to access AOD or
mental health services.

Source: [234, 776, 1686–1695].

Table 61: Considerations for AOD services providing support to Aboriginal and Torres
Strait Islander clients

• Create a welcoming environment, including demonstrating cultural respect.

• Provide flexible service delivery, with consistent and reliable staff members with whom people
can build trust and rapport. Consider cultural differences in service delivery, such as using cultural
mapping to understand family and community dynamics.

• Include Aboriginal and Torres Strait Islander voices in AOD services by consulting and engaging
relevant communities. Establish a consultation protocol and communicate regularly to
Aboriginal and Torres Strait Islander communities about the work you are doing.
Part C: Specific population groups 311

Table 61: Considerations for AOD services providing support to Aboriginal and Torres
Strait Islander clients (continued)

• Collaborate with Aboriginal and Torres Strait Islander organisations and workers to identify
and address service gaps.

• Provide opportunities to staff to improve knowledge of Aboriginal and Torres Strait Islander
issues, culture, and history, including specific training in gender roles, communication, and
trauma.

• Make efforts to recruit and retain Aboriginal and Torres Strait Islander workers within your
organisation.

• Better integration of mental health and AOD services, and greater collaboration between these
services and other organisations (e.g., housing, education) [108].

• Greater promotion of available services (e.g., active presence of mental health/AOD workers at
local community events).

• Provide 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 [1696].

• 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).

Source: Network of Alcohol and other Drugs Agencies [1675]; Lee et al. [1668]; and Liu et al. [108].

People from culturally and linguistically diverse backgrounds

Little research has been carried out in Australia on people from culturally and linguistically diverse (CALD)
backgrounds in AOD services – let alone on those with co-occurring mental health conditions. As such, it
is not clear whether co-occurring conditions are more common among people from CALD backgrounds
than other groups. It should also be noted that there are differences between organisations in how
people from CALD backgrounds are defined (e.g., country of birth, language spoken at home), which has
implications in terms of the ability of some services to adequately capture and respond to behavioural
patterns and trends in some CALD communities.
312 Part C: Specific population groups

Findings from the most recent Australian National Drug Strategy Household Survey illustrate that
compared to people from non-CALD backgrounds, people from CALD backgrounds are less likely to use
alcohol, tobacco, or illicit drugs [1697]. While there is some evidence that people from CALD backgrounds
may be more likely than those from non-CALD backgrounds to use harm reduction strategies with
regards to their alcohol use [1698], the reverse has been observed among men from CALD backgrounds
who inject performance enhancing drugs [1699]. As with other population groups, people from CALD
backgrounds are not homogenous and there is variability between groups in terms of prevalence rates of
mental and AOD use disorders.

Australians born overseas are underrepresented in AOD treatment services. Although 30% of Australia’s
population in 2020 were born overseas, the proportion of clients born overseas entering AOD treatment
services in 2019-20 was only 13% [432, 1700]. This underrepresentation is likely a product of many barriers
to treatment including [389, 1701–1704]:

• Strong feelings of shame and guilt.

• Fear of stigmatisation/judgement surrounding treatment and associated social disconnectedness.

• Cultural differences between client and therapist.

• Confusion and lack of education or exposure to public health campaigns.

• Different expectations of treatment and difficulty clarifying these due to language barriers.

• Lack of familiarity with what AOD treatment services are available, and how to access services.

• Lack of available culturally accessible services.

• Language difficulties which make participation in AOD treatment programs difficult.

• Fear of deportation or being placed in detention.

• Fear of authority related to previous experiences with government services.

Due to the multicultural nature of Australian society, it is imperative that AOD workers develop an
awareness of issues related to working with people from CALD backgrounds. Each geographic area has
its own unique cultural diversity 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 they are from a
certain cultural background, that does not mean that they necessarily subscribe to the values and beliefs
of that culture [102, 1705, 1706]. Reid and colleagues [1707] recommend consultation with the separate
cultural 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 [1708]:
Part C: Specific population groups 313

• 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 their country of origin); bicultural (client has a mix of new and old beliefs, values, and behaviours);
acculturated (client has modified their old beliefs, values, and behaviours in an attempt to adjust);
assimilated (client has completely given up their 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
stressors 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.

Some people in the Australian CALD community may feel pressured to consume alcohol to adapt to the
Australian culture [1709]. AOD use may also be used as a strategy to cope with trauma experienced both
pre- and post-migration, such as political oppression, living in refugee camps, witnessing death of family
members, and violence [1710]. These unique stressors not only increase the risk of developing a mental
disorder [1711], they can also act as barriers to seeking and engaging with treatment and, as such, AOD
workers should develop strategies to manage or reduce these stressors [389].

Rickwood [1712] provides a general summary of the types of problems that are specific to CALD groups
in the community and makes recommendations regarding the provision of treatment services. These
recommendations (such as cultural and religious awareness and the appropriate use of interpreters)
would also apply to those with co-occurring mental health conditions. As with Aboriginal and Torres Strait
Islander clients, screening tools should be validated for CALD groups and need to be administered and
interpreted with care, although it should be noted that few validated screening tools exist.

Below is a range of useful points which may improve assessment and treatment when working with
people from CALD backgrounds [431, 1705, 1713–1715]:

• Contextualise the person’s ethnicity, cultural identity, and migration/settlement experience (e.g.,
ask about AOD use in the context of the client’s culture). Respond to client issues from a cultural
perspective that resonates with the client’s own understanding of these issues. Notably, there is
diversity between CALD communities in terms of conceptualising mental health and AOD use, as
well as needs and preferences for treatment.

• Keep what you know about mental illness in mind but ensure that you try to understand the client’s
cultural understanding of their problems. People from different cultures often have different views
on what constitutes mental illness. The DSM-5-TR [10] makes it clear that diagnoses can only be
made if the person’s behaviour is abnormal within their culture. While there are similarities in the
314 Part C: Specific population groups

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 [431].

• Provide holistic and family-sensitive care. Where possible, and with the client’s permission, involve
the family in treatment. Allow the client to pick who from their family or community participates.

• 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 sure to address the client appropriately and pronounce their name correctly. Ask the client how
you should address them.

• Provide language support. 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 their family, or family members may
not want certain information disclosed to people outside the family and may edit what is being
said. Consider whether the interpreter may belong to the same community as the client, and if so,
whether other options are available (e.g., telephone interpreters). When using interpreters, be aware
that some meaning can be lost in translation and address issues of confidentiality.

• Address gaps in health literacy, using unambiguous language and regularly checking that you and
the client understand one another. Be clear, concrete, and specific.

• Discuss and clarify the client’s expectations of treatment.

• Address confidentiality and promote safety to increase engagement.

• Ensure that all treatment options are clearly explained, including rationale and processes.

• Provide flexibility in service delivery.

• Make allowances for variations in the use of personal space, including degrees of closeness. For
example, people from some cultures may feel more comfortable sitting next to AOD workers, rather
than being separated by a desk [1705].

• Customise the physical environment to be more culturally sensitive (e.g., hang culturally
appropriate pictures).

• 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.
Part C: Specific population groups 315

• 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.

• Use appropriate messaging to reduce stigma/shame.

• Look for verbal and non-verbal signs of discomfort or confusion. Do not take silence as consent or
agreement. Similarly, the word ‘yes’ may infer politeness or acknowledgment of possibility rather
than assent in some languages [1716]. 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 doing so may help to build trust.

• Support the client and their family in accessing other relevant services. People from CALD
backgrounds 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 B5) [431, 1714].

• Work in partnership with CALD community leaders and bi-cultural workers.

People who identify as gender and sexual diverse

While this section has used the term ‘gender and sexual diverse’ to describe people who identify as
lesbian, gay, bisexual, asexual, trans, non-binary, queer, or intersex, or who are attracted to same sex/
genders that differ from heterosexual or cisgender norms, we acknowledge there is no all-inclusive term.
Our intention in utilising this term is to describe the evidence regarding co-occurring conditions in
relation to people who identify as gender and sexual diverse.

Overall, there is a lack of research examining co-occurring AOD and mental health conditions among
people who identify as gender and sexual diverse in Australia [1717]. The research that does exist suggests
that AOD and mental health conditions are between three and six times more prevalent among people
who identify as sexual or gender diverse than the general Australian population [1653, 1718]. There is also
evidence that people who identify as sexual or gender diverse are between two and nine times more
likely to experience co-occurring AOD and mental disorders than those who identify as heterosexual or
cisgender (i.e., a person whose gender identity corresponds to their biological sex) [1719–1724]. They are
also at increased risk of experiencing suicidal ideation and suicide attempts, and multiple disorders
[1718, 1720, 1723]. Although comparative research is lacking, it is important to note that there may be
differences between groups who do not identify as heterosexual or cisgender [1719]. For example, women
who identify as bisexual report more co-occurring conditions than other sexual diverse and heterosexual
people (e.g., 38% of bisexual women compared to 12% of heterosexual women and 25% of lesbian women
[1725]).

Although there is considerably less research examining co-occurring conditions among people who
identify as gender diverse, one recent review found higher rates of depression, anxiety, AOD use, self-
harm, and suicidal ideation among people identifying as gender diverse compared to those who
identified as cisgender, and highlighted adolescence as a particularly vulnerable period [1726]. Research
316 Part C: Specific population groups

has also found that medical gender reassignment may be insufficient to improve functioning and
mental health outcomes among trans youth; those who experienced poorer mental health outcomes
and functioning before reassignment continued to experience similar problems post-reassignment
[1727]. Of note, people who identify as gender diverse may experience significant barriers to accessing
and engaging in treatment due to gender segregation within many treatment facilities (e.g., housing,
treatment sessions), which were designed to treat cisgender people [1728].

Fundamentally, treatment for people who identify as gender and sexual diverse is the same as for any
other client group and should focus on the specific needs of the client [1729]. People who identify as
gender and sexual diverse represent a diverse group of people from varying backgrounds; thus, like all
other clients, a holistic view should be adopted considering all aspects of their presentation. People who
identify as gender and sexual diverse often experience stigma, internal pressure, adverse childhood
events, feelings of shame, isolation, guilt, being lied to, and loss of social support among other things, all
increasing the risk of mental health and AOD problems [1725, 1730, 1731]. As such, co-occurring conditions
among people who identify as gender and sexual diverse are likely to be a consequence of being in a
minority group within the community, rather than being same sex attracted.

Key principles for inclusive service response when working with people who identify as gender and sexual
diverse include [1723, 1732]:

• Freedom from discrimination: Ensuring there are no direct or indirect discriminatory practices
(e.g., appropriate use of culturally sensitive language; auditing intake processes, including
language, to ensure they are inclusive of people who identify as gender and sexual diverse).

• Affirmation: Encouraging and celebrating diversity, sexual and gender identity (e.g., providing an
accepting and affirming approach to the client’s sexual or gender identity; ensuring staff are aware
of gender and sexual diverse support services; affirmation of non-traditional family networks;
assisting the client develop strategies for dealing with stigma, discrimination, and stress).

• Access and equity: Ensuring people who identify as gender and sexual diverse can access care
and incorporating organisational processes that can adapt service delivery to improve outcomes
(e.g., providing a welcoming, non-judgemental, and respectful environment; providing appropriate
education and training for staff; ensuring there is a high regard for confidentiality around personal
information).

• Visibility: Regular participation in community and inclusion events, and committing to inclusive
practice (e.g., presence of gender and sexual diverse staff and positive gender and sexual diverse
role models; surveying your workforce to assess whether they experience inclusivity at work).

• Co-design: Ongoing engagement with people who identify as gender and sexual diverse as well as
community stakeholders, to improve experience of services and treatment outcomes (e.g., partner
with gender and sexual diverse organisations to gain expertise on content and to increase access
to gender and sexual diverse communities; ensure the workforce reflects diversity and the broader
society).

• Recognition and acknowledgement of the principles of the Ottawa Charter: In particular,

that health promotion is a process of increasing a person’s capacity to manage and improve their
health.
Part C: Specific population groups 317

AOD workers are encouraged to access additional resources provided in the ACON and NADA inclusivity
guidelines: www.nada.org.au/resources/aod-lgbtiq-inclusive-guidelines-for-treatment-providers/.

Discussing sexuality and related issues requires a sensitive approach and, depending on the issues
raised, may lead to the AOD worker assisting with safety, support, accommodation, and harm reduction.
Asking people about their sexual identity is vital to informing the needs of AOD clients. People who
identify as gender and sexual diverse are often missing from routinely collected data within health
services – both at an individual and service level, which means sexual and gender-specific health issues
may not be adequately represented or reflected in discussions regarding funding or resource allocation
[1733]. While the purpose for questioning people about their sexual and gender diversity is important, it is
equally important that workers consider and use professional judgement; for example [1732, 1734]:

• Ask clients open ended questions (i.e., who/what/when/where/why/how) to assist in rapport

building, and practice with role play, for example:

• How do you identify sexually (provide options as prompts, such as lesbian, gay, heterosexual,
bisexual and so on)?

• What gender do you identify with?

• What are your pronouns (she/her, he/him, they/their, something else)?

• When speaking with you or referring to you with others, what name would you like me to use?

• How comfortable is the person with their sexuality and with talking about it with others?

• Have they told family/friends? How have these people reacted (or how might they)?

• Is it their decision to tell someone or are they being forced?

• How much support do they have?

• Are they 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 sexual and gender identity
may be a principal concern and may require increased attention during treatment. Several treatments
have been evaluated among people who identify as sexual or gender diverse, though none have been
evaluated extensively. These include:

• Effective Skills to Empower Effective Men (ESTEEM): a 10-session CBT-based intervention focusing on
improving coping strategies and reducing minority stress processes. An RCT conducted among
young gay and bisexual men with depression or anxiety co-occurring with harmful alcohol use
found that ESTEEM reduced depressive symptoms, alcohol use problems, and improved sexual
health behaviours, relative to a wait list control [1735].

• Empowering Queer Identities in Psychotherapy (EQuIP): based on modules from ESTEEM, EQuIP also
comprises 10 sessions focused on minority stressors such as the impact of gender norms
on relationships, the intersection of sexism with other forms of oppression, and exposure to
harassment. An RCT conducted among sexual diverse women with co-occurring depression or
318 Part C: Specific population groups

anxiety and heavy alcohol use found that those randomised to receive EQuIP demonstrated greater
reductions in anxiety and depression, as well as the amount of problems associated with alcohol
use, compared to a wait-list control [1736].

• Seeking Safety: a CBT-based intervention for co-occurring PTSD and AOD use (discussed in Chapter
B7). A single pilot study conducted among transgender women found 12 sessions of Seeking Safety
was associated with reductions in PTSD symptoms and the severity of AOD use [1737].

Sex workers
People who engage in sex work present with unique vulnerabilities for numerous health issues. In
addition to being at increased risk of experiencing sexually transmitted infections and blood borne
viruses such as HIV/AIDS or hepatitis [1738–1741], sex workers are at increased risk of experiencing
both AOD and mental health conditions [1742]. Previous international studies from the UK and US have
estimated that among people who use AOD, a history of sex work ranges between 31 – 51% of women and
8 – 19% of men, with an estimated 41% of women and 11% of men engaging in sex work in the past year
[1739, 1743]. Internationally, these rates appear to be higher among people attending AOD treatment than
people who use AOD in the general population [1739, 1743]. Compared to Australians who inject drugs who
have never engaged in sex work, sex workers in Australia who inject drugs also are more likely to start
using AOD at a younger age, and have more AOD-related problems [1744].

There is also evidence of poor mental health among sex workers, including high rates of depression,
psychosis, anxiety, suicide attempts, and mental health treatment [1739, 1745]. However, estimates vary
based on whether a person is engaged in sex work that is considered legal as opposed to illegal sex work.
Compared to licensed brothel workers and private operators, people who engage in illegal sex work are
four times more likely to present with mental health problems in Australia, and these increased rates
of mental health problems are associated with more adverse experiences prior to entering the industry
[1746]. Trauma exposure is almost universal among Australian sex workers (99%) [1747] with estimates of
violence against sex workers ranging between 45-75% [1748]. A higher incidence of violence has also been
found among street-based sex workers compared with other types of sex workers (e.g., indoor) [1749, 1750].

Australia’s approach to regulating sex work is complex, involving legalisation, criminalisation, and
decriminalisation of particular aspects of sex work, which varies between Australian jurisdictions. A full
review of regulatory approaches is beyond the scope of these Guidelines; however, AOD workers should
be aware that Australia’s policy approach has significant implications for those working in the sex
work industry. For example, at the time of writing, the operation of licensed brothels and registered sex
workers in Victoria are decriminalised, while other unlicensed activities remain criminalised [1751]. In
contrast, Tasmania has criminalised brothels, but private sex work (excluding street-based) is legal. The
legal status of a person’s workplace has implications for their health and safety (e.g., reasonable shift
length, breaks, use of safety equipment such as condoms), and may also impact on the likelihood of the
person seeking help. Both Australian and international research demonstrates that people who engage in
sex work in legalised or decriminalised environments report greater awareness of health conditions and
health risk behaviours, and engage in safer sexual practices (e.g., increased condom use), in comparison
with those working in criminalised environments [1738, 1752]. As such, decriminalising sex work may help
Part C: Specific population groups 319

to improve the safety and representation of sex workers, though Treloar and colleagues [1753] argue that
decriminalisation is not sufficient to reduce the pervasive stigma associated with sex work, which may
also prevent a person accessing health services.

Several key barriers to accessing healthcare have been described, with 70% of sex workers in one study
identifying one or more institutional barriers to accessing health services [1754], including stigma,
discrimination, social exclusion, violence, and criminalisation of sex work [1755]. Sex workers may fear
judgement from service providers, feel uncomfortable about disclosing the details of their employment,
or fear the consequences of disclosing any illegal sex work. The fear of disclosing the nature of their work
may also extend to families and/or friends, with the constant vigilance needed to maintain multiple
identities contributing to isolation and fatigue [1753].

A study of healthcare professionals in the UK concluded that the main barriers to providing healthcare to
people who engage in sex work are institutional, such as services being inflexible, under-resourced, and
not trauma-informed [1756]. These barriers may explain the low rates of sex workers accessing mental
health treatment. In an Australian study, only 14% of people who engaged in sex work reported accessing
counselling services and 11% reported accessing mental healthcare [1742].

There is little research to guide treatment approaches for working with people who engage in sex
work specifically, but given the aforementioned issues, AOD workers should be guided by the guiding
principles for working with people with co-occurring conditions (see Chapter A3), trauma-informed care
(see Chapter B2), assessing risk (see Chapter B4), and coordinating care (see Chapter B5).

Rural and remote populations

The term ‘rural and remote’ in this section refers to all geographic areas outside major cities in Australia,
which includes both inner and outer regional, as well as remote and very remote areas [1757]. People
living in rural and remote communities experience a variety of social, attitudinal, economic, geographic,
and community barriers which means that they are likely to have difficulties accessing treatments and
specialist care [1758, 1759]. Youth in these communities are at particularly high-risk, and alcohol-related
and rural stressors are likely to play a role in the high rates of suicide among males [1760–1763].

The lack of specialists in rural and remote regions tends to result in heavy reliance on primary and AOD
health care providers. Compared to major cities, rural areas have significantly less access to specialised
mental health care, with per-person supply of employed medical practitioners decreasing according to
remoteness [1758]. Although there is a national focus across Australia to increase the supply of health
workers to rural and remote areas, it is estimated that regional areas access 42% of psychiatrists, 89% of
mental health nurses, and 59% of psychologists per 100,000 people compared to major cities, with even
poorer access for remote areas [1764]. Moreover, Medicare expenditure on mental health services in inner
regional and remote areas is considerably lower than that in major cities [1759, 1765], which suggests
lower per-person access to, and receipt of, healthcare services.

People living in rural areas have indicated that addressing treatment barriers by investing in medical
infrastructure and increasing the number of healthcare providers would improve their ability to receive
adequate treatment for their co-occurring conditions [1766]. This evidence aligns with experiences of
320 Part C: Specific population groups

healthcare workers in rural areas, who have highlighted difficulties in providing adequate services due to
personnel, resource and infrastructure shortages, such as lack of high-speed internet, or equipment for
e-health/telehealth [1767, 1768]. Such disruptions impact on the continuity of care, and can result in rural
patients being the least likely to receive follow-up monitoring for AOD use issues relative to people living
in less remote locations [1769].

The health of rural and remote Australians is comparatively poorer than Australians living in major cities
[1758], and the lack of resources and healthcare workers makes working in these settings particularly
challenging. Self-harm, and suicide rates similarly increase with remoteness in Australia, and are almost
three times higher in very remote areas (29.4 per 100,000 people) compared to major cities (10.9 per
100,000 people; [1759]).

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 [1770, 1771]. 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
and psychoeducation focused on best-practice treatment and management of mental health in rural and
remote areas [1770, 1771].

Although accessing treatment has been identified as a particular challenge in this population group,
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 [1772]. For example, moodgym is a free online CBT self-help
program for anxiety and depression (http://www.moodgym.com.au) that has been shown to be effective
in treating symptoms of anxiety and depression [1131, 1773], MindSpot provides therapist-guided online
psychological treatment for anxiety, depression, stress and low-mood (http://www.mindspot.org.au),
and Mental Health Online (formerly Anxiety Online) comprises five e-therapy programs for GAD, SAD, panic
disorder, PTSD, and OCD (http://www.mentalhealthonline.org.au/; [1195, 1196]). Although definitive
evidence regarding the efficacy of Mental Health Online is lacking, two naturalistic studies found that
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. Significant improvements in
quality of life were also consistently observed for GAD, SAD, and PTSD e-therapy programs, but not the
OCD or panic disorder programs [1195, 1196]. Furthermore, in an RCT conducted among participants
with co-occurring depression and AOD use, the efficacy of computerised CBT/MI among both urban
and rural participants was compared to face-to-face treatment [1774]. 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 [1774].

In terms of feasibility and acceptability of these approaches, while there is evidence that clinicians
working in rural areas are optimistic about the use of e-health interventions, until recently there has
been a preference for e-health approaches to be integrated alongside existing services, and used as
Part C: Specific population groups 321

an adjunct rather than alternative to more traditional face-to-face approaches [1775]. As described in
Chapter B6 however, the COVID-19 pandemic has necessitated a rapid revolution to the way in which
healthcare is delivered and accessed, with approximately 35% of mental health-related services delivered
via telehealth between March and September 2020, following the introduction of telehealth items to
the Medicare Benefits Schedule [1776]. While e-health interventions have the potential to address many
limitations associated with service accessibility among people living in rural and remote areas, evidence
suggests that resistance to e-health may be overcome by enhancing community education and program
familiarity [1777, 1778].

A systematic review examining telehealth services in rural and remote Australia summarised six key
factors associated with the successful integration of telehealth into practice [1779]:

• Vision: Clear, realistic, and feasible outline of the purpose of the service.

• Ownership: Inclusive and genuine consultative service development with stakeholders;

supportive management; clinicians who are actively engaged and participating in service delivery
(service champions).

• Adaptability: Recognition of the need to remain responsive to stakeholders; willingness to adapt

the service model in response to clients, clinicians, and services.

• Economics: Deliver cost savings, prioritising required services for delivery of healthcare; provide
value for money for clients; achieve comparable care with clinical benefits.

• Efficiency: Clearly defined, efficient processes for managing activity; recognition that quantity is
not reflective of success; high levels of activity not necessary for sustainability.

• Equipment: Careful consideration of required, affordable infrastructure, with plans to manage

technical support.

Patterns of AOD use and the types of stressors experienced are likely to vary across different rural and
remote areas. For example, inhalants are a particular problem in some rural and remote areas, especially
within Aboriginal and Torres Strait Islander populations [1650], whereas cocaine and hallucinogens
are more likely to be used in major cities and inner regional areas [1780]. People living in remote and
very remote areas are also more likely to use cannabis, non-prescription pharmaceuticals, and opioids
compared to people living in major cities [1759, 1780]. The proportion of people drinking alcohol at risky
levels increases with increasing remoteness, with certain occupational groups (in particular, farming
communities) at particularly high risk, and hospitalisation and mortality associated with alcohol
consumption is considerably higher for rural communities relative to urban communities [1780, 1781].
Significantly more people living in rural and remote areas smoke tobacco, although daily smoking rates
have declined over the past 10 years in major cities, inner regional, remote, and very remote areas [1780].
People living in rural and remote areas may also experience unique stressors to those in urban areas. For
instance, regional and remote incomes can be heavily reliant on industries affected by external factors,
such as farming, forestry and mining, which can increase stress when conditions are unfavourable [1759].

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
322 Part C: Specific population groups

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.

Homelessness
The 2016 Australian Census estimated more than 116,000 people experiencing homelessness in Australia,
which increased by 5% from 2011; Table 62 [1782]. Homelessness refers not only to sleeping rough or
being without shelter. 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. A stable home provides safety and security as well as
connections to friends, family, and a community [1783].

There tend to be higher rates of AOD use and mental health conditions among homeless people as
compared to the Australian general population. A recent study examining the electronic medical records
of active patients (defined as ≥3 visits within the past two years) of a multi-site specialist homelessness
GP service in Perth found 68% had at least one diagnosed mental health condition, 62% at least one AOD
use disorder, and 48% had been diagnosed with a co-occurring AOD and mental health condition (Figure
21) [1784]. More than one third (38%) of people had also been diagnosed with a chronic physical health
condition in addition to their co-occurring AOD and mental health condition. Compared to people who are
not homeless, those who are homeless are also more likely to be hospitalised for AOD and mental health
issues [1785].

As described in Chapter B5, however, it can be extremely difficult for a person to engage in and maintain
progress in relation to their AOD or mental health treatment if they do not know where they are going
to live, or how they are going to feed themselves or their family. Therefore, addressing housing as part
of treatment is vital, and is also in line with the approach of ‘treating the person, not the illness’ [9]. In
addition to problems relating to housing, AOD and mental health, people experiencing homelessness
present with a range of physical, financial, and social issues, and are at high risk of victimisation [1786,
1787]. High rates of exposure to other forms of trauma are also evident. In one sample of homeless
adults, 88% reported having experienced adverse childhood events, and level of exposure was positively
associated with negative outcomes for mental health and AOD use [1788]. For these reasons, a trauma-
informed approach to treating people who experience homelessness is essential [1787]. The Trauma and
Homelessness Initiative similarly emphasises the unique opportunity for homelessness agencies, as a
primary contact for homeless people, to engage with homeless people to facilitate trauma recovery [1789].

Given the range and complexity of issues faced by people who are homeless it is important to adopt
a holistic and pragmatic view when identifying treatment needs (see Chapter B5). The complexity
of problems experienced by people who are homeless is compounded by having reduced access to
services and resources [1790, 1791], and it is very difficult to provide mental health or AOD treatment to
those without access to stable housing [650, 1792]. 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 [1791]. For example, consideration of whether the client has 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 client’s perceived needs, as well as AOD worker judgement.
Part C: Specific population groups 323

Table 62: Accommodation of homeless people in Australia, Census night 2016

Accommodation type Number of people (%)

Severely overcrowded dwellings 51,088 (44%)

Supported accommodation for the homeless 21,235 (18%)

Temporarily staying with other households 17,725 (15%)

Boarding houses 17,503 (15%)

Sleeping rough 8,200 (7%)

Temporary lodging 678 (0.6%)

Clients and service providers have highlighted the importance of providing integrated services for people
who are homeless whereby services work together and coordinate care in a cohesive approach [1793–
1795]. Homeless clients from less integrated services are more likely to experience difficulties accessing
help due to the lack of coordination between homelessness, AOD, and mental health services [1796]. By
contrast, clients from more integrated services are more likely to have a case coordinator and report
positive outcomes than those from less integrated services [1797]. 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 [1798]. Chapter B5 contains
further information about coordinating care and working with other services.

Figure 21: Prevalence of mental and AOD use disorders among homeless people in Perth
Depression 41

Anxiety disorder 23
PTSD 11
Schizophrenia 9
Emotionally unstable personality disorder 6
Bipolar disorder 5
Any mental health condition 68
Amphetamine use disorder 21
Alcohol use disorder 21
Opiate use disorder 12
Benzodiazepine use disorder 11
Any AOD use disorder 62

Chronic physical health condition 68

Co-occurring AOD and mental health condition 48

Co-occurring AOD, mental and chronic physical health condition 38

0 20 40 60 80
Percentage
Source: Vallesi et al. [1784].
324 Part C: Specific population groups

A further barrier to people who are homeless accessing care is stigma [1799]. Being homeless involves
additional stigmatisation to the already marginalising attitudes directed towards people with AOD
and mental health conditions. Approximately one in three homeless people report having experienced
stigma related to their homelessness, with 9% having experienced homelessness-related stigma from
healthcare providers [1800]. As described in Chapter B5, perceived and actual stigma can lead to a
mistrust of healthcare providers and services. It is important to be patient and attentive, and take the
time to establish trust and rapport with the client, as homeless people who mistrust practitioners may
conceal their needs [1801, 1802]. The following strategies may be useful when working with homeless
clients [599, 1803]:

• 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.

There have been several interventions developed for people who are homeless, although they have not
been evaluated extensively. These include:

• Housing First interventions: interventions which provide stable housing and other health services
without first requiring people to be ‘housing ready’ (i.e., attending treatment and being abstinent
from AOD use [1804]), and are endorsed by the Alcohol and Drug Foundation as an effective
intervention for homeless people [1805]. A systematic review of Housing First relative to Treatment
First programs (i.e., programs that require people to achieve abstinence and be attending treatment
before being offered access to housing [1804]) concluded that Housing First programs improved
housing stability and reduced hospitalisation more effectively, though both programs led to
similar reductions in mental health symptoms and AOD use [1804]. Evidence from interviews with
homeless people attending Housing First programs suggest that the sense of security and dignity
associated with stable housing is the most influential factor supporting changes in mental and
physical health, self-esteem, and interpersonal relationships [1799].

• Mindfulness-Oriented Recovery Enhancement (MORE): a manualised mindfulness-based group

intervention for people with co-occurring psychological distress and AOD use [1177]. An RCT
conducted among homeless men with co-occurring mental health conditions and AOD use found
that compared to CBT, those who received MORE experienced greater improvements in post-
traumatic stress, negative affect, and AOD cravings from pre to post treatment [1177].
Part C: Specific population groups 325

• EQIIP SOL: an intensive outreach intervention team for homeless people with co-occurring
conditions. A prospective longitudinal study found homeless youth with co-occurring psychosis
and AOD use reported reductions in the severity of psychotic symptoms and the likelihood of
reaching the diagnostic threshold for an AOD disorder following 6 months of EQIIP SOL [956].

Women
Although rates of AOD use and related harms have historically been higher among men compared to
women, the gap between men and women has narrowed in recent years, particularly among young
adults [1806, 1807]. The changing rates of AOD use among women are important to consider, as the
psychological, social, and physical contexts of AOD use and mental health are quite different for women
as opposed to men [1807–1809]. There is increased stigma associated with female AOD use (particularly
among those who are pregnant) which is likely to lead to greater guilt and shame [389, 1801, 1810]. This
stigma may lead some women to delay treatment seeking so that, by the time they enter treatment, their
AOD use is quite severe. Childcare considerations, family responsibilities, fear of the removal of children,
factors related to relationships (e.g., family conflict, support from partner), and financial issues have also
been identified as some of the barriers experienced by women seeking treatment [827, 1810, 1811]. Women
presenting for AOD treatment are also more likely to show greater financial vulnerability compared to
men, including a decreased likelihood of employment despite similar education levels, and an increased
likelihood of being financially dependent on another person [1812].

Among women with problems related to their AOD use, rates of depression, anxiety, and personality
disorders are particularly high [1813, 1814]. Poor self-esteem and self-image, high rates of suicide attempts
and self-harm, psychological distress, loneliness, and co-occurring ED are also particularly common to
women with AOD use issues [1811, 1815–1819]. Women, and younger women in particular, are more likely
to use maladaptive coping mechanisms like AOD use [1820] to cope with negative emotional situations,
manage pain, and cope with trauma [1821–1824].

Women who experience problems with AOD use are more likely than men, or women who do not
experience problems with AOD use, to have experienced neglect or sexual, physical, or emotional abuse
as children, as well as domestic violence [434, 1812, 1813, 1825, 1826]. Relative to men, this abuse is also
more likely to be severe, occur at home, and be instigated by a current or former romantic partner [1827,
1828]. In addition, AOD use can often lead to revictimisation via dangerous or risky situations such as
unsafe sex and sex work [1829]. Because of the high rates of trauma among women, often perpetrated by
men, it is imperative to provide a treatment environment in which women feel safe and secure [389]. The
following strategies may be helpful in creating such an environment [389, 1811]:

• Provide the client with the option of a female AOD worker.

• If attending group therapy, offer a women-only group if possible.

• If attending rehabilitation services, offer information and/or referral to women only AOD services.

• Ensure that treatment is gender-sensitive and addresses gender-specific issues and barriers to
treatment.
326 Part C: Specific population groups

• If appropriate, consider facilitating access to childcare, which can enable female parents and
caregivers to attend treatment.

• Where appropriate, consider family inclusive practice, which incorporates the client’s family and
community relationships.

• Where appropriate, ensure sexual health and safety are incorporated into the treatment plan.

Men
In contrast to women, men may be less forthcoming with information concerning their mental health,
which may affect their help-seeking behaviour. In general, men may be less likely than women to
visit a health professional, have lengthy consultations with health professionals, or seek treatment
before symptoms become advanced [1830–1834]. There are a number of barriers that may prevent men
accessing mental health treatment, including [1810, 1835, 1836]:

• Feeling uncomfortable and/or finding it difficult to discuss problems and feelings.

• Not wanting to appear weak, feeling embarrassed, afraid, or ashamed of their distress.

• Feeling very aware of stigma associated with mental health difficulties and accessing services.

• Not recognising feelings of emotional distress.

• Having a preference to work things out for themselves.

• Not considering their mental health a high priority.

• Believing that no one can help them.

• Previous unsuccessful attempts at seeking help.

• Not being aware of available services, and/or not considering the services ‘male friendly’.

• Having a tendency to manage emotional issues through silence or avoidance.

• Preferring ‘acceptable’ male outlets such as alcohol abuse or aggression to release feelings.

Although men are less likely to seek help, they make up 64% of those entering AOD treatment settings
[432]. Physical, sexual, and emotional abuse are highly prevalent among men accessing AOD treatment
settings, and can be accompanied by feelings of shame, guilt, and powerlessness [389]. There are also
strong associations between AOD use (alcohol in particular) and the perpetration of domestic and other
forms of violence, which is often exacerbated by the ways in which men are socialised, such as to display
aggression and emotional restraint, rather than the use of adaptive coping strategies [389]. Difficulties
regulating emotions in particular are associated with increased AOD use among men [1837] and, where
appropriate, emotion management strategies should be integrated into treatment [389]. Men are also at
considerably higher risk than women of death by overdose [1838] or completed suicide [1839], typically by
more lethal means than women [1840], highlighting the importance of risk assessment (see Chapter B4;
[389, 1817, 1841]).
Part C: Specific population groups 327

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 [1842, 1843]. In
fact, coercion into treatment may present an opportunity which the client may never have previously
considered, and evidence suggests that some people 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
[1844, 1845]. It is important for the AOD worker to present treatment as a positive opportunity from which
the client may experience some benefit. A positive attitude on behalf of the AOD worker and efforts to
engage coerced clients are key, as a better therapeutic alliance is associated with better mental health
related treatment outcomes [1845]. Given that the motivation to engage in treatment may come largely
from external sources [776], educational and motivational interventions may require more attention in
treatment planning and provision.

Nevertheless, there are some special considerations that AOD workers ought to be aware of when working
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 [389]. 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 [776].
Treatment resistance may also be a problem, as motivation to engage in treatment among coerced
clients is typically external. Harm reduction is also an important consideration when working with
coerced clients [389]. Harm reduction 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 [776, 1846]. The AOD worker,
however, can play an important role in clarifying what the realistic goals are for each client.

Coerced clients may be accessing treatment services for the first time or may be accessing a different
type of service. This avenue provides the opportunity for a thorough assessment which may identify
previously undiagnosed co-occurring disorders and presents an opportunity for treatment. However,
as clients who are coerced into treatment may present with strong emotional reactions and a reduced
sense of autonomy, AOD workers may need to spend time managing these reactions [1847]. AOD workers
should focus on building a therapeutic relationship, and avoid overly intrusive questions that might be
perceived as judgemental [389]. Barber [1848] suggests that in cases of coercion the worker should adopt
a negotiation or mediation role and follow six steps in this process:

• Clear the air with the client (present with a positive attitude and make efforts to engage).

• Identify legitimate client interests.

• Identify non-negotiable aspects of intervention.

• Identify negotiable aspects of intervention.

• Negotiate the case plan.

• Agree on criteria for progress.

328 Part C: Specific population groups

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 they
have all medications post-release and that they are aware of services, referred to and accepted by service
providers where necessary [1849, 1850].

Incarcerated clients
Working with incarcerated clients in a prison setting presents several challenges. As with people in
the community, those in prison settings with co-occurring AOD and mental health conditions often
experience a range of complex, long-term problems and have likely come into contact with numerous
services in the past. In general, people in contact with the justice system are more likely to be socially
and economically disadvantaged, experience higher rates of homelessness and unemployment, have
a history of imprisonment or previous criminal involvement, and have experienced childhood neglect
and/or trauma compared to those in the general community [1851–1854]. There is evidence to suggest
that incarceration can exacerbate previous traumatic experiences through environmental triggers (e.g.,
discipline from authority figures, strip searches), institutionalised racism, lack of connection to culture
for Aboriginal and Torres Strait Islander people, separation from children or family, or further exposure to
trauma in prison [389, 1855–1857].

The most recent Health of Australia’s Prisoners survey conducted in 2018, found high rates of AOD use
and mental disorders compared to the general population [1851]. Two in five prisoners (40%) had been
previously diagnosed with a mental health condition, including an AOD use disorder, and just under one
in four (23%) were currently taking medication for their mental health, most commonly antidepressants.
People entering prison were twice as likely to be experiencing high or very high levels of psychological
distress compared to the general population (26% vs 13%), and 21% reported a history of self-harm. There
is evidence that people in prison are 10 times more likely than the general population to have experienced
suicidal ideation and previous attempts in the past year [1858]. Due to this elevated risk of suicide and
self-harm, conducting risk assessments is especially important (see Chapter B4, Chapter B5).

Also common among people entering prison are smoking (75%) and poor physical health, with 30%
reporting experiencing at least one chronic physical health condition (including arthritis, asthma,
cancer, cardiovascular disease, diabetes), and 28% reporting that their physical health causes significant
psychological distress [1851]. Rates of blood-borne viruses such as hepatitis B and C are higher than
in the general community [1851], which is likely due to the lack of available sterile injecting equipment
[1859, 1860]. Harm minimisation strategies for AOD use, such as only re-using personal injecting
equipment to minimise the risk of blood borne viruses, should be encouraged [389].

As with clients who have been coerced into treatment, AOD treatment within the prison environment
may present an opportunity which incarcerated clients had not previously considered. It is important for
the AOD worker to positively frame the opportunity for treatment and maintain a positive attitude, hope
and optimism. Many of the treatment principles for working with people who are incarcerated are similar
to those for working with coerced clients. Importantly, any limits of confidentiality should be outlined
clearly and early on, as they may differ to limits within community settings [389]. Due to the inherent
power imbalances and structures of correctional settings, AOD workers may need to make additional
Part C: Specific population groups 329

efforts to engage an incarcerated client and build a trusting, therapeutic relationship, which are key to
good outcomes [117–119]. Clients may experience difficulties establishing a trusting environment and
may disclose information slowly to gauge worker reactions [1861]. As with coerced clients, the role of
educational and motivational interventions may require more attention.

Given the high rates of trauma exposure among incarcerated clients, a trauma-informed approach
should be adopted (see Chapter B2; [389]), bearing in mind that clients in prison settings may not feel
safe to disclose the details of their trauma history. With regard to treating PTSD, the majority of research
conducted among prisoners has focused on present-/non-trauma-focused therapies [1862]. As with
community samples, past-/trauma-focused therapies appear to be more effective, but implementation
is challenging in a setting that does not provide a safe and consistent environment within which trauma
processing can occur [1862]. With regard to treating PTSD among prisoners with a history of co-occurring
AOD use disorders, research to date has been limited to pilot studies of the present-/non-trauma-
focused therapy Seeking Safety, conducted among female prisoners in the US [1863–1865] and male
prisoners in Australia [1866], all of which have positive preliminary evidence supporting its acceptability.

There are also significant challenges associated with release from prison, including transitioning
from a controlled environment with routine and stability, finding accommodation and employment,
managing finances on a low income, returning to the same peer groups, risk of overdose, and returning
to communities with few opportunities [1867, 1868]. The 2018 Health of Australia’s Prisoners survey
found that one in three people were homeless in the month prior to incarceration, and less than half had
stable accommodation arranged post discharge [1851]. It can also be difficult for some people who were
able to access AOD and mental health care in prison to access the same care in a community setting
[1851, 1868]. Linking in with post-release services and coordinating with community-based treatment,
where appropriate, may help clients transition into the community. In fact, having access to effective
interpersonal support, community-based resources, employment, secure housing, continuity of care
throughout the release process, and enrolment in treatment programs are protective factors following
release from prison [1869–1872], and many of these factors can be targeted or addressed prior to release
[1873].

Young people
Adolescence and young adulthood can be a difficult, turbulent time for many people, with issues of
personal change, development, identity formation, experimentation, rebellion, and uncertainty impacting
upon a person’s thoughts, feelings, and behaviour [389]. It is also a critical time for the development
of AOD and mental health conditions. Mental and AOD use disorders are leading global causes of
burden of disease in young people [1874]. The peak of this disability occurs in those aged 15-24 years
and corresponds with the typical period of onset of these conditions [1875]. In Australia, at least five
of the top 10 causes of disability-adjusted life-years are directly related to mental health or AOD use
disorders [1876]. Added to this are concerns that we may see an increase in psychological distress and
problematic AOD use among young Australians in response to the combined effects of recent national
disasters (e.g., bushfires, floods), climate change anxiety, and the impacts of the COVID-19 pandemic
[75, 1877], as young people are being disproportionately impacted by these events [1878, 1879]. Despite
330 Part C: Specific population groups

significant government investment in health services for young Australians (e.g., the expansion of
headspace services), young people are commonly undertreated and there remains significant unmet
need, particularly for young people who have more complex needs such as co-occurring AOD and mental
health conditions [1880]. An Australian study conducted among young people aged 16-21 years attending
specialist AOD treatment services reported that co-occurring depression (39%) and anxiety (34%)
were common [1881]. Early intervention when symptoms of co-occurring conditions emerge is key to
preventing a long-term chronic course of illness into adulthood [55] and addressing co-occurring mental
health conditions has been identified as a key component to youth AOD treatment [1882].

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-TR [10] and be aware of possible variations of
symptom expression.

It is also 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 to meet the developmental challenges faced by young people [102, 1882, 1883]. For instance,
Christie and colleagues [1882] suggest that young people may be more likely to present for treatment due
to external pressures (e.g., family, school, legal issues), so a focus on engagement, building rapport, harm
minimisation, and the use of motivational interviewing should be a key focus of care. Scare tactics and
confrontational approaches on the other hand, should be avoided [389, 1884].

Other features of ‘youth friendly’ services 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 (see Chapter B5), and interventions that recognise different cognitive
capacities and developmental/maturational lags [776, 1882]. 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, using appropriate language and questioning
to relate to young people on their level. E-health interventions, described in Chapter B6, may also be
particularly useful for engaging young people in treatment and overcoming some of the barriers to face-
to-face engagement [109].

With regards to confidentiality, although there may be jurisdictional differences in relation to

operationalisation, most young people would be considered ‘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 [389]. In most circumstances,
however, it is helpful to involve families (especially parents or carers) and this should be discussed
with the young person at the outset of treatment and their consent for involvement sought [389, 1882].
Parents and carers may require support, education, and empowerment in order to assist with continued
care and help prevent client relapse upon discharge [452, 1885].
Part C: Specific population groups 331

Older people
The world’s population is ageing rapidly. In Australia, it is estimated that the proportion of adults aged
over 65 years will increase from approximately 15% in 2017 to 21-23% in 2066, whilst the proportion of
adults aged over 85 is expected to double over the same period from around 2% to 4% [1886]. 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 co-occurring mental disorders among older people, and
how these differ from younger populations [431].

Rates of AOD use among older Australians are increasing, with the highest rates of daily drinking found
among people over 70 [1780]. The proportion of older Australians presenting for some AOD treatment
services, such as withdrawal management and pharmacotherapy, have also increased from 2018-19 to
2019-20 [1887, 1888]. In 2019, Australians aged over 60 also accounted for one third of all drug-induced
suicides, both intentional and unintentional [1652].

Internationally, 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 [1889]. One-in-four deaths from self-
harm are also found among this age group [1889]; however, suicide rates overall are not elevated among
older (65+) Australians compared to middle-aged (35-64) Australians [1890]. Co-occurring conditions are
common, with one medical chart audit of an older adult-specific AOD treatment service within Australia
reporting that 89% of clients had at least one co-occurring mental health condition, the most common of
which were depression (67%) and anxiety (53%) [81]. However, mental illness is often difficult to identify
due to co-occurring 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, loss of autonomy or independence, social isolation, financial difficulties, diminishing
cognitive function, and reduced capacity to self-care and manage their affairs [431, 1891, 1892]. Depression
and suicide are also easily overlooked among older adults, and people who are socially isolated without
supportive networks are at particular risk [431, 1893, 1894]. National Australian data suggests that suicide
rates are also elevated among people with chronic pain, which is more common among Australians
aged over 60 [1895]. Similarly, AOD and mental health conditions are often overlooked or misdiagnosed
among older adults, who are uniquely at risk of AOD-related harms, as well as increased vulnerability to
intoxication and overdose [389]. The ageing process can enhance physiological and cognitive sensitivity
to adverse effects of AOD use [389, 1896].

International research has found that older adults are significantly more likely to be prescribed
medication with abuse potential, with 25-53% of older adults prescribed psychoactive medication
[1897, 1898], 23.9% of older adults receiving at least one potentially inappropriate prescription (the most
common of which were sedatives and hypnotics) [1899], and 9.1% receiving excessive (>10) medications
[1900]. Research from Australia has similarly found that one fifth to one half of older Australians
are prescribed medications for durations that exceed recommended limits [1901], and 60% of older
Australians receive potentially inappropriate prescriptions (the most common of which are opiates and
benzodiazepines) [1902]. These factors are particularly problematic for people with dementia or cognitive
impairment, and specialised medical practitioners in mental health services for older people need to
332 Part C: Specific population groups

maintain a proactive role in reviewing medications and advising appropriate prescribing practices for
older people [431, 1903]. Other common co-occurring conditions and risk factors for AOD use among older
adults who use AOD include anxiety, depression, sleep problems, delirium, chronic pain, and self-harm
[1891, 1893, 1904–1906]. Other factors that may contribute to the increased risk of AOD use problems in
older adults include [389, 1903, 1907–1910]:

• 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. These harms include an
increased risk of falls and burns.

• 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,
which can be associated with changes in social roles and status.

• Reduced coping skills resulting from factors such as family conflict and bereavement.

• More medications available for a range of conditions, which may be a contributing factor in the
increased use of psychoactive substances.

• Opioids, benzodiazepines, 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, or perceive the need for, help for mental health and AOD
use disorders [1911, 1912]. Several barriers that may prevent older adults from accessing treatment include
[1907, 1913]:

• Transport, mobility, language, visual, or hearing difficulties, particularly for those who are frail or
housebound, in rural or remote areas.

• Social isolation, which can result in serious problems going undetected.

• 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 ageing 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.

• A lack of readiness to stop using AOD.

Part C: Specific population groups 333

It is critical to be aware that older adults with co-occurring 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 appropriate interventions. The following may be useful for AOD workers managing and treating
older adults [389, 1906, 1907]:

• Ensure AOD programs are age-specific, supportive, non-confrontational, culturally sensitive, aim to
build self-esteem and coping skills, and foster an environment of respect.

• Ensure risk assessments are conducted (see Chapter B4), 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.

• Practise care coordination (see Chapter B5), and take care to foster links with medical, ageing, and
other relevant services. Be proactive with follow-up and care coordination.

• Take a holistic approach to treatment (see Chapter B1), and incorporate age-specific psychological,
social, and health problems.
Appendices
Appendix A: Other Australian guidelines 335

Appendix A: Other Australian guidelines

Below is a selection of other Australian guidelines that may be useful to those working with clients
experiencing co-occurring AOD and mental health conditions. Note that some of these resources are
somewhat dated, but we have retained them where more recent guidance is unavailable. Readers should
nonetheless be aware that given their age, some of the information contained may not be based on the
most current evidence. Although the guidelines below are Australian, there are many good sources of
guidelines internationally that readers may find useful and relevant, such as the UK’s National Institute
for Health and Care Excellence (NICE; www.nice.org.uk/), as well as the US’s Substance Abuse and Mental
Health Services Administration (SAMHSA; www.samhsa.gov/).

Other Australian guidelines

ACON. 2018. AOD LGBTIQ inclusive guidelines for treatment providers. Sydney: ACON & NADA.
www.nada.org.au/resources/aod-lgbtiq-inclusive-guidelines-for-treatment-providers

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.
www.health.vic.gov.au/publications/clinical-treatment-guidelines-for-alcohol-and-drug-clinicians-
co-occurring-acquired

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: Dovetail.
www.dovetail.org.au/media/1186/dovetail_gpg_1_framework-for-youth-aod-practice.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: Victorian Dual Diagnosis Initiative Advisory
Group.
www.drugsandalcohol.ie/20288/

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: Dovetail.
www.dovetail.org.au/media/1189/dovetail_gpg_4_learning-from-each-other_working-with-
aboriginal-and-torres-strait-islander-young-people.pdf

Gordon A. 2008. Comorbidity of mental disorders and substance use: A brief guide for the primary care clinician.
Canberra: Australian Government Department of Health and Ageing.
www.sahealth.sa.gov.au/wps/wcm/connect/68872d8041785aab92bdff67a94f09f9/Comorbidity+Me
ntal+Disorders+Substance+Use+Guide_2008-DASSA-Oct2013+pdf.pdf?MOD=AJPERES&CACHEI
D=ROOTWORKSPACE-68872d8041785aab92bdff67a94f09f9-nKLdhdq
336 Appendix A: Other Australian guidelines

Grigg J, Manning V, Arunogiri S, Volpe I, Frei M, Phan V, Rubenis A, Dias S, Petrie M, Sharkey M, Lubman
DI. 2018. Methamphetamine treatment guidelines: Practice guidelines for health professionals (2nd edition).
Richmond: Turning Point.
www.turningpoint.org.au/sites/default/files/2019-05/Turning-Point-Methamphetamine-Treatment-
Guidelines.pdf

Henderson C, Everett M, Isobel S. 2018. Trauma-Informed Care and Practice Organisational Toolkit (TICPOT): An
Organisational Change Process Resource, Stage 1 - Planning and Audit. Mental Health Coordinating Council
(MHCC).
www.mhcc.org.au/resource/ticpot-stage-1-2-3/

Henderson C, Everett M, Isobel S. 2018. Trauma-Informed Care and Practice Organisational Toolkit (TICPOT): An
Organisational Change Resource, Stage 2 - Supporting Organisational Change and Stage 3 – Implementation. Mental
Health Coordinating Council (MHCC).
www.mhcc.org.au/resource/ticpot-stage-1-2-3/

Haber PS, Riordan BC. 2021. Guidelines for the Treatment of Alcohol Problems (4th edition). Sydney: Speciality of
Addiction Medicine, Faculty of Medicine and Health, The University of Sydney.
www.alcoholtreatmentguidelines.com.au

Jenner L, Baker A, Whyte I, Carr V. 2004. Psychostimulants: Management of acute behavioural disturbances:
Guidelines for police services. Canberra: Australian Government Department of Health and Ageing.

Lee K, Freeburn B, Ella S, Miller W, Perry J, Conigrave K. 2012. Handbook for Aboriginal alcohol and drug work.
Sydney: University of Sydney.
https://www.sydney.edu.au/content/dam/corporate/documents/faculty-of-medicine-and-health/
disciplines/indigenous-handbook-alcohol-drug-work.pdf

Manning V, Gooden JR, Cox C, Petersen V, Whelan D, Mroz K. 2021. Managing Cognitive Impairment in AOD
Treatment: Practice Guidelines for Healthcare Professionals. Richmond, Victoria: Turning Point.
https://www.turningpoint.org.au/treatment/clinicians/Managing-Cognitive-Impairment-in-AOD-
Treatment-Guidelines

Marsh A, Towers T, O’Toole S. 2017. Trauma-informed treatment guide for working with women with alcohol and
other drug issues (3rd edition). Perth: Improving Services for Women with Drug and Alcohol and Mental
Health Issues and their Children Project.
www.whfs.org.au/resources/professional-resources

Mental Health Coordinating Council (MHCC). 2018. Recovery oriented language guide. Sydney: MHCC.
https://mhcc.org.au/2021/10/recovery-oriented-language-guide-quick-reference/
Appendix A: Other Australian guidelines 337

National Indigenous Drug and Alcohol Committee. 2014. Alcohol and other drug treatment for Aboriginal and
Torres Strait Islander peoples. Canberra: Australian National Council on Drugs.
www.healthinfonet.ecu.edu.au/healthinfonet/getContent.php?linkid=592238
&title=Alcohol+and+other+drug+treatment+for+Aboriginal+and+Torres+Strait+Islander+peoples

Network of Alcohol and other Drugs Agencies (NADA). 2017. Aboriginal Inclusion Tool: A tool to improve Aboriginal
inclusion in AOD services. Sydney: NADA.
www.nada.org.au/resources/aboriginal-inclusion-tool-2

Network of Alcohol and other Drugs Agencies (NADA). 2021. Access and equity: Working with diversity in the
alcohol and other drugs setting (2nd edition). Sydney: NADA.
www.nada.org.au/resources/working-with-diversity

Network of Alcohol and other Drugs Agencies (NADA). 2013. Complex needs capable: A practice resource for drug
and alcohol services. Sydney: NADA.
www.nada.org.au/resources/complex-needs-capable

Network of Alcohol and other Drugs Agencies (NADA). 2021. NADA practice resource: Engaging men who
perpetrate domestic and family violence in the alcohol and other drugs treatment context. Sydney: NADA.
www.nada.org.au/resources/engaging-men-who-perpetrate-domestic-and-family-violence-in-the-
alcohol-and-other-drugs-treatment-context

Network of Alcohol and other Drugs Agencies (NADA). 2021. NADA practice resource: Working with women
engaged in alcohol and other drug treatment (3rd edition). Sydney: NADA.
www.nada.org.au/resources/nada-practice-resource-working-with-women-engaged-in-alcohol-and-
other-drug-treatment

Network of Alcohol and other Drugs Agencies (NADA). 2020. Workforce Capability Framework: Core capabilities
for the NSW non-government alcohol and other drugs sector. Sydney: NADA.
www.nada.org.au/resources/workforce-capability-framework

NSW Department of Health. 2009. NSW clinical guidelines for the care of persons with comorbid mental illness
and substance use disorders in acute care settings. Sydney: NSW Department of Health.
www.health.nsw.gov.au/aod/resources/Publications/comorbidity-report.pdf

NSW Department of Health. 2008. NSW Health drug and alcohol psychosocial interventions. Sydney: NSW
Department of Health (last reviewed 2018, currently being updated).
www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2008_009.pdf

NSW Department of Health. 2015. Guidelines to consumer participation in NSW drug and alcohol services. North
Sydney: NSW Department of Health (last reviewed 2020).
www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_006.pdf
338 Appendix A: Other Australian guidelines

Roche A, Trifonoff A, Ryan K. 2019. Methamphetamine use among Aboriginal and Torres Strait Islander people:
Intervention options for workers. Adelaide: National Centre for Education and Training on Addiction (NCETA).
www.nceta.flinders.edu.au/application/files/8716/0156/0381/EN749_Roche.pdf

Stone J, Marsh A, Dale A, Willis L, O’Toole S, Helfgott S, Bennetts A, Cleary L, Ditchburn S, Jacobson H, Rea R,
Aitken D, Lowery M, Oh G, Stark R, Stevens C. 2019. Counselling Guidelines: Alcohol and other drug issues (4th
edition). Perth: Mental Health Commission.
www.mhc.wa.gov.au/media/2604/mhc_counselling-guidelines-4th-edition.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: Victorian Dual Diagnosis
Initiative Education and Training Unit.
www.nceta.flinders.edu.au/application/files/9915/0646/7727/Healing_Ways_Manual.pdf

Wallace R, Allan J. 2019. Alcohol and Other Drugs Treatment Guidelines for Working with Aboriginal & Torres Strait
Islander People in a Non-Aboriginal Setting. Sydney: Network of Alcohol and other Drugs Agencies.
www.nada.org.au/wp-content/uploads/2021/01/NADA-Aboriginal-Guidelines-Web-2.pdf

Western Australian Network of Alcohol and other Drug Agencies (WANADA). 2011. Healthy eating for wellbeing:
A nutrition guide for alcohol and other drug agency workers. Perth: Western Australian Network of Alcohol and
other Drug Agencies.
www.wanada.org.au/index.php?option=com_docman&view=download&alias=45-
healthyeatingfohealthy-eating-for-wellbeing-a-nutrition-guide-for-alcohol-other-drug-agency-
workers&category_slug=healthy-eating-and-wellbeing-guides&Itemid=265

Winstock A, Molan J. 2007. The patient journey: KIT2: Supporting GPs to manage comorbidity in the community.
Sydney: NSW Department of Health.
www.health.nsw.gov.au/mentalhealth//Documents/pj-kit2.pdf
Appendix B: Other useful resources 339

Appendix B: Other useful resources

Below is a selection of other resources that may be useful for those working with clients experiencing
co-occurring AOD and mental health conditions. Note that some of these resources are somewhat dated,
but we have retained them where more recent resources are unavailable. Readers should nonetheless
be aware that given their age, some of the information contained may not be based on the most current
evidence.

Other useful resources

Australian Association of Social Workers. 2013. National practice standards for social workers 2013. Canberra,
Australia (currently being updated).
www.aasw.asn.au/practitioner-resources/practice-standards

Australian Government Department of Health. 2012. Mental health statement of rights and responsibilities.
Canberra, Australia.
www.health.gov.au/resources/publications/mental-health-statement-of-rights-and-
responsibilities-2012

Back S, Foa E, Killeen T, Mills KL, Teesson M, Cotton BD, Carroll KM, Brady KT. 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 NK, Claire M, Jenner L. 2003. A brief cognitive behavioural intervention for regular
amphetamine users. Canberra, Australia: Australian Government Department of Health and Ageing.
www.drugsandalcohol.ie/13632/1/NTA_AMPHETAMINE_cognitive-intervention.pdf

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.

eMHPrac e-Mental Health in Practice Project. 2021. A guide to digital mental health resources. Brisbane,
Queensland: Queensland University of Technology.
www.emhprac.org.au/wp-content/uploads/2019/12/eMHPrac-Resource-Guide-September-2021.pdf

Miller W, Rollnick S. 2013. Motivational interviewing: Helping people change (3rd edition). New York, NY, US:
Guildford Press.
340 Appendix B: Other useful resources

Mills KL, Marel C, Baker A, Teesson M, Dore G, Kay-Lambkin F, Manns L, Trimingham T. 2011. Comorbidity
information booklets. Sydney, New South Wales: National Drug and Alcohol Research Centre.
• Anxiety and substance use: https://www.sydney.edu.au/content/dam/corporate/documents/
matilda-centre/resources/booklets/anxiety-substance-use.pdf
• Mood and substance use: https://www.sydney.edu.au/content/dam/corporate/documents/
matilda-centre/resources/booklets/mood-and-substance-use.pdf
• Trauma and substance use: https://www.sydney.edu.au/content/dam/corporate/documents/
matilda-centre/resources/booklets/trauma-and-substance-use.pdf
• Psychosis and substance use: https://www.sydney.edu.au/content/dam/corporate/documents/
matilda-centre/resources/booklets/psychosis-and-substance-use.pdf
• Personality and substance use: https://www.sydney.edu.au/content/dam/corporate/documents/
matilda-centre/resources/booklets/personality-and-substance-use.pdf

Network of Alcohol and other Drugs Agencies (NADA). 2017. Aboriginal Inclusion Tool: A tool to improve Aboriginal
inclusion in AOD services. Sydney: NADA.
https://nada.org.au/resources/aboriginal-inclusion-tool-2/

Network of Alcohol and other Drugs Agencies (NADA). 2018. Language matters. Sydney: NADA.
https://nada.org.au/resources/language-matters/

Reilly PM, Shopshire MS. 2019. Anger management for substance abuse and mental health clients: A cognitive-
behavioural therapy manual. Rockville, MD, US: Substance Abuse and Mental Health Services Administration.
www.store.samhsa.gov/product/Anger-Management-for-Substance-Abuse-and-Mental-Health-
Clients-A-Cognitive-Behavioral-Therapy-Manual/PEP19-02-01-001

Substance Abuse and Mental Health Services Administration. 2019. Enhancing motivation for change
in substance use disorder treatment. Rockville, MD, US: Substance Abuse and Mental Health Services
Administration.
www.samhsa.gov/resource/ebp/tip-35-enhancing-motivation-change-substance-abuse-treatment

Stapinski L, Rapee R, Haggman S, Sannibale C, Winkler C, Baillie AJ. 2021. Combined Cognitive Behavioural
Therapy for Social Phobia and Harmful Drinking: Therapist Guide, Revised Version. Sydney, New South Wales: CASP
Project. Centre for Emotional Health, Macquarie University.
www.osf.io/xuqcr/

Turning Point. 2013. Screening and assessment tools. Victoria.

www.turningpoint.org.au/treatment/clinicians/screening-assessment-tools

Victorian Government Department of Health. 2013. National practice standards for the mental health workforce.
Melbourne, Victoria.
www.health.gov.au/sites/default/files/documents/2021/04/national-practice-standards-for-the-
mental-health-workforce-2013.pdf
Appendix C: Sources of research, information and other resources 341

Appendix C: Sources of research, information and other

resources
Below is a selection of other research and information organisations and other resources that may be
useful for those working with clients experiencing co-occurring AOD and mental health conditions.

Organisation name Contact Service

ACON www.acon.org.au A health promotion organisation

specialising in support for people who
identify as sexual or gender diverse, or
have HIV, in NSW.

Alcohol and Drug www.adf.org.au A not-for-profit NGO committed to

Foundation (ADF) preventing and minimising AOD-related
harms across Australia.

Alcohol, Tobacco, and www.atoda.org.au Peak body representing government

Other Drug Association and NGO alcohol and other drug sector
ACT (ATODA) in the Australian Capital Territory.

Alcohol, Tobacco and www.atdc.org.au The peak body representing the NGO,
Other Drugs Council not-for-profit Alcohol, Tobacco and Other
Tasmania (ATDC) Drug (ATOD) sector in Tasmania.

Alcohol and Other www.aodknowledgecentre.ecu. Alcohol and other drugs information

Drugs Knowledge edu.au resource for Aboriginal communities.
Centre

Association of Alcohol www.aadant.org.au Peak body for the alcohol and other drug
and Other Drug sector in the Northern Territory.
Agencies NT (AADANT)

Australasian www.apsad.org.au Professional body for individuals

Professional Society working in the alcohol and other drugs
on Alcohol and Other field.
Drugs (APSAD)

Australasian www.atca.com.au Peak body representing therapeutic

Therapeutic communities in Australasia.
Communities
Association (ATCA)
342 Appendix C: Sources of research, information and other resources

Australian Association www.aasw.asn.au Professional body for social workers in

of Social Workers Australia.
(AASW)

Australian Indigenous www.healthinfonet.ecu.edu.au Information and resources for

HealthInfoNet Indigenous health.

Australian Injecting www.aivl.org.au The peak national organisation

and Illicit Drug Users representing peer-based AOD
League organisations and people with lived
experience of AOD use.

Australian Institute of www.aic.gov.au The peak national organisation for

Criminology research and knowledge on crime and
justice.

Australian Institute of www.aihw.gov.au The peak national organisation for

Health and Welfare research and knowledge on health and
welfare.

Australian www.psychology.org.au Professional body for psychologists in

Psychological Society Australia.
(APS)

Beyond Blue www.beyondblue.org.au A national, independent, not-for-profit

organisation working to address
issues associated with depression,
anxiety, and related substance misuse
disorders in Australia.

Black Dog Institute www.blackdoginstitute.org.au A not-for-profit research, education,

and training institute with expertise in
diagnosis, treatment, and prevention of
mood disorders.

Brain and Mind Centre www.sydney.edu.au/brain- Network of researchers and clinicians

mind/ who aim to develop treatments for
brain and mind conditions and improve
health outcomes.

Burnet Institute www.burnet.edu.au A research institute which aims to

achieve better health for vulnerable
communities in Australia and
internationally.
Appendix C: Sources of research, information and other resources 343

Centre for Rural and www.crrmh.com.au Centre that provides leadership in rural
Remote Mental Health and remote mental health research and
program delivery.

Community Mental www.cmhdaresearchnetwork. Network that aims to broaden

Health Drug and com.au involvement of the community mental
Alcohol Research health and AOD sector in practice-
Network based research and promote the value
of research and the use of research
evidence in practice.

Cracks in the Ice www.cracksintheice.org.au Online toolkit providing evidence-

based information and resources about
crystal methamphetamine (‘ice’) for the
Australian community.

Drug and Alcohol www.damec.org.au NGO providing support, education,

Multicultural research, and training about drug and
Education Centre alcohol issues for CALD groups in NSW.
(DAMEC)

Drug and Alcohol www.danaonline.org Peak body representing alcohol and

Nurses of Australasia other drug nursing in Australasia.
(DANA)

Deakin University www.deakin.edu.au/ Research centre focusing on the

Centre for Drug Use, psychology/our-research/ psychological, biological, socio-political,
Addictive and Anti- centre-for-drug-alcohol-and- and clinical aspects of AOD use, other
Social Behaviour addiction-research addictive behaviours, and consequent
Research harm.

Drug and Alcohol www.sahealth.sa.gov.au/wps/ A statewide South Australian health

Services South wcm/connect/public+content/ service for people with alcohol and/or
Australia sa+health+internet/ other drug related problems.
services/mental+health+
and+drug+and+alcohol+
services/drug+and+alcohol
+services/
drug+and+alcohol+services
344 Appendix C: Sources of research, information and other resources

Drug and Alcohol Within Sydney Metropolitan Area: Free 24/7 clinician-operated telephone
Specialist Advisory (02) 8382-1006 service that provides general advice
Service (DASAS) Regional, Rural & Remote NSW: to NSW-based health professionals on
1800 023 687 clinical diagnosis and management of
patients with AOD-related concerns.
https://www.svhs.org.au/
our-services/list-of-services/
alcohol-drug-service/drug-
alcohol-specialist-advisory-
service

Dual Diagnosis www.dualdiagnosis.org.au/ An online community of people

Australia and New home interested in contributing to better
Zealand outcomes for persons with co-occurring
substance use and mental health
disorders.

eCliPSE www.eclipse.org.au Online portal that facilitates free 24/7

access to evidence-based online
screening, eHealth treatments and
resources for people experiencing co-
occurring mental health and substance
use problems, and the clinical services
supporting them.

EveryMind www.everymind.org.au Institute focusing on delivering best-

practice mental health and suicide
prevention programs.

Family Drug Support 1300 368 186 Assists families throughout Australia
Australia www.fds.org.au to deal with drug issues and achieve
positive outcomes.

Foundation for www.fare.org.au A not-for-profit organisation which

Alcohol Research and develops evidence-informed policy,
Education enables advocacy, and delivers health
promotion programs designed to
reduce the risk of alcohol-related harm.

GROW Mental 1800 558 268 A 12-step program for people

Wellbeing Programs www.grow.org.au experiencing mental illness. Services
include meetings across Australia and
a residential service in Australia.
Appendix C: Sources of research, information and other resources 345

Headspace www.headspace.org.au A government-funded youth mental

health information site.

eheadspace www.headspace.org.au/online- Online and telephone support service

and-phone-support/ for young people experiencing mental
health issues.

Hepatitis Australia 1800 437 222 The peak, national NGO representing
and the National www.hepatitisaustralia.com the interests of the Australian viral
Hepatitis Infoline hepatitis community sector; provides
a number of useful resources and
referrals to state-based organisations.

Homelessness www.homelessnessaustralia. Peak body for homelessness in

Australia org.au Australia.

InsideOut Institute for https://insideoutinstitute.org. National institute for research,

Eating Disorders au translation and clinical excellence in
eating disorders.

The Kirby Institute www.kirby.unsw.edu.au A medical research organisation

dedicated to the prevention and
treatment of infectious diseases and
endemic response based in New South
Wales.

The Matilda Centre for www.sydney.edu.au/matilda- A research centre that brings together
Research in Mental centre world-leading researchers, clinicians,
Health and Substance people with lived experience and
Use community to share skills, synergise
data, harness new technologies and
trial innovative programs to prevent
and treat mental and substance use
disorders.

The Mental Health www.themhs.org Learning network aimed at improving

Services (TheMHS) mental health services in Australia and
Learning Network New Zealand.

Menzies School of www.menzies.edu.au A national medical research

Health Research organisation dedicated to improving
the health and wellbeing of Aboriginal
and Torres Strait Islander people, as well
as tropical health.
346 Appendix C: Sources of research, information and other resources

Mental Health www.mhaustralia.org The peak, national NGO representing

Australia and promoting the interests of the
Australian mental health sector.

Mental Health www.mhcsa.org.au The peak body promoting the interests

Coalition of South of NGOs supporting people with a
Australia psychiatric disability in SA.

Mental Health www.mhccact.org.au The peak body representing the non-

Community Coalition profit community mental health sector
ACT (MHCC ACT) in the ACT.

Mental Health www.mhcc.org.au The peak body for community mental

Coordinating Council health organisations in NSW.
(MHCC)

Mental Health Council www.mhct.org The peak body representing the

of Tasmania (MHCT) interests of non-government mental
health consumer organisations, carer
organisations and service provider
organisations in Tasmania.

Mental Health First www.mhfa.com.au Provides evidence-based mental health

Aid Australia first aid education to all.

Mental Health Victoria www.mhvic.org.au The peak body for mental health in
Victoria.

Mission Australia www.missionaustralia.com.au A national organisation that provides

community services throughout
Australia.

MindSpot Clinic www.mindspot.org.au An online mental health clinic that

provides free, anonymous assessment
and treatment for adults experiencing
stress, anxiety, depression, OCD, PTSD
and chronic pain.

moodgym www.moodgym.com.au A CBT self-help training program for

depression and anxiety.

National Centre www.nceta.flinders.edu.au Research centre that specialises in AOD

for Education and workforce development.
Training on Addiction
Appendix C: Sources of research, information and other resources 347

National Centre for www.ncysur.centre.uq.edu.au Centre that aims to promote the

Youth Substance Use health and wellbeing of young people
Research by increasing Australia’s capacity
to respond effectively to the harm
associated with alcohol, tobacco, and
other drug misuse.

National Drug and www.ndarc.med.unsw.edu.au Centre that conducts research that can
Alcohol Research be put into practice in order to develop
Centre and improve approaches to both
prevention and treatment of addiction
related problems.

National Drug www.ndri.curtin.edu.au Institute that conducts and

Research Institute disseminates research that contributes
to effective policy, strategies and
practice to prevent and reduce harmful
AOD use.

National Eating www.nedc.com.au Collaboration dedicated to developing

Disorders and implementing a nationally
Collaboration consistent, evidence-based system of
care for the prevention and treatment of
eating disorders.

National Health and www.nhmrc.gov.au Australian national council that creates

Medical Research pathways to a healthier future through
Council research funding, health guidelines and
ethical standards.

The National Institute www.nice.org.uk Institute that develops guidance,

for Health and Care advice, quality standards and
Excellence (UK) information services for health, public
health and social care in the UK.

Network of Alcohol and www.nada.org.au The peak organisation for NGO AOD
Other Drugs Agencies services in New South Wales.
(NADA)

Northern Territory www.ntcoss.org.au The peak body for the social and
Council of Social community sector in the Northern
Service (NTCOSS) Territory.
348 Appendix C: Sources of research, information and other resources

Northern Territory www.ntmhc.org.au The peak body representing the

Mental Health community-based mental health sector
Coalition in the NT.

ORYGEN Youth Mental www.orygen.org.au A national not-for-profit organisation

Health Australia and research centre for young people
with mental health issues.

Phoenix Australia: www.phoenixaustralia.org A national non-for-profit organisation

Centre for for people experiencing trauma and
Posttraumatic Mental posttraumatic stress.
Health

Positive Choices www.positivechoices.org.au An online portal with AOD-related

resources for schools, parents, and
communities.

Project Air www.uow.edu.au/project-air Organisation that conducts research,

education and treatment into
personality disorders.

Queensland Alliance www.qamh.org.au The peak body for community mental

for Mental Health health organisations in Queensland.
(QAMH)

Queensland Network of www.qnada.org.au The peak organisation for NGO AOD

Alcohol and other Drug agencies throughout Queensland.
Agencies (QNADA)

ReachOut www.au.reachout.com An online service providing information

and referrals to young people with a
variety of problems including AOD and
mental health.

ReachOut Schools https://schools.au.reachout. An organisation that provides online

com/ wellbeing resources for parents,
teachers, and carers of young people.

Royal Australian and www.ranzcp.org The body responsible for training,

New Zealand College educating and representing
of Psychiatrists psychiatrists in Australia and New
Zealand.
Appendix C: Sources of research, information and other resources 349

Sax Institute www.saxinstitute.org.au Institute that develops, tests and

delivers best-practice approaches to
working at the interface of research and
health decision-making.

SMART Recovery www.smartrecoveryaustralia. A peer-managed self-help group that

Australia com.au assists recovery from AOD use.

SMART Family and https:// Support program designed to assist

Friends smartrecoveryaustralia.com. anyone affected by the addictive
au/family-friends/ behaviour of someone close to them.

Society for Mental www.smhr.org.au National body for individuals engaged

Health Research in research relating to mental health.
(SMHR)

South Australian www.sandas.org.au The peak body for NGOs working in the
Network of Drug and AOD field in South Australia.
Alcohol Services
(SANDAS)

Substance Abuse and www.samhsa.gov US-based agency that aims to reduce

Mental Health Services the impact of substance abuse and
Administration (US) mental illness on communities.

Telethon Kids Institute www.telethonkids.org.au Medical research institute that aims

to improve the health and wellbeing of
children through excellence in research.

Turning Point Alcohol www.turningpoint.org.au National addiction treatment, education

and Drug Centre and research centre.

Victorian Alcohol www.vaada.org.au The peak body representing AOD

and Drug Association services in Victoria.
(VAADA)

Western Australian www.waamh.org.au The peak mental health representative

Association for Mental body in Western Australia for NGO non-
Health (WAAMH) profit agencies.

Western Australian www.wanada.org.au The peak body for the non-profit AOD
Network of Alcohol and sector in Western Australia.
Other Drug Agencies
(WANADA)

Youth Support and www.ysas.org.au Victorian-based youth-specific

Advocacy Service community service organisation.
350 Appendix D: DSM-5-TR and ICD-11 classification cross-reference

Appendix D: DSM-5-TR and ICD-11 classification cross-

reference
Below is a cross-reference of the DSM-5-TR disorders described in Chapter A4 with the corresponding
ICD-11 codes.

DSM-5-TR disorder
ICD-11 classification ICD-11 coding
classification

Attention-deficit/hyperactivity Attention deficit hyperactivity 6A05

disorder (ADHD) disorder

Schizophrenia Schizophrenia 6A20

Schizoaffective disorder Schizoaffective disorder 6A21

Brief psychotic disorder Acute and transient psychotic 6A23

disorder

Delusional disorder Delusional disorder 6A24

Bipolar I disorder Bipolar type I disorder 6A60

Bipolar II disorder Bipolar type II disorder 6A61

Cyclothymic disorder Cyclothymic disorder 6A62

Major depressive disorder Single depressive disorder 6A70

Recurrent depressive disorder 6A71

Persistent depressive disorder Dysthymic disorder 6A72

Generalised anxiety disorder Generalised anxiety disorder 6B00

(GAD)

Panic disorder Panic disorder 6B01

Agoraphobia Agoraphobia 6B02

Social anxiety disorder (SAD) Social anxiety disorder 6B04

Specific phobia Specific phobia 6B03

Obsessive-compulsive disorder Obsessive-compulsive disorder 6B20

(OCD)
Appendix D: DSM-5-TR and ICD-11 classification cross-reference 351

Post traumatic stress disorder Post traumatic stress disorder 6B40

(PTSD) Complex post traumatic stress 6B41
disorder

Anorexia nervosa Anorexia nervosa 6B80

Bulimia nervosa Bulimia nervosa 6B81

Binge eating disorder Binge eating disorder 6B82

Antisocial personality disorder Personality disorder (mild, 6D10.0, 6D10.1, 6D10.2

(ASPD) moderate, severe); trait domain
Borderline personality disorder qualifier:
(BPD) • negative affectivity 6D11.0
• detachment 6D11.1
• dissociality 6D11.2
• disinhibition 6D11.3
• anankastia 6D11.4
• borderline 6D11.5
352 Appendix E: Motivational interviewing

Appendix E: Motivational interviewing

A useful tool in AOD client management is motivational interviewing (MI), irrespective of whether the
client is experiencing co-occurring mental health conditions. MI can be beneficial for clients with co-
occurring conditions by increasing treatment motivation, adherence, and readiness to change [762, 947,
1090, 1914, 1915], although it may not prove effective in all cases [762, 947]. A number of useful resources
for MI are given in Appendix B, including Miller and Rollnick [758], the Substance Abuse and Mental
Health Services Administration [1847], Baker and Velleman [122], and Clancy and Terry [448], from which
this section draws upon.

MI is a directive, non-confrontational, client-centred counselling strategy aimed at increasing a

person’s motivation to change. This strategy assumes equity in the client-AOD worker relationship and
emphasises a client’s right to define their problems and choose their own solutions. It is, in this sense, a
counselling style based on collaboration rather than confrontation, evocation rather than education and
autonomy instead of authority, as opposed to a set of techniques [1916].

Principles of MI include:

• Avoid argumentation. Confrontation is unhelpful to change and is likely to increase resistance.

• Express empathy, warmth, and genuineness in order to facilitate engagement and build
rapport.

• Support self-efficacy. Build confidence that change is possible.

• Roll with resistance. Arguing, interrupting, negating and ignoring are signs a client is resistant to
change.

• Develop discrepancy. Generate inconsistency between how the client sees their current situation
and how they would like it to be. This strategy is based on the notion that discomfort motivates
change and internal inconsistency or ambivalence is a cause of human discomfort.

Thus, MI aims to rouse feelings of ambivalence and discomfort surrounding current behaviour in order
to motivate change. Key to facilitating change are the concepts of ‘change talk’ (a process whereby a
person becomes more committed to a position by arguing for that position) and ‘sustain talk’ (the more
argument against change is evoked, the less likely a person is to change).

MI involves four overlapping processes (Figure 22, Table 63) [758]:

• 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.
Appendix E: Motivational interviewing 353

Figure 22: Four processes of MI

Source: Miller and Rollnick [758].

Table 63: Questions regarding each MI process

Engaging
• How comfortable is the client talking with you?

• How supportive/helpful are you being?

• Does this feel like a supportive/collaborative partnership?

Focusing
• What goals for change does the client really have?

• Are you working together with a common purpose?

• Does it feel like you’re moving together or in opposing directions?

Evoking
• What are the client’s own reasons for change?

• Is the reluctance about confidence or importance of change?

• Are you pushing the client too far or too quickly in a particular direction?

Planning
• What would be a reasonable next step towards change?

• Are you remembering to evoke rather than prescribe a plan?

• Are you offering advice or information with permission?

Source: Miller and Rollnick [758].

354 Appendix E: Motivational interviewing

Core skills of MI
Miller and Rollnick [758] identify five core skills that are used throughout the different processes of MI,
which can be remembered with the OARS + I&A acronym:

• Asking Open questions.

• Affirming.

• Reflective listening.

• Summarising.

• Informing and Advising (with permission, elicit-provide-elicit).

Asking open questions

Asking open questions refers to a questioning method that does not invite short answers, which
increases information flow and trust, and invites the client to reflect and elaborate. While there are
times when asking closed questions may be necessary (e.g., gathering information for screening or
assessment), 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 the client and AOD worker [758]. Certain kinds of open questions are particularly suited to the
different processes involved in MI (e.g., engaging, evoking). Some examples of closed and open questions
are provided in Table 64. AOD workers may also find the range of open questions provided in Table 66
useful [776], which have been grouped according to the stages of change model [446, 1917]. The goal of
open-ended questions is to elicit self-motivational statements from the client [776]. There should be
a balance between asking open questions and reflective listening [1847]. Among clients who may be
experiencing symptoms of co-occurring mental health conditions, these questions should be simplified.
Compound questioning (two questions in one sentence) should be avoided [1847].

Table 64: Examples of closed and open questions

Closed questions Open questions

You’ve come in today because you’re worried about how What brings you in today?
much alcohol you’ve been drinking lately, is that right?

Do you have any children? Tell me about your family.

How old were you when you drank alcohol for the first Tell me about the first time you drank
time? alcohol.

On a typical day, how much cannabis do you use? Tell me about your cannabis use on a typical
day.

Do you think it would be a good idea for you to go into What do you think about the possibility of
detoxification? going through detoxification?

Adapted from SAMHSA [1847].

Appendix E: Motivational interviewing 355

Affirming
Affirming is a way of enhancing the confidence of clients to take action, by the AOD worker showing
their genuine appreciation and positive regard for the client [758]. It is the client, rather than the AOD
worker, who produces change in MI, and as such, the process of MI relies on the client’s own personal
strengths, efforts and resources. Affirming therefore focuses on the positive with direct compliments and
statements of appreciation and understanding rather than attempting to produce change by making
the client feel bad [758]. The technique of affirming helps build rapport, self-efficacy and reinforces open
exploration.

Among clients who may be experiencing symptoms of co-occurring mental health conditions, affirming
can be inspiring and build rapport [1918]. Affirming 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) [758]. AOD workers may
find the following strategies helpful to consider when affirming [1847]:

• Focus on the client’s strengths, previous successes and efforts, however small, to achieve their
change goals.

• Take care not to confuse affirming with praise. Praise implies the worker is approving the client,
expresses judgement (of praise or blame), and is more likely to begin with an ‘I’.

• Use phrases that begin with ‘you’ rather than ‘I’, to maintain focus on the client. For example, rather
than ‘I am proud you came in today’, which shifts the focus to the AOD worker, try ‘You worked really hard
and persisted in being here today’, which illustrates appreciation and maintains focus on the client.

Some other examples of affirming statements that AOD workers may find useful include [758, 1847]:

• ‘You took a big step in coming here today.’

• ‘That is a great suggestion for how you might avoid situations where you might be tempted to use.’

• ‘Your intention was really good, even though it may not have turned out as you would have liked.’

• ‘You were discouraged this week, but you still came back. You are persistent.’

• ‘Welcome back! It’s good to see you.’

Reflective listening
Reflective listening is a key component of showing empathy and a core skill of person-centred therapy. It
involves listening to what the client is saying, forming an understanding of what they are talking about
and then giving voice (reflecting) to that understanding. Reflecting shows respect and acceptance to
clients, establishes trust and helps with the exploration of perceptions and values, enables the building
of a collaborative and non-judgemental relationship, and allows the AOD worker to show their support
without necessarily agreeing with the client’s ideas or statements [758].

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. Reflecting can range from
simple (i.e., repeating or rephrasing the client’s words) to complex (i.e., reflecting the underlying meaning
356 Appendix E: Motivational interviewing

or feelings with the use of different words). The depth of reflection increases with the level of the AOD
worker’s experience and expertise. Importantly, reflective listening is not making assumptions about
the underlying meaning of clients’ statements, but rather forming hypotheses about the meaning or
feeling and listening carefully to the client’s response after the hypothesis is tested. Simple reflections
are useful for client engagement and obtaining their perspective 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. More complex reflections can expand a client’s
self-exploration [758, 1847]. Some examples of simple and complex reflections are provided in Table 65.

Table 65: Examples of reflective listening responses

Client AOD worker

Type Purpose Considerations
statement response

Simple

Repeat My girlfriend is Your girlfriend is Shows empathy. Avoid mimicking.

hassling me about hassling you about Builds rapport.
how much I smoke. how much you
smoke.

Rephrase My girlfriend is Your girlfriend Shows empathy. Moves the

hassling me about is pestering you Emphasises conversation along
how much I smoke. about how much selected but slower than with
you smoke. meaning or complex reflections.
feeling.

Feeling I’d like to give up You’re afraid that Emphasises Reinforce change
smoking pot so your girlfriend’s selected feeling. talk, avoid reinforcing
I don’t make my asthma will get Emphasises sustain talk.
girlfriend’s asthma worse if you keep discrepancy
worse. smoking pot. between values
and behaviour.

Meaning I’d like to stop You want to protect Emphasises Reinforce change
smoking pot your girlfriend from selected talk, avoid reinforcing
because my the possibility that meaning. sustain talk.
girlfriend has her asthma will Emphasises
asthma and I heard get worse if you discrepancy
that second-hand continue to smoke between values
smoke can make pot. and behaviour.
asthma worse, and
I don’t want that to
happen to her.
Appendix E: Motivational interviewing 357

Table 65: Examples of reflective listening responses (continued)

Client AOD worker

Type Purpose Considerations
statement response

Complex

Double- I know I should quit Giving up smoking Resolves Use ‘and’ to join
sided smoking pot but pot would be hard ambivalence. reflections.
it’s the only time I and you recognise Acknowledges Start with sustain talk
have for myself. that it’s time to sustain talk and reflection and end with
stop. emphasises change talk reflection.
change talk.

Amplified I think my pot There are Amplifies Use sparingly.

smoking is just not absolutely sustain talk to Avoid being caught in
a problem for me. no negative evoke change sustain talk.
consequences of talk.
smoking pot.

Adapted from SAMHSA [1847].

Among clients experiencing 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 them time to consider these reflections [1919].

Summarising
Summarising is a type of reflective listening that links together the core components of several
important client statements and reflects them back to the client. 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. Summarising should be
conducted often to promote meaningful relationships and contrasts between statements to enhance
motivation to change [1918]. Some examples of summarising techniques include:

• Linking summary: making associations between two parts of the discussion.

• Collecting summary: gathering a few themes from what the client has said.

• Ambivalence summary: gathering a few client statements about change and sustain talk, to
acknowledge sustain talk but reinforce and highlight change talk.

• Transitional summary: shifting focus from one area to another.

• Recapitulation summary: gathering change talk from many conversations.

358 Appendix E: Motivational interviewing

Table 66: Examples of open questions to elicit self-motivational statements

Stage of Self-motivational
Open question examples
change statement

Pre- Problem recognition • What things make you think that this is a problem?
contemplation (e.g., ‘I guess there • What difficulties have you had in relation to your AOD
might be more of use?
a problem than I • What difficulties have you had in relation to your
mood?
thought’)
• 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 • What worries do you have about your AOD use?
(e.g., ‘I’m worried about • What can you imagine happening to you?
this’) • 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 • You seem a bit stuck at the moment. What would
(e.g., ‘This isn’t how I have to change to fix this?
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?
Appendix E: Motivational interviewing 359

Table 66: Examples of open questions to elicit self-motivational statements

(continued)

Stage of Self-motivational
Open question examples
change statement

Maintenance Optimism (e.g., ‘I think I • What would make you more confident about making
can do this’) 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?

Adapted from NSW Department of Health [776].

Informing and advising

Informing and advising refers to the offering of information or advice. Although MI adopts a client centred
approach, this does not mean that offering advice or information to clients is always 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
[758]:

• Offering information or advice with permission.

• When advice is provided, the perspective of the client is explored, particularly in terms of the
relevance of the information to them and helping them to reach their own conclusions.

Miller and Rollnick [758] recommend using the ‘elicit-provide-elicit’ approach when exchanging
information with a client.

Elicit

• Ask permission to give information or advice: ‘May I…?’

• Clarify the client’s information needs and gaps: ‘What do you know about…?’, ‘Is there any
information I can help you with?’

Provide

• Prioritise: what does the client most want/need to know?

• Be clear: avoid jargon.

360 Appendix E: Motivational interviewing

• Support autonomy: do not offer too much information at once; allow the client time to reflect.

• Do not prescribe the client’s response: acknowledge their freedom to disagree or ignore, present
what you know without interpreting its meaning for the client.

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 their own arguments for change in order to [758]:

• Recognise the disadvantages of current behaviour.

• Recognise the advantages of change.

• Express optimism about change.

• Express intent to change.

These strategies include:

• Typical day.

• Decisional balance.

• Elaboration.

• Querying extremes.

• Asking about lifestyle and stresses.

• Looking back.

• Looking forward.

• Exploring goals and values.

• Strengthening commitment.

Typical day
Often a client deems certain aspects of their life irrelevant to treatment or they are insignificant to the
client and overlooked and therefore not disclosed during therapy. However, this information can help
an AOD 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 client’s life. Furthermore, this information can highlight to the client aspects of their life
that they had not been aware of (e.g., ‘I hadn’t realised I was drinking that much’).
Appendix E: Motivational interviewing 361

In order to attain this information, it can be useful to ask the client to explain how they spend 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 they have 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, AOD 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 [758].

Decisional balance (good and not so good aspects)

This technique involves a conscious weighing up of the pros and cons of certain behaviours (e.g., AOD
use). Considering the pros and cons 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 [758]. 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 as a useful way of determining their stage of change in regard to their substance use.

Begin by asking questions such as:

• ‘What do you like about your use of…?’

• ‘Tell me about your AOD use. What do you like about it? What’s positive about using for you?’

For clients who have difficulty articulating things they like about using, it may be useful to offer a menu
of options for them to choose from, although this should be done sparingly. Remember the focus should
be on finding out what the client enjoys about using, not making assumptions about why they like it!
Encourage the client to write down good things they have identified (a useful template is included at the
end of this MI summary).

Briefly summarise the good aspects of AOD use that the client has identified. Next, ask the client about
the not-so-good things about their AOD use. Try to avoid using negative words such as the ‘bad things’ or
‘problems’. Questions that may be useful in obtaining this information include:

• ‘So, we have talked about some of the good things about AOD use. Now could you tell me some of
the less good things?’

• ‘What are some of the things that you don’t like about your AOD/substance use?’

• ‘Tell me what some of the not-so-good things about using are’.

362 Appendix E: Motivational interviewing

Again, it may be useful to provide some options or ask questions (based on collateral information),
such as, ‘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 getting arrested twice is a bit of a problem?’ The success of MI rests on the client’s
personal exploration of their AOD use, and the good and not-so-good effects that it has on them. 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 their mental health symptoms, explore this in particular detail: for instance, enquire about
longer-term effects [1920]. It is important to maintain focus on the client’s perspective of the less good
things. It can be useful to ask follow up questions such as:

• ‘How does this affect you?’

• ‘What don’t you like about it?’

Or ask for more detail:

• ‘Could you tell me a little more about that?’

• ‘Could you give me a recent example of when that happened?’

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 the importance it holds for them. This exercise
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 their AOD use, this automatically
presents a direct concern for them.

Now give a double-sided, selective summary. For example:

• ‘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 their own conclusions, for example:

• ‘Now that you’ve gone through both sides, where does this leave you?’

• ‘How do you feel about your AOD 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.
Appendix E: Motivational interviewing 363

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 [1920]. 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 [448].

Elaboration
Once a motivational topic has been raised, it is useful to ask the client to elaborate, which can help 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 activity can sometimes help when a client is expressing little desire for change. For instance, you
may ask:

• ‘What concerns you the most?’

• ‘What are your worst fears about what might happen if you don’t make a change?’

• ‘What do you suppose are the worst things that may happen if you keep on the way you’ve been
going?’

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?’

Ask about lifestyle and stresses

Asking about lifestyle and stresses involves discussing routines and day-to-day stresses. Examples of
some questions might be:

• ‘How does your AOD use affect your:

• Mental health?

• Physical health?

• Relationships?

• Finances?’
364 Appendix E: Motivational interviewing

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 their circumstances 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 them.

NOTE: Among clients experiencing symptoms of a co-occurring depressive condition, this strategy
should be avoided or used with caution [1920].

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:

• ‘What would you like to be doing in two years’ time?’

• ‘What do you think will happen if you keep using? How do you feel about that?’

• ‘If you decided to make a change, what are your hopes for the future?’

• ‘How would you like things to turn out for you?’

• ‘I can see that you’re feeling really frustrated right now… How would you like things to be different?’

• ‘What are your options at the moment?’

• ‘What would be the best results you could imagine, if you make a change?’

• ‘If you were to have a week off from your problems/symptoms, what would you do first?’

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 five 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.
Appendix E: Motivational interviewing 365

NOTE: Among clients experiencing symptoms of a co-occurring depressive condition, this strategy
should be avoided or used with caution [1920].

Exploring goals and values

It can be useful to ask clients about their goals and what is most important to them, comparing their
goals to the current situation. Rather than perceiving a person as unmotivated, it may be more useful to
understand their different goals and priorities [758]. 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., AOD use) fits
into this picture.

For example:

• ‘Where do you think your AOD use fits in?’

• ‘What effect is your current behaviour likely to have on your goals and values?’

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 [758]. MI is a method of facilitating the natural growth of
commitment. The AOD worker will consolidate all issues raised by the client and help them 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 micro skills outlined above. It can be
useful to encourage the client to confront the idea and process of change. For example:

• ‘Where do we go from here?’

• ‘What does everything we’ve discussed mean for your AOD use?’

• ‘How would your life be different if…?’

• ‘What can you think of that might go wrong with your plans?’

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 their 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 favoured [131, 1921] as mental health
symptoms may be exacerbated by AOD use. In particular, those with more severe mental disorders (or
366 Appendix E: Motivational interviewing

cognitive impairment) may have adverse experiences even with low levels of substance use [795]. 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 substances.
Although abstinence is favoured, many people with co-occurring conditions prefer a goal of moderation,
and that goal should be respected. 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 [1920].
Appendix E: Motivational interviewing 367

Good things & not-so-good things worksheet

Good things about current behaviour Not-so-good things about current behaviour

Good things about change Not-so-good things about change

368 Appendix F: Case formulation table

Appendix F: Case formulation table

Presenting issues: Initial signs, symptoms, challenges or difficulties that are clinically relevant:

Biological Psychological Social

(e.g., genetic factors, (e.g., resilience, (e.g., socioeconomic

medications, personality, thoughts, background,
environment) feelings, behaviours) relationships, family,
school, work, cultural
factors, spirituality,
community, social
supports and
connectedness)

Predisposing factors

Factors over a person’s

lifetime that may have
contributed to problem

Precipitating factors

Any triggers or events

that have initiated or
exacerbated problem

Perpetuating factors

Factors that may

maintain problem or
make it worse if not
addressed

Protective factors

Internal and external

supports

Adapted from PsychDB (2022). Biopsychosocial model and case formulation. Retrieved from https://www.psychdb.com/
teaching/biopsychosocial-case-formulation#biopsychosocial-model-and-case-formulation
Appendix G: Mental state examination 369

Appendix G: Mental state examination

Name: D.O.B. Date:

Appearance
Physical appearance? (Posture, grooming, clothing, signs of AOD use, nutritional status)

Behaviour
General behaviour? Behaviour to situation and to examiner? (Angry/hostile, uncooperative, withdrawn,
inappropriate, fearful, hypervigilant)

Speech
Rate, volume, tone, quality and quantity of speech?
370 Appendix G: Mental state examination

Language (form of thought)

Incoherence/illogical/irrelevant thinking? Amount? Rate?

Mood and affect

How does the client describe their 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?
Appendix G: Mental state examination 371

Cognition
Level of consciousness? Attention? Memory? Orientation? Abstract thoughts? Concentration?

Insight and judgement

Awareness? Decision making?
Appendix H: Integrated Motivational Assessment Tool (IMAT)
372

Motivation regarding AOD treatment

Pre- Contemplation Preparation/ Action Maintenance

contemplation Determination

Pre-
contemplation

Contemplation

Preparation/
Determination

Action

Motivation regarding psychiatric treatment

Maintenance

Source: Clancy R, Terry M. (2007). Psychiatry and substance use: An interactive resource for clinicians working with clients who have mental health and substance use
Appendix H: Integrated Motivational Assessment Tool (IMAT)

problems [DVD-ROM]. Newcastle: NSW Department of Health.

Appendix I: Additional screening tools 373

Appendix I: Additional screening tools

The General Health Questionnaire (GHQ) is a self-report screening instrument which detects the
presence of psychological symptoms [1922]. 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 [1922, 1923]. 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 people who use drugs could be expected to obtain scores
of 10 or more upon entering treatment; therefore, clients need to be reassessed after entering treatment
[1585]. If the client continues to score 10 or more, a more in-depth psychological assessment should be
conducted. The GHQ has demonstrated good validity among people attending treatment for AOD use
[1924].

The Symptom Checklist-90-Revised (SCL-90-R) is a 90-item self-report questionnaire measuring

symptoms of somatisation, obsessive compulsive, interpersonal sensitivity, depression, anxiety,
hostility, phobic anxiety, paranoid thoughts, and psychoticism [1925]. It has been used among people
with AOD-related conditions and has been found to perform better than other general measures of
psychological functioning [1926]. It has also demonstrated good reliability and validity in clinical and
non-clinical populations [1927, 1928]. The scale provides scores for severity, intensity and extensiveness
of symptoms and has been shown to have superior sensitivity to competing scales [1929].

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 [1930].
However, the long and short forms of the SCL-90-R are copyrighted and must be purchased by registered
psychologists [1925]. 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. It has been shown to be effective in various populations of people
who use AOD [1931, 1932]. However, the reliability and validity of the scale is dependent upon clinical
expertise and specific training [1926]. 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 [1933, 1934].

The Psychiatric Diagnostic Screening Questionnaire consists of 132-items designed to screen

for over 13 different DSM-IV-TR [29] Axis I disorders, including AOD use disorders [1935]. 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
[1935–1937]. 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
[1938].
374 Appendix I: Additional screening tools

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 [1939, 1940]. 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 [1941, 1942]. 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 [1943]. It has been shown to have high internal consistency and test-retest reliability. It also
shows good discriminant validity when distinguishing between low and high suicide risk among people
with mental health disorders [1944]. 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 suicidal ideation [1945]. 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 [1926]. This scale has been found to have similar psychometric
properties to other reliable and valid measures of suicide risk assessment [1946]. The Beck Anxiety
Inventory [1947] consists of 21 items, each describing a common symptom of anxiety. The respondent
is asked to rate how much they have 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
[1947–1950]. 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 General Anxiety Disorder Screener (GAD-7) also measures anxiety, and was developed as an
anxiety-specific version of the Patient Health Questionnaire [1951]. This self-report measure consists
of seven symptoms of anxiety that correspond to those for GAD in the DSM-IV [29], and clients rate
the frequency with which they have experienced these symptoms in the last fortnight on a four-point
scale. These items are summed to obtain a total score, and an additional item assesses the extent to
which anxiety symptoms have affected overall functioning. The GAD-7 demonstrates good reliability and
validity among people with both single mental and AOD use disorders [1952–1955], as well as the general
population [1956]. A brief two-item version demonstrates similar diagnostic accuracy to the seven-item
version [1952]. This measure can be downloaded from: www.phqscreeners.com/select-screener.

The Montreal Cognitive Assessment (MoCA) is a 30-item clinician-administered questionnaire which

assesses for cognitive impairment and takes around 10 minutes to complete [1957]. This screening tool
assesses several cognitive domains including memory, orientation, and attention. Before being able to
administer and score the MoCA, clinicians must first complete official MoCA training and be certified. The
MoCA should be interpreted in the wider context of a person’s presentation and history [1958], particularly
among people with co-occurring conditions due to the complex presentation of this population. As the
MoCA is a screening rather than a diagnostic instrument, a low score would indicate the need for referral
to a neurocognitive specialist for assessment and/or treatment [1959]. The MoCA has been shown to be
valid and accurate among people with single mental and AOD use disorders [1960–1963]. One study which
evaluated screening tools for cognitive impairment additionally concluded that the MoCA demonstrates
the most consistent adequate diagnostic accuracy among adults with AOD use disorders [1964]. This
measure, and the related training and certification, are available from: www.mocatest.org.
Appendix I: Additional screening tools 375

The Patient Health Questionnaire (PHQ-9) is a nine-item self-report questionnaire which assesses
the presence and frequency of depression symptoms corresponding to those for major depressive
disorder in the DSM-IV [29, 1965, 1966]. Clients rate the frequency with which they have experienced these
symptoms in the last fortnight on a four-point scale. These items are summed to obtain a total score,
and an additional item assesses the extent to which these symptoms have affected overall functioning.
The PHQ-9 demonstrates good reliability and validity among people with both single mental and AOD
use disorders [1952, 1967–1969]. Among people with AOD use disorders, the PHQ-9 similarly predicts
an increased risk of suicidal behaviour [1970], and an evaluation of different measures for screening
depression concluded the PHQ-9 has the highest diagnostic accuracy [1971]. As the PHQ was originally
developed to screen for five disorders, there have been several versions of the PHQ developed, including
a 15-item scale for somatic symptoms, a seven-item scale for generalised anxiety (the GAD-7; described
above), and brief two-item versions of both the depression and anxiety scales [1972]. Although the
evidence described in this section refers to the nine-item version, the two-item version demonstrates
similar diagnostic accuracy [1952]. The PHQ-9 is available to download from: www.phqscreeners.com/
select-screener.
376 Appendix J: CANSAS-P

Appendix J: CANSAS-P

Name:

Other identifying information (e.g., date of birth):

Date of completion:

Instructions: please tick one box in each row (22 in total)

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

Do not want to answer

Unmet need
Met need
No 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 given clear information about your medication?
Appendix J: CANSAS-P 377

Do not want to answer

Unmet need
Met need
No need
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?

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 Dependents
Do you have any dependents, e.g., children under 18?

18 Basic education
Do you have any difficulty in reading, writing or understanding English?

19 Digital communication
Do you have a phone and access to the internet?

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. (2020). Camberwell Assessment of Need (2nd Ed.). Cambridge, UK: Cambridge
University Press. www.researchintorecovery.com/measures/can
378 Appendix K: Depression Anxiety Stress Scale (DASS 21)

Appendix K: 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:
0. Did not apply to me at all
1. Applied to me to some degree, or some of the time
2. Applied to me to a considerable degree, or a good part of the time Office use
3. Applied to me very much, or most of the time D A S

1. I found it hard to wind down 0 1 2 3

2. I was aware of dryness of my mouth 0 1 2 3

3. I couldn't seem to experience any positive feeling at all 0 1 2 3

4. I experienced breathing difficulty (e.g., excessively rapid 0 1 2 3

breathing, breathlessness in the absence of physical
exertion)
5. I found it difficult to work up the initiative to do things 0 1 2 3

6. I tended to overreact to situations 0 1 2 3

7. I experienced trembling (e.g., in the hands) 0 1 2 3

8. I felt that I was using a lot of nervous energy 0 1 2 3

9. I was worried about situations in which I might panic and 0 1 2 3

make a fool of myself
10. I felt that I had nothing to look forward to 0 1 2 3

11. I found myself getting agitated 0 1 2 3

12. I found it difficult to relax 0 1 2 3

13. I felt downhearted and blue 0 1 2 3

14. I was intolerant of anything that kept me from getting on 0 1 2 3

with what I was doing
15. I felt I was close to panic 0 1 2 3

16. I was unable to become enthusiastic about anything 0 1 2 3

17. I felt I wasn't worth much as a person 0 1 2 3

Appendix K: Depression Anxiety Stress Scale (DASS 21) 379

Office use
D A S

0 1 2 3
18. I felt that I was rather touchy
0 1 2 3
19. I was aware of the action of my heart in the absence of
physical exertion (e.g., sense of heart rate increase, heart
missing a beat)
0 1 2 3
20. I felt scared without any good reason
0 1 2 3
21. I felt that life was meaningless

Totals

Source: Lovibond SH, & Lovibond PF. (1995). Manual for the Depression Anxiety Stress Scales (2nd. ed). Sydney, Australia:
Psychology Foundation.
380 Appendix K: Depression Anxiety Stress Scale (DASS 21)

DASS-21 Scoring template and interpretation

The Depression Anxiety Stress Scale (DASS) [467] has been shown to be a valid and reliable measure
of the dimensions of depression, anxiety, and stress separately but also taps into a more general
dimension of psychological distress [468, 469]. The DASS is available in two forms: the DASS-21 and the
DASS-42. The use of either test is sufficient in the screening process (i.e., the use of both is unnecessary).
The two forms have 21 and 42 items respectively and are each rated on a 4-point scale of how much each
particular statement applies to the person. The DASS is a self-report instrument, and no special skills
are required to administer or score it. However, decisions based on particular score profiles should be
made only by experienced clinicians who have carried out an appropriate clinical examination [467].
Nevertheless, it is a useful tool for screening and assessment.

For all questions, the client circles the answer truest to them in the past week. Scores are summed for
each scale (D = Depression, A = Anxiety, S = Stress), and the total for each scale multiplied by 2. A guide to
interpreting DASS scores is provided in Table 67.

Currently, no studies have been conducted to validate the DASS as a measure of anxiety among people
with AOD use disorders. However, one study has shown that the DASS can reliably screen for depression
symptoms among people seeking treatment for AOD use [470]. Similarly, another study has shown that
the DASS can be used as a reliable screen for symptoms of PTSD among people with AOD use disorders
[471].

Table 67: Interpreting DASS scores

Depression Anxiety Stress

Normal 0-9 0-7 0-14

Mild 10-13 8-9 15-18

Moderate 14-20 10-14 19-25

Severe 21-27 15-19 26-33

Extremely severe 28+ 20+ 34+

Adapted from: Lovibond SH, & Lovibond PF. (1995). Manual for the Depression Anxiety Stress Scales (2nd. ed). Sydney,
Australia: Psychology Foundation.
Appendix L: Indigenous Risk Impact Screener (IRIS) 381

Appendix L: Indigenous Risk Impact Screener (IRIS)

Name: Date:

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?

1. Never 2. Sometimes when I stop 3. Yes, every time

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

4. Once a week 5. More than once a week 6. Most days/Every day

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 or 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?

1. At night 2. In the afternoon 3. Sometimes in the 4. As soon as I wake up

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

8. How often do you feel down in the dumps, sad or slack?

1. Never/Hardly ever 2. Sometimes 3. Most days/Every day

382 Appendix L: Indigenous Risk Impact Screener (IRIS)

9. How often have you felt that life is hopeless?

1. Never/Hardly ever 2. Sometimes 3. Most days/Every day

10. How often do you feel nervous or scared?

1. Never/Hardly ever 2. Sometimes 3. Most days/Every day

11. Do you worry much?

1. Never/Hardly ever 2. Sometimes 3. Most days/Every day

12. How often do you feel restless and that you can’t sit still?

1. Never/Hardly ever 2. Sometimes 3. Most days/Every day

13. Do past events in your family still affect your wellbeing today (such as being taken away
from family)?

1. Never/Hardly ever 2. Sometimes 3. 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.
Appendix L: Indigenous Risk Impact Screener (IRIS) 383

IRIS interpretation
The Indigenous Risk Impact Screen (IRIS) [472] was developed by an expert group of Indigenous
and non-Indigenous researchers in Queensland to assist with the early identification of AOD problems
and mental health risks. This screen has been shown to be reliable, simple, and effective [473]. It has
also been validated for use in Indigenous prison populations [474, 475]. The IRIS consists of 13 items
which are asked by the AOD worker. The IRIS is made up of two sets of questions, with items 1–7 forming
the ‘AOD risk’ component and items 8– 13 forming the ‘mental health and emotional wellbeing risk’
component. The items assessing mental health and emotional wellbeing focus on symptoms of anxiety
and depression. The client chooses the answer from a list of response options which best describes
their current situation. After tallying up the corresponding numbers, a score of 10 or greater on the AOD
component indicates problematic use of AOD is likely, while a score of 11 or greater indicates the need for
further assessment or brief intervention regarding mental health and emotional wellbeing [473].
384 Appendix M: Kessler psychological distress scale (K10)

Appendix M: 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 previous question was ‘none of the time’.

In the past four weeks: None A little Some Most All of

of the of the of the of the the
time time time time time
1. About how often did you feel 1 2 3 4 5
tired out for no good reason?
2. About how often did you feel 1 2 3 4 5
nervous?
3. About how often did you 1 2 3 4 5
feel so nervous that nothing
could calm you down?
4. About how often did you feel 1 2 3 4 5
hopeless?
5. About how often did you feel 1 2 3 4 5
restless or fidgety?
6. About how often did you feel 1 2 3 4 5
so restless you could not sit
still?
7. About how often did you feel 1 2 3 4 5
depressed?
8. About how often did you feel 1 2 3 4 5
that everything is an effort?
9. About how often did you feel 1 2 3 4 5
so sad that nothing could
cheer you up?
10. About how often did you feel 1 2 3 4 5
worthless?
Total:

Test: Kessler, RC. (1996). Kessler’s 10 Psychological Distress Scale. Boston, MA: Harvard Medical School.
Normative data: Australian Bureau of Statistics. (1997). National Survey of Mental Health and Well-being. Canberra,
Australia.
Appendix M: Kessler psychological distress scale (K10) 385

K10 scoring and interpretation

The Kessler psychological distress scale (K10) [476] is a widely used, simple self-report measure of
psychological distress which can be used to identify those in need of further assessment for anxiety and
depression. This measure was designed for use in the general population; however, it may also serve as a
useful clinical tool. The K10 comprises 10 questions that are answered using a five-point scale (where 5 =
all of the time, and 1 = none of the time). For all questions, the client circles the answer truest for them in
the past four weeks. Scores are then summed with the maximum score of 50 indicating severe distress,
and the minimum score of 10 indicating no distress. A guide to interpreting K10 scores is provided in
Table 68.

A number of studies have been conducted to test the reliability and validity of the K10, and its brief
version, the K6. Good reliability and validity have been found when these measures have been used with
individuals with AOD use disorders [479, 1973, 1974].

Table 68: Severity of psychological distress according to K10 score

K10 score Level of psychological distress

10-15 Low

16-21 Moderate

22-29 High

30-50 Very high

Source: Andrews G, & Slade T. (2001). Interpreting scores on the Kessler Psychological Distress Scale (K10). Australian
and New Zealand Journal of Psychiatry, 25, 494-497.
386 Appendix
Appendix N: The PsyCheck N: PsyCheck
screening tool

Appendix N: The PsyCheck screening tool

Client’s name: DOB:

Service: UR:

Mental health services assessment required? No Yes

Suicide/self-harm risk (please circle): High Moderate Low

Date: Screen completed by:

Clinician use only

Complete this section when all components of the PsyCheck have been administered.

Summary
Section 1 Past history of mental health problems No Yes

Section 2 Suicide risk completed and action taken No Yes

Section 3 SRQ score 0 1-4 5+

Interpretation/score – Self-Reporting Questionnaire (SRQ)

Score of 0* on the SRQ No symptoms of depression, anxiety and/or somatic complaints indicated at
this time.

Action: Re-screen using the PsyCheck Screening Tool after four weeks if
indicated by past mental health questions or other information. Otherwise
monitor as required.
Score of 1-4* on the SRQ Some symptoms of depression, anxiety and/or somatic complaints indicated
at this time.

Action: Give the first session of the PsyCheck Intervention and screen again in
four weeks.
Score of 5+* on the SRQ Considerable symptoms of depression, anxiety and/or somatic complaints
indicated at this time.

Action: Offer sessions 1–4 of the PsyCheck Intervention.

Re-screen using the PsyCheck Screening Tool at the conclusion of four sessions.

If no improvement in scores evident after re-screening, consider referral.

*Regardless of the client’s total score on the SRQ, consider intervention or referral if in significant
distress.
 The PsyCheck screening tool
Appendix N: PsyCheck 387

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 No Yes

problems or problems with your ‘nerves’/anxieties/worries?

Details:

2. Have you ever been given medication for emotional problems or problems with your ‘nerves’/
anxieties/worries?

No, never

Yes, in the past but not currently Medication(s):

Yes, currently Medication(s):

3. Have you ever been hospitalised for emotional problems or No Yes

problems with your ‘nerves’/anxieties/worries?
Details:

4. Do you have a current mental health worker, psychiatrist, psychologist, general practitioner or other
health provider? If ‘No’, go to Question 5.

Psychiatrist Psychologist

Name: Name:

Contact details: Contact details:

Role: Role:

Mental health worker General practitioner

Name: Name:

Contact details: Contact details:

Role: Role:

Other - specify Other - specify

Name: Name:

Contact details: Contact details:

Role: Role:
5. Has the thought of ending your life ever been
No Yes If ‘No’, go to Section 3
on your mind?

Has that happened recently? No Yes If ‘Yes’, go to Section 2

388 Appendix
Appendix N: The PsyCheck N: PsyCheck
screening tool

PsyCheck risk assessment

Name: Date:

Clinician to administer this section

If the person says ‘Yes’ to recently thinking about ending their 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.

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.

Risk factor Low risk Moderate risk High risk

History of harm to self • Previous low • Moderate lethality • High lethality,

lethality frequent

History of harm in • Previous low • Moderate lethality • High lethality,

family members or lethality frequent
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.

Risk factor Low risk Moderate risk High risk

Intent • No intent • No immediate • Immediate intent

intent
Plans • Vague plan • Viable plan • Detailed plan

Means • No means • Means available • Means already

obtained

Lethality • Minor self-harm • Planned overdose, • Firearms,

behaviours, serious cutting, hanging, jumping,
intervention intervention intervention
unlikely impossible unlikely
 The PsyCheck screening tool
Appendix N: PsyCheck 389

3. Mental health factors: Assess for history and current mental health symptoms, including depression
and psychosis.

Risk factor Low risk Moderate risk High risk

History of current • Lowered or • Enduring lowered • Depression

depression unchanged mood mood diagnosis

Mental health disorder • Few or no • Pronounced clinical • Multiple

symptoms or signs symptoms with no
well-managed management
significant illness

4. Protective factors: These include social support, ability or decision to use support, family involvement,
stable lifestyle, adaptability and flexibility in personality style etc.

Risk factor Low risk Moderate risk High risk

Coping skills and • Many • Some • Few

resources

Family/friendships/ • Many • Some • Few

networks

Stable lifestyle • Many • Some • Few

Ability to use • Many • Some • Few

supports
390 Appendix
Appendix N: The PsyCheck N: PsyCheck
screening tool

Self-reporting questionnaire (SRQ)

Name: Date:

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

2. Is your appetite poor? No Yes

3. Do you sleep badly? No Yes

4. Are you easily frightened? No Yes

5. Do your hands shake? No Yes

6. Do you feel nervous? No Yes

7. Is your digestion poor? No Yes

8. Do you have trouble thinking clearly? No Yes

9. Do you feel unhappy? No Yes

10. Do you cry more than usual? No Yes

11. Do you find it difficult to enjoy your daily activities? No Yes

12. Do you find it difficult to make decisions? No Yes

13. Is your daily work suffering? No Yes

14. Are you unable to play a useful part in life? No Yes

15. Have you lost interest in things? No Yes

16. Do you feel that you are a worthless person? No Yes

17. Has the thought of ending your life been on your mind? No Yes

18. Do you feel tired all the time? No Yes

19. Do you have uncomfortable feelings in the stomach? No Yes

20. Are you easily tired? No Yes

Total score (add circles):

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.
Appendix O: Adult ADHD Self-Report Scale (ASRS) 391

Appendix O: Adult ADHD Self-Report Scale (ASRS)

Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist Instructions

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 utilised 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.
392 Appendix O: Adult ADHD Self-Report Scale (ASRS)

Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Patient Name: Today’s Date:

Please answer the questions below, rating yourself on each

of the criteria shown using the scale on the right side of the
page. As you answer each question, place an X in the box that
best describes how you have felt and conducted yourself

Sometimes

Very often
over the past 6 months. Please give this completed checklist

Rarely
Never

Often
to your healthcare professional to discuss during today’s
appointment.

1. How often do you have trouble wrapping up the final

details of a project, once the challenging parts have been
done?

2. How often do you have difficulty getting things in order

when you have to do a task that requires organisation?

3. How often do you have problems remembering

appointments or obligations?

4. When you have a task that requires a lot of thought, how

often do you avoid or delay getting started?

5. How often do you fidget or squirm with your hands or feet

when you have to sit down for a long time?

6. How often do you feel overly active and compelled to do

things, like you were driven by a motor?

Part A

7. How often do you make careless mistakes when you have

to work on a boring or difficult project?

8. How often do you have difficulty keeping your attention

when you are doing boring or repetitive work?

9. How often do you have difficulty concentrating on what

people say to you, even when they are speaking to you
directly?

10. How often do you misplace or have difficulty finding

things at home or at work?

11. How often are you distracted by activity or noise around

you?
Appendix O: Adult ADHD Self-Report Scale (ASRS) 393

Sometimes

Very often
Rarely
Never

Often
12. How often do you leave your seat in meetings or other
situations in which you are expected to remain seated?

13. How often do you feel restless or fidgety?

14. How often do you have difficulty unwinding and relaxing

when you have time to yourself?

15. How often do you find yourself talking too much when
you are in social situations?

16. When you’re in a conversation, how often do you find

yourself finishing the sentences of the people you are
talking to, before they can finish them themselves?

17. How often do you have difficulty waiting your turn in

situations when turn taking is required?

18. How often do you interrupt others when they are busy?

Part B
394 Appendix O: Adult ADHD Self-Report Scale (ASRS)

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 (Schweitzer, et al. 2001; Barkley 1998; Biederman, et al. 1993; AMA
2000). 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 Organisation (WHO), and the Workgroup on Adult ADHD that included the following team of
psychiatrists and researchers:

Lenard Adler, MD Ronald C. Kessler, PhD

Associate Professor of Psychiatry and Neurology Professor, Department of Health Care Policy

New York University Medical School Harvard Medical School

Thomas Spencer, MD

Associate Professor of Psychiatry

Harvard Medical School

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 (Schweitzer, et al. 2001).

The checklist takes about 5 minutes to complete and can provide information that is critical to
supplement the diagnostic process.

References:

Schweitzer JB, et al. Med Clin North Am. 2001;85(3):10-11, 757-777.

Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. 1998.

Biederman J, et al. Am J Psychiatry. 1993;150:1792-1798.

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
Organisation Adult ADHD Self-Report Scale (ASRS). Psychological Medicine, 35, 245-256.
Appendix P: The International Trauma Questionnaire (ITQ) 395

Appendix P: The International Trauma Questionnaire (ITQ)

Instructions: Please identify the experience that troubles you most and answer the questions in relation
to this experience.

Brief description of the experience:

When did the experience occur? (circle one)

a. Less than 6 months ago

b. 6 to 12 months ago

c. 1 to 5 years ago

d. 5 to 10 years ago

e. 10 to 20 years ago

f. More than 20 years ago

Below are a number of problems that people sometimes report in response to traumatic or stressful life
events. Please read each item carefully, then circle one of the numbers to the right to indicate how much
you have been bothered by that problem in the past month.

Not A little Quite

Moderately Extremely
at all bit a bit

P1. Having upsetting dreams that 0 1 2 3 4

replay part of the experience
or are clearly related to the
experience?

P2. Having powerful images or 0 1 2 3 4

memories that sometimes come
into your mind in which you feel
the experience is happening
again in the here and now?

P3. Avoiding internal reminders of 0 1 2 3 4

the experience (for example,
thoughts, feelings, or physical
sensations)?

P4. Avoiding external reminders 0 1 2 3 4

of the experience (for example,
people, places, conversations,
objects, activities, or
situations)?
396 Appendix P: The International Trauma Questionnaire (ITQ)

Not A little Quite

Moderately Extremely
at all bit a bit

P5. Being ‘super-alert’, watchful, or 0 1 2 3 4

on guard?

P6. Feeling jumpy or easily startled? 0 1 2 3 4

In the past month have the Not A little Quite

Moderately Extremely
above problems: at all bit a bit

P7. Affected your relationships or 0 1 2 3 4

social life?

P8. Affected your work or ability to 0 1 2 3 4

work?

P9. Affected any other important 0 1 2 3 4

part of your life such as
parenting, or school or college
work, or other important
activities?

Below are problems that people who have had stressful or traumatic events sometimes experience.
The questions refer to ways you typically feel, ways you typically think about yourself and ways you
typically relate to others. Answer the following thinking about how true each statement is of you.

Not A little Quite

How true is this of you? at all bit
Moderately
a bit
Extremely

C1. When I am upset, it takes me a 0 1 2 3 4

long time to calm down.

C2. I feel numb or emotionally shut 0 1 2 3 4

down.

C3. I feel like a failure. 0 1 2 3 4

C4. I feel worthless. 0 1 2 3 4

C5. I feel distant or cut off from 0 1 2 3 4

people.

C6. I find it hard to stay emotionally 0 1 2 3 4

close to people.
Appendix P: The International Trauma Questionnaire (ITQ) 397

In the past month, have the

above problems in emotions, Not A little Quite
Moderately Extremely
in beliefs about yourself and in at all bit a bit
relationships:

C7. Created concern or distress 0 1 2 3 4

about your relationships or
social life?

C8. Affected your work or ability to 0 1 2 3 4

work?

C9. Affected any other important 0 1 2 3 4

parts of your life such as
parenting, or school or college
work, or other important
activities?

Source: Cloitre, M., Shevlin M., Brewin, C.R., Bisson, J.I., Roberts, N.P., Maercker, A., Karatzias, T., & Hyland, P. (2018). The
International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and Complex PTSD. Acta
Psychiatrica Scandinavica, 139, 536-546.
398 Appendix P: The International Trauma Questionnaire (ITQ)

ITQ: Scoring and interpretation

PTSD. A diagnosis of PTSD requires the endorsement of at least one of the two symptoms from each of
the symptom clusters of (1) re-experiencing in the here and now (P1 or P2), (2) avoidance (P3 or P4), and
(3) sense of current threat (P5 or P6); plus endorsement of at least one indicator of the three types of
functional impairment associated with these symptoms (P7, P8 or P9).

Endorsement of a symptom or functional impairment item is defined as a score ≥ 2.

CPTSD. A diagnosis of CPTSD requires the endorsement of at least one of the two symptoms from each
of the three PTSD symptom clusters described above (i.e., re-experiencing in the here and now, avoidance,
and sense of current threat) and at least one of the two symptoms from each of the three Disturbances in
Self-Organisation (DSO) clusters: (1) affective dysregulation (C1 or C2), (2) negative self-concept (C3 or C4),
and (3) disturbances in relationships (C5 or C6). Functional impairment must also be identified where at
least one indicator of the three types of functional impairment is endorsed related to the PTSD symptoms
(as described above), and one indicator of the three types of functional impairment is endorsed related to
the DSO symptoms (C7, C8, or C9).

Endorsement of a symptom or functional impairment item is defined as a score ≥ 2.

An individual can receive either a diagnosis of PTSD or CPTSD, but not both. If a person meets the criteria
for CPTSD, that person does not also receive a PTSD diagnosis.
Appendix Q: Life Events Checklist for DSM-5 (LEC-5) 399

Appendix Q: Life Events Checklist for DSM-5 (LEC-5)

Instructions: Listed below are a number of difficult or stressful things that sometimes happen to
people. For each event, check one or more of the boxes to the right to indicate that: (a) it happened to
you personally; (b) you witnessed it happen to someone else; (c) you learned about it happening
to a close family member or close friend; (d) you were exposed to it as part of your job (for example,
paramedic, police, military, or other first responder); (e) you’re not sure if it fits; or (f) it doesn’t apply to
you.

Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events.

Happened Witnessed Learned Part of Not Doesn’t

Event
to me it about it my job sure apply

1. Natural disaster
(for example, flood,
hurricane, tornado,
earthquake)

2. Fire or explosion

3. Transportation
accident (for
example, car
accident, boat
accident, train
wreck, plane crash)

4. Serious accident
at work, home, or
during recreational
activity

5. Exposure to toxic
substance (for
example, dangerous
chemicals,
radiation)

6. Physical assault
(for example, being
attacked, hit,
slapped, kicked,
beaten up)
400 Appendix Q: Life Events Checklist for DSM-5 (LEC-5)

Happened Witnessed Learned Part of Not Doesn’t

Event
to me it about it my job sure apply

7. Assault with
a weapon (for
example, being shot,
stabbed, threatened
with a knife, gun,
bomb)

8. Sexual assault
(rape, attempted
rape, made to
perform any type of
sexual act through
force or threat of
harm)

9. Other unwanted
or uncomfortable
sexual experience

10. Combat or exposure

to a war-zone (in
the military or as a
civilian)

11. Captivity (for

example, being
kidnapped,
abducted, held
hostage, prisoner of
war)

12. Life-threatening
illness or injury

13. Severe human

suffering

14. Sudden violent

death (for example,
homicide, suicide)

15. Sudden accidental

death
Appendix Q: Life Events Checklist for DSM-5 (LEC-5) 401

Happened Witnessed Learned Part of Not Doesn’t

Event
to me it about it my job sure apply

16. Serious injury,

harm, or death you
caused to someone
else

17. Any other very

stressful event or
experience

Source: Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M. (2013). The Life Events
Checklist for DSM-5 (LEC-5) – Standard. [Measurement instrument]. Available from www.ptsd.va.gov.
402 Appendix R: Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)

Appendix R: Primary Care PTSD Screen for DSM-5 (PC-

PTSD-5)
Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic.
For example:

• a serious accident or fire

• a physical or sexual assault or abuse

• an earthquake or flood

• a war

• seeing someone be killed or seriously injured

• having a loved one die through homicide or suicide.

Have you ever experienced this kind of event?

YES NO

If no, screen total = 0. Please stop here.

If yes, please answer the questions below.

In the past month have you: Yes No

1. Had nightmares about the event(s) or thought about the event(s) 1 0

when you did not want to?

2. Tried hard not to think about the event(s) or went out of your way to 1 0
avoid situations that reminded you of the event(s)?

3. Been constantly on guard, watchful, or easily startled? 1 0

4. Felt numb or detached from people, activities, or your 1 0

surroundings?

5. Felt guilty or unable to stop blaming yourself or others for the 1 0

event(s) or any problems the event(s) may have caused?

Source: Prins, A., Bovin, M. J., Kimerling, R., Kaloupek, D. G., Marx, B. P., Pless Kaiser, A., & Schnurr, P. P. (2016). Primary
Care PTSD Screen for DSM-5 (PC-PTSD-5) [Measurement instrument]. Available from www.ptsd.va.gov.
Appendix R: Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) 403

PC-PTSD-5: Scoring and interpretation

The measure begins with an item designed to assess whether the respondent has had any exposure to
traumatic events. If a respondent denies exposure, the PC-PTSD-5 is complete with a score of 0.

If a respondent indicates a trauma history – experiencing a traumatic event over the course of their life
– the respondent is instructed to answer five additional yes/no questions about how that trauma has
affected them over the past month.

Preliminary results from validation studies suggest that a cut-point of 3 on the PC-PTSD-5 (e.g.,
respondent answers ‘yes’ to any 3 of 5 questions about how the traumatic event(s) have affected them
over the past month) is optimally sensitive to probable PTSD. Optimising sensitivity minimises false
negative screen results. Using a cut-point of 4 is considered optimally efficient. Optimising efficiency
balances false positive and false negative results.

Total score is sum of ‘YES’ responses in items 1 to 5.

404 Appendix S: PTSD Checklist for DSM-5 (PCL-5)

Appendix S: PTSD Checklist for DSM-5 (PCL-5)

Instructions: Below is a list of problems that people sometimes have in response to a very stressful
experience. Please read each problem and then select one of the options to indicate how much you have
been bothered by that problem in the past month. The options include not at all, a little bit, moderately,
quite a bit, and extremely.

In the past month, how much Not A little Quite

Moderately Extremely
were you bothered by: at all bit a bit

1. Repeated, disturbing, and unwanted 0 1 2 3 4

memories of the stressful
experience?

2. Repeated, disturbing dreams of the 0 1 2 3 4

stressful experience?

3. Suddenly feeling or acting as if the 0 1 2 3 4

stressful experience were actually
happening again (as if you were
actually back there reliving it)?

4. Feeling very upset when something 0 1 2 3 4

reminded you of the stressful
experience?

5. Having strong physical reactions 0 1 2 3 4

when something reminded you
of the stressful experience (for
example, heart pounding, trouble
breathing, sweating)?

6. Avoiding memories, thoughts, or 0 1 2 3 4

feelings related to the stressful
experience?

7. Avoiding external reminders of the 0 1 2 3 4

stressful experience (for example,
people, places, conversations,
activities, objects, or situations)?

8. Trouble remembering important 0 1 2 3 4

parts of the stressful experience?
Appendix S: PTSD Checklist for DSM-5 (PCL-5) 405

In the past month, how much Not A little Quite

Moderately Extremely
were you bothered by: at all bit a bit

9. Having strong negative beliefs 0 1 2 3 4

about yourself, other people, or
the world (for example, having
thoughts such as: I am bad, there is
something seriously wrong with me,
no one can be trusted, the world is
completely dangerous)?

10. Blaming yourself or someone else 0 1 2 3 4

for the stressful experience or what
happened after it?

11. Having strong negative feelings 0 1 2 3 4

such as fear, horror, anger, guilt, or
shame?

12. Loss of interest in activities that 0 1 2 3 4

you used to enjoy?

13. Feeling distant or cut off from other 0 1 2 3 4

people?

14. Trouble experiencing positive 0 1 2 3 4

feelings (for example, being unable
to feel happiness or have loving
feelings for people close to you)?

15. Irritable behavior, angry outbursts, 0 1 2 3 4

or acting aggressively?

16. Taking too many risks or doing 0 1 2 3 4

things that could cause you harm?

17. Being ‘super alert’ or watchful or on 0 1 2 3 4

guard?

18. Feeling jumpy or easily startled? 0 1 2 3 4

19. Having difficulty concentrating? 0 1 2 3 4

20. Trouble falling or staying asleep? 0 1 2 3 4

Source: Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD Checklist for
DSM-5 (PCL-5) – Standard [Measurement instrument]. Available from www.ptsd.va.gov.
406 Appendix S: PTSD Checklist for DSM-5 (PCL-5)

PCL-5: Scoring and interpretation

Respondents are asked to rate how bothered they have been by each of 20 items in the past month on
a 5-point Likert scale ranging from 0-4 (0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 =
Extremely). Items are summed to provide a total severity score (range 0-80).

The PCL-5 can determine a provisional diagnosis in two ways:

• Summing all 20 items (range 0-80) and using a cut-point score of 31-33 which appears to be
reasonable based upon current psychometric work. However, when choosing a cut-off score, it is
essential to consider the goals of the assessment and the population being assessed. The lower
the cut-off score, the more lenient the criteria for inclusion, increasing the possible number of
false-positives. The higher the cut-off score, the more stringent the inclusion criteria and the more
potential for false-negatives.

• Treating each item rated as 2 = ‘Moderately’ or higher as a symptom endorsed, then following the
DSM-5 diagnostic rules which requires at least: 1 Criterion B item (questions 1-5), 1 Criterion C
item (questions 6-7), 2 Criterion D items (questions 8-14), 2 Criterion E items (questions 15-20). In
general, use of a cut-off score tends to produce more reliable results than the DSM-5 diagnostic
rule.

If a patient meets a provisional diagnosis using either of the methods above, they need further
assessment (e.g., Clinical Administered PTSD Scale for DSM-5: CAPS-5) to confirm a diagnosis of PTSD.

There are currently no empirically derived severity ranges for the PCL-5.
Appendix T: Psychosis Screener (PS) 407

Appendix T: Psychosis Screener (PS)

1. In the past 12 months, have you felt that your thoughts were being No Yes
directly interfered with or controlled by another person?

a. Did it come about in a way that many people would find hard to No Yes
believe, for instance, through telepathy?

2. In the past 12 months, have you had a feeling that people were too No Yes
interested in you?

a. In the past 12 months, have you had a feeling that things were No Yes
arranged so as 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

a. Do you belong to a group of people who also have these special No Yes
powers?

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.
408 Appendix U: Alcohol Use Disorders Identification Test (AUDIT)

Appendix U: Alcohol Use Disorders Identification Test

(AUDIT)
The Alcohol Use Disorders Identification Test: Self-Report Version

PATIENT: Because alcohol use can affect your health and can interfere with certain medications and
treatments, it is important that we ask some questions about your use of alcohol. Your answers will
remain confidential so please be honest. Circle one box that best describes your answer to each question.

0 1 2 3 4

1. How often do you have a drink Never Monthly 2-3 2-3 4 or

containing alcohol? times a times a more
month week times a
week

2. How many drinks containing 1 or 2 3 or 4 5 or 6 7 to 9 10 or

alcohol do you have on a more
typical day when you are
drinking?

3. How often do you have six or Never Less Monthly Weekly Daily or
more drinks on one occasion? than almost
monthly daily

4. How often during the last year Never Less Monthly Weekly Daily or
have you found that you were than almost
not able to stop drinking once monthly daily
you had started?

5. How often during the last year Never Less Monthly Weekly Daily or
have you failed to do what than almost
was normally expected of you monthly daily
because of drinking?

6. How often during the last year Never Less Monthly Weekly Daily or
have you needed a first drink than almost
in the morning to get yourself monthly daily
going after a heavy drinking
session?

7. How often during the last year Never Less Monthly Weekly Daily or
have you had a feeling of guilt than almost
or remorse after drinking? monthly daily
Appendix U: Alcohol Use Disorders Identification Test (AUDIT) 409

0 1 2 3 4

8. How often during the last Never Less Monthly Weekly Daily or
year have you been unable to than almost
remember what happened the monthly daily
night before because of your
drinking?
9. Have you or someone else No Yes, but Yes,
been injured because of your not in during
drinking? the last the last
year year

10. Has a relative, friend, doctor, or No Yes, but Yes,

other health care worker been not in during
concerned about your drinking the last the last
or suggested you cut down? year year

Total:

Source: Babor, TF, Higgins-Biddle, JC, Saunders, JB, & Monteiro, MG. (2001). The Alcohol Use Disorders Identification
Test: Guidelines for Use in Primary Care, Second Edition. Geneva, Switzerland: World Health Organisation, Department of
Mental Health and Substance Dependence.
410 Appendix U: Alcohol Use Disorders Identification Test (AUDIT)

AUDIT Scoring: Clinician use only

The number in the column of each response circled by the client should be entered by the scorer in the
extreme right-hand column. All responses should be added and recorded in the Total box.

Risk level AUDIT score* Intervention

Zone I: Low risk 0 to 7 Alcohol education

Zone II: Hazardous 8 to 15 Simple advice and patient education materials

Zone III: Harmful 16 to 19 Simple advice plus brief counselling and ongoing
monitoring

Zone IV: Dependent 20 to 40 Referred to a specialist for diagnostic evaluation and

possible treatment

*The cut-off score may vary slightly depending on the country’s drinking patterns, the alcohol content
of standard drinks, and the nature of the screening program. Clinical judgement should be exercised in
cases where the patient’s score is not consistent with other evidence, or if the patient has a prior history
of alcohol dependence. It may also be instructive to review the patient’s responses to individual questions
dealing with dependence symptoms (Questions 4, 5 and 6) and alcohol-related problems (Questions 9
and 10). Provide the next highest level of intervention to patients who score 2 or more on Questions 4, 5
and 6, or 4 on Questions 9 or 10.

Source: Babor, TF, Higgins-Biddle, JC, Saunders, JB, & Monteiro, MG. (2001). The Alcohol Use Disorders Identification
Test: Guidelines for Use in Primary Care, Second Edition. Geneva, Switzerland: World Health Organisation, Department of
Mental Health and Substance Dependence.
Appendix V: CAGE Substance Abuse Screening Tool 411

Appendix V: CAGE Substance Abuse Screening Tool

Yes No

1. Have you ever felt you should cut down on your drinking? 1 0

2. Have people annoyed you by criticising your drinking? 1 0

3. Have you ever felt bad or guilty about your drinking? 1 0

4. Have you ever had a drink first thing in the morning to steady your 1 0
nerves or to get rid of a hangover (eye-opener)?

Source: Ewing, J. A. (1984). Detecting alcoholism. The CAGE questionnaire. JAMA, 252(14), 1905–1907.
412 Appendix V: CAGE Substance Abuse Screening Tool

CAGE: Scoring and interpretation

Directions

Ask your patients these four questions and use the scoring method described below to determine if
substance abuse exists and needs to be addressed.

Scoring

Item responses on the CAGE questions are scored 0 for ‘no’ and 1 for ‘yes’ answers, with a higher score
being an indication of alcohol problems. A total score of two or greater is considered clinically significant.

The normal cut-off for the CAGE is two positive answers, however, it is recommended that primary care
clinicians lower the threshold to one positive answer to cast a wider net and identify more patients who
may have substance abuse disorders.
Appendix W: Drug Abuse Screening Test (DAST-10) 413

Appendix W: Drug Abuse Screening Test (DAST-10)

Instructions:

‘Drug use’ refers to (1) the use of prescribed or over-the-counter drugs in excess of the directions, and (2)
any nonmedical use of drugs.

The various classes of drugs may include cannabis, solvents (e.g., paint thinner), benzodiazepines (e.g.,
Valium), cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or opioids (e.g., heroin). The questions
do not include alcoholic beverages.

Please answer every question. If you have difficulty with a statement, then choose the response that is
mostly right.

These questions refer to drug use in the past 12 months. Please answer No or Yes.

No Yes

1. Have you used drugs other than those required for medical reasons?

2. Do you use more than one drug at a time?

3. Are you always able to stop using drugs when you want to?

4. Have you had ‘blackouts’ or ‘flashbacks’ as a result of drug use?

5. Do you ever feel bad or guilty about your drug use?

6. Does your spouse (or parents) ever complain about your

involvement with drugs?

7. Have you neglected your family because of your use of drugs?

8. Have you engaged in illegal activities in order to obtain drugs?

9. Have you ever experienced withdrawal symptoms (felt sick) when

you stopped taking drugs?

10. Have you had medical problems as a result of your drug use (e.g.,
memory loss, hepatitis, convulsions, bleeding, etc.)?

Source: Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behavior, 7(4), 363-371.
414 Appendix W: Drug Abuse Screening Test (DAST-10)

DAST-10: Scoring and interpretation

Scoring

Score 1 point for each question answered ‘Yes’, except for question 3 for which a ‘No’ receives 1 point. A
guide to interpreting scores is provided in Table 69.

Total score:

Table 69: Interpreting DAST-10 score

Degree of problems related to

Score Suggested action
drug abuse

0 No problems reported None at this time

1-2 Low level Monitor, reassess at a later date

3-5 Moderate level Further investigation

6-8 Substantial level Intensive assessment

9-10 Severe level Intensive assessment

Appendix X: Drug Use Disorders Identification Test (DUDIT) 415

Appendix X: Drug Use Disorders Identification Test (DUDIT)

Here are a few questions about drugs. Please answer as correctly and honestly as possible by
indicating which answer is right for you.

1. How often do you use drugs other than alcohol?

Never Once a month or 2-4 times 2-3 times 4 times a week

less often a month a week or more often

2. Do you use more than one type of drug on the same occasion?

Never Once a month or 2-4 times 2-3 times 4 times a week

less often a month a week or more often

3. How many times do you take drugs on a typical day when you use drugs?

0 1-2 3-4 5-6 7 or more

4. How often are you influenced heavily by drugs?

Never Less often than Every month Every week Daily or almost
once a month every day

5. Over the past year, have you felt that your longing for drugs was so strong that you could not
resist it?

Never Less often than Every month Every week Daily or almost
once a month every day

6. Has it happened, over the past year, that you have not been able to stop taking drugs once
you started?

Never Less often than Every month Every week Daily or almost
once a month every day
416 Appendix X: Drug Use Disorders Identification Test (DUDIT)

7. How often over the past year have you taken drugs and then neglected to do something you
should have done?

Never Less often than Every month Every week Daily or almost
once a month every day

8. How often over the past year have you needed to take a drug the morning after heavy drug
use the day before?

Never Less often than Every month Every week Daily or almost
once a month every day

9. How often over the past year have you had guilt feelings or a bad conscience because you
used drugs?

Never Less often than Every month Every week Daily or almost
once a month every day

10. Have you or anyone else been hurt (mentally or physically) because you used drugs?

No Yes, but not over the past year Yes, over the past year

11. Has a relative or a friend, a doctor or a nurse, or anyone else, been worried about your drug
use or said to you that you should stop using drugs?

No Yes, but not over the past year Yes, over the past year

Source: Berman, A. H., Bergman, H., Palmstierna, T., & Schlyter, F. (2003). DUDIT. The Drug Use Disorders Identification Test
Manual. Stockholm, Sweden: Karolinska Institutet.
Appendix X: Drug Use Disorders Identification Test (DUDIT) 417

DUDIT: Scoring and interpretation

The Drug Use Disorders Identification Test (DUDIT) is an 11-item tool, which can be self or clinician
administered, developed as a parallel to the AUDIT to identify problematic past year AOD use [522]. As
with the AUDIT, items 1 to 9 are scored on a 0 to 4 scale, with the final two questions scored 0, 2, 4 (Table
70). The maximum score is 44. Scoring guidelines suggest that a score of 6 or more among men, and 2
or more among women, may be indicative of drug-use-related problems. A score of 25 points or more,
regardless of sex, is strongly indicative of dependence [522].

Table 70: Scoring each DUDIT item

Item Scoring
1-9 0, 1, 2, 3, 4
10-11 0, 2, 4
418 Appendix Y: The Michigan Alcohol Screening Test (MAST)

Appendix Y: The Michigan Alcohol Screening Test (MAST)

The MAST is a simple, self-scoring test that helps assess if you have a drinking problem. Answer ‘yes’ or
‘no’ to the following questions:

Yes No
1. *Do you feel you are a normal drinker? (by normal, we mean you drink less than or as
much as most other people)
2. Have you ever awakened the morning after drinking the night before and found that
you could not remember a part of the evening?
3. Does your partner, a parent, or other near relative ever worry or complain about your
drinking?
4. *Can you stop drinking without a struggle after one or two drinks?
5. Do you ever feel guilty about your drinking?
6. *Do friends or relatives think you are a normal drinker?
7. *Are you able to stop drinking when you want to?
8. Have you ever attended a meeting of Alcoholics Anonymous (AA) because of your own
drinking?
9. Have you ever gotten into physical fights when drinking?
10. Has drinking ever created problems between you and your partner, a parent, or other
near relative?
11. Has your partner, a parent, or other near relative ever gone to anyone for help about
your drinking?
12. Have you ever lost friends or partners because of your drinking?
13. Have you ever gotten into trouble at work or school because of drinking?
14. Have you ever lost a job because of your drinking?
15. Have you ever neglected your obligations, your family, or your work for two or more
days in a row because you were drinking?
16. Do you drink before noon fairly often?
17. Have you ever been told you have liver trouble, such as cirrhosis?
18. After heavy drinking, have you ever had delirium tremens (DTs), severe shaking, or
heard voices or seen things that weren't really there?
19. Have you ever gone to anyone for help about your drinking?
20. Have you ever been in a hospital because of drinking?

21. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of
a general hospital where your drinking was part of the problem that resulted in
hospitalisation?
22. Have you ever been seen at a psychiatric or mental health clinic or gone to any doctor,
social worker, or clergy member for help with any emotional problem where your
drinking was part of the problem?
23. Have you ever been arrested for drunken driving, driving while intoxicated, or driving
Appendix Y: The Michigan Alcohol Screening Test (MAST) 419

Yes No
22. Have you ever been seen at a psychiatric or mental health clinic or gone to any doctor,
social worker, or clergy member for help with any emotional problem where your
drinking was part of the problem?
23. Have you ever been arrested for drunken driving, driving while intoxicated, or driving
under the influence of alcohol?
24. Have you ever been arrested, even for a few hours, because of other drunken
behaviour?

Source: Selzer, M. (1971). The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument.
American Journal of Psychiatry, 127, 1653–1658.
420 Appendix Y: The Michigan Alcohol Screening Test (MAST)

MAST: Scoring and interpretation

The Michigan Alcohol Screening Test (MAST) is a 24-item self-report tool designed to identify
lifetime problems with alcohol use [523]. Several modified versions of the MAST have been developed,
varying in length (e.g., the Short MAST or SMAST, containing 13-items; the Brief MAST or bMAST, containing
10-items), and for use in different population groups (e.g., MAST-Geriatric version, MAST-Adolescent
version).

The MAST can either be scored using a weighted scoring system or by assigning one point per item. Raw
unweighted scores are calculated by summing the points assigned to each question (yes = 1, no = 0).
Questions 1, 4, 6 and 7 are reverse scored (yes = 0, no = 1). Raw scores range from 0 to 24 with higher scores
indicative of more problematic alcohol use. Weighted scores are calculated by summing the weighted
points assigned to each question (see Table 71). Weighted scores range from 0 to 53, with higher scores
indicative of more problematic alcohol use. While there is little evidence for one scoring method over
another and weighted and unit scoring systems are highly correlated [524], treatment recommendations
are based on weighted scores (see Table 72).

Table 71: Calculating MAST scores

Points for raw Points for weighted

Questions
(unweighted) score score

1, 4, 6, 7 Yes = 0, No = 1 Yes = 0, No = 2

2, 10 – 15, 17, 18, 21 – 24 Yes = 1, No = 0 Yes = 2, No = 0

3, 5, 9, 16 Yes = 1, No = 0 Yes = 1, No = 0

8, 19, 20 Yes = 1, No = 0 Yes = 5, No = 0

Table 72: Interpreting MAST weighted scores

Weighted
Interpretation Suggested action
score

0–4 No alcohol use disorder indicated No need for further action

5–6 Further evaluation by a healthcare Possible alcohol use disorder

professional indicated

7 – 53 Comprehensive AOD use evaluation by a Indicates alcohol use disorder

healthcare professional indicated

8, 19, 20 Yes = 1, No = 0 Yes = 5, No = 0

Source: PAR Staff. (2021). Administration and Scoring of the Michigan Alcoholism Screening Test (MAST) [technical
supplement]. Florida, US: PAR Inc.
Appendix Z: Suicide risk screener scorer and interpretation 421

Appendix Z: Suicide risk screener scorer and 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 • Some of the • A little of the • None of the
time time time time

2. In the past 4 weeks, how often did you feel no hope for the future?

• All of the time • Most of the • Some of the • A little of the • None of the
time time time time

3. In the past 4 weeks, how often did you feel intense shame or guilt?

• All of the time • Most of the • Some of the • A little of the • None of the
time time time time

4. In the past 4 weeks, how often did you feel worthless?

• All of the time • Most of the • Some of the • A little of the • None of the
time time time time

5. Have you ever tried to kill yourself? 6. Yes* 7. No

If Yes:

a. How many times have you tried to kill yourself? 2. Once 3. Twice 4. 3+

b. How long ago was the last attempt (mark below)? Have things changed since?

• In the last 2 • 2-6 months • 6-12 months • 1-2 years ago • More than 2
months ago ago years ago

6. Have you gone through any upsetting events recently? (tick all that apply) 7. Yes 8. No

• Family • Conflict relating • Child custody • Chronic • Impending

breakdown to sexual identity issues pain/illness legal
prosecution

• Loss of • Relationship • Trauma • Other

loved one problem (specify)
422 Appendix Z: Suicide risk screener scorer and interpretation

7. Have things been so bad lately that you have thought about killing 8. Yes* 9. No
yourself?

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?

4. Very intense 5. Intense 6. Somewhat intense 7. Not at all intense

d. How intense have these thoughts been in the last week?

5. Very intense 6. Intense 7. Somewhat intense 8. Not at all intense

If No: Skip to 10

8. Do you have a current plan for how you would attempt suicide? 9. Yes* 10. 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?

4. Very likely 5. Likely 6. Unlikely 7. 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 11. Yes 12. No
serious problem?

a. Who is/are this/these person/people?

b. How often are you in contact with this/these person/people?

1. Daily 2. A few days a 3. Weekly 4. Monthly 5. Less than

week once a month

11. What has helped you through difficult times in the past?

* indicates a high or moderate risk answer

Appendix Z: Suicide risk screener scorer and interpretation 423

Client:
Date: Screen completed by:

Client presentation/statements (tick all that apply)

• 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

Worker rated risk level: • Low • Moderate • High

Level of risk Suggested response

Low

• No plans or intent. • Monitor and review risk frequently.

• No prior attempt/s. • Identify potential supports/contacts and
• Few risk factors. provide contact details.
• Identifiable ‘protective’ factors. • Consult with a colleague or supervisor for
guidance and support.
• Refer client to safety plan and keep safe
strategies should they start to feel suicidal.
Moderate

• Suicidal thoughts of limited frequency, • Request permission to organise a specialist

intensity and duration. mental health service assessment as soon as
• No plans or intent. possible.
• Some risk factors present. • Refer client to safety plan and keep safe
• Some ‘protective’ factors. strategies as above.
• Consult with a colleague or supervisor for
guidance and support.
• Remove means where possible.
• Review daily.

High*

• Frequent, intense, enduring suicidal thoughts. • If the client has an immediate intention to
• Clear intent, specific/well thought out plans. act, contact the mental health crisis team
• Prior attempt/s. immediately and ensure that the client is not
• Many risk factors. left alone.
• Few/no ‘protective’ factors. • Remove means where possible.
• Call an ambulance/police if the client will not
*or highly changeable accept a specialist assessment, or the crisis
team is not available.
• Consult with a colleague or supervisor for
guidance and support.

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.
424 Appendix AA: Referral pro forma

Appendix AA: Referral pro forma

Patient identified with possible Date:

mental health condition Referral from:

Patient details:

Name: Year of birth:

Address: Postcode:

Aboriginal or Torres Strait Islander: Yes No

Gender identity:

Patient lives: Alone With carer/family

Patient contact details:

Phone:

Patient may be contacted at this number Yes No

Patient can be contacted at home during B/H Yes No

Leave message with household member Yes No

Reason for referral

Multiple responses permitted

Diagnostic assessment

Psychoeducation

Other:

Presenting problem

Multiple responses permitted

Alcohol and/or other drug use/disorder

Attention-deficit/hyperactivity disorder (ADHD)

Psychotic disorder

Bipolar disorder

Depression
Appendix AA: Referral pro forma 425

Anxiety

Obsessive compulsive disorder (OCD)

Post traumatic stress disorder (PTSD)

Eating disorder:

Borderline personality disorder (BPD)

Antisocial personality disorder (ASPD)

Substance-induced disorder

Cognitive impairment

Unexplained somatic disorder

Unknown

Other:

Provide relevant clinical information

Current medications

Risk assessment

Within 2 weeks Within 1 month

426 Appendix BB: Cognitive behavioural techniques

Appendix BB: 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 [1090, 1978, 1979]. 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
Antecedent
Cognitive restructuring is a useful method Event that triggers automatic thoughts
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
Beliefs about event
[1980]. The idea is that our behaviours and Automatic thoughts
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 Consequences

thoughts and beliefs that can be modified. A Feelings/behaviours that result from
thoughts
simple process of recognition and modification
of these thoughts and beliefs can be conducted
with clients using the A–E model depicted to the
right. Disputing automatic thoughts
Look for evidence to support/
In this model there is an initial event (the disprove these thoughts
antecedent) which leads to automatic thoughts
(beliefs about the event). These thoughts have
resulting feelings and behaviours (consequences).
Alternative explanation
Because these thoughts are automatic and
Rational alternatives to the
often negative, they are rarely based on any automatic thought
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 they come 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.
Appendix BB: Cognitive behavioural techniques 427

Some common negative automatic thoughts and beliefs which can be challenged by using cognitive
restructuring exercises include:

All or none (black and white or dichotomous) 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.’

(Adapted from Leahy [1981], Josefowitz and Myran [1982] and Kuru et al. [1983]).

Client information sheets on common negative thoughts and cognitive restructuring are included in the
Worksheets section of these Guidelines.
428 Appendix BB: Cognitive behavioural techniques

Structured problem solving

Structured problem solving is also a useful means to manage the symptoms of anxiety/depression
as these symptoms are often the result of an inability (or perceived inability) to deal effectively with
problems [1984, 1985]. Some simple steps suggested by Renn et al. [1986] and Nezu et al. [1987] can be a
useful guide in assisting the client:

• Identify the problem (try to break it down) and define it in concrete terms.

• Set a realistic goal for problem solving.

• Step back from the problem and try to view it as an objective challenge. Consider major obstacles
to achieving the goal.

• Brainstorm possible solutions (realistic and unrealistic).

• Think about each solution in practical terms, and evaluate the pros and cons.

• Decide on the best solution (and a second, ‘back-up’ solution).

• Put the solution into action.

• Evaluate how effective the solution was and whether it can be improved.

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 [1988, 1989].

According to Stone and colleagues [389], goals should be:

• 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 their goals.

• Based on process rather than outcome.

Appendix BB: Cognitive behavioural techniques 429

• Short term – break down overall goals into shorter-term ones in order to increase motivation and
feelings of success.

• 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).

A goal setting worksheet is provided in the Worksheets section of these Guidelines.

Pleasure and mastery events scheduling

Individuals with depressive symptoms often stop engaging in behaviours that give them a sense of
pleasure and achievement. This disengagement can lead to a cycle in which they become very inactive,
leading to more negative feelings and lower mood and energy, which then leads to even less engagement
in activities, and so on [389, 1990].

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.
430 Appendix CC: Anxiety management techniques

Appendix CC: Anxiety management techniques

Relaxation techniques are also a common means to manage the distressing and distracting symptoms
of anxiety [1991]. Some useful relaxation methods include:

• Progressive muscle relaxation.

• Controlled or abdominal breathing.

• Meditation.

• Calming response.

• Visualisation and imagery.

• Grounding.

Each method works best if practiced daily by clients for 10-20 minutes but, again, not every technique
may be appropriate for every client.

Progressive muscle relaxation

Progressive muscle relaxation involves tensing and relaxing of different muscle groups in succession. It
is particularly useful for clients with intrusive thoughts. Before starting, make sure the client is sitting
in a quiet and comfortable place. Ask the client that when they tense a particular muscle group, they do
so strongly and hold the tension for 10 seconds. Encourage the client to concentrate on the feelings of
tension and release in their body. Tell the client when relaxing muscles to feel the tension draining out
of their body and enjoy the sensation of relaxation for 15 seconds. Isolate each muscle group at a time,
allowing the other muscle groups to remain relaxed. The following instructions are based on Bourne
[1992]. A client copy is also available in the Worksheets section of these Guidelines.

1. Take two to three deep abdominal breaths, exhaling slowly each time, imagining the tension
draining out of your body.

2. Clench your fists. Hold for seven to 10 seconds (AOD workers may want to count to 10 slowly),
before releasing and feeling the tension drain out of your body (for 15-20 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.
Appendix CC: Anxiety management techniques 431

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. This area is often especially tense, so this step can be repeated twice.

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.

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.

Controlled or abdominal breathing

When tense, a person’s breathing is rapid and shallow, which can lead to hyperventilation or panic
attacks. Hyperventilation is a process where shallow breathing gets rid of too much carbon dioxide which
can lead to light-headedness, breathlessness, feeling of suffocation, blurred vision, and numbness or
tingling in hands or feet as well as a hot, flustered feeling. Mild hyperventilation can lead to increased
perpetual anxiety and apprehension [1992].

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 technique with abdominal breathing
based on the following instructions for the client provided by Bourne and Garano [1993]:
432 Appendix CC: Anxiety management techniques

1. Rate your level of anxiety or tension.

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. Pause briefly before inhaling again.

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.

7. Now re-rate your level of anxiety or tension and see if it has changed.

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.

Meditation
This technique builds on the benefits of breathing exercises by incorporating deliberate attention
or awareness to the present moment. There are many types of meditation, though non-judgemental
awareness, acceptance of the present moment, and detachment from thoughts and emotions are
common components [1992].

The following 10-30 minute meditation exercise was adapted from Bourne [1992]:

1. Start by focusing on your breathing, and expand your attention to include an awareness of your
whole body. Focus on your arms and legs, along with your breath cycle. You can extend your
attention to your hands and feet.

2. Don’t judge yourself if your mind wanders. Each time you find yourself distracted, gently bring
your attention back to your arms, legs, and breath cycle. With practice, your concentration should
improve. Start by practicing for 10 minutes a day, working your way gradually up to 30 minutes.

A list of additional meditation exercises compiled by headspace is available from

www.headspace.com/meditation/exercises.
Appendix CC: Anxiety management techniques 433

Calming response
This quick skill was developed by Montgomery and Morris [1994] 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.

Visualisation and imagery

This relaxation technique might be only useful for a select few clients and should not be used where a
client finds the process difficult or has unpleasant effects as a result [1992].

1. Sit comfortably in a chair, close your eyes and breathe deeply. Clear your mind of all thoughts and
images.

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) [1995].

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 and Peckham [702, 1995].

Examples of mental grounding:

• Describe objects in your environment in detail using all your senses.

• Describe an everyday activity, such as eating or driving to work, in detail.

• Use a grounding statement. ‘I am Jo, I am 23 years old, I am safe here, today is...’.
434 Appendix CC: Anxiety management techniques

• Say the alphabet slowly.

• Counting backwards from 20.

Examples of physical grounding:

• Run cool or warm water over your hands.

• Press your heels into the floor.

• Touch objects around you as you say their names.

• Jump up and down.

• Change your posture to a more upright one.

• Stretch.

• As you inhale say ‘in’, and when you exhale say ‘out’ or ‘calm’ or ‘easy’ or ‘safe’.

• Ask for a hug from a trusted person.

Examples of soothing grounding:

• 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.

• Look at photographs of people or animals you care about.

• 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.
Worksheets
436 Identifying negative thoughts

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:

Negative thought Example

All or none (black and white) ‘If I fail partly, it means I am a total failure.’
thinking

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 People often discount positive things that happen.

experiences
‘I stayed clean because I didn’t run into any of my using mates.’

Sources: Leahy, R. L. (2017). Cognitive therapy techniques: A practitioner’s guide. New York: Guildford Press; Josefowitz, N.,
& Myran, D. (2021). CBT made simple. Oakland, CA: New Harbinger Publications.
Cognitive restructuring 437

Cognitive restructuring
Unhelpful thoughts produce negative emotions and behaviours. Often these thoughts can be extreme
and inaccurate. However, this automatic process can be broken through awareness and thought
restructuring.

Step 1: Identification of negative/

inaccurate thoughts
Thoughts are often automatic, but you can learn to
identify and alter these negative thoughts through
monitoring.

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.

Antecedent
Event that triggers automatic thoughts

Step 2: Notice how thoughts

cause feelings and motivate
behaviour Beliefs about event
Automatic thoughts
A good way to think of the relationships between
thoughts and behaviours is through the ‘ABC’
model:

Consequences
Feelings/behaviours that result from
thoughts
438 Cognitive restructuring

Step 3: Challenging and replacing negative thoughts

After you become aware of the thoughts and their resulting feelings and behaviours, you should examine
and challenge those thoughts for evidence and accuracy.

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?

Putting it into perspective:

• Is it as bad as I’m making out?

• Is there anything good about this situation?

• How likely is it that the worst will happen?

• What is most likely to happen?

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?
Cognitive restructuring 439

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
440

A B C

Activating Beliefs/ Consequences: Challenge negative thoughts

event/trigger thoughts/ feelings/
interpretations behaviours
What is the Is there any other What do you think
Date What happened? What were you What were you evidence for and way of looking at now?
thinking? feeling? What against your this situation?
did you do? thoughts?
Cognitive restructuring worksheet
Structured problem-solving 441

Structured problem-solving worksheet

1. What is the problem?
(Break it down into manageable smaller problems)

2. Step back and view problem objectively and without

emotion, as if it were happening to someone else.

3. What can I do?

(Brainstorm a list of possible solutions, good and bad, real
and unreal)

Solution Pros Cons

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.
5. Write down your favourite three.
1.
2.
3.
6. Put it into action!
(What do you need to do to implement it? Did it work? Why/why not? Would another solution work
better?)
442 Goal setting

Goal setting worksheet

I want to…

(e.g., stop smoking)

For these reasons…

(e.g., to prove that I can, to improve my health)

The obstacles stopping me are…

(e.g., routine)

I can overcome these by…

(e.g., avoiding situations where I am tempted)

These people can help…

(e.g., family)
Goal setting 443

By…

(e.g., providing support)

I will start working towards this goal…

(e.g., today)

I know I will have achieved this goal because…

(e.g., I no longer crave)

444 Pleasure and mastery

Pleasure and mastery worksheet

Create a list of activities you do for pleasure or you get a sense of achievement from.

Try to think of more each day and add to the list.

Make note of how each activity makes you feel.

Find time to complete some of these tasks every day.

A list of examples is included on the next page to help start you off.

Task How I feel

Pleasure and mastery 445

Examples of fun activities

• Listening to music • Talking to others • Going to parties
• Playing soccer • Camping • Exercise
• Playing golf • Going on holiday • Having a meal with friends
• Having a bath • Going to the beach • Singing
• Going for a swim • Going fishing • Going sailing
• Watching a movie • Having a relaxed evening • Praying
• Watching favourite TV show • Debating • Going to concerts or plays
• Going shopping • Going to the zoo/aquarium • Sewing
• Going bowling • Eating • Working
• Working on car/bike • Going to the gym • Reading books
• Sex • Playing cricket • Playing board games
• Reading poetry • Playing hockey • Volunteering
• Cooking • Driving • Having a BBQ
• Surfing • Doing jigsaws • Eating out
• Playing video games • Buying things • Acting
• Have coffee at a café • Playing basketball • Cleaning
• Riding bike • Doing martial arts • Meditating
• Playing pool/billiards • Playing netball • Playing with children
• Looking at photos • Yoga • Sleeping
• Bushwalks • Playing squash • Gardening
• Playing volleyball • Playing tennis • Going canoeing
• Picnics • Going to church/ • Painting/drawing
• Playing cards synagogue/temple/ • Skating
• Discussing politics mosque • Skiing
• Playing with pets • Photography • Writing
• Woodworking • Surfing the net • Reading newspaper
• Getting a massage • Getting hair done • Dancing
• Watching a sporting event • Going to museums and • Rock climbing
• Hobbies (e.g., collecting galleries
things) • Doing crosswords/word
• Going horse riding games
• Lying in the sun • Throwing parties
446 Progressive muscle relaxation

Progressive muscle relaxation

1. Take three deep abdominal breaths, exhaling slowly each time, imagining the tension draining out
of your body.
2. Clench your fists. Hold for seven to 10 seconds, before releasing and feeling the tension drain out
of your body (for 15-20 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. This area is often especially tense, so this step can be repeated twice.
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.
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.

Source: Bourne, E. J. (2020). The anxiety and phobia workbook.

Oakland, CA: New Harbinger Publications.
Controlled abdominal breathing 447

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.

7. Now re-rate your level of anxiety and see if it has changed.

448 Visualisation and imagery

Visualisation and imagery

1.1. Sit comfortably in a chair, close your eyes and breathe deeply. Clear your mind of all thoughts and
images, like a blank page.

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?

3. Think about how your body feels in this place:

• 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.
Food and activity diary

Time of Food eaten Physical activity Mood

Date
day
Food and activity diary

Adapted from: Western Australian Network of Alcohol and other Drug Agencies (2016). Healthy eating for wellbeing: A nutrition guide for alcohol and other drug
449

consumers. Perth, Australia: WANADA.

450 Common reactions to trauma

Common reactions to trauma

After a traumatic event, it is common to experience a range of reactions. These might include:

Feelings of sadness/depression

It is common to:

• Experience feelings of hopelessness and despair.

• Have thoughts of suicide.

• Have an altered perception of yourself (e.g., I am a bad

person).

• Lose interest in once pleasurable activities.

Feeling a loss of control or trust

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.

Feelings of guilt and shame

These feelings are a common reaction to trauma survival.

You might find yourself second-guessing your reactions or

blaming yourself.

Re-experiencing the event

This includes:

• Flashbacks – feeling the trauma is re-occurring.

• Intrusive thoughts – memories that you can’t control.

• Nightmares about the event.

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.

Although these reactions can be overwhelming and distressing, it is important to remember they are a normal
response when someone has experienced a traumatic event.
Common reactions to grief and loss 451

Common reactions to grief and loss

There is a multitude of different sources of grief and loss and not all involve death. Individuals
experiencing grief from a loss may choose a variety of ways of expressing it. No two people will respond to
the same loss in the same way. However, some frequent reactions include:

Changed behaviours:

• Seeking solitude, withdrawal.

• Change in social activities.

• Inappropriate behaviour (e.g., laughing).

• Absent mindedness.

Sleep and energy disturbances:

• Feeling fatigued, restless, lethargic.

• Sleep difficulties.

Other physical symptoms:

• Changed eating habits.

• Gastro-intestinal complaints.

• Decreased interest in pleasurable activities.

• Decreased sex drive.

A range of troubling emotions:

• Feelings of denial, disbelief, numbness, shock, panic, or sadness.

• Feelings of isolation.

• Mood fluctuations.

• Anger, guilt, frustration, hostility, blaming.

Cognitive difficulties such as forgetfulness, confusion or a lack of concentration.

Spiritual emptiness and pessimism.

Constant thought about the deceased or a feeling of their presence.

Although these reactions can be overwhelming and distressing, it is important to accept and not to avoid them. It is
also useful to remember your reactions are common and natural and you are not alone.
452 Wellbeing plan

Wellbeing plan
Name: Date:

Step Description/Examples Plan

Things that are important to List some of the things that How will you fit in the things you
me you enjoy and value, such as need to do and the things that
hobbies, leisure and social are important to you? Are there
activities, spending time with any resources you need to help
family, going to the gym: you do these things (what and
from who)?

Triggers List some of the things that What can you can do to lessen
cause you stress, such as not the impact?
asking for support when you
need it, significant events, times
or situations:

Warning signs List some of your warning signs What actions can you take?
that suggest you may need to What has helped in the past?
take action, such as feeling
unusually tired, irritable or overly
sensitive, negative self-talk,
difficulty sleeping:
Wellbeing plan 453

Step Description/Examples Plan

Strategies List some strategies below that Are there things other people
you can use to help manage could do to help you?
difficult situations, such as
talking to someone you trust,
remembering how you have
gotten through difficulties in the
past, identifying your strengths:

Trusted people I can talk to List some of your main, trusted Are there any other people in
support people, such as your your life who support you?
partner, family member,
workmate, neighbour, best
friend:

Professional support List some of the main names

and numbers/locations of AOD/
mental health professionals,
crisis teams, hospitals and
support services you can
contact.
In an emergency, always call
000.

Sources: Heads up. (2020). Personal wellbeing plan. Available from https://www.headsup.org.au/your-mental-
health/taking-care-of-yourself-and-staying-well; Repper, J., Perkins, R., & Meddings, S. (2013). A personal health and
wellbeing plan for family, friends and carers. Central and North West London NHS Foundation Trust. (2019). Health and
Wellbeing Plan. Available from https://www.cnwl.nhs.uk/services/recovery-and-wellbeing-college/resources
References
References 455

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