Responding to mental health issues
Many young people with problematic substance use are also contending with co-occuring mental health symptoms or problems. During the withdrawal process, some withdrawal symptoms are similar to mental health symptoms (particularly anxiety) and it can often be difficult to discern if the symptoms may be an emerging mental health issue, or if they are likely to resolve naturally as the withdrawal proceeds.

Some young people undergoing withdrawal can experience an escalation in symptoms in the early phases.  This can be a source of additional distress and concern. It is important that young people are prepared for the potential that this may occur. 

Where mental health issues are known but also where they emerge during a withdrawal an integrated care plan should be put in place that details support and treatment options particular focused on how a deterioration in mental health will be managed (Christie & Temperton, 2008). This often involves integrating the involvement of specialist mental health services into the care plan. At times, the withdrawal that a young person is undergoing is a part of a care plan formed by a specialist mental health service.  

Anxiety
It is common for young people withdrawing from substances to experience anxiety.  There are to reasons for this:

• The uncertainty associated with undertaking a withdrawal or participating in a program, particularly when it is for the first time, can create anxiety. Further, young people might also be anxious about how life will unfold post withdrawal and program involvement.
• Anxiety is a symptom that forms part of the withdrawal syndrome for particular substances

Practitioners can assist young people to manage anxiety through ensuring that young people and others involved in their care:

• Realise that anxiety is a natural and normal part of withdrawing from some substances and accessing program (Normalisation)
• Understand anxiety and how it can be managed (Education)
• Are supported to implement practical strategies to manage anxiety (i.e. exercise, healthy food, and adequate sleep can all reduce the frequency and intensity of symptoms) (Management)
• Have ongoing access to timely support and continuous reassurance (Support)
• Are referred for specialist treatment where required (particularly where symptoms don’t subside as expected or where the young person is finding symptoms overwhelming (Referral)

C5i. Relaxation exercises
This CBT element introduces the basic skills to teach in regards to managing symptoms of anxiety, including progressive muscle relaxation.

Depression and low mood
During and following the withdrawal process the mood of each young person is expected to be more changeable than normal. Most withdrawal syndromes are characterised by low mood, poor sleep and fatigue but where these symptoms persist there may be an underlying mood disorder.  It is crucial that practitioners monitor each young person’s mood and where required suicide risk assessment should be conducted (Christie & Temperton, 2008). Supported referral for specialist treatment might be required.

Psychotic symptoms and paranoia
The use of cannabis, amphetamines or and/or substances with hallucinogenic properties can manifest in psychotic symptoms often featuring and paranoia. Where known, these symptoms should be a part of a management plan as a young person participates in a withdrawal program. These symptoms should naturally abate during the withdrawal. 

Psychotic symptoms can also emerge during a withdrawal. This is often associated with the absence of depressant substances where their use has masked or moderated symptoms of mental health problems or conditions. In the case of severe alcohol withdrawal, hallucinations can form part of the withdrawal syndrome and require management.

All cases involving psychosis require suicide risk assessment and should prompt the inclusion of specialist treatment into care plans.

Sleep deprivation
Another condition that support people, practitioners and young people themselves need to be aware of during the withdrawal process is sleep deprivation.  Sleep deprivation can lead to fatigue, concentration difficulties, variable moods, anger outbursts and the exacerbation of anxiety, paranoia and other psychotic symptoms. A poor sleep pattern is common where substance use has interfered with the normal circadian rhythm and is also a feature of most withdrawal syndromes.  For many young people, sleep problems contribute to escalating substance use. Sleep problems should be normalised and young people provided with strategies and guidance to manage their sleep disturbance. At times, referral for expert assistance is required.

Careful consideration should be given to the prescription of benzodiazepines and other medication for sleep disturbance, particularly when young people have not previously been exposed to these substances. In the right circumstances, medication can assist the young people to establish a regular sleep pattern.

Trauma
Many clients with substance use problems have histories featuring abuse and neglect, experiences of violence (either as a witness or victim), insecure attachment, and grief and loss issues.  Substance use can be a way that young people manage the distressing symptoms associated with such traumatic experiences. Some young people meet the criteria for a diagnosis of post traumatic stress disorder (PTSD). This may be undiagnosed. Withdrawal from substances can therefore result emotional dysregulation and increased distress as symptoms surface such as flash-backs, panic attacks, intrusive memories or nightmares. This can also lead to young people engaging in self injury in an effort to manage distress.

Where possible, these issues should be identified and with the young person and their supporters management plans (see below) should be formulated for managing these symtoms. Specialist advice and access to treatment might also be required.

Practitioners supporting a young person through a withdrawal process can provide reassurance, emotional support and practical strategies for managing trauma related symptoms. Tramatised young people benefit from stability and predictability. Practitioners should be aware of distress triggers for each young person and seek to minimise disruptions and relationship conflicts.

Where young people wish to disclose their trauma history, it is best contained to supportive conversations with a key worker (where possible) and referral for specialist or on-going support can be made during the withdrawal program. A young person going through withdrawal is particularly vulnerable, so it may not be a suitable time for going into depth about the trauma, but a chance to provide validation and strategies for managing the symptoms. (See the Trauma module in this toolbox)

G1i. Validation Strategies
A core skill of DBT, this element explains the importance and power of validating a person’s experience and feelings with accurate empathy.

Developing a management plan for risk issues
All young people undergoing withdrawal in the care of youth AOD services will have a care plan in place. The care plan of young people can include a specific management plan for issues that have the potential to disrupt the withdrawal process and involvement in withdrawal programs, particularly in residential settings. 

A management plan helps the young person and everyone involved in their care to prevent and where necessary respond to these issues effectively. Management plans most often pertain to a specific issue or behaviour. They commonly apply where there is heightened risk of self injury, suicide, aggressive behavior, psychosis, panic & anxiety, emotional dysregulation and dissociation.

G2ii. Chain Analysis
Chain analysis is a dialectical behavior therapy technique that can help practitioners and their clients to understand more about a specific issue or behaviour and how it might best be managed. Vital information can be gathered to facilitate the development of more nuanced and effective plans.

Management (or Support) Plans typically make clear:

• The bi-directional influence of the withdrawal syndrome and the specific issue or behaviour
• The triggers for the behavior or risk conditions that intensify the impact of the issue or behaviour
• The specific strategies for preventing and minimising the impact of behaviour
• The roles of the young person and others involved in their care (including program staff, management, emergency services, outside specialists and professionals, family members, etc) in preventing and minimising the impact of the issue of behaviour
• A transition plan, including duty of care issues should the discharge be unplanned

All care plans and associated management plans should be formulated and administered in accordance with the auspicing organisation’s clinical governance framework and relevant policies