Minnesota Co-occurring Mental Health & Substance Disorders Competencies:

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1 Minnesota Co-occurring Mental Health & Substance Disorders Competencies: This document was developed by the Minnesota Department of Human Services over the course of a series of public input meetings held in the fall of Contributors included representatives from mental health treatment agencies, addiction treatment agencies, health plans, counties, consumers and family members accessing treatment services, higher education institutions, licensing boards and other interested individuals. Various research articles and federal publications were also consulted during its development. This framework is intended to establish provider competencies needed to deliver effective integrated co-occurring mental health and substance use disorder treatment. The framework identifies core beliefs, attitudes, values, knowledge and skills, for working with individuals who have co-occurring disorders in a variety of service settings. It is expected that programs will use the competencies to develop guidelines for recruitment of new personnel and training plans of existing staff based on their agency s mission and goals for delivering integrated treatment. Provider Beliefs, Attitudes and Values Competencies were developed using criteria contained in the Dual Disorder Capability in Addiction Treatment (DDCAT), the Dual Disorder Capability in Mental Health Treatment (DDMHT), information available from Minnesota and other COSIG states as well as a variety of journal articles. These competencies are also applicable to practitioners using Integrated Dual Disorder Treatment (IDDT) fidelity scales. a. The provider values and demonstrates a commitment to work with all people who have both substance use and mental disorders by taking the initiative to identify co-occurring disorders through screening and assessment. b. The provider possesses and maintains a welcoming attitude toward all persons with co-occurring disorders regardless of the severity or acuity of their disorder. c. The provider maintains and communicates an attitude of hopefulness and a belief that recovery for both illnesses is possible. d. The provider holds the belief that every client with co-occurring disorders is a unique individual, and displays an accepting and non-judgmental attitude that acknowledges and appreciates each client s individuality. e. The provider demonstrates the value of client self-determination by recognizing and affirming the inherent strengths, and selfefficacy of all clients with a co-occurring disorder regardless of the severity and persistence of their illness. f. The provider believes a co-occurring disorder is always a possibility and that all clients need careful and consistent screening and evaluation g. The provider believes that treatment of both disorders simultaneously with an integrated approach is an evidenced-based best practice. h. The provider believes that good service requires a consistent, continuous supportive helping relationship throughout the process of recovery regardless of the client s motivation to participate or their tendency to relapse. i. The provider places primary importance on the needs of the client and recognizes that understanding his or her perspective drives the design of the treatment service. j. The provider appreciates that recovery for co-occurring disorders often involves multiple setbacks and requires ongoing support and a willingness to re-engage the client when indicated. k. The provider displays a team attitude and believes that all providers can contribute to 1

2 the care of people with co-occurring disorders and holds the value that collaboration is essential in providing high quality service. l. The provider demonstrates the value of collaboration by participating within a community of providers beyond the confines of their own agency. Collaboration in this context becomes a mechanism for insuring long-term recovery by enabling the agency at the end of service to engage in a collaborative process that ensures continuity in sustaining the quality of care over time. m. The provider embraces the belief that family and friends are important contributors to the client s recovery and who also often need information on co-occurring disorders and support for themselves. n. Collaboration with each client regarding his or her desire for family involvement and respect of whom the client recognizes as family and agrees to have involved is primary. o. The provider recognizes, values and seeks to understand the unique cultural perspective of each client p. The provider believes in the importance of collaboration and consultation with someone of the client s culture or with someone who has knowledge and experience with the culture when he or she needs help in understanding the client s cultural perspective. q. The provider believes in the importance of pharmacological interventions for mental health and substance use disorders and works with the client and prescriber to enhance client s motivation to use medication responsibly as an adjunct to treatment and recovery. r. The provider recognizes that inadequate funding for both mental and chemical health is often a barrier to comprehensive care. He or she works to reduce these barriers through advocacy on behalf of the agency and the client. Skill Engagement Service Delivery Relationship development Bio-psycho-social etiology Life cycle Screening Assessment Knowledge The provider demonstrates knowledge and use of engagement strategies appropriate to the client s current stage of change and treatment and the level of severity for both mental illness and substance use. The provider understands the service delivery system in which he or she and the agency reside and is able to identify barriers that exist to achieve service integration. The provider demonstrates an ability to establish trust and build a working collaborative alliance with the client through the use of skills such as empathic listening and responding, genuine affirmation, acknowledgement of client strengths, and instillation of hope, The provider understands the etiology of co-occurring disorders and is able to explain the cause, interaction, and exacerbation of symptoms to the client and others who may benefit from this knowledge in terms they are able to comprehend. The provider is knowledgeable about how people change across their life span and understands the significant developmental stages as they relate to how substance abuse and mental illness interact at various points. The provider demonstrates an ability to use this information as part of an integrated assessment. Ability to administer, score and interpret a standardized, valid and reliable screening instrument for both substance use and mental disorders. 2

3 Longitudinal assessment Collateral interview Functional analysis Diagnostic categories Trauma assessment Reimbursement Pharmacological Agents, Alcohol and Drugs of Abuse Severity & Acuity Diagnosis Demonstrate an ability to gather a clinical history of functioning across a variety of domains (relationships, family, school, work, housing, legal) that identify the interaction of substance use and mental health symptoms over time, provides an understanding of their impact and the factors that contribute to it. The provider uses this information in collaboration with the client to develop a plan for treatment. With the consent of the client, the provider interviews family members and/or others to obtain relevant history and current functioning to assist in completing a comprehensive assessment. Family members and other significant client contacts are viewed as having needs of their own and are provided information and resources to assist them when indicated. Demonstrate an ability to identify individualized internal and external stimuli (cognitive, behavioral, emotional, environmental) and the client s associated response (positive or negative) that maintain or increase substance use, diminish use, or interferes with recovery Knowledge of the most recent DSM criteria for both substance use and mental disorders and the ability to use this information to understand the client s history, use of specific psychotropic medications, severity and acuity, interaction of medications and drug of abuse, and the determination of appropriate placement. The provider is knowledgeable regarding the interaction between trauma symptoms and substance abuse and is able to assess for signs and symptoms among diverse populations. Trauma includes but is not limited to physical and sexual assault, war, torture, natural disasters, human trafficking, witnessing trauma, and traumatic brain injury. The provider understands the reimbursement system as it relates to the ability of the client to receive the full contingent of co-occurring disorder treatment and completes the needed documentation in order to receive payment in a timely manner. The ability to identify the major classifications of psychotropic medication for mental disorders and psychotherapeutic medication for addiction treatment. The provider is capable of gaining quick access to information on dosage, side effects and interaction of medications with drugs of abuse, over-the-counter medications, vitamins, supplements and nutraceuticals through available resources such as a Physicians Desk Reference or reliable Internet sources. The provider knows when to consult with a prescriber and readily requests assistance for the client in the prescription, modification and management of medication. Demonstrates an understanding of the need for continuation of prescribed psychotropic medications for clients with serious mental disorders and active substance use. Knowledge of criteria for serious and persistent mental illness (SPMI) and the ability to identify when present. The ability to assess duration, disability and functional capacity associated with mental health and substance use disorders (individually and together) including the ability to determine client eligibility based on program acceptance standards. The ability to make a formal diagnosis of a mental or substance use disorder if the 3

4 Stage of Change and Stage of Treatment Explanation of Findings Psychiatric and substance use emergencies and crisis management license of the assessor permits and the ability to rule out either disorder through the collection of comprehensive assessment information, formal screening or other valid and reliable assessment instruments. A formal diagnosis is not required to complete an integrated assessment. The ability to develop and maintain a collaborative relationship with an adequate number of readily available competent licensed clinicians in order to obtain a formal diagnostic assessment (when the primary assessor is not licensed to do so) that supports the full range of mental health and substance use disorder information on all five axes of the DSM IV multi-axial system. The knowledge of and ability to assess the client s stage of change and the stage of treatment for both mental health and substance use disorders using a recognized instrument or protocol. The ability to summarize and explain the results of the assessment to the client, family and others in terms they can understand. Explanation includes diagnostic assessment, screening information, psychological test results, and treatment recommendations. Ability to assess and manage the emotional, intoxication, or withdrawal state of a client in crisis. This includes an ability to assess suicide risk and develop a risk management plan that includes knowledge of available resources to assist with crisis management when indicated. Possess a thorough understanding of the policies and procedures that govern crisis management within the agency where the provider is employed. Skill Treatment Plan Development Treatment Knowledge The ability to utilize the results of an integrated assessment over time in collaboration with the client and other providers to develop an integrated treatment plan that captures and addresses the interaction between mental health and substance abuse. The provider develops a treatment plan that: Addresses both the substance related and mental disorder concurrently with a level of intensity based on the client s assessment information and consistent with the acuity, severity and disability associated with each disorder. Contains specific detail as indicated by clear, objective, measurable outcomes with targeted behaviors and goals aimed at reducing the adverse consequences of both disorders and their interaction. Identifies the client s strengths and supports the use of them in reaching desired outcomes Suggests intervention strategies compatible with each stage of change and stage of treatment for each disorder Uses both substance use and mental disorder symptom reduction as well as abstinence based substance abuse models matched to the client s stage of 4

5 Stage Wise Interventions Monitor Progress Evidenced Based Treatment Interventions change. Clearly articulates the treatment plan in writing and has it available in the client s record for review at case consultation, supervision or updates by all involved in the clinical treatment team. The knowledge and ability to select intervention strategies consistent with the client s stage of change and stage of treatment. The provider recognizes that the client may be at a different stage of change or treatment for each disorder and considers this when selecting interventions. Ability to regularly monitor and document the client s treatment progress that reflects a detailed, systematic in-depth focus on both disorders and the interactive course between them. Monitoring also includes the ability to collaborate at regular intervals with other members of the treatment team and make revisions to the treatment plan as indicated. The knowledge and ability to intervene when a client relapses or has a psychiatric crisis that necessitates the implementation of measures designed to stabilize the client so he or she is able to return to treatment with renewed hope and determination. This requires an ability to safely and effectively manage individuals in crisis within the program whenever possible. And, the ability to determine the need for external crisis management and the ability to secure services of a crisis provider immediately if necessary. Knowledge of the variety of specialized evidenced based interventions that are frequently used in the treatment of client s with co-occurring disorders. All methods should be implemented consistent with the client s stage of change and stage of treatment. The following are examples of typical interventions and providers should have the knowledge and ability to effectively utilize those that fit within their scope of practice and the setting where the intervention occurs. The knowledge and skills associated with Motivational Interviewing including: o Knowledge and use of the spirit & principles of MI o The ability to direct and consistently focus the interview toward client behaviors that are targets for change o Demonstrate an ability to use simple and complex reflections o The ability to recognize, evoke and strengthen change talk. o The ability Identify and encourage client commitment talk o The ability to facilitate action planning with the client based on his or her stage of change, strengths, resources and capabilities, goals and preferences. o Demonstrate a commitment to use and improve MI competency by consistently reviewing skills with supervisor and colleagues through feedback and practice The knowledge and skills to administer a co-occurring disorder psychoeducational curriculum for clients, families and concerned others that is comprehensive, diversity sensitive and provided at a time and location that is easily accessible. Group treatment designed to teach life enhancement skills such as identifying life goals, drug refusal, stress management, relaxation training, recreation, health, social skills, assertiveness training, problem solving, anger management, 5

6 employment, self-help and peer support, etc. Cognitive Behavioral Interventions specific to recognizing and altering thoughts associated with internal and external cues that trigger craving and lead to use. Relaxation techniques and other stress reduction methods. The knowledge and ability to explain the philosophy of 12-step and other peer support groups including knowledge of the various groups that exist within the community. Cognitive Behavioral Interventions and other intervention models aimed at overcoming barriers to relationship and other social involvement; e.g., teaching and coaching social and other needed coping skills in both an individual and group format. Skill Recovery as a longterm process Maintaining a continuous relationship Recourse advocacy Promote client selfefficacy Evaluate client progress Integrated Discharge and Continuing Care Knowledge The provider understands and communicates to clients and significant others that while recovery is a long-term process, it is possible and help is always available. The provider seeks to maintain an ongoing supportive relationship with the client after discharge such that the client is able to contact the provider during vulnerable times when symptoms increase or sobriety is threatened. The provider collaborates with a variety of available resource providers that can help support the client and creates a discharge and recovery plan that includes follow-up to assure the client receives the needed service. The provider works to increase the client s ability to act in his or her own behalf through supporting increased responsibility for the management of his or her recovery. The ability to utilize an integrated case consultation model to evaluate the program s ability to work effectively with clients who do not improve over time or whose symptoms increase and to decide if other settings or treatment goals may be more able to meet the client s needs 6

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