9/25/2015. Parallels between Treatment Models 2. Parallels between Treatment Models. Integrated Dual Disorder Treatment and Co-occurring Disorders

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1 Integrated Dual Disorder Treatment and Co-occurring Disorders RANDI TOLLIVER, PHD HEARTLAND HEALTH OUTREACH, INC. ILLINOIS ASSOCIATION OF PROBLEM-SOLVING COURTS OCTOBER 8, 2015 SPRINGFIELD, IL Parallels between Treatment Models 2 Alcoholism/Addiction A biological illness Hereditary ( in part) Chronicity Leads to lack of control of behavior and emotions Positive and negative symptoms Mental Illness A biological illness Hereditary (in part) Chronicity Leads to lack of control of behavior and emotions Positive and negative symptoms Parallels between Treatment Models Substance Use Affects the entire family Progression of the disease without treatment Symptoms can be controlled with proper treatment Disease of denial as to both disease and chronicity 3 Mental Illness Affects the entire family Progression of the disease without treatment Symptoms can be controlled with proper treatment Disease of denial as to both disease and chronicity 1

2 Historically Philosophical & Clinical Barriers to Integrated Treatment 4 SUBSTANCE USE SYSTEM Peer Counseling Model Spiritual Recovery Self- Help Confrontation and expectation Detachment/Empowerment Episodic Treatment Recovery ideology Psychopathology is secondary to addiction MENTAL HEALTH SYSTEM Medical/Professional Model Scientific Treatment Medication Individualized support Case management/care Continuity of Responsibility Deinstitutionalization ideology Substance use is secondary to psychopathology Some Differences Between Mental Health and Substance Use Treatment Systems and Services Historic and cultural Levels of care (physical settings) Workforce Evidence-based practices Role of assertive community treatment Persons served (MH: Q1, Q2 & Q4; SU: Q1, Q3 & Q4) 5 SAMHSA Definition 6 Co-occurring disorders may include any combination of two or more substance abuse disorders and mental disorders identified in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). There are no specific combinations of.disorders that are defined uniquely as co-occurring disorders. In A Report to Congress on the Prevention and Treatment of Co- Occurring Substance Abuse Disorders and Mental Disorders 2

3 Why Focus on Co-occurring Disorders? 7 Single focus Sequential treatment of both disorders Parallel treatment of both disorders Integrated treatment of both disorders Why Focus on Co-occurring Disorders? Substance use disorders are common in people with mental health disorders Mental health disorders are common in people with substance use disorders Co-occurring disorders lead to worse outcomes and higher costs than single disorders Courtesy of Mark McGovern, Ph.D. 8 Why Focus on Co-occurring Disorders? Evidence-based models exist and can be implemented Providers and consumers want a better system and services Few (<10%) people get the treatments they need. Courtesy of Mark McGovern, Ph.D. 9 3

4 Past Year Services Use by Adults with Co-occurring Substance Use Disorder and Serious Psychological Distress Substance Abuse and Mental Health Services Administration. (2008). Results from the 2007 national survey on drug use and health: National findings (Office of Applied Studies, NSDUH Series 10 H-34, DHHS Publication No. SMA ). Rockville, MD. 11 Co-occurring disorders is the expectation, not the exception. What Is Integrated Treatment for Co-Occurring Disorders? Integrated Treatment is a research-proven model of treatment for people with serious mental illnesses and co-occurring substance use disorders Individuals receive combined treatment for mental illnesses and substance use disorders from the same practitioner or treatment team. They receive one consistent message about treatment and recovery. SAMHSA IDDT Powerpoint 4

5 Practice Principles for Integrated Treatment for Co-Occurring Disorders Mental health and substance abuse treatment are integrated to meet the needs of people diagnosed with cooccurring disorders Integrated treatment specialists are trained to treat both substance use and serious mental illnesses Co-occurring disorders are treated in a stagewise fashion with different services provided at different stages Motivational interventions are used in all stages, but especially in the persuasion stage SAMHSA IDDT Powerpoint Practice Principles for Integrated Treatment for Co-Occurring Disorders Substance abuse counseling, using a cognitive-behavioral approach, is used in the active treatment and relapse prevention stages Multiple formats for services are available, including individual, group, self-help, and family Medication services are integrated and coordinated with psychosocial services SAMHSA IDDT Powerpoint Treatment is Integrated Mental health and substance abuse treatment are evaluated and addressed Ideally: Same team Same location Same time Treatment targets the individual needs of people diagnosed with co-occurring disorders and is integrated on organizational and clinical levels SAMHSA IDDT Powerpoint 5

6 Stage of Motivation and Stage-Wise Treatment Precontemplation Engagement Assertive outreach, practical help (e.g., housing) and an introduction to individual, family, group, and self-help treatment formats Contemplation and Preparation Persuasion Education, goal setting, and building awareness of problem through motivational engagement and counseling Action Active treatment Counseling and treatment based on cognitive-behavioral techniques, skills training, and support from families and self-help groups Maintenance Relapse prevention Continued counseling and treatment based on relapse prevention techniques, skill building, and ongoing support to promote recovery SAMHSA IDDT Powerpoint, adapted Integrated Treatment Recovery Model Hope is critical Services and treatment goals are consumerdriven Unconditional respect and compassion for individuals is essential Integrated treatment specialists are responsible for engaging individuals and supporting their recovery Focus on individual goals and functioning, not on adherence Consumer choice, shared decision-making, and consumer/family education are important SAMHSA IDDT Powerpoint, adapted Integrated Treatment Recovery Model Integrated treatment is associated with the following positive outcomes: Reduced substance use Improvement in psychiatric symptoms and functioning Decreased hospitalizations Increased housing stability Fewer arrests and Improved quality of life SAMHSA IDDT Powerpoint; Drake et al,

7 So, How Do We Treat COD? Guiding Principles and Recommendations 19 GUIDING PRINCIPLES (SAMHSA, TIP 42) Employ a recovery perspective (long term process of internal change in stages) Develop a phased approach to treatment (stage appropriate treatment) Plan for cognitive and functional impairments Use support systems to maintain and extend treatment effectiveness 20 CORE SERVICE DELIVERY COMPONENTS (SAMHSA, TIP 42) Provide access Complete a full assessment Achieve integrated treatment - Treatment Planning and Review - Psychopharmacology Ensure continuity of care 21 7

8 VISION OF FULLY INTEGRATED TREATMENT (SAMHSA, TIP 42) One program that provides treatment for both disorders Mental and substance use disorders are treated by the same clinicians The clinicians are trained in psychopathology, assessment, and treatment strategies for both disorders The focus is on preventing anxiety rather than breaking through denial 22 VISION OF FULLY INTEGRATED TREATMENT (CON T) Treatment is characterized by a slow pace and a longterm perspective Providers offer stage-wise and motivational counseling 12-Step groups or peer recovery supports are available to those who choose to participate Pharmacotherapies are utilized according to consumers psychiatric and other medical needs Sensitivity to issues of trauma 23 IDDT Model 24 Treatment Characteristics: Multidisciplinary Team Stage-Wise Interventions Access to Comprehensive Services Time-Unlimited Services Assertive Outreach Motivational Interviewing 8

9 IDDT Model 25 Substance Abuse Counseling Group Treatment Family Psycho education Participation in Alcohol & Drug Self-Help Groups Pharmacological Treatment Interventions to Promote Health Secondary Interventions for Non-Responders to Substance Abuse Treatment Beyond Treatment Importance of recovery support services in treatment Importance of recovery support services outside or after treatment Evaluating a Program s Capability to Provide Co-occurring Disorder Services When is a program capable of providing co-occurring disorder services? How do you know? 9

10 LEVELS OF PROGRAM CAPACITY Beginning Addiction Only Treatment IntermediateAdvanced Addiction Addiction COD COD Capable* Enhanced** Fully Integrated COD Integrated Advanced Intermediate Beginning Mental Health Mental Health Mental Health COD Enhanced** COD Capable* Only Treatment What challenges have you encountered in moving toward the center? What have you done to overcome these challenges? 28 DDCAT & DDCMHT (4.0): 7 DIMENSIONS & CONTENT OF 35 ITEMS Dimension Content of items I Program Structure Program mission, structure and financing, format for delivery of mental health or addiction services. II Program Milieu Physical, social and cultural environment for persons with mental health or substance use problems. III Clinical Process: Assessment Processes for access and entry into services, screening, assessment & diagnosis. IV Clinical Process: Treatment Processes for treatment including pharmacological and psychosocial evidence-based formats. V Continuity of Care Discharge and continuity for both substance use and mental health services, peer recovery supports. VI Staffing Presence, role and integration of staff with mental health and/or addiction expertise, supervision process VII Training Proportion of staff trained and program s training strategy for co-occurring disorder issues. 29 RESOURCE LINKS

11 References 31 Evidence based Practices Implementation Resource Kits SAMHSA - Center for Mental Health Services On the Internet: References 32 McGovern, M.P., Xie, H., Segal, S. R., Siembab, L., & Drake, R. E. (2006). Addiction treatment services and co-occurring disorders: Prevalence estimates, treatment practices, and barriers. Journal of Substance Abuse Treatment (31), Mueser, KT, Noordsy, DL, Drake, RE, & Fox, L. (2003). Integrated Treatment for Dual Disorders: A Guide to Effective Practice. New York: Guilford. CSAT. (2005). Substance Abuse Treatment for Persons with Cooccurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Pub. No. (SMA) Rockville, MD: SAMHSA. [800/ ] References Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change, 2 nd Ed. New York: Guilford. Squires, D.D. & Moyers, T.B. (2002). Motivational Interviewing. Online at (There are actually two different papers, one is in the substance abuse section and the other is in the MISA section.) Drinking evaluation: inking.html Motivational Interviewing webpage