Integrating Treatment for Co-Occurring Disorders. Brought to you by:

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1 Integrating Treatment for Co-Occurring Disorders Brought to you by:

2 Today s Moderators Marty Harding Director of Training and Consultation Hazelden Publishing Gerald McCleery, Ph.D VP for Business Development Relias, Home of Essential Learning

3 Today s Presenters Mary Woods, RNC, LADC, MSHS Chief Executive Officer Westbridge Community Services Tim Sheehan, Ph.D. Director of Institutional Effectiveness Hazelden Graduate School of Addiction Studies

4 Web Conference Objectives Discuss the prevalence of co-occurring disorders in substance abuse treatment programs

5 Web Conference Objectives Discuss the prevalence of co-occurring disorders in substance abuse treatment programs Contrast co-occurring treatment with traditional addiction treatment

6 Web Conference Objectives Discuss the prevalence of co-occurring disorders in substance abuse treatment programs Contrast co-occurring treatment with traditional addiction treatment Give a rationale for integrated treatment

7 Web Conference Objectives Discuss the prevalence of co-occurring disorders in substance abuse treatment programs Contrast co-occurring treatment with traditional addiction treatment Give a rationale for integrated treatment List instruments helpful for screening

8 Web Conference Objectives Discuss the prevalence of co-occurring disorders in substance abuse treatment programs Contrast co-occurring treatment with traditional addiction treatment Give a rationale for integrated treatment List instruments helpful for screening Describe evidence-based therapies helpful in treating co-occurring disorders

9 Web Conference Objectives Discuss the prevalence of co-occurring disorders in substance abuse treatment programs Contrast co-occurring treatment with traditional addiction treatment Give a rationale for integrated treatment List instruments helpful for screening Describe evidence-based therapies helpful in treating co-occurring disorders Access new training programs available through Essential Learning and Hazelden

10 Who is participating? Thanks so much for participating in this program! We have almost a thousand people registered. For what type of agency do you work? Our agency treats substance use disorders only Our agency treats mental health disorders only Our agency provides integrated co-occurring disorders treatment I work as an independent practitioner, not for an agency

11 Part One: Introduction to Co-Occurring Disorders

12 Scope of Practice An Addiction Professional s scope of practice varies with education, training and state requirements. With over 600 people on line today, each practitioner should keep his or her scope of practice in mind as we conduct this presentation.

13 Defining Co-Occurring Disorders 50 to 75% of all clients who are receiving treatment for a substance use disorder also have another diagnosable mental health disorder. Further, of all psychiatric clients with a mental health disorder, 25 to 50% of them also currently have or had a substance use disorder at some point in their lives.

14 Defining Co-Occurring Disorders Co-morbidity of Substance Use and Psychiatric Disorders Among a sample of about 10,000 adults: 13.5% had an alcohol use disorder. Of those, 36.6% also had a psychiatric disorder. 6.1% had a drug use disorder. Of those, 53.1% also had a psychiatric disorder. 22.5% had a psychiatric disorder. Of those, 28.9% also had an alcohol or drug use disorder. Source: Regier et al. 1990

15 Defining Co-Occurring Disorders Psychiatric Disorders in Addiction Treatment Two studies of Prevalence rates in addiction treatment settings had similar findings. Persons with substance use disorders are also like to have mood and anxiety disorders. Source: Cacciola et al, 2001; Ross, Glaser and Germanson 1988

16 Defining Co-Occurring Disorders Addiction Treatment Provider Estimates by Psychiatric Disorder 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Mood Disorders Anxiety Disorders Post-Traumatic Stress Disorders Antisocial Personality Disorders Borderline Personality Disorders Severe Mental Illness

17 Defining Co-Occurring Disorders Mental health disorder (MHD): significant and chronic disturbances with feelings, thinking, functioning and/or relationships that are not due to drug or alcohol use and are not the result of a medical illness 22 Bipolar disorder Major depressive disorder Schizophrenia Obsessive-compulsive disorder Social phobia Borderline personality disorder Posttraumatic stress disorder

18 Defining Co-Occurring Disorders Substance use disorder (SUD): a behavioral pattern of continual psychoactive substance use that can be diagnosed as either substance abuse or substance dependence

19 Defining Co-Occurring Disorders Co-occurring disorders (COD): the simultaneous existence of one or more disorders relating to the use of alcohol and/or other drugs of abuse as well as one or more mental [health] disorders. 18

20 Severity of Co-occurring Disorders Co-occurring mental health disorders are often placed on a continuum of severity. Non-severe: early in the continuum and can include mood disorders, anxiety disorders, adjustment disorders and personality disorders. Severe: include schizophrenia, bipolar disorder, schizoaffective disorder and major depressive disorder.

21 Severity of Co-occurring Disorders The classification of severe and non-severe is based on a specific diagnosis and by state criteria for Medicaid qualification but can vary significantly based on severity of the disability and the duration of the disorder.

22 Quadrants of Care high Substance use severity low III high substance use severity and low mental health disorder(s) severity I low substance use severity and low mental health disorder(s) severity IV high substance use severity and high mental health disorder(s) severity II low substance use severity and high mental health disorder(s) severity low Mental health disorder(s) severity high

23 Part Two: What is Co-Occurring Treatment and How Is It Different?

24 Models of Treatment Clients with co-occurring disorders have historically received substance abuse treatment services in isolation from mental health treatment services. As more research on co-occurring disorders began to be conducted, the many limitations this approach places on the client and his or her success in treatment began to surface.

25 Models of Treatment A twenty-eight year-old-woman named Anita entered an addiction treatment center where she was assessed as having alcohol dependence. Six months earlier, Anita had been diagnosed with major depressive disorder and was prescribed medication by her family doctor. At the treatment facility, it was recommended that Anita be re-assessed and treated, if necessary, at a mental health clinic, located nearby in town. What model of treatment does this scenario represent? single model of treatment sequential model of treatment parallel model of treatment integrated model of treatment

26 Models of Treatment Single model of care - It was believed that once the primary disorder" was treated effectively, the client s substance use problem would resolve itself because drugs and/or alcohol were no longer needed to cope. Sequential model of treatment - acknowledges the presence of co-occurring disorders but treats them one at a time. Parallel model of treatment - mental health disorders are treated at the same time as co-occurring substance use disorders, only by separate treatment professionals and often at separate treatment facilities.

27 Integrated Model of Treatment Integrated model of treatment an approach to treating co-occurring disorders that utilizes one competent treatment team at the same facility to recognize and address all mental health and substance use disorders at the same time.

28 Integrated Model of Treatment The integrated model of treatment can best be defined by following seven components: 1) Integration

29 Integrated Model of Treatment The integrated model of treatment can best be defined by following seven components: 1) Integration 2) Comprehensiveness

30 Integrated Model of Treatment The integrated model of treatment can best be defined by following seven components: 1) Integration 2) Comprehensiveness 3) Assertiveness

31 Integrated Model of Treatment The integrated model of treatment can best be defined by following seven components: 1) Integration 2) Comprehensiveness 3) Assertiveness 4) Reduction of negative consequences

32 Integrated Model of Treatment The integrated model of treatment can best be defined by following seven components: 1) Integration 2) Comprehensiveness 3) Assertiveness 4) Reduction of negative consequences 5) Long-term perspective

33 Integrated Model of Treatment The integrated model of treatment can best be defined by following seven components: 1) Integration 2) Comprehensiveness 3) Assertiveness 4) Reduction of negative consequences 5) Long-term perspective 6) Motivation-based treatment

34 Integrated Model of Treatment The integrated model of treatment can best be defined by following seven components: 1) Integration 2) Comprehensiveness 3) Assertiveness 4) Reduction of negative consequences 5) Long-term perspective 6) Motivation-based treatment 7) Multiple psychotherapeutic modalities

35 Integrated Model of Treatment The integrated model of treatment can best be defined by following seven components: 1) Integration 2) Comprehensiveness 3) Assertiveness 4) Reduction of negative consequences 5) Long-term perspective 6) Motivation-based treatment 7) Multiple psychotherapeutic modalities

36 Benefits of an Integrated Model of Care Benefits of an Integrated Model of Care Reduced need for coordination

37 Benefits of an Integrated Model of Care Benefits of an Integrated Model of Care Reduced need for coordination Reduced frustration for clients

38 Benefits of an Integrated Model of Care Benefits of an Integrated Model of Care Reduced need for coordination Reduced frustration for clients Shared decision-making responsibilities

39 Benefits of an Integrated Model of Care Benefits of an Integrated Model of Care Reduced need for coordination Reduced frustration for clients Shared decision-making responsibilities Families and significant others are included

40 Benefits of an Integrated Model of Care Benefits of an Integrated Model of Care Reduced need for coordination Reduced frustration for clients Shared decision-making responsibilities Families and significant others are included Transparent practices help everyone involved share responsibility

41 Benefits of an Integrated Model of Care Benefits of an Integrated Model of Care Reduced need for coordination Reduced frustration for clients Shared decision-making responsibilities Families and significant others are included Transparent practices help everyone involved share responsibility Clients are empowered to treat their own illness and manage their own recovery

42 Benefits of an Integrated Model of Care Benefits of an Integrated Model of Care Reduced need for coordination Reduced frustration for clients Shared decision-making responsibilities Families and significant others are included Transparent practices help everyone involved share responsibility Clients are empowered to treat their own illness and manage their own recovery The client and his/her family has more choice in treatment, more ability for self-management, and a higher satisfaction with care

43 Co-occurring Disorders Interactions An integrated model of care assumes that: One disorder does not necessarily present as primary. There isn t necessarily a causal relationship between co-occurring disorders. These are co-occurring brain diseases that need to be treated simultaneously.

44 Screening and Assessment Screening: The first phase of evaluation where the potential client is interviewed to determine if he or she is appropriate for that specific treatment facility and to determine the possible presence or absence of a substance use or mental health problem.

45 Screening and Assessment Assessment: The second phase of evaluation where a systematic interview is necessary to verify the potential presence of a mental health or substance use disorder detected during the screening process.

46 Screening and Assessment Complexities of Screening and Assessment Intoxication Withdrawal Substance-induced disorders Motivational factors Feelings, symptoms, and disorders

47 Co-occurring Disorders Interactions >Substances and Negative Emotions

48 Screening and Assessment The choice of screening measures depends on: 1) The skill of the screening professional 2) The cost of the screening materials 3) How simple the scale is to interpret and use across disciplines 4) Psychometric qualities 5) The relevance of screening to prevalent disorders 6) Movement from very sensitive (generic) measures to more specific measures

49 Screening and Assessment Integrated Assessment Process 12 Steps 1. Engage the Client

50 Screening and Assessment Integrated Assessment Process 12 Steps 1. Engage the Client 2. Identify and Contact Collaterals

51 Screening and Assessment Integrated Assessment Process 12 Steps 1. Engage the Client 2. Identify and Contact Collaterals 3. Screen for and Detect Co-occurring Disorders

52 Screening and Assessment Integrated Assessment Process 12 Steps 1. Engage the Client 2. Identify and Contact Collaterals 3. Screen for and Detect Co-occurring Disorders 4. Determine Quadrant and Locus of Responsibility

53 Screening and Assessment Integrated Assessment Process 12 Steps 1. Engage the Client 2. Identify and Contact Collaterals 3. Screen for and Detect Co-occurring Disorders 4. Determine Quadrant and Locus of Responsibility 5. Determine Level of Care

54 Screening and Assessment Integrated Assessment Process 12 Steps 1. Engage the Client 2. Identify and Contact Collaterals 3. Screen for and Detect Co-occurring Disorders 4. Determine Quadrant and Locus of Responsibility 5. Determine Level of Care 6. Determine Diagnosis

55 Screening and Assessment Integrated Assessment Process 12 Steps 1. Engage the Client 2. Identify and Contact Collaterals 3. Screen for and Detect Co-occurring Disorders 4. Determine Quadrant and Locus of Responsibility 5. Determine Level of Care 6. Determine Diagnosis

56 Screening and Assessment Integrated Assessment Process 12 Steps 7. Determine Disability and Functional Impairment

57 Screening and Assessment Integrated Assessment Process 12 Steps 7. Determine Disability and Functional Impairment 8. Identify Strengths and Supports

58 Screening and Assessment Integrated Assessment Process 12 Steps 7. Determine Disability and Functional Impairment 8. Identify Strengths and Supports 9. Identify Cultural and Linguistic Needs and Supports

59 Screening and Assessment Integrated Assessment Process 12 Steps 7. Determine Disability and Functional Impairment 8. Identify Strengths and Supports 9. Identify Cultural and Linguistic Needs and Supports 10. Identify Problem Domains

60 Screening and Assessment Integrated Assessment Process 12 Steps 7. Determine Disability and Functional Impairment 8. Identify Strengths and Supports 9. Identify Cultural and Linguistic Needs and Supports 10. Identify Problem Domains

61 Screening and Assessment Integrated Assessment Process 12 Steps 7. Determine Disability and Functional Impairment 8. Identify Strengths and Supports 9. Identify Cultural and Linguistic Needs and Supports 10. Identify Problem Domains 11. Determine Stage of Change

62 Screening and Assessment Integrated Assessment Process 12 Steps 7. Determine Disability and Functional Impairment 8. Identify Strengths and Supports 9. Identify Cultural and Linguistic Needs and Supports 10. Identify Problem Domains 11. Determine Stage of Change 12. Plan Treatment

63 Determining Level of Care American Society of Addiction Medicine Patient Placement Criteria 2 nd Edition Revised (ASAM PPC-2R) dimensions of care Dimension 1: Acute Intoxication and/or Withdrawal Potential Dimension 2: Biomedical Conditions and Complications Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use or Continued Problem Potential Dimension 6: Recovery/Living Environment

64 Determining Level of Care Level I: Outpatient treatment. Level II: Intensive outpatient treatment, including partial hospitalization. Level III: Residential/medically monitored intensive inpatient treatment. Level IV: Medically managed intensive inpatient treatment.

65 Evidence-Based Practices In most treatment addiction centers, the three primary evidence-based practices used are: motivational enhancement therapy (MET) cognitive-behavioral therapy (CBT) twelve step facilitation (TSF) All of these treatment models are widely used often without formal training by addiction professionals around the country and can be easily applied to clients suffering from co-occurring disorders.

66 Evidence-Based Practices The Integrated Combined Therapies model combines these three EBPs (Evidence-Based Practices) into a stage-wise treatment plan whereby: motivational enhancement therapy is first utilized to initiate change and engage the client in the therapeutic process; cognitive-behavioral therapy is then used to help make change within the client; and twelve step facilitation is essential to helping maintain and sustain changes.

67 Stages of Change/Stages of Treatment

68 Stages of Change/Stages of Treatment

69 Stages of Change/Stages of Treatment

70 Stages of Change/Stages of Treatment

71 Other Considerations Managing Medications Involving the Family Encouraging Participation in Peer-Support Recovery Programs

72 Collaboration with the prescriber Even though the prescriber is ultimately responsible for ensuring safety and effectiveness of pharmacotherapies, addiction professionals can also help in this effort. Since addiction professionals tend to see the client more often, they are well-positioned to: recognize danger signs (including recent psychoactive substance use) recognize abnormal side effects monitor and support medication compliance

73 Managing Medications Pharmacotherapy can only work if medications are taken as prescribed. Some clients with co-occurring disorders are required to manage a regimen of multiple medications each day. Clients often have difficulty strictly adhering to a dosing schedule, making them more prone to relapse and hospitalization. Clinicians can help prepare clients to manage their medications. >

74 Involving the client s family Involving families in treatment It is a myth that people with co-occurring disorders are disconnected from their families. Research has shown that outcomes for substance use and mental health disorders are improved, including fewer relapses, when families are actively engaged in the treatment process. Unfortunately, family members of a client who has co-occurring disorders often experience considerable stress, heartbreak, and confusion.

75 Involving the client s family Involving families in treatment Encourage family member involvement and develop a collaborative relationship as early as possible in the treatment process Use an evidence-based practice for family treatment Encourage families to attend self-help groups such as Al-Anon and NAMI

76 Dual-Recovery Mutual Self-Help Specific dual-recovery groups can provide essential peer support: Double Trouble in Recovery Mental Illness Anonymous Dual Disorders Anonymous Dual Recovery Anonymous Dual Diagnosis Anonymous

77 Guiding Principles of Recovery There are many pathways to recovery. Recovery is self-directed and empowering, involving personal recognition of the need for change and transformation. Recovery exists on a continuum of improved health and wellness. Recovery involves addressing discrimination and transcending shame and stigma. Recovery is supported by peers and allies, and involves joining and rebuilding a life in the community. Recovery is a reality. (from CSAT s Regional Recovery Meetings, May 2008)

78 Part Three: Training Opportunities

79 The Co-Occurring Disorders Program Written by the faculty from the Dartmouth Medical School, CDP provides practical tools for implementing evidence-based, integrated treatment practices.

80 The Co-Occurring Disorders Program Components of CDP include: Clinical Administrator s Guide Curriculum 1: Screening and Assessment Curriculum 2: Integrating Combined Therapies Curriculum 3: Cognitive-Behavioral Therapy Curriculum 4: Medication Management Curriculum 5: Family Program DVD A Guide for Living with Co-occurring Disorders Training and technical assistance is available for all components: Call , ext or training@hazelden.org

81 Hazelden and NAADAC online training Integrating Treatment for Co-occurring Disorders: An Introduction to What Every Addiction Counselor Needs to Know is a skill-based training program that will help addiction counselors improve their ability to assist clients who have co-occurring disorders, within their scope of practice.

82 Hazelden and NAADAC online training Through case studies, video presentations, interactive exercises and extensive written resources, participants learn: the many myths related to mental illness treatment barriers to assessing and treating co-occurring disorders relevant research and prevalence data commonly encountered mental disorders applicable screening and assessment instruments issues surrounding medication management coordinating with other mental health professionals the integrated model of mental health and addiction treatment services >

83 Hazelden and NAADAC online training Now available through Essential Learning! Integrating Treatment for Co-Occurring Disorders: An Introduction to What Every Addiction Counselor Needs to Know. Learn at your own pace through presentations, videos, case studies, and interactive exercises. Available 24/ CEs from NAADAC; 6 CEs from APA

84 The Hazelden/Essential Learning Partnership Provides Affordable Access to Online Training Essential Learning offers e-learning course libraries though a webbased staff training management system (LMS) EL focuses on community-based behavioral health and human services organizations More than 1,000 organizational customers in 50 states and Canada We partner with organizations like the National Council and Hazelden to bring leading edge online training to the provider community In 2012 Vista Equity Partners acquired Essential Learning and a sister company, Silverchair Learning Systems that specializes in senior care training. The companies were combined to form Relias Learning

85 Access Additional Training Through the Partnership Our health and human services online library offers hundreds of courses in areas such as: Mental health Addictions Workforce skills, supervision and management Our Hazelden library category includes 34 courses on topics such as: Co-Occurring Disorders Adolescent Drug Abuse Older Adults and Addiction Mindfulness and Multidisciplinary Treatment of Addiction For additional information about how we can help meet your training needs please contact Mary McFadden at: ext : 296

86 Time for discussion!

87 Thank you for participating!