Individuals & Families with Co-Occurring Mental Health and Substance Use Conditions

1. Individuals & Families with Co-Occurring Mental Health and Substance Use Conditions

2. Background & Status of Maine’sCo-Occurring Integration Initiative • The Co-occurring Initiative has been active in the State for over 12 years. Much of the work has been done through the Co-occurring Collaborative of the State of Maine, which provides training, networking and technical assistance to providers statewide. • Maine is in the 3rd cohort of a total of 19 states to be awarded COSIG Grants by SAMHSA (Center for Substance Abuse Treatment). • COSIG is a 3.4 million dollar, five-year grant now in its third year.

4. COSII Initiative and Activities • Regional Performance Improvement Partnership Meetings • Support the development of co-occurring best practices in agencies throughout each Region • Groups made up of providers, DHHS Regional Team representatives, peers and the COSII Project Team meet regularly to discuss implementation challenges, to provide mutual, Co-learning support and mentoring, and to exchange strategies for co-occurring practice. • The CCSME provides technical assistance, personal perspective from peers and training • State Level Committee Work • Licensure, Screening and Assessment, Workforce Development, Clinical Practice, Advisory, Steering and Peer input committee • Pilot/Expansion Sites • Implement COD Capability • Collect data • Learn from each other with Pilot meetings • Technical Assistance • Meetings with Pilot Coordinator, Joanne Ogden • Evaluation

5. COSIIWhat We’ve Done • Focus on collaboration between OSA and Mental Health • Moved the licensing/regulatory agenda forward • Developed agency capacity to provide integrated, person centered care • Developed an Integration Policy • Begun to define clinical protocols and standards • Defined COD Capable Recovery based Services • Included COD clinical criteria & service review of ASO • Provided multiple hours of training and technical assistance to agencies • Begun to work with MaineCare on Policy change • Begun a cost study to determine what savings might accrue from integrated care • Collection of significant data on; people in Maine with co-occurring issues

6. Commissioner’s Integrated Service Policy

7. COSIIPilot Sites’ Role: • Partnership in a change process! • Develop the infrastructure for co-occurring capability within your agency • Try out new approaches & let us know what works and what gets in your way • Be a leader in defining integrated services in Maine • Gather data to assess what is working

8. The Vision Maine provides a welcoming, integrated system of services to people of all ages with co-occurring conditions where access, services, and payment are aligned.

9. Prevalence According to the US Surgeon General in the 1999 Mental Health Report (DHHS, 1999): • Forty-one to 65% of individuals with a lifetime substance abuse disorder also have a lifetime history of at least one mental health disorder. • About 51% of those with one or more lifetime mental disorders also have a lifetime history of at least one substance disorder. Youth: • 43% of youth who receive mental health services in US are people with a co-occurring substance use disorder • 62% of males and 82% of females entering substance abuse treatment have been diagnosed with emotional disorders, including behavioral health issues

10. Rates of Lifetime Substance Use Disorder(SUD) among Recently Admitted Psychiatric Inpatients(N=325) (Mueser et al., 2000)

11. Rates of Co-occurring Psychiatric Issues among Adolescents Rates of co-occurring psychiatric problems among adolescents (n=4421) interviewed between 1998-2004 with the Global Appraisal of Individual Needs (GAIN) across 64 adolescent treatment grantees Source: Turner, W. (2005)

12. Service Use: higher among people with a co-occurring diagnosis Maine Health Access Study 2005

13. Associated Issues • Complicated Clinical Symptoms • Worse Outcomes • Frequent starts and stops with possible re-hospitalization • Homelessness and incarceration • Social relationships • Risky behaviors and infectious diseases • Trauma-related issues • Cognitive disorders • Medical conditions • Smoking-related consequences • Communicable diseases – HCV, HCB, HIV, STD • Increased service utilization and costs • Poor engagement in development of personal recovery plan

14. Past Year Treatment Among Adults Aged 18 or Older with Both Serious Psychological Distress and a Substance Use Disorder, 2005 5.2 Million Adults with Co-Occurring SPD and SUD Source (SAMHSA, 2006)

15. Why is Co-Occurring Integration Important? • The impetus for the COSIG developed from the President’s New Freedom Report about the fractured mental health system in this country and SAMHSA’s resulting desire to address SA and MH issues in an integrated way. This is a top priority in SAMHSA’s strategic plan. • Co-Occurrence of mental health and substance abuse is highly prevalent • Individuals and families with co-occurring conditions are not receiving treatment • Individuals and families with co-occurring conditions often have poorer outcomes

16. Complexity of Co-Occurring Disorders • In time, with intensity in use of drugs and alcohol, they can mimic psychiatric disorders • It is not unusual for people with substance use issues to have problems with sleep & anxiety • When people experience extreme ups (Mania) it is indistinguishable from stimulant use • Withdrawal is experienced in many ways, sometimes anxiety and depression are not uncommon

17. Why Integrate? • Co-occurring disorders exist not simply by chance and occur frequently • There is always a relationship between the disorders that affects outcomes • By-and-large, effective responses to persons with either mental health or substance use disorders are compatible • Research evidence supports the claim that, person centered, integrated recovery plans lead to better personal outcomes!

18. Co-Occurring Treatment Models

19. Guiding Principles of COD Treatment • Co-occurring disorder is an expectation, not an exception. • All individuals with co-occurring psychiatric and substance disorders are not the same • Empathic, mutual, co-learning, hopeful, integrated relationships promote successful and personally satisfying outcomes • What works for one person might not work for another. When individuals and families with co-occurring psychiatric and substance use issues create individualized personal plans that match their own goals, hopes, and dreams, it is accompanied by success. • Clinical outcomes for people with co-occurring psychiatric and substance use disorders must be individualized. • The system of care operates in partnership with persons receiving services and all concerned significant others

20. Essential Attitudes and Values for Clinicians • Hope that people change and willingness to work with COD’s • Appreciation of human resilience and the complexities of life • Awareness of how you have come to know the world and personal reactions to feelings • Recognition of one’s own ability for growth in knowledge and expertise • Recognition of the expertise people bring to their own personal recovery plan

21. Essential Attitudes and Values for Clinicians • Patience, perseverance and therapeutic optimism • Ability to listen for a persons hopes, goals, dreams and values • The understanding that we have all come to know the world in a different way • Belief that everyone has personal strengths and capability of growth/development • Recognizing the rights of people to create personally meaningful recovery plans

22. Co-Occurring Capable • Each program designs its policies, procedures, screening, assessment, program content, interagency relationships and staff competencies. • Routinely provide person centered integrated services with the individuals and families experiencing co-occurring disorders, who routinely present, are aligned within the context of the program’s mission, design, licensure and resources. Systems, Programs, Practitioners and people

23. Inclusive, Mutual delivery of Services and Core Components

24. Integrated coordination of recovery focused person centered care success derive from the implementation and maintenance of an empathic, hopeful, mutual and continuous relationships.

25. Assessment: Areas for Integration • The person’s hopes, goals, dreams & values • Most Stable Baseline • Relationship of mental health to substance abuse • Time lines • Stages of Change • Functional Analysis • Formulation

26. Hope is; • The cornerstone of effective recovery for individuals with co-occurring disorders • A continuous process that is not static

27. Important principles to follow • Always meet the person where they are • Find strengths, support self-efficacy • Use empathy, acceptance, and a non-judgmental style • More support , recognize efforts - avoid confrontation • Do not focus on denial or resistance • Ask questions in a direct, but non-judgmental, non-confrontational manner. • Ask open-ended questions. • Use motivational interviewing • Remember clients sometimes tell us what they think we want to hear. Gently probe below the surface.

28. A Day In the Life of a person with a Co-occurring disorder • Walk through a typical day • Be inquisitive, authentic, honest, mutual and patient • Be person centered (We are the expert of our life) • We have come to know the world in a unique way, be curious

29. Pay-Off Matrix Not changing Changing Advantages Disadvantages

30. How Do People Change? • People change voluntarily when • We become interested andconcernedabout the need for change • We convince ourselves the change we make is in our best interest and the benefit will be more than the cost • We organize a plan of action that we are dedicated to implementing • Wetake the actions necessary to make the changes we want to sustain

31. Stage of Change Labelsand Patient (personal) Tasks DiClemente CC. In: Miller WR, Carroll KM, eds. Rethinking Substance Abuse: What The Science Shows and What We Should Do About It. New York: Guilford Press; 2006:81-96.

32. How To Get Started for Yourself and in your Organization • Welcome and encourage conversations about co-occurring issues • Address stigma/culture • Obtain good clinical supervision In organizations • Requires both top down and bottom up efforts • Requires overt commitment and communication throughout the organization on multiple levels • Create & define the architecture for change • Organize a “Champions” group • Hold conversations on personal change, system change and planning how to make that happen • Typically begins with Welcoming, Measuring Prevalence, and Enhancing Screening & Assessment (Stages of Change) • Change occurs through continuous quality improvement process with measurable, data driven incremental steps

33. Tips to Create Change • Agencies/Staff see different results with positive reinforcement, strengths approach, share success and focus on what we want to see for change • Training by itself doesn’t result in change • Cultural change is experienced in many ways and is a process • Structural barriers are real & need to be addressed on multiple levels to develop, maintain & sustain change • Mentoring and Peer involvement works—agencies can learn from each other and challenge each other within a safe environment • Agencies/programs and people are in different stages of change • Change requires simultaneous work in multiple systems

34. Welcoming Practice • Wherever a person with co-occurring mental health and substance use disorder appears in the system of care, it is the right place for them to access the recovery hope filled services of the system. • Within an integrated system, there is NO Wrong Door. Ken Minkoff