Cultural Clashes in Co-Occurring Disorders and What To Do About It

1. Cultural Clashes in Co-Occurring Disorders and What To Do About It David Mee-Lee, M.D. www.DMLMD.com 

2. Philosophical Clashes- Polarized on Presenting Problem 3 D’s Deadly Disease Denial Detachment 3P’s Psychiatric Disorders Psychopharmacology Process

3. Philosophical Clashes- Different Theories, Treatments 1. Addiction vs Mental Health System • 3 D’s and 3 P’s - implications for medication, staff credentials, attitudes towards physicians, role of staff and team, data gathering, 12 Step programs

4. Philosophical Clashes- Different Theories, Treatments 2. Integrated vs Parallel or Sequential • Hybrid programs - staffing difficulties; numbers of patients and variability, but one-stop treatment • Parallel programs - use of existing programs and staff, but more difficult to case manage

5. Philosophical Clashes- Different Theories, Treatments 3. Care versus Confrontation • Mental health - care, support, understanding, passivity • Addiction - accountability, behavior change

6. Philosophical Clashes - Different Theories, Treatments 4. Abstinence-oriented versus Abstinence-mandated • Treatment as a process, not an event • Respective roles in both approaches

7. Philosophical Clashes- Different Theories, Treatments 5. Deinstitutionalization versus Recovery and Rehabilitation • Role of “least restrictive” setting • Role for individualized treatment with continuum of care (Ken Minkoff, 1991)

8. “Every Door is the Right Door” People with co-occurring disorders: “individuals who have at least one mental disorder as well as an alcohol or drug use disorder. While these disorders may interact differently in any one person…at least one disorder of each type can be diagnosed independently of the other” (In “A Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders”)

9. SAMHSA Report to Congress “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.”

10. Underlying Principles 1. Firstly people of all ages with co-occurring disorders are people first, fully deserving of respect 2. At same time, consumers, recovering persons and their families need be involved in all aspects of their treatment and recovery 3. Peoplewith co-occurring disorders can and do recover. Be optimistic about prospects for achieving stability and recovery, provide long-term support needed to maintain their progress

11. Recovery in Addiction • “Recovery is the process through which severe alcohol and other drug problems (here defined as those problems meeting DSM-IV criteria for substance abuse or substance dependence) are resolved in tandem with the development of physical, emotional, ontological (spirituality, life meaning), relational and occupational health.” (White, W. & Kurtz, E. (2005). “The Varieties of Recovery Experience”. Chicago, IL. Great Lakes Addiction Technology Transfer Center. Posted at http//:www.glattc.org)

12. Recovery in Mental Health • “Recovery occurs when people with mental illness discover, or rediscover, their strengths and abilities for pursuing personal goals and develop a sense of identity that allows them to grow beyond their mental illness” (Pat Deegan, a consumer leader and psychologist with schizophrenic disorder defines recovery from serious mental illness)

13. Underlying Principles (cont.) 4. People with co-occurring disorders deserve access to services they need to recover. To put these beliefs into practice, development of this report has been guided by following principles: • Ensure development of system in which “any door is the right door” to receive treatment for co-occurring disorders. This means people with co-occurring disorders can enter any appropriate agency in service system and be provided or referred to appropriate services

14. Underlying Principles (cont.) • Develop client-centered, individualized treatment plans based on accurate assessment of person's condition and degree of service coordination he or she requires. Family members must be involved in treatment, where appropriate • Ensure maximum feasible degree of integration for individuals with most serious substance abuse disorders and mental disorders

15. Underlying Principles (cont.) • Provide prevention and treatment services that are culturally competent, age, sexuality and gender appropriate and that reflect diversity in community • Promote expansion and enhancement of service providers’ capabilities to treat individuals of all ages who have co-occurring substance abuse disorders and mental disorders

16. Underlying Principles (cont.) 5. Not recommending creation of separate system of care for people with dual diagnosis. Indeed, people with co-occurring disorders must be able to receive treatment in mainstream systems of care that are well-prepared to support their recovery 6. Formation of partnerships should be developed at all levels, from national to community and neighborhood, for developing/enhancing seamless systems of care that allow people to move freely between and among entire constellation of services

18. What to Do About Philosophical Clashes?- Person-Centered Services Assessment: (ASAM PPC-2R, 2001)  1. Acute Intoxication and/or Withdrawal Potential 2. Biomedical Conditions and Complications 3. Emotional, Behavioral or Cognitive Conditions and Complications 4. Readiness to Change 5. Relapse/Continued Use, Continued Problem Potential 6. Recovery Environment

19. Individualized Treatment Patient/Participant Assessment BIOPSYCHOSOCIAL Dimensions Progress Treatment Response Problems/Priorities Proximal Outcomes e.g Build alliance working with Session Rating Scale (SRS) Multidimensional Assessment Outcome Rating Scale (ORS) Plan Intensity of Service – Modalities and Levels of Service (Clinical and wrap-around services)

21. Biopsychosocial Treatment Treatment Matching - Modalities • Motivate- Dimension 4 • Manage – All Six Dimensions • Medication – Dimensions 1, 2, 3, 5 • Meetings – Dimensions 2, 3, 4, 5, 6 • Monitor - All Six Dimensions

22. Treatment Levels of Service I Outpatient Treatment II Intensive Outpatient and Partial Hospitalization III Residential/Inpatient Treatment IV Medically-Managed Intensive Inpatient Treatment

23. People and Personnel Clashes and Solutions • Collaborative, concurrent interdisciplinary team • Vulnerabilities inhibiting team cohesiveness • Team communication • Staff-program match • Stress of working with multiple vulnerabilities

24. People and Personnel Clashes and Solutions (cont.) • Tolerance – To listen to another’s opinion • Open-mindedness – To give up old views • Patience – To explore before jumping to diagnosis • Education – To learn more about SUD and MH • Serenity – To realize we don’t have all the answers

25. Policy and Program Clashes and Solutions- Program Issues • Mission of the program, department, institution or agency • Equal emphasizes both mental health and addictions issues • Admission criteria and patient mix - what can staff/program manage

26. Policy and Program Clashes and Solutions- Program Issues (cont.) • Terminology and treatment tools e.g., “disorientated”; “reformed alcoholic” • Non-cognitive, activity groups e.g., time use charts; collages • Groups – education about dual identity and feelings groups to learn to cope

27. Policy and Program Clashes and Solutions- Program Issues (cont.) • Family involvement; systems work and continuing care • Self/mutual help groups - preparation for AA/NA mainstreaming; MICA and Dual Diagnosis Anonymous; Dual Recovery Anonymous • Staff composition reflects training proportionate to program’s clientele

28. Policy and Program Clashes and Solutions- Payment Issues • Person- centered funding of services based on priorities in all assessment dimensions • Move from medical necessity (withdrawal, biomedical, psychiatric severity), to multidimensional severity requiring interventions in any/all six dimensions

29. Policy and Program Clashes and Solutions- Payment Issues (cont.) • Fund case management to allow proactive, not reactive treatment • Turf battles between mental health and addiction services (often more neglected of the two systems due to fewer numbers of clients and/or stigma)

30. Data to Identify Gaps • Systems issues cannot change quickly. Each incident of inefficient or inadequate care can be a data point that promotes systems change • Finding efficient ways to gather data as it happens in daily care of clients can provide hope, direction for change

31. Data to Identify Gaps (cont.) PLACEMENT SUMMARY Level of Care/Service Indicated Level of Care/Service Received

32. Data to Identify Gaps (cont.) PLACEMENT SUMMARY Reason for Difference - Circle only one number -- 1. Level of care or Service not available; 2. Provider judgment; 3. Client preference; 4. Client is on waiting list for appropriate level/service; 5. Level of care or Service available, but no payment source; 6. Geographic inaccessibility etc.

38. David Mee-Lee, M.D.  www.DMLMD.com