TIP 42 (and Beyond) — Substance Treatment for Persons with Co-Occurring Disorders

1. TIP 42 (and Beyond) — Substance Treatment for Persons with Co-Occurring Disorders Stanley Sacks, Ph.D., Center for the Integration of Research & PracticeNational Development & Research Institutes, Inc. European Federation of Therapeutic Communities Conference Ljubljana, Slovenia ► June 2007

2. SAMHSA’s Definition of Co-Occurring Disorders The term refers to co-occurring substance use (abuse or dependence) and mental disorders. Clients said to have co-occurring disorders have one or more mental disorders as well as one or more disorders relating to the use of alcohol and/or other drugs. Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)

3. Mental Disorders A C B Substance Use Disorders Co-Occurring Mental and Substance Use Disorders Adapted from Osher, F.C. (1996)

4. COD & Treatment Outcomes • COD clients have poorer outcomes, such as higher rates of HIV infection, relapse, rehospitalization, depression and suicide risk. • COD clients have better outcomes with treatment designed for their special needs. Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)

5. COD Advances Timeline 1979 1981 1989 1993 Mid 1990’s Early 1990’s Woody & Blaine Substance Abuse & Depression PepperChronic Young Adult Minkoff Integrated Treatment Kessler National Comorbidity Survey Drake ACT Ries TIP 9 2000-2003 2002-Pres. Mid 1990’s 1996-7 Late 1998 1999 Evidenced-Based Practices for SMI Sacks & De Leon MTC DATOS Studies NASADADNASMPHD Four Quadrants Research on Strategies & Models TIP 42Report to CongressCo-Occurring Center for ExcellenceState InitiativesToolkits

6. mental health programs1 clients with substance use disorder 20% — 50% drug treatment facilities1 clients with mental disorder (most not severe) 50% — 75% General Population (National Comorbidity Survey2) have mental disorder of those with lifetime addictive disorder 50% 50% have substance use disorder of those withlifetime mental illness disorder Over 4 million with serious mental disorders3 Source: 1 Sacks et al. 1997; 2 Kessler, R. et al. 1994; 3 Grant et al. 2004; SAMHSA, 2004 Prevalence of Co-Occurring Disorders

7. III Less severe mental disorder/more severe substance abuse disorder IV More severe mental disorder/more severe substance abuse disorder High Severity Alcohol and other drug abuse I Less severe mental disorder/less severe substance abuse disorder II More severe mental disorder/less severe substance abuse disorder Mental Illness Low Severity High Severity The Four Quadrants Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)

8. Assessment Screening Diagnosis Person Individualized Treatment Plan Treatment Services (referral or provision) Developing Treatment Resources The Clinical Planning Process

9. Screening Definition • Screening is a formal process of testing to determine whether or not a person has a disorder that warrants further attention at the time of testing and, within this context, to determine whether or not a co-occurring substance use or mental disorder may be present (Center for Substance Abuse Treatment [CSAT], 2005a; 2005b). • The screening process for co-occurring disorders seeks to answer a “yes” or “no” question: Does the client with a substance use [or mental] disorder show signs of a possible mental [or substance use] disorder? • The screening process does not necessarily identify the type or the severity of the disorder, but determines only whether or not the person has a disorder and indicates when additional assessment is needed. Source: CSAT 2005a, b

10. Features of Screening Instruments • High sensitivity • Brief • Low cost and no cost • Minimal staff training required • Consumer friendly Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)

11. Measures of Precision Defined • Sensitivity: the probability that the screening test is positive given that the person has the disorder. This is also know as the true positive rate. A large sensitivity means that a negative test can rule out the disorder. • Specificity: the probability that the screening test is negative given that the person does not have the disorder. This is also known as true negative rate . A large specificity means that a positive test can rule in the disorder. • Overall Accuracy: is the combination of sensitivity and specificity – the probability that the screening test is positive given that the person has the disorder combined with the probability that the screening test is negative given that the person does not have the disorder.

12. Validation Results – Any Mental Disorder

13. Counselor Role in Screening • In substance abuse or mental health treatment settings, every counselor or clinician who conducts intake should be able to screen for the most common COD and know how to implement the protocol for obtaining COD assessment information and recommendations. Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)

14. List of Screening Instruments

15. COCE Recommendations for a Selection Process • Screening Instruments in the Matrix review are all acceptable. • Decide if you want a screening instrument for substance use disorder, a screening instrument for mental disorders or both. • If the latter, either use a combination of SA and MH screening instruments (for example, MINI Screen Modified/DALI) or use the GAIN. • COCE recognizes that the use of other instruments may be desirable in a particular circumstance and that there are other viable options available. • Consider customizing your instrument with additional items selected from the comprehensive list of instruments. • Involve stakeholders and users in the instruments selection process. • Begin parallel development of coordinated assessment instruments, placement determination, treatment planning and treatment resources.

16. Assessment Definition • Gathers information and engages in a process with the client that enables the provider to establish (or rule out) the presence or absence of a co-occurring disorder. • Determines the client’s readiness for change, identifies client strengths or problem areas that may affect the processes of treatment and recovery, and engages the client in the development of an appropriate treatment relationship. Source: CSAT 2005b.

17. Basic Assessment Consists of: • Background • Substance use • Psychiatric problems • Integrated assessment Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)

18. List of Selected Assessment Instruments

19. List of Selected Assessment Instruments Continued

20. Additional Considerations • Assessment should be a clinical driven process- involves clinician making connection with the client. • Consider the client in a context (i.e. setting) and fit assessment process to the setting. • Take into account the system of care the person is in – think of systems available so you can do treatment planning.

21. Advice to the Counselor: Do’s and Don’ts of Assessment for COD • Do keep in mind that assessment is about getting to know a person with complex and individual needs. Do not rely on tools alone for a comprehensive assessment. • Do always make every effort to contact all involved parties. • Don’t allow preconceptions about addiction to interfere with learning about what the client really needs. • Do become familiar with the diagnostic criteria for common mental disorders, including personality disorders, and with the names and indications of common psychiatric medications. • Don’t assume that there is one correct treatment approach or program for any type of COD. • Do become familiar with the specific role that your program or setting plays in delivering services related to COD in the wider context of the system of care. • Don’t be afraid to admit when you don’t know, either to the client or yourself. • Most important, do remember that empathy and hope are the most valuable components of your work with a client. Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)

22. Treatment PlanningDefinition • Develops a comprehensive set of staged, integrated program placements and treatment interventions for each disorder that is adjusted as needed to take into account issues related to the other disorder. • The plan is matched to the individual needs, readiness, preferences, and personal goals of the client. Source: CSAT 2005b

23. What is an Evidence-Based Practice? • In the area of COD treatment, EBP is defined by COCE primarily as the use of current and best research evidence in making clinical and programmatic decisions about services to client[s). The research considerations involved in determining what constitutes an evidence-based practice include not only the robustness of the study findings but also the type of design employed and the methodological rigor of the procedures. • A broader definition of EBP also includes taking into account clinician expertise and patient values, as indicated by the Institute of Medicine (2000) and more recently by the American Psychological Association (2005). Center for Substance Abuse Treatment. (2005c)

24. Pyramid of Evidence Based Practices in COD: Type of Design Center for Substance Abuse Treatment. (2005c)

25. Quality of the Research • Sample Representativeness • Psychometric Features of Interview Instruments • Appropriateness of Analytic Techniques • Robustness of the Findings • Threats to Validity

26. Readiness for Dissemination • Curriculum • Training • Technical Assistance • Supervision • Quality Assurance of Fidelity

27. Table of Consensus- and Evidence-Based Practices for COD 1 The last two in this column are specific to those with co-occurring disorders. 2 Based on Drake, R., O’Neal, E.L., & Wallach, M.A. A systematic review of research on interventions for people with co-occurring severe mental and substance use disorders.Journal of Substance Abuse Treatment, (in press).

28. to structure more flexible activities shorter meetings & activities more staff guidance more staff responsibility as role models to process fewer sanctions engagement emphasis individually paced progress in program flexible criteria for moving to next stage live-out re-entry (aftercare) essential Modified TCKey Modifications to elements • accent on orientation & instruction • individualized task assignments • engagement emphasis throughout • activities proceed at a slower pace • counseling to assist use of community Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders TIP, 2005a

29. Summary • The Modified TC is • more flexible • less intense • more individualized • The quintessential elements remain • peer self-help • community-as-method Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders TIP, 2005a

30. # of Drugs # of Drugs Drug Use Drug Use Alcohol Alcohol Employment Employment baseline 2-yearfollow-up Outcomes baseline vs 2-year follow-up Modified TC2 TAU De Leon, G., Sacks, S., et al. 2000.

31. Benefit Cost Analysis incremental benefit of modified TC $273,115 cost per client of modified TC treatment $20,361 total net benefit per client ($273,115 - $20,361)$252,114 $6 Benefit cost ratio $252,114/$20,361 = (13:1— data winsorized 6:1)$6 benefit for every $1 of cost Source: French, M., McCollister, K., Sacks, S. et al 2002.

32. reincarceration rates MICA Offender 12 Month Outcomes 33% MH TC +after-care 16% 5% TC only Total n= 139 n=64 n=32 n=43 Sacks, S., Sacks, J., et al. 2004

33. Substance AbuseIllegal Drug Use (P<.05) 86% 79% 44% 25%

34. MTC for Co-Occurring Disorders: A Meta-Analysis of Three Studies (Four Comparisons) Summary of meta-analysis combined study comparisons — random effects analysis (differential treatment effects: MTC vs. Comparison) *p<0.05; **p<0.01; ***p<0.001 † An odds ratio less than one indicates a greater improvement for clients in the MTC group than in the comparison group. Source: Sacks, Banks, McKendrick et al 2007

35. Advice to Counselors & Administrators: Recommended Treatment and Services From the MTC Model • Treat the whole person. • Provide a highly structured daily regimen. • Use peers to help one another. • Rely on a network or community for both support and healing. • Regard all interactions as opportunities for change. • Foster positive growth and development. • Promote change in behavior, attitudes, values, and lifestyle. • Teach, honor, and respect cultural values, beliefs, and differences. Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders TIP 42, 2005a

36. Services Integration and Other Forms of Integration Center for Substance Abuse Treatment, (2005d)

37. Fully Integrated COD Integrated Beginning Addiction Only Tx Intermediate COD Capable Advanced COD Enhanced Beginning Mental Health Only Tx Advanced COD Enhanced Intermediate COD Capable Substance Abuse Tx Mental Health Tx More Tx for Mental Disorders More Tx for Substance Abuse Disorders Levels of Program Capacity in COD Adapted from CSAT, 2005a, Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP 42

38. Principles That Guide Provider Activity For People With COD • Co-occurring disorders must be expected and treatment approaches should incorporate this assumption in all screening, assessment and treatment planning. • Within the treatment context, both co-occurring disorders are considered of equal importance1. • Empathy, respect, and the belief in the individual’s capacity for change are fundamental provider attitudes. • Treatment should be individualized to accommodate the specific needs and personal goals of unique individuals in different stages of change. 1Adapted from original Center for Substance Abuse Treatment. 2005e

39. Building Blocks for Constructing a Co-Occurring Treatment System Clinical Capacity Infrastructure Evaluation and Monitoring Information Sharing Evidence and Consensus- Based Practices Certification and Licensure Workforce Development and Training Financing Mechanisms Screening, Assessment, & Treatment Planning Systems Change Definitions, Terminology, Classification Services Integration

40. Conclusion • Much has been accomplished in the field of COD in the last 10 years, and the knowledge acquired is ready for broader dissemination and application. • The importance of the transfer and application of knowledge and technology has likewise become better understood. • New government initiatives (for example, COSIG, COCE, and MHT) are underway that improve services by promoting innovative technology transfer strategies using material that reflect the recent advances in the field. Source: Center for Substance Abuse Treatment. 2005a

41. References Center for Substance Abuse Treatment. 2005a. Substance Abuse Treatment for Persons With Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series, Number 42. DHHS Pub. No. (SMA) 05-39920. Rockville, MD: Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment (CSAT). (2005b) Screening, Assessment, and Treatment Planning. Co-Occurring Center for Excellence (COCE) Overview Paper No. 2. DHHS Publication No. (SMA) XX-XXXX. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA), and Center for Mental Health Services (CMHS). Retrieved online 09/08/06 at http://coce.samhsa.gov/cod_resources/index_right_2.aspx?obj=77.Center for Substance Abuse Treatment. 2005d. Services Integration. COCE Overview Paper. Rockville, MD: Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment. 2005c. The Use of Evidence- and Consensus-Based Practices in Treating Persons With Co-Occurring Disorders. COCE Overview Paper No. 4. Rockville, MD: Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment. 2005d. Services Integration. COCE Overview Paper. Rockville, MD: Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment. 2005e. Overarching Principles in the Planning, Implementation, and Delivery of Service for Persons with Co-Occurring Disorders. COCE Overview Paper. Rockville, MD: Substance Abuse and Mental Health Services Administration. De Leon, G., Sacks, S., Staines, G., & McKendrick, K. 2000.Modified therapeutic community for homeless MICAs: Treatment Outcomes. American Journal of Drug and Alcohol Abuse, 26(3), 461-480. Drake, R., O'Neal, E.L., & Wallach, M.A. (2007) A Systematic Review of Research on Interventions for People with Co-occurring Severe Mental and Substance Use Disorders. Journal of Substance Abuse Treatment, special issue, accepted for publication. French, M.T, McCollister, K.E., Sacks, S.,McKendrick K. & De Leon, G. 2002. Benefit-cost analysis of a modified TC for mentally ill chemical abusers. Evaluation and Program Planning, 25(2), 137-148. CSAT/SAMHSA COCE OVERVIEW PAPERS CAN BE DOWNLOADED AT http://coce.samhsa.gov/

42. References Grant, B.F., Stinson, F.S., Dawson, D.A., Chou, S.P., Dufour, M.C., Comptom, W., Pickering, R.P. & Kaplan, K. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders. Archives of General Psychiatry, 61, 807–816, 2004. Kessler, R.C., McGonagle, K., Zhao, S., Nelson, C.D., Hughes, M., Eshleman, S., Wittchen, H., and Kendler, K. Lifetime and 12-month prevalence of DSM-IIIR psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry 51:8–19, 1994. Mueser, K.T., Torrey, W.C., Lynde, D., Singer, P., & Drake, R.E. 2003. Implementing evidence-based practices for people with severe mental illness. Behavior Modification, 27(3), 387-411. Sacks, S., Sacks. J.Y., De Leon, G., Bernhardt, A.I. & Staines. G.L. 1997. Modified therapeutic community for mentally Ill chemical abusers: Background; influences: Program description: Preliminary findings. Substance Use and Misuse, 32(9), 1217‑1259. Sacks, S., Sacks, J.Y., McKendrick, K., Banks, S., & Stommel, J. 2004. Modified TC for MICA Offenders: Crime Outcomes. Behavioral Sciences & The Law, 22, 477-501. Sacks, S., Banks, S., McKendrick, K., Sacks, J., & Cleland, C. 2007. Modified Therapeutic Community for Co-Occurring Disorders: A Research Synthesis Using Meta Analysis. Submitted to the American Journal on Addictions. Substance Abuse and Mental Health Services Administration. 2002.Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Disorders. Rockville, MD: Substance Abuse and Mental Health Services Administration. Substance Abuse & Mental Health Administration. 2004. Results from the 2003 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies.

43. Contact informationStanley Sacks, Ph.D.Director, Center for the Integration of Research & PracticeNational Development & Research Institutes, Inc.71 W 23rd Street, 8th FloorNew York, NY 10010tel 212.845.4429  fax 212.845.4650http://www.ndri.org stansacks@mac.com European Federation of Therapeutic Communities Conference Ljubljana, Slovenia ► June 2007