Who We Are and What We’re Doing Today

1. PROVIDING INTEGRATED TREATMENT SERVICES: BECOMING DUAL DIAGNOSIS CAPABLE OR DUAL DIAGNOSIS ENHANCEDDawn Collinge, LPC, NCC, MAC, ACSGeorgia State DirectorTracy Batten, MS, CADCII, CCDP-DRSAT DirectorSpectrum Health Systems, Inc.

2. Who We Are and What We’re Doing Today Goals: • Define American Society of Addictions Medicine (ASAM) concepts of addictions only, dual diagnosis capable and dual diagnosis enhanced treatment programs. • Outline difficulties inherent in this change process and preparation needed to address these difficulties. • Utilization of Substance Abuse and Mental Health Services Evidenced-Based Practices KIT for Integrated treatment for Co-Occurring Disorders and Treatment Improvement Protocol 42: Substance Abuse Treatment for Persons with Co-Occurring Disorders. • Review use of Dual Diagnosis Capability in Addiction Treatment Rating Scale (DDCAT) as guide for moving program services from addictions only to dual diagnosis capable or enhanced

3. Part I Industry Guides and Instruments National and Federal Guidelines American Society of Addiction Medicine (ASAM) Dual Diagnosis Capability in Addiction Treatment (DDCAT) rating scale/index CSAT Treatment for Improvement Protocol (TIP) 42 – For Persons with COD SAMHSA Evidence-Based Practices KIT

4. Terminology MICA - mentally ill chemical abuser MISA - mentally ill substance abuser MISU - mentally ill substance using CAMI - chemically abusing mentally ill SAMI - substance abusing mentally ill MICD - mentally ill chemically dependent Dually diagnosed Dually disordered Comorbid disorders Co-Occurring or COD Person with co-occurring mental and substance use disorders

5. Types of Services Per ASAM PPC-2R, there currently exist 3 different types of programs for people with COD: • Addiction Only Services • Dual Diagnosis Capable • Dual Diagnosis Enhanced

6. AOS Cannot accommodate psychiatric illnesses however stable and however well functioning the individual Policies and procedures do not accommodate dual diagnosis, e.g. psychotropic medications not accepted; coordination/collaboration with mental health not routinely present; mental health issues not addressed in treatment

7. Dual Diagnosis Capable Routinely accept co-occurring disorders Can meet needs if psychiatric disorders sufficiently stable; independent functioning so mental disorders do not interfere with addiction treatment Address co-occurring disorders in policies, procedures, assessment, treatment planning, program content, and discharge planning

8. Dual Diagnosis Capable Have arrangements for coordination and collaboration with mental health services Can provide psychopharmacologic monitoring and psychological assessment/consultation on site; or well-coordinated off-site

9. Dual Diagnosis Enhanced • Can accommodate unstable/disabled needing specific psychiatric, mental health support, monitoring and accommodation necessary to participate in addiction treatment • Not so acute/impaired to present severe danger to self/others, nor need 24-hour, psychiatric supervision

10. Dual Diagnosis Enhanced Psychiatric, mental health and also addiction treatment professionals. Cross-training for all staff. Relatively high staff to patient ratios; close monitoring of instability and disability Policies, procedures, assessment, treatment and discharge planning accommodate co-occurring disorders

11. Dual Diagnosis Enhanced Dual diagnosis-specific, mental health symptom management groups incorporated in addiction treatment. Motivational enhancement therapies more likely (particularly in outpatient settings) Close collaboration/integration with mental health program for crisis back-up services and access to mental health case management and continuing care

12. What Is Integrated Treatment for Co-Occurring Disorders? Per SAMHSA: • Integrated Treatment is a research-proven model of treatment for people with serious mental illnesses and co-occurring substance use disorders • Consumers 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.

13. Practice Principles for Integrated Treatment for Co-Occurring Disorders • Mental health and substance abuse treatment are integrated to meet the needs of people with co-occurring disorders • Integrated treatment specialists are trained to treat both substance use and serious mental illnesses • Co-occurring disorders are treated in a stage-wise fashion with different services provided at different stages • Motivational interventions are used to treat consumers in all stages, but especially in the persuasion stage.

14. Practice Principles for Integrated Treatment for Co-Occurring Disorders • Substance abuse counseling, using a cognitive-behavioral approach, is used to treat consumers 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

15. Practice Principles for Integrated Treatment for Co-Occurring Disorders • Mental health and substance abuse treatment are evaluated and addressed • Same team • Same location • Same time Treatment targets the individual needs of people with co-occurring disorders and is integrated on organizational and clinical levels

16. Treatment in a Stage-Wise Fashion Precontemplation – Engagement Assertive outreach, practical help (housing, entitlements, other), 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 counseling

17. Treatment in a Stage-Wise Fashion 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

18. Integrated Treatment Recovery Model Hope is critical Services and treatment goals are consumer-driven Unconditional respect and compassion for consumers is essential Integrated treatment specialists are responsible for engaging consumers and supporting their recovery

19. Integrated Treatment Recovery Model Focus on consumers’ goals and functioning, not on adhering to treatment Consumer choice, shared decision making, and consumer/family education are important

20. Why Change? • Co-occurrence is common; about 50% of individuals with SMI are affected by substance abuse • Co-occurring disorders are associated with a variety of negative outcomes, including higher rates of relapse, hospitalization, incarceration, homelessness and serious infections such as HIV and hepatitis • Parallel but separate mental health and substance abuse treatment systems…deliver fragmented and in-effective care Substance abuse and mental health services administration, 2009, 3 - 4

21. Integrated Treatment Recovery Model Per SAMHSA, Integrated treatment is associated with the following positive outcomes: • Reduced substance use • Improvement in psychiatric symptoms and functioning • Decreased hospitalization • Increased housing stability • Fewer arrests and • Improved Quality of Life

22. Challenges Historical Struggles Between the Fields of Substance Abuse Treatment and General Mental Health Treatment • Both the separateness of the treatment systems and the stigma of both disorders keep this population from being effectively treated. • At one point in the client’s recovery, the chemical dependency may be top priority, and at another point, the co-occurring problem may need to be the top priority. • Clients may be resistant while in one treatment program to admit to the other problem, and if they are referred between programs, the different information they receive may cause them to leave treatment. Miller, 58 - 59

23. Challenges • 12 Differences that have existed between MH and SA treatment communities : • MH treatment providers used to say, “Control the underlying psychiatric problem, and the drug abuse will disappear.” SA treatment providers used to say, “Get the patient clean and sober and the mental health problems will resolve themselves.” • In the MH system, partial recovery from one’s problems is more readily acceptable than in SA programs. • Clients are more reluctant to seek help from the MH system than from SA treatment programs. • MH relies more on medication to treat the client whereas SA programs tend to be divided between promoting a drug-free philosophy and substituting a less-damaging drug such as methadone in a harm reduction maintenance program. • MH uses case management, shepherding clients from one service to another; whereas SA programs have traditionally emphasized self-reliance.

24. Challenges • 12 Differences that have existed between MH and SA treatment communities: • MH has traditionally utilized a supportive psychotherapeutic approach, whereas many SA programs continue to use confrontation techniques. • Both the MH system and the SA system have problems with sharing information because of confidentiality laws and regulations. • In MH the treatment is composed of professionally prepared individuals whereas some SA programs are composed primarily of recovering substance abusers.

25. Challenges • 12 Differences that have existed between MH and SA treatment communities: • MH relies on scientifically based treatment approaches. SA programs often rely on the philosophy “what works for me will work for you.” • MH pays a lot of attention to the idea of preventing the client from getting worse. In the past, SA programs, taking their cue from early 12-step fellowship beliefs, had a tendency to allow people to hit bottom to break through their denial. • In MH, treatment is individualized, whereas many traditional SA programs tend to be “one size fits all”. • MH and SA education during treatment are structured and knowledge based, but SA education also places importance on long-held traditions and peer experiences. Inaba, pp 523 - 524

26. Preparation for Change

27. Six Guiding Principles in Treating Clients with COD From SAMHSA TIP 42: Employ a recovery perspective - long term process of internal change that proceeds through various stages. Adopt a multi-problem format – services should be comprehensive Develop a phased approach to treatment – engagement, stabilization, treatment and aftercare Address specific real-life problems early in treatment – problems arise in context of personal social problems Plan for the client’s cognitive and functional impairments - interventions must be compatible with client needs and functioning. Use support systems to maintain and extend treatment effectiveness- mutual self-help groups, building community and reintegration with family and community

28. Preparation for Change Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index • Based on ASAM taxonomy of program dual diagnosis capability • Fidelity instrument for measuring addiction treatment program services for persons with co-occurring disorders • Has been subjected to a series of psychometric studies and implemented in a number of state and national systems • Serves to guide programs and system authorities in assessing and developing the dual diagnosis capacity of addiction treatment services

29. DDCAT Evaluates 35 program elements subdivided into 7 dimensions: • Program Structure • Program Milieu • Clinical Process • Assessment & Treatment • Continuity of Care • Staffing • Training

30. SAMHSA EBT Kit Integrated Treatment for Co-Occurring Disorders • Evidence-Based Practice KIT: • Provides practice principles about integrated treatment for co-occurring disorders, an approach that helps people recover by offering mental health and substance abuse services at the same time and in one setting. Offers suggestions from successful programs. • Find downloads at www.samhsa.gov

31. SAMHSA EBT Kit KIT Includes: • Getting Started with Evidence-Based Practices • Building Your Program • Training Frontline Staff • Evaluating Your Program • The Evidence • Using Multimedia • Brochure • Powerpoint • Introductory video

32. DDCAT Dual Diagnosis Capability in Addiction Treatment Index: • Based on the American Society of Addiction Medicine (ASAM) taxonomy of program dual diagnosis capability • Fidelity instrument for measuring addiction treatment program services for persons with co-occurring disorders • Has been subjected to a series of psychometric studies and implemented in a number of state and national systems • Serves to guide programs and system authorities in assessing and developing the dual diagnosis capacity of addiction treatment services McGovern, et al, 2006

33. QUESTIONS? Comments? BREAK!!

34. Part II: Integration and Culture Change • COD Epidemiology • Studies conducted in mental health settings found 20 to 50 percent of clients had a lifetime co-occurring substance use disorder • Studies conducted in substance abuse treatment agencies found 50 to 75 percent of clients had a lifetime co-occurring mental disorder

35. Why Integrate MH & SA Services COD is more common than not CODs are associated with higher rates of relapse, hospitalization, incarceration, homelessness and infectious diseases Most Mental health providers are not trained to deliver substance abuse treatment interventions Parallel but separate mental health and substance abuse treatment systems . . . Deliver fragmented and in-effective care SAMHSA 2009

36. National Prevalence Estimates 5 million US adults have a serious mental illness and a co-occurring disorder MH treatment settings: 20% – 50% have a lifetime co-occurring substance use disorder SA treatment settings: 50% - 75% have a lifetime co-occurring mental health disorder

37. Persons with Serious Mental Illness (SMI) are Dying of Preventable Causes • Higher Rates of Modifiable Risk Factors: • Smoking • Alcohol consumption • Poor nutrition/obesity • Lack of exercise • Unsafe sexual behavior • IV drug use • Reside in group care facilities/homeless shelters (NASMHPD)

38. Preventable Causes (cont) • Vulnerability due to higher rates of: • Homelessness • Victimization/trauma • Unemployment • Poverty • Incarceration • Social isolation

39. COD Screening Instruments Mental Health Screening Form – III (MHSF-III) Mini-International Neuropsychiatric Interview Global Appraisal of Individual Needs (GAIN) Level of Care Utilization System (LOCUS) Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD) CAGE – AID (CAGE adapted to include drugs)

40. Four-Quadrant Model of COD HIGH SUD LOW HIGH MI

41. DDCAT Evaluates 35 program elements that are subdivided into 7 dimensions: Program Structure – general organizational factors that foster or inhibit the development of COD treatment Program Milieu – the culture of program and whether the staff and physical environment of the program are receptive and welcoming to persons with COD

42. DDCAT Dimensions (cont) 3rd and 4th dimensions Clinical Process Assessment & Treatment – Whether specific clinical activities achieve specific benchmarks for COD assessment and treatment

43. DDCAT Dimensions (cont) Continuity of Care – long-term treatment issues and external supportive care issues commonly associated with persons who have COD. Staffing – staffing patterns and operations that support COD assessment and treatment. Training – the appropriateness of training and supports that facilitate the capacity of staff to treat persons with COD.

44. COD Program Design

45. COD Program Design Loel Meckel, LCSW, Assistant Director, Forensic Services Division, DMHAS

46. Integrated Dual Diagnosis Treatment (IDDT)Essential Components* • Multi-Disciplinary Team • Integrated Treatment Specialist • Stage-Wise Interventions • Access Comprehensive Services • Time-Unlimited Services • Outreach • Motivational Interviewing, CBT *All elements with a focus on co-occurring disorders

47. Integrated Dual Diagnosis Treatment (IDDT)continued • Substance Abuse Counseling • Group Treatment for COD • Family Psycho-education/Support for COD • Pharmacological Treatment • 12 Step Self-Help Groups (Dual Recovery, Double Trouble) • Interventions to Promote Health • Secondary Interventions for Non-Responders

48. Moving from AOS to DDC (CT)

49. DDC by Level of Care (CT)

50. Recovery • SAMHSA defines “recovery” as: A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.