COD: Rumors of My Death Have Been Greatly Exaggerated

1. COD: Rumors of My Death Have Been Greatly Exaggerated 2013 Adolescent Conference Marcia Monroe & Doris Nardelli

2. How do we meet the needs of … . . . . Persons with co-occurring substance abuse and mental health disorders

3. Workshop Objectives • Define Continuous Comprehensive Integrated System of Care (CCISC) • Identify Dual Diagnosis Capable (DDC) system components • Differentiate between DDC and Dual Diagnosis Enhanced (DDE)

4. You may be asking yourself… Why are we talking about co-occurring again? Haven’t we been here before and isn’t it already done?

5. A While Back… June 28, 2008 • General Butterworth, then Department of Children and Families Secretary, announced launch of a statewide initiative

6. GOAL Become a universally co-occurringcapablestatewide System of care

7. VISION An inclusive system that is welcoming and meets the needs of Florida’s citizens

8. WHY do this? In 2001 Florida Commission Report found Floridians age 15-54 Meets diagnostic criteria for a mental health or substance abuse disorder

9. COD Definition Co-occurring is used to describe individuals who have a DSM-IV Axis I major mental disorder (e.g. psychotic, depressive and bipolar disorder) and a substance abuse disorder.

10. What is the Latest? The term “co-occurring disorders” is used instead of “dual diagnosis” or “dual disorders” because persons in this population often have more than two disorders simultaneously

11. But What is COD Really? Mental Health disorder(s) and Addictive disorder(s) occurring simultaneously and independently of each other

12. Experts Declare Clients with COD should be the “expectation, not the exception” for treatment providers in the public substance abuse and mental health treatment systems

13. Basic Facts - Persons with COD have High Rates of: Physical Illnesses DEATH Homelessness & Unemployment Criminal Justice Involvement

14. They Don’t Stay Well Either The primary cause of relapse into mental illness is untreated substance abuse and the primary cause of relapse into substance abuse is untreated mental illness But many programs often exclude people with Co Occurring Disorders and they “fall through the cracks” or are shuffled back and forth between providers

15. Parallel Treatment Track Mental Health System Substance Abuse System

16. Recovery The DDC program systematically embraces the philosophy of recovery for substance related disorders but it also includes a recovery philosophy for co-occurring mental health disorders but primarily as it impacts the recovery from the substance abuse related disorder

17. Parallels Process of Recovery P H A S E Stabilization of active substance use or acute psychiatric symptoms 1 Stabilization P H A S E Engagement Motivational Enhancement Engagement in treatment - Contemplation, Preparation, Persuasion 2 P H A S E Active treatment, Maintenance, Relapse Prevention 3 • Prolonged Stabilization P H A S E Continued sobriety and stability - One year - ongoing 4 Recovery & Rehab

18. Elements of Comprehensive, Continuous, Integrated Systems of Care (CCISC)

19. Elements of CCISC • Optimism and Recovery • Acceptance • Accessibility • Integration • Continuity • Comprehensiveness • Individualized Treatment • Emphasis on Quality • Responsible System Implementation

20. Basic Characteristics Integrated Treatment Philosophy System Level Change CCISC Efficient Use of Existing Resources Incorporation of Best Practices

21. Eight Principles of Treatment for the CCISC Model

22. Principle Dual diagnosis is an expectation, not an exception

23. Principle All people with COD are not the same! The national consensus four quadrant model for categorizing co-occurring disorders can be used as a guide for service planning on the system level

24. Principle Empathic, hopeful, integrated treatment relationships are one of the most important contributors to treatment success in any setting. It is an evidence based best practice for individuals with the most severe combinations of psychiatric and substance difficulties.

25. Principle Case management and care must be balanced with empathic detachment, expectation, contracting, consequences, and contingent learning for each client, and in each service setting

26. Principle When psychiatric and substance disorders coexist, both disorders should be considered primary, and integrated dual (or multiple) primary diagnosis-specific treatment is recommended

27. Principle Both mental illness and addiction can be treated within the philosophical framework of a "disease and recovery model" with parallel phases of recovery (acute stabilization, motivational enhancement, active treatment, relapse prevention, and rehabilitation/recovery)

28. Principle There is no single correct intervention for COD. For each individual interventions must be individualized according to: quadrant diagnoses level of functioning external constraints or supports phase of recovery/stage of change and (in a managed care system) multidimensional assessment of level of care requirements.

29. Principle Clinical outcomes for COD must also be individualized, based on similar parameters for individualizing treatment interventions

30. Traditional Service Model

31. Traditional Service Model Recovery is conceptualized as a cure, and this level is not frequently achieved Recovery With ongoing case management, professional support, and social services, some clients can achieve stability Prolonged Stabilization The main goal is to connect the person with long-term counseling and case management Intensive Treatment, Case Management The assumption is that most people start with acute stabilization Acute Stabilization

32. CCISC Model

33. A full array of services is used to support recovery based on the client’s current needs Engagement and Motivational Enhancement Housing Short-term Residential Acute Stabilization Community Support Recovery Case Management Peer Support Family Involvement Individual or Group Outpatient Counseling Strength based Intervention Planning

34. Summing up… CCISC

35. CCISC • Co-morbidity • Integrated treatment • Acknowledgement that readiness varies (which fits best with what modalities?) • Continuous relationships with providers • Both diagnosis are primary • Chronic, relapsing illnesses

36. Four Quadrant Model NOTE: Mental retardation or other less severe mental disorders are not included in most studies even though they are common and frequently co-exist with substance abuse disorders. However, personality disorders are currently being studied more and more.

37. Four Quadrant Model High severity III Less severe mental disorder/ more severe substance abuse disorder IV More severe mental disorder/ more severe substance abuse disorder I Less severe mental disorder/ less severe substance abuse disorder II More severe mental disorder/ less severe substance abuse disorder Alcohol and other Drug Abuse Low severity Mental Health High severity

38. This model can be used as a guide for service planning on the system level Fluidity for the person moving through the system Programs remain in the quadrants Collaborative agreements service individuals and organization A reminder: persons do not move in a linear fashion. Four Quadrant Model

39. Quad I Mild Psychopathology with Mild Substance Abuse Patients who usually present in outpatient setting with various combinations of psychiatric symptom (e.g. anxiety, depression, family conflict) and patterns of substance misuse an abuse, but not clear cut substance dependence

40. Quad II Serious & Persistent Mental Illness with Substance Abuse Patients with serious and persistent mental illness (e.g. schizophrenia, major affective disorders with psychosis, serious PTSD) which is complicated by substance abuse, whether or not the patient sees substances as a problem

41. Quad III Includes both substance-induced psychiatric disorders and substance-exacerbated psychiatric disorders Psychiatrically Complicated Substance Dependence Persons with alcoholism and/or drug addition who have significant psychiatric symptomatology and/or disability but who do NOT serious and persistent mental illness. Includes the following psychiatric disorders: anxiety/panic, depression/hypo mania, psychosis, PTSD, Personality traits/disorders, symptoms secondary to misuse/abuse of medication

42. Quad IV A Serious and Persistent Mental Illness with Substance Dependence Persons with SPMI, who also have alcoholism and or drug addiction, and who need treatment for addiction, mental illness, or for both. This may include sober individuals who may benefit from psychiatric treatment in a setting which also provides sobriety support and Twelve-step programs

43. Quad IV B Severe Same as Quadrant III The difference between Quadrant III and Quadrant IV B is severity These persons are folks that don’t clear and most likely are not in a priority population

44. Definitions DDC & DDE Dual Diagnosis Capable and Enhanced

45. Dual Diagnosis Capable (DDC) Primary focus is on the treatment of the mental health/substance use/abuse diagnosis but also is capable of treating patients who have a relatively stable diagnostic or sub diagnostic co-occurring disorder related to an emotional, behavioral or cognitive disorder Dual diagnosis capable: Considered an “evolving concept” (Minkoff & Cline, 2006) in which all agencies and programs that serve persons with MH or SA disorders develop a core capacity to provide appropriate services to persons with co-occurring disorders.

46. Dual Diagnosis Enhanced (DDE) These programs, by contrast, are designed to treat persons whohave more unstableor disabling co-occurring mental health/substance use/abuse disorders in addition to their primary diagnosed disorder by the respective agency

47. Dual Diagnosis Capable is achieved by modifying all parts of the organization Who is responsible to make your organization dual diagnosis capable? Summation

48. Current Treatment Options

49. Stage of Change Motivational Interviewing Dialectical Behavioral Therapy (DBT and DBT S) Dual Focused Schema Therapy (DFST) Transtheoretical Modified Therapeutic Community

50. Minkoff Principles