Module 1

1. Module 1 Substance Abuse Treatment for Persons with Co-Occurring DisordersInservice Training Based on A Treatment Improvement Protocol TIP 42

2. What is a TIP? • Best-practice guidelines for treatment of substance use disorders • Developed by Center for Substance Abuse Treatment (CSAT) • Draws on experience and knowledge of clinical, research, and administrative experts in a particular topic area • Consensus Panel for TIP 42, page xi

3. ATTC Network 2001-2006 NorthwestFrontierATTC Prairielands ATTC ATTC ofNew England NortheastATTC Great LakesATTC ATTC National Office MountainWestATTC Central East ATTC Mid-AmericaATTC Central EastATTC Mid-Atlantic ATTC PacificSouthwestATTC Southeast ATTC Gulf Coast ATTC Southern CoastATTC NorthwestFrontierATTC Caribbean Basin, Hispanic/Latino & US Virgin Islands ATTC

4. Introduction—Module 1 The Evolving Field of Co-Occurring Disorders

5. In This Module . . . • Overview of the evolving field of Co-Occurring Disorders • Understanding of the important developments that led to TIP 42 • Initial exploration of TIP 42 and how it is organized.

6. TIP Exercise—Terms • Read the left column on Page 27 • Discuss with your partner: • Which of these terms have you ever used or heard? • Which of these terms are used in your programs? • What advantages does the term “co-occurring disorders” have over “dual diagnosis” and “dual disorder”? Over the other terms?

7. Co-Occurring Disorders Co-occurring disorders • Refers to co-occurring substance use (abuse or dependence) and mental disorders. Clients said to have co-occurring disorders have: • one or more disorders relating to the use of alcohol and/or other drugs of abuse and one or more mental disorders. Diagnosis of co-occurring disorders (COD) occurs when • at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from the one disorder.

8. Co-Occurring Disorders:Your setting 1. Do these definitions describe clients in your practice/program? (Estimate percentage or describe prevalence) 2. How has serving clients with COD affected your practice/program? 3. What challenges do clients with COD present to your clinical knowledge and skills?

9. Co-Occurring Disorders:Implications • Treatment • Prevalence of COD, multiple problems they create, impact on treatment and treatment outcome, new models/strategies are receiving attention and encouraging treatment innovation • Clinicians & Knowledge Dissemination • Knowledge of both mental health and substance abuse is essential and dissemination of knowledge has become widespread

10. Why a new TIP on Co-Occurring Disorders? • Availability of data • Treatment innovations for other populations with COD • Changes in treatment delivery • Advances in treatment • Recent developments

11. Prevalence of COD • In 2002, 4 million adults met the criteria for both serious mental illness (SMI) and substance dependence and abuse. • An estimated 10 million Americans of all ages and in both institutional and non-institutional settings have COD in any given year.

12. Prevalence of COD among SMI and SA Adult Populations

13. Prevalence and Other Data Data now show: • COD are common in general adult population. • Increased prevalence of people with COD and programs for people with COD. • People with COD are more likely to be hospitalized and the rate may be increasing. • Rates of mental disorders increase as the number of substance use disorders increase.

14. Why a new TIP on Co-Occurring Disorders? • Availability of data • Treatment innovations for other populations with COD • Changes in treatment delivery • Advances in treatment • Recent developments

15. Advances in Treatment of COD • “No wrong door” policy • Mutual self-help for people with COD • Integrated care as a priority for people with severe and persistent mental illness • Development of effective approaches, models, and strategies • Pharmacological advances

16. Recent Developments • National Registry of Effective Programs and Practices (NREPP) • Co-Occurring Disorders State Incentive Grants (COSIG) • Co-Occurring Center for Excellence (COCE) • Report to Congress on the Prevention and Treatment of Co-Occurring Substance Use Disorders and Mental Disorders • Co-Occurring Disorders: Integrated Dual Disorders Treatment Implementation Resource Kit

17. Module 2 Introduction Definitions, Terms and Classification Systems for Co-Occurring Disorders

18. In This Module . . . Review and discuss terms related to: • Substance Use Disorders • Mental Disorders • Clients • Treatment • Programs • Systems

19. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) • Produced by the American Psychiatric Association (APA). • Establishes criteria for diagnosing specific disorders. • Used by the medical and mental health fields as a reference for diagnosing substance use and mental health disorders. • Provides for a common language for communicating about disorders.

20. Terms Related to Substance Use Disorders • Substance Abuse • Substance Dependence • addiction

21. Terms Related to Mental DisordersPersonality Disorders Cluster A: • Involve odd or eccentric behavior. • Includes paranoid, schizoid, and schizotypal personality disorders. Cluster B: • Involve dramatic, emotional, or erratic behavior. • Includes antisocial, borderline,histrionic, and narcissistic personality disorders. Cluster C: • Involve anxious, fearful behavior. • Includes avoidant, dependent, and obsessive-compulsive personality disorders.

22. Psychotic Disorders • Delusions • Hallucinations • These clients constitute what is commonly referred to as the serious and persistent mentally ill population • Schizophrenia • Paranoid type • Disorganized type • Catatonic type • Undifferentiated type • Residual type

23. Mood and Anxiety Disorders • Mood disorders • Depression • Mania • Bipolar disorder • Anxiety disorders • Social phobia • Panic disorders • Post traumatic stress disorder (PTSD)

24. Terms Related to Clients • Person-centered terminology • Terms for co-occurring disorders • Diagnosis vs. symptoms

25. Terms Related to TreatmentLevels of Service

26. Terms Related to Treatment Quadrants of Care

27. Terms Related To Treatment • Interventions • Integrated Interventions • Episodes of Treatment • Integrated Treatment • Culturally Competent Treatment • Integrated Counselor Competencies

28. Terms Related to Programs Key Programs • Mental health-based programs • Substance abuse treatment programs Program Types • Addiction only services • Dual diagnosis capable • Dual diagnosis enhanced

29. Terms Related to Systems • Substance Abuse Treatment System • Mental Health Services System • Interlinking Systems • Comprehensive Continuous Integrated System of Care

30. Discussion From a client or clinician or system perspective: • How does terminology help and hinder service to clients with co-occurring disorders? • Which of the terms mentioned are most useful to you? Which do you want to know more about?

31. Module 3A Introduction Keys to Successful Programming: Guiding Principles and Core Components

32. TIP Chapter 3 • Module 3A • Guiding principles in treatment • Core components in delivery of services • Module 3B • Improving substance abuse treatment systems and programs • Workforce development and staff support

33. In This Module . . . Effective Treatment • Guiding Principles for effective treatment of clients with COD Effective Delivery • Core Components for ideal delivery of services for clients with COD

34. Delivery of Services Core Components

35. TIP Exercise—Guiding Principles & Core Components 1. In your own words explain your assigned Guiding Principle. • Give examples of how you apply (or need to apply) this principle in your practice or program. 2. In your own words explain your assigned Core Component. • Is this an area of strength or challenge for your agency? Explain. (15 minutes)

36. Quick TIP Exercise— Levels of Program Capacity With your group 1. Review Figure 3-2 on page 44 and explanatory text on page 43 (left column). 2. Where on the graph would you place your agency? Why? (5 minutes)

37. Module 3B Introduction Keys to Successful Programming: Improving Substance Abuse Treatment Systems & Programs and Workforce Development & Staff Support

38. Delivery of ServicesCore Components

39. TIP Chapter 3 • Module 3A • Guiding principles in treatment • Core components in delivery of services • Module 3B • Improving substance abuse treatment systems and programs • Workforce development and staff support

40. Improving Substance Abuse Treatment Systems & Programs Challenges include: • How do we organize a system that will provide continuity of care? • How do we access funding for program improvement? • How do we integrate research and practice to give clients the benefit of proven treatment strategies?

41. TIP Exercise—Attitudes & ValuesSelf-Assessment For each item in Figure 3-7 (p. 57) assess yourself based on your observable behavior, the way you think an outside evaluator would assess you. (3 minutes)

42. TIP Exercise—Basic Competencies Self-Assessment For each item in Figure 3-8 (p. 58) assess yourself based on your observable behavior, the way you think an outside evaluator would assess you (5 minutes)

43. TIP Exercise—Avoiding BurnoutSelf-Assessment For each item bulleted on page 62 assess how well you take care of yourself by complying with these recommendations Which two are most difficult? (3 minutes)

44. Module 4A Introduction Assessment: Screening and Step 1 & Step 2

45. TIP Chapter 4: Assessment • Module 4A • Introduction, terminology, Step 1–Step 2 • Module 4B • The Assessment Process: Step 3–Step 7 • Module 4C • The Assessment Process: Step 8–Step 12 • Case studies, review of relevant appendices, and key considerations in treatment matching.

46. Screening • Screening for COD seeks to answer a “yes” or “no” question: • Does the substance abuse client being screened show signs of a possible mental health problem? OR • Does the mental health client being screened show signs of a possible substance abuse problem?

47. TIP Exercise— Screening Instruments Option 1:Behavioral Rehearsal & DiscussionWith your partner, take turns administeringwhichever instrument is least familiar: • Mental Health Screening Form-III (p. 500) • Simple Screening Instrument for Substance Abuse (p. 506) You have 10 minutes total!

48. TIP Exercise— Screening Instruments Option 2:Review & Discussion Review instrumentsin: • Appendix H (p. 497) and Appendix G (p. 487). Discuss with your partner: • Which instruments have you used? • What, in your experience, are advantages and disadvantages of each? • Which would you recommend? Why? You have 10 minutes total!

49. Screening Protocol • A professionally designed screening process or protocol establishes precisely . . . • How any screening tools or questions are scored • What constitutes scoring positive for a particular possible problem (“establishing cut-off scores”) • What happens if a client scores in the positive range • and provides the standard forms to document • Results of all later assessments • That each staff member has carried out his or her responsibilities in the process

50. Screening+Assessment Tx Plan • Screening is a process for evaluating the possible presence of a particular problem. • Assessment is a process for defining the nature of that problem and developing specific treatment recommendations for addressing the problem. • A comprehensive assessment serves as the basis for an individualized treatment plan. The treatment plan must be matched to individual needs.