Joan E. Zweben, Ph.D. Executive Director: EBCRP and 14 th Street Clinic

1. Treating Addiction and Other Mental DisordersCutting Edge 2004Palmerston North, New ZealandSeptember 3, 2004 Joan E. Zweben, Ph.D. Executive Director: EBCRP and 14th Street Clinic Clinical Professor of Psychiatry; University of California, San Francisco

2. Systems Issues Have the elements of your systems been aligned to create incentives and not barriers?

3. Obstacle Providers are expected to collaborate to provide care, but government entities frequently do not communicate about common issues. This leads to conflicting expectations and requirements.

4. Remedy: Explicit Policies • Do you have joint, interagency policy statement confirming commitment to, and expectations for, treatment for persons with COD? • Statement should clearly identify the impropriety of excluding persons with COD from either treatment system or other service systems

5. Licensing & Certification • Naïve expectation that professional credentials include proficiency in addressing substance abuse • No framework for specialized licensing and site certification • Overlapping and conflicting requirements between health services, mental health, alcohol/other drug, social services, criminal justice system, etc.

6. Licensing & Certification • Need comprehensive framework for program licensing and site certification, or • Specify programs that are exempt from existing requirements • Remove regulatory barriers that discourage providers from serving this population • Create incentives through adequate reimbursement

7. Documentation Nightmares Have you streamlined documentation requirements? • Funding sources require different elements in the clinical chart, and have different audit protocols • Need for a universal chart to reduce extra work, save many trees, and allow consistent data collection.

8. Training • Need mechanism to cross-train professionals and continuously develop skill base of non-credentialed workers • Need to align all elements of the system to promote mastery of content defined as important: intake process, treatment plan, staff evaluations, etc. • Need for regular clinical supervision

9. Terminology: Common Confusions • Dual vs multiple disorders • Medical comorbidities • AOD and any coexisting psychiatric disorder • AOD and severe and persistent mental illness • What is available in your community, and for whom?

10. Barriers to Addressing Psychiatric Disorders • Mistrust professionals • Don’t have good diagnosticians • Belief that TC or 12-step will fix everything • Enabling phobia vs individualized treatment planning • Resistance/misunderstanding about meds • Inappropriate expectations about time course • Attitudes about chronic illness affect stance towards relapse

11. Barriers to Addressing AOD Use • Failure to recognize and assess • Minimize the role of AOD use; minimize the role of other mental disorders • Toxicology screens not readily available • Lack of understanding of and respect for the self-help system • Medications: some physicians overprescribe, misprescribe, cloud the diagnosis • System barriers

12. Programming: Guiding Principles • Employ a recovery perspective • Adopt a multi-problem viewpoint • Develop a phased approach to tx • Address specific real-life problems early in tx • Plan for the clients’ cognitive and functional impairments • Use support systems to maintain and extend treatment effectiveness (COD TIP, in press)

13. “No Wrong Door” • Assessment, referral and tx planning must be consistent with this principle • Use creative outreach to promote engagement • Programs and staff may need to change expectations and requirements to engage reluctant clients • Tx plans based on client’s changing needs • Seamless system of care to provide continuity; interagency cooperation (COD TIP, in press)

14. Integrated Treatment for COD’S • Treatment at a single site, by cross-trained clinicians • Medications OK and monitored when possible • Appropriate adaptations for SMI: emphasis on reduction of harm, lowering anxiety, appropriate pacing, self help offered but not mandated (COD TIP, in press)

15. Basic Counselor Competencies • Screen for COD; ability to refer for formal diagnostic assessment • Form preliminary diagnostic impression to be verified by trained professional • Preliminary screening of danger to self or others • De-escalate client who is agitated, anxious, angry or otherwise vulnerable (COD TIP, in press)

16. Counselor Competencies, cont • Manage crisis, including threat of harm to self or others • Refer to mental health facility if appropriate and follow up to assure that services were received • Coordinate care with mental health counselor; coordinate treatment plans (COD TIP, in press)

17. Philosophical Differences:Harm Reduction & Abstinence

18. Philosophical Divisions:Harm Reduction vs Abstinence • Historical overview • Treatment outcome data; implications • Pitfalls of abstinence-oriented approach • Pitfalls of harm reduction approach • Blended models: when and how • Harborview Program, Seattle

19. Pitfalls of Abstinence-Oriented Treatment • Failure to assess motivation level before pushing abstinence commitment • Failure to understand factors promoting continued use • Unrealistic timetables • Power struggle vs clinical approach • Failure to recognize fluctuating motivation • Inappropriate termination of treatment

20. Pitfalls of Harm Reduction Approach • Inappropriately low expectations for what client can achieve • Difficulty setting clear goals • Reluctance to ask client to abstain completely • Underestimate risks/lethality • Clinician alcohol and/or illicit drug use

21. Steps in the Assessment Process (2) 7. Determine disability and functional impairment 8. Identify strengths and supports 9. Identify cultural and linguistic needs and supports 10. Identify problem domains 11. Determine stage of change 12. Plan treatment (COD TIP, in press)

22. Types of Program Capability • Addiction-Only Services (AOS) • Dual Diagnosis Capable (DDC) • Dual Diagnosis Enhanced (DDE)

23. Distinguishing Substance Abuse from Psychiatric Disorders • Wait until withdrawal phenomena have subsided (usually by 4 weeks) • Physical exam, toxicology screens • History from significant others • Longitudinal observations over time • Construct time lines: inquire about quality of life during drug free periods

24. TreatmentModels & Issues

25. Psychotic Disorders:Counselor Recommendations • Learn signs and sx of the disorder • Expect crises and have resources • Include education on the psychiatric condition and on medications • Monitor medication, promote adherence • Provide frequent breaks, shorter mtgs • Use structure and support; avoid confrontation • Present material in simple, concrete terms and use multimedia tools (COD TIP, in press)

26. Sequential, Parallel and Integrated Treatment (1) SEQUENTIAL • when abstinence is necessary for other interventions to be effective • when psychiatric condition must be stabilized • when problem is severe in one area but mild in the other (Ries 1993)

27. Sequential, Parallel and Integrated Treatment (2) PARALLEL TREATMENT • when problem is severe in one area but mild in another • clients with HIV PROBLEMS: • need to be highly functional to navigate systems • lack of coordination

28. Sequential, Parallel and Integrated Treatment (3) • Mental health and addiction care combined at one site • Clinicians cross trained in both fields • Unified case management • Differences in philosophy reconciled within the program • Useful for severe problems in several areas • Flexibility promotes good conflict resolution

29. Integrated Treatment Premise: treatment at a single site, featuring coordination of treatment philosophy, services and timing of intervention will be more effective than a mix of discrete and loosely coordinated services Findings: • decrease in hospitalization • lessening of psychiatric and substance abuse severity • better engagement and retention (Rosenthal et al, 1992, 1995, 1997; Hellerstein et al 1995.)

30. What is Recovery:Mental Health Perspective • Recovery is recapturing a positive sense of self in spite of the challenge of a psychiatric disability • Recovery is actively self-managing one’s life and mental illness • Recovery is reclaiming social roles and a life beyond the mental health system

31. Specialized Treatment for SMI: Assertive Community Treatment • AOD and significant mental health disorder • Severe and persistent mentally ill • Severe functional impairments • Avoided or responded poorly to traditional tx • Co-occurring homelessnes • Co-occurring criminal justice involvement (COD TIP, in press)

32. Essential Features of ACT • Services provided in the community, frequently in client’s living environment • Assertive engagement, active outreach • High intensity of services • Small caseloads • Continuous 24 hour responsibility • Multidisciplinary team • Close work with support system • Continuity of staffing (COD TIP, in press)

33. Modified Therapeutic Community (MTC) • Increased flexibility in activities • Decreased intensity • Conflict resolution group, vs encounter • Shorter duration • More emphasis on instruction • Increased role modeling • Greater individualization (COD TIP, in press)

34. Harborview Recovery & Rehabilitation Program (HaRRP) Pre-phase program: • case manager based • focused around food, shelter and harm reduction • brief medication/money groups (Club Med) • drop-in lounge (Richard K. Ries, MD)

35. HaRRP Stages (2) Phase I: • highly structured groups, 3x week • focus on recognition and acceptance of both psychiatric and substance abuse problems • development of group process • movement toward (but not requirement of) sobriety

36. HaRRP Phases (3) Phase II: • participants have attained at least 3 months sobriety • IIa: lower functioning but sober; more activity based groups • IIb: can utilize more abstract, recovery-oriented process Phase III: vocational issues

37. Disability Benefit Management as a Treatment Intervention (1) HARBORVIEW PROGRAM, SEATTLE Goals:1) insure that $ went to food, shelter, basic needs; 2) increase treatment compliance • computerized system with a range of levels of control • case managers disburse benefits in conjunction with treatment activities (Ries & Comptois, 1997)

38. Benefit Management (2) • Payees (vs non-payees) were male, had diagnosis of schizophrenia, history of high inpatient utilization • Higher current ratings of psychiatric symptoms, substance use and functional disability These characteristics usually predict poor compliance and adverse outcomes, however: • Payees attended 2x number of outpt sessions and were no more likely to be currently homeless, hospitalized or incarcerated; comparable to nonpayee group

39. Preparing Psychiatric Patients for 12-Step Meetings • medication is compatible with recovery, but meetings are best selected carefully • some meetings are more tolerant than others of medication or eccentric behavior • schizophrenics benefit from coaching on how to behave in meetings • 12-step structure often beneficial; non-intrusive and stable

40. Cross-Training Issues • Resistances of credentialed professionals • Resistances of non-credentialed staff • Effective training designs • Incentives • Mandates • Using training to facilitate system change