Mixing Oil and Water: Bridging the Gap Between Addiction and Mental Health

1. Mixing Oil and Water: Bridging the Gap Between Addiction and Mental Health Andrew L. Cherry, DSW, ACSW Oklahoma Endowed Professor of Mental Health, University of Oklahoma, School of Social Work, Tulsa Campus OU OK-COSIG Project Evaluator : 2004 through 2009 Mary E. Dillon, Ed.D, MSW Adjunct Faculty University of Oklahoma, School of Social Work, Tulsa Campus OU OK-COSIG Associate Evaluator  Joseph F. Kavanagh, MIS, MPA, MSW Student, University of Oklahoma, School of Social Work, Tulsa Campus OU OK-COSIG Assistant Evaluator

2. Presentation Outline • Transforming mental health and substance abuse treatment. • Lessons learned from the OK-COSIG project. • Determining what to teach to prepare Social Work students for a career in addiction and mental health treatment. • Identifying services and treatment modalities that meet the criteria for “best-practices?” • Common ground between the two traditions of addiction and mental health treatment. • Implications for Social Work Student education.

3. The Clarion Call • Changes in the scientific thinking occur when new data changes in basic assumptions (Kuhn, 1962). • The President's New Freedom Commission's report, responded to this paradigm shift by calling for a transformation in mental health and substance abuse care in the United States (Farkas, & Anthony, 2006). • National health care legislation and policy (that will be enacted) will demand a transformation in mental health and substance abuse treatment. • Social work educators are well positioned to bridge the gap between the old and the transformed mental health and substance abuse treatment communities. • We can prepare our students to practice in this environment.

4. A Paradigm Shift • Since the 1990s, a paradigm shift in assumptions has occurred in the fields of addictionology and mental health (Farkas & Anthony, 2006). • Although, “evidence based practice” can vastly improved treatment for addiction, mental health, and co-occurring disorders, the research suggests that the early identification of people needing treatment has lagged behind these treatment improvements. • This lag in early identification is a major reason that people with these disorders have not benefited as much as was expected from improvements in behavioral health care (Baron, Hay & Easom, 2003).

5. Early identification is a major need • Social workers will often be the first professionals to encounter people burdened with unidentified or denied addiction and mental health disorders. • Similar shifts in assumptions have had a profound impact on science and on the social work curriculum in the past; we should expect nothing less as a result of the transformation taking place in behavioral health (Hoge, Huey & O'Connell, 2004).

7. The Numbers • The accumulated research over the last 10 years shows that between 50% and 75% of the people who enter addiction treatment and between 20% and 50% of people entering a mental health treatment center have the co-occurring problem of substance misuse and a mental health disorder. • As important to our students is the percentage of people in the general population who have a behavioral health disorder that they will encounter in their practice. • In the U.S. about 22% of the population is affected by mental disorders, 6% of the population is effected by substance misuse disorders, and over 3% of adults have both substance misuse and mental health disorders (SAMHSA, 2005).

8. Dealing with reality • To deal with these realities, Substance Abuse and Mental Health Services Administration (SAMHSA) provided five year Co-Occurring State Incentive Grants (COSIG) to states to develop infrastructure that would develop and sustain treatment for people with co-occurring disorders. In October 5, 2004, The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) received one of the COSIG grants. • The Oklahoma COSIG project proposed to develop an integrated system of care for persons with co-occurring disorders in State funded mental health and substance abuse treatment facilities. The system of care was to be accessible to consumers and their families, culturally competent, and grounded in evidence-based practices.

9. Moving Science to Service • Moving science to service in a way that is sustainable, is more about changing the field than it is about the science or the services provided. • Scientific discoveries can become a reason for change. • Even so, the science cannot be the how of changing. • No one in the behavioral health fields disagree that best practices should be provided to people seeking mental health and addiction treatment. • The conundrum, however, is how to make changes in the educational and treatment communities.

10. Lesson’s Learned from the OK-COSIG Project • The OK-Co-occurring State Incentive Grant (OK-COSIG) project achieved agreement on the need for change using consensus building activities and skills. • Scientific findings and new “best practices” were introduced as a reason to change. • A core level training was developed and delivered. • The training was provided to all participating agency staff, both professionals and non-professionals. • The focus of the training was on engagement, screening, assessing and using integrated treatment approaches with people who have co-occurring disorders. • The evaluation best tells the story.

11. The Mezzo Level Evaluation Preliminary Findings: Differences between Model programs and Control programs on identifying people with a co-occurring disorder (N = 19,241).

12. The Mezzo Level Evaluation (cont 2) Preliminary Findings: Differences between Model programs and Control programs on Treatment Completion (N = 19,241).

13. The Mezzo Level Evaluation (cont 3) Preliminary Findings: Differences between Mental Health Model programs and Control programs on Days in Treatment (N = 19,241).

14. The Mezzo Level Evaluation (cont 4) Preliminary Findings: Differences between Substance Abuse TX Model programs and Control programs on Days in Treatment (N = 19,241).

15. The New Paradigm • As in any change effort, the OK-COSIG team was unable to change many of the traditions held near and dear in the large complex organizations. • Even so, the OK-COSIG implementation team did accomplish a great deal. • In Oklahoma today, people with a co-occurring disorder have a much greater chance of being identified and receiving treatment that is responsive to his or her co-occurring disorder. • As a clinician observed during one of the evaluation focus groups, “Without the OK-COSIG project, this level of service and treatment for people with a co-occurring disorder would not have been available for years to come.” • Professional training pays dividends.

16. Determining what to teach • The primary issues for social work educators is how to prepare our students to participate and contribute to this transformation. • How do we determine what to teach? What services and modalities meet the criteria of “best-practices?” • And as critical, is the task of equipping students with skills to identify “best practices” as the science evolves. This skill will serve them throughout their professional career.

17. “State-of-the-Art” treatment • The concept of using "best practices" carries the connotation of being “state-of-the-art” treatment (Bushy, 2006). • This presentation highlights research conducted over four years. • The observations are based on both qualitative and quantitative data gathered over 5 years during the implication of a ‘state of the art’ treatment model for people with a co-occurring disorder by a state mental health and substance abuse department.

18. Identifying “best practices.” • While conducting the OK-COSIG, we spent time identifying the “best practices,” to use for screening, assessment, and treatment of people with a co-occurring disorder. During that process, we found that there were five basic characteristics that “best practices” all have in common. • One characteristic that indicates a practice is not a “best practice” is when the practice (i.e., Scream Therapy, creator Arthur Janov) is spread as a fad. Clinical research needed to validate a practice takes time and the involvement of a number of independent groups studying its effects.

19. Five basic characteristics among “best practices” • Five basic characteristics that “best practices” have in common are: • A “best practice” evolves over time. • A “best practice” has a body of research that examines its strengthens and weaknesses. • A “best practice” tends to be low risk. • For social work, a “best practice” does not breach the Social Work Code of Ethics, and • A “best practice” increases optimal outcome over standard treatment.

20. “Best practices” Evolves Over Time • A “best practice” evolves over time. Its development and the studies that support it can be followed in the professional literature over several years. • For Example: The development of “best practice” interventions for people with the co-occurring disorders of a mental health and substance abuse disorder began to evolve in the mid 1990s and in particular since 2003.

21. A “best practice” has a body of research supporting it • A “best practice” has a body of research that examines its strengthens and weaknesses. • For Example: The research on “best practice” in the treatment of people with co-occurring disorders was conducted by private and public research centers. They were shown that an intergraded treatment approach was more successful. • When, “evidenced-based studies” suggested integrated treatment was more effective than standard treatment, SAMHSA supported the implementation of integrated services for people with a co-occurring disorder.

22. A “best practice” tends to be Low Risk • Do no Harm. Social Workers in the United Kingdom have come to view social work as embracing an ethos of “virtue ethics,” i.e., the concept that social workers have a call to higher standards. • The NASW code of ethics denotes that “best practice” minimize unwanted results "(NASW, 2000,5.02 [c]). • For example: Rebirthing, compression therapy, also called the holding-nurturing process has been used to treatbirth trauma, attachment disorders, and other emotional disorders. • In 2001, several therapists using rebirthing techniques were sentenced to 16 years in prison for suffocating a 10-year-old Colorado girl during a 'rebirthing' session. Candace's Law, made the practice illegal in the state of Colorado.

23. “Best practice” and the Social Work Code of Ethics • For social work, a “best practice” does not breach the Social Work Code of Ethics, • Evidence-based practices must meet the value-based principals of social work practice. • For example: a best practice intervention must also be culturally appropriate.

24. A “best practice” increases optimal outcome • A “best practice” must increase optimal outcomes for participants (Bushy, 2006; Petr & Walter, 2005). • For example,There is good evidence to show that integrated treatment for people with a co-occurring disorder is more effective than standard treatment.

25. A Coherent Model • Given the prevalence of people with an addiction and mental health disorder on the caseloads of social workers in direct practice. • In our desire to increase the curriculum content on addiction and mental health, the pedagogical quandary is finding a coherent model that incorporates the best practices of the addiction and mental health treatment traditions. • Currently the two traditions in many areas contradict each other. This became evident during efforts to develop integrated treatment for people with the co-occurring disorder of addiction and mental illness.

26. Our Common Ground is our Professional Ethnics • We can merge the two traditions of Mental Health and Substance Abuse treatment if we screen out concepts and practices that are not based in Social Work ethic and historical practice competencies. • Using Social Work Ethics and Practice we can screen new interventions and compare their effectiveness with standard practice. • Using these standards we will be able to retain the best of each tradition and discard the less effective concepts and interventions. • The focus of Social Work practice, when working with people with a Mental Health Disorders and/or a Substance Use Disorder is to practice the profession’s core values of social justice, dignity and worth of the person, the importance of human relationships, integrity and competence as delineated in the Code of Ethics of the National Association of Social Workers (1999).

27. Our Common Ground is our Professional Practice Competencies • We have competencies that can be expressed as Social Work Practice when working with people who are distressed and struggling with a mental health and/or substance use disorders. • Competencies we have in common: 1) Ability to engage the person in a manner that is respectful and non-judgmental. 2) Ability to screen and assess using appropriate assessment tools and methods. 3) Ability to use appropriate and empirically supported interventions with people with a mental health and/or substance use disorder.

28. Our Common Ground is our Professional Practice Competencies (cont.) • 4) Ability to provide referrals for appropriate services and supports. • 5) Ability to advocate for individual clients, as well as to identify and advocate for appropriate policies. • 6) Ability to identify, evaluate, and utilize relevant research. • 7) Knowledge of pertinent social policies. • 8) Knowledge of the biopsychosocial, cultural, and spiritual ramifications. • 9) An understanding of the impact of a mental health and/or substance use disorders on the person we are working with and the consequences for the family. • Given this skill set we can learn to identify and use the best concepts and treatment intervention that become available.

29. Scrap Paternalistic Attitudes • To start this process, I recommend that clinicians discard the paternalistic attitudes endemic in mental health treatment (e.g., Angell, 2006; Sowers, 2005; Lefley, 1998). • The lack of expectation of people with a mental disorder has blinded us to individual potential. • Numerous individuals who hide their mental illness are quite successful, i.e. John Nash, Mike Wallace (CBS), Mel Gibson. The list goes on and on. • All interactions and treatments need to be based on the expectation that the person will recover and resume or become engaged in a productive life.

30. Scrap Punitive Approaches • We also recommend that the punitive approach that has been one of the distinguishing characteristic of substance abuse treatment be scrapped as brutish and not supported by the standards that define best practices (e.g., Quinn, Bodenhamer-Davis, & Koch, 2004; Dongier, 2005; Minkoff, 2001). • There are “best practices” that are more effective than “confrontational approaches.” • For example: “Motivational Interviewing” and “Cognitive Behavioral Therapy” is at the other end of the spectrum from the “confrontational” approach.

31. Social Work Students Need Knowledge of… • We are not suggesting that all social work students need to become specialist in the diagnosis and treatment of addiction, mental health, and co-occurring disorders. But, we are proposing that: 1) all social work students be trained to recognize clients that are likely to have a behavioral health problem; 2) all social work students be trained to advocate for “best practices” for their clients needing treatment, and 3) all social work students learn the importance of referral and follow-up with clients who may need treatment for an addiction and/or mental health disorder.

32. Thank You