THE INTEGRATED DUAL DIAGNOSIES PROGRAM OF VENTURA COUNTY BEHAVIORAL HEALTH Presented by Linda Gertson, Ph.D. Behaviora

1. THE INTEGRATED DUAL DIAGNOSIES PROGRAM OF VENTURA COUNTY BEHAVIORAL HEALTHPresented by Linda Gertson, Ph.D.Behavioral Health Manager

2. SOME CORE COMPETENCIES FOR STAFF WORKING WITH CO-OCCURING SEVERE MENTAL ILLNESS AND ADDICTION • Recognize that addiction is a disease • Understand the neurobiology of stress and addiction • Be aware that these disorders do not co-occur; they interact. All elements of a treatment program should be based on this awareness • Be familiar with the co-morbidity of trauma and addiction • Know the difference between single event, acute trauma and early-onset, chronic trauma • Understand trauma-informed approaches • Be trained in Motivational Enhancement Techniques • Conduct phase-oriented treatment • Respect the philosophy and nature of 12 step programs

3. ADDICTION IS A DISEASE Disease is defined as “any deviation from or interruption of the normal structure or function of any part, organ, or system (or combination) of the body that is manifested by a characteristic set of symptoms and signs, and whose etiology, pathology, and prognosis may be known or unknown.” Dorlands Illustrated Medical Dictionary, Twenty-Seventh Edition. Philadelphia: Saunders, 1988.

4. “Drugs kept me alive until I was ready to live” Client with heroin addiction and trauma

5. PROGRAM OVERVIEW

6. PROGRAM OVERVIEW • Over 40 percent of the VCBH client population has co-occurring mental illness and substance use disorders. • The interaction of mental illness and substance use disorders in this population was found to be associated with: • symptom severity • hospitalizations • incarcerations • family conflict • homelessness and other residential problems • health problems • medication non-compliance • unemployment • socio-economic status.

7. PROGRAM OVERVIEW (continued) Chronology of the VCBH IDDT Program • The Program was implemented in September 2005. • The Program is evaluated every six months by an independent Program Evaluator. • In September 2006 the Program was awarded a $2,000,000 five-year SAMHSA grant to extend IDDT services to homeless individuals with co-occurring mental illness and substance use disorders. • In September 2007 the Program was awarded the SAMHSA Science & Service Award as one of four outstanding dual diagnosis programs in the US.

8. PROGRAM OVERVIEW (continued) In a report to be published this December in the Journal of Psychiatric Rehabilitation titled “Implementation of Integrated Dual Disorders Treatment in Eight California Programs, Program Evaluator Dr. Daniel Chandler stated: “Unlike the other counties who participated in this study, Ventura County created an IDDT team by hiring or transferring experienced dual disorders clinicians. In addition, the team leader used the (SAMHSA) fidelity scale as a template for designing and implementing the program.”

9. PROGRAM OVERVIEW (continued) According to Dr. Daniel Chandler: “The very high fidelity achieved by the Oxnard IDDT program (4.8 of 5.0) is rare. And in the recent SAMHSA funded National Evidence-Based Practices study of different EBPs only two of 13 IDDT programs achieved high fidelity within three years. IDDT is a difficult model to implement because it requires a significant change in clinical practice and upgrading of clinical skills. The Oxnard program is the only IDDT program to have achieved high fidelity within six months. Reports from the National Project and from Ohio, where over 25 IDDT programs have been implemented, indicate a period of years is typical.”

10. IDDT SERVICES

11. IDDT SERVICES The IDDT Program provides integrated treatment for individuals with mental illness and co-occurring substance abuse. Between September 2005 and September 2009 the IDDT Team has conducted over 400 assessments.

12. IDDT SERVICES (continued) What does the term “integrated” mean in the context of “dual diagnosis INTEGRATED treatment?” In this context “integrated” refers to the philosophy that both disorders (mental illness and substance misuse) must be treated simultaneously by one treatment team. It does not refer specifically to the integration of two different systems (e.g., a mental health program and a drug/alcohol program) but to the integration of treatment by a treatment team which understands the interaction of mental illness and addiction.

13. IDDT SERVICES (continued) • The Program rests on six evidenced-based elements: • accurate and thorough assessment • client-centered recovery plans • dual diagnosis counseling (individual therapy with licensed clinicians) • integrated dual diagnosis groups • appropriate psychopharmacology • case management.

14. IDDT SERVICES (continued) Integrated Assessment • The clients attending the IDDT Program undergo a comprehensive integrated assessment that evaluates both their psychiatric symptoms and their use of addictive substances. • The assessment is designed to assist clients in developing an understanding of how their disorders not only co-exist but how these disorders INTERACT. • The assessment assists the client with clarifying how they perceive the advantages and disadvantages of using their substance(s) of choice.

15. IDDT SERVICES (continued) Client-Centered Integrated Recovery Plansinclude: • the client’s symptoms of both disorders and functional impairments • the client’s recovery goals as stated in their own words • the client’s strengths (including past accomplishments, motivations and attributes) • barriers to successful recovery • six-month objectives • specific interventions agreed to by both the client and the staff • community/family support • discharge criteria and follow-up plan

16. IDDT SERVICES (continued) Individual/Group/Family Sessions • All clients participate in at least one group session per week and one individual session, as needed and/or requested. • These sessions are designed to explore the disorders so that clients achieve a better understanding of their disorders and the interaction between the two. • Each group is two hours in duration with the first hour consisting of educational material with handouts and the second hour for group discussion of personal issues.

17. IDDT SERVICES (continued) In addition to the “generic” IDDT group clients can attend one or more of the following groups: • Trauma Group: Due to the high co-morbidity between substance abuse and trauma, the IDDT program includes a specific group for clients with a history of sexual and/or physical abuse and other traumatic experiences. The program uses the manual Seeking Safety developed by Lisa Najavitz (an evidenced-based program endorsed by SAMHSA). • Anger Management Group: The program has implemented an evidenced-based Anger Management Group developed by SAMHSA.

18. IDDT SERVICES (continued) • Life Enhancement Training: This group utilizes skills training similar to Dialetical Behavior Therapy developed by Marsha Linehan.

19. IDDT SERVICES (continued) Case Management The case managers assist clients with: • access to health care • money management • housing • benefits (such as General Relief, MediCal, SDI, and SSI) • employment services • social support services, including legal and family services.

20. IDDT SERVICES (continued) Family Group: The IDDT Program includes an education group for the clients’ family members and significant others. This group presents educational material related to co-occurring disorders and affords the participants an opportunity to discuss problems specific to their family/significant other situation. Participation in Alcohol/Drug Self-Help Groups: Clients are strongly encouraged to attend 12-step programs and other peer support groups.

21. IDDT SERVICES (continued) Peer Support Specialists The IDDT now has two peer support specialists (referred to as Recovery Coaches), one in Ventura and one in Oxnard. These individuals attend the groups, participate in staff meetings, conduct client outreach/engagement services and provide individual peer counseling. Students The program includes both psychology interns and practicum students. We also have two Research Assistants.

22. DEMOGRAPHICS

23. DEMOGRAPHICS Clients Served in the IDDT Program (Data is for the Third Quarter of Fiscal Year 08/09) Referral In: OxVentEast Self 52% 58% 83% Inpatient facility 6% 17% 3% Outpatient provider 9% 5% 4% Other: (case managers, assessment/triage) 33% 20% 10% (Ox=Oxnard; Vent=Ventura; East=Thousand Oaks & Simi)

24. DEMOGRAPHICS (continued) Clients Served in the IDDT Program (cont) Sex: OxVentEast Male 57% 56% 43% Female 43% 44% 57% Race: White 59% 79% 93% Hispanic 29% 13% 7% Black 9% 2% 0% Asian 0% 0% 0% Other 3% 6% 0%

25. DEMOGRAPHICS (continued) Clients Served in the IDDT Program (cont) Language: OxVentEast English 97% 96% 97% Spanish 3% 4% 3% Primary Diagnosis: Psychosis 17% 13% 23% Depression 57% 48% 33% Mood 9% 29% 40% Anxiety 6% 10% 4%

26. PROGRAM OUTCOMES

27. PROGRAM OUTCOMES Stages of Treatment • Clients who recover from dual disorders participate in the treatment process through a series of four stages: engagement persuasion active treatment relapse prevention • The goal of treatment is to assist clients with movement along this continuum of stages.

28. Graph of Stage of Treatment Change over 12 Months This change is highly statistically significant

29. PROGRAM OUTCOMES (continued) Stages of Change • People who change maladaptive behaviors progress through a series of distinct stages: precontemplation contemplation preparation action maintenance • As with stages of treatment, the goal is to assist clients in movement along the continuum of the stages of change.

30. Graph of Stage of Change Transitions over 12 Months This change is also highly statistically significant

31. PROGRAM OUTCOMES (continued) Risk Reduction Factors (First 6 Months of Treatment) • 80 % of the clients in the IDDT Program avoided hospitalizations • and incarcerations • 80% reduced the frequency and/or amount of substances (if not totally clean and sober) • 81% of the clients were compliant with their medication regimen • Only 1% of the clients were never completely clean and sober (for a period of 30 continuous days) during the first 6 months of treatment

32. Graph of Indicators of Reduced Risk Associated with Treatment at 12 Months

33. PROGRAM OUTCOMES (continued) Changes in Income Categories for 53 Clients Homeless at Program Entry BaselineSix Months Disability Income 5 persons 16 persons Average Disability Income $80.00 $270.00 Employment 0 persons 9 persons Mean Wage Increase Per Month $3,803.00$5,072.00

34. Graph of Changes in Major Income Categories for Clients Homeless at Time of Entry and at Six Months All changes are statistically significant

35. PROGRAM OUTCOMES (continued) The next graph shows how client self-rating of overall health status improved. In particular the percentage with poor health declined dramatically.

36. Graph of Overall Self-Rating of Health Changes in “Good” and “Poor” are statistically significant

37. PROGRAM OUTCOMES (continued) Mean Number of Days the Symptom was Experienced During the Previous 30 Days (All changes are statistically significant) BaselineSix Months Depression 17.3 11.7 Anxiety 18.0 12.0 Hallucinations 5.6 2.6 Cognition* 16.0 16.0 Violent Behavior 5.2 1.6 *(comprehension/concentration/memory – these mental functions can be impaired for an extended amount of time following abstinence)

38. Graph of Mean Number of Symptoms (experienced per day) at Baseline and Six Months

39. PROGRAM OUTCOMESCLIENTS WITH TRAUMA HISTORY A significant body of research indicates a very high co-morbidity between substance use disorders and trauma. Incidence rates in our program are: MalesFemales Childhood Physical Abuse 48% 52% Childhood Sexual Abuse 32% 63% Adult Abuse 13% 78% Abuse of Any Type 48% 94%

40. Mean Beck Depression Scale Scores

41. Mean Beck Anxiety Scale Scores

42. Mean Beck Hopelessness Scale Scores

43. Statistical significance of association between number of group therapy or individual therapy sessions and outcomes at six months (N=99) Outcome Group Sessions Individual Visits Attend12-step Hospitalized in the Not Significant Significant Not Significant 6 months Positive Effect SATS improvement Not Significant Significant Not Significant Positive Effect Combined outcomes* Not Significant Significant Not Significant Positive Effect*Combined outcomes includes hospitalization, jail, never being clean, never being sober, relapsing. Each outcome was assigned a numeric value of 1, resulting in groups of 0, 1, 2, 3 and 4 outcomes having occurred (though in practice no one had 4).

44. WHY VCBH IDDT WORKS(from our perspective!!) IDDT has been fully and successfully implemented in Ventura County as a result of: • Complete and continuous support of VCBH Administration • Manager and staff with experience in dual diagnosis assessment and treatment WHO WERE FULLY COMMITTED TO SUCCESS OF THE PROGRAM (particularly in the Oxnard site) • Immediate implementation of IDDT (during training rather than waiting for completion of training) • Willingness to change and adapt

45. WHY VCBH IDDT WORKS(from our perspective!!) • Ongoingclinical supervision by an experienced dual diagnosis clinician • Staff participation in the development of program forms, program development and outcome measures • Advertisement of the program in behavioral health newsletters and other outlets • Development of staff cohesiveness • Groups composed of individuals in various Stages of Change and Treatment

46. WHY VCBH IDDT WORKS(from our perspective!!) • Inclusion of PTSD/trauma, anger management and LET groups • Flexibility of staff schedules (e.g., evening groups) • Groups conducted onsite and offsite • Encouragement of client development of Dual Recovery Anonymous groups • Inclusion of outcome measures • Feedback to staff of client outcomes • Use of outcome measures in for continuous program improvement

47. WHAT NEEDS IMPROVEMENT? • We need to decrease attrition rate. Many clients have disengaged from IDDT services prior to completion of the program. We hope that the inclusion of the Recovery Coaches will increase our ability to provide outreach to clients who have disengaged from the Program. • Addiction is considered a “chronic relapsing disease.” Clients are at risk for relapse even following relatively long periods of abstinence. We are continuously making efforts to improve our understanding and treatment of this disease through intensification of treatment, analysis of our outcomes and participation in continuing education.

48. CLIENT TESTIMONIALS • “Participating in group discussion in IDDT with other people facing the same problems – homelessness, isolation, poverty, unemployment, depression and addiction – has helped me feel less uniquely impaired.” • “The IDDT Program has allowed me to learn a way of dealing with life on life’s terms.” • “I know more about myself than I ever have.” • “This program has helped me to be more aware of my problems and how to better mange them. It has also helped me to realize that I have the capacity to be a regular person.” • “From my perspective, there is only one perspective. You have to treat both disorders at the same time.”