Transcript Successes and sustainability: Lessons learned from the

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
1
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.
2
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.
3
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).
4
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).
5
Serious Mental Illness and Substance Use
Disorders among Adults Aged 18+
6%
19 million
Substance
Use
Disorder
Only
22%
46 million
3%
10
million
Mental
Illness
Only
People with Co-Occurring
Disorders
6
6
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).
7
Dealing with reality
• To deal with these realities, Substance Abuse and Mental Health
Services Administration (SAMHSA) provided five year CoOccurring 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.
8
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.
9
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.
10
The Mezzo Level Evaluation
Preliminary Findings: Differences between Model
programs and Control programs on identifying people
with a co-occurring disorder (N = 19,241).
Model and
Control
Programs
MEN
No COD
MEN
COD
Women
No COD
Women
COD
Model
54.5%
45.5%
66.3%
33.7%
Control
75.5%
24.5%
82.2%
17.8%
11
The Mezzo Level Evaluation (cont 2)
Preliminary Findings: Differences between Model
programs and Control programs on Treatment
Completion (N = 19,241).
Model and
Control
Programs
MEN
No COD
MEN
COD
Women
No COD
Women
COD
Model
57.5%
70.4%
45%
65.5%
Control
25.5%
29%
15%
17%
12
The Mezzo Level Evaluation (cont 3)
Preliminary Findings: Differences between Mental
Health Model programs and Control programs on Days
in Treatment (N = 19,241).
Model and
Control
Programs
MEN
No COD
MEN
COD
Women
No COD
Women
COD
Model
86
41
109
54
Control
192
190
212
222
13
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).
Model and
Control
Programs
MEN
No COD
MEN
COD
Women
No COD
Women
COD
Model
79
70
76
66
Control
55
50
71
54
14
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 cooccurring 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.
15
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.
16
“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.
17
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.
18
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.
19
“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.
20
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 cooccurring disorder.
21
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 treat birth 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.
22
“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 valuebased principals of social work practice.
• For example: a best practice intervention must
also be culturally appropriate.
23
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 cooccurring disorder is more effective than standard
treatment.
24
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.
25
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).
26
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 nonjudgmental.
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.
27
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.
28
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.
29
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.
30
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 followup with clients who may need treatment for an addiction and/or
mental health disorder.
31
Thank You
32