Transcript Treating Co-Occurring Mental Disorders

Treating Addiction and
Other Mental Disorders
Cutting Edge 2004
Palmerston North, New Zealand
September 3, 2004
Joan E. Zweben, Ph.D.
Executive Director: EBCRP and 14th Street Clinic
Clinical Professor of Psychiatry; University of California, San
Francisco
Systems Issues
Have the elements of your systems
been aligned to create incentives and
not barriers?
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.
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
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Licensing & Certification
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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.
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
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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.
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
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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?
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Barriers to Addressing
Psychiatric Disorders
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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
Barriers to Addressing
AOD Use
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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 selfhelp system
Medications: some physicians overprescribe,
misprescribe, cloud the diagnosis
System barriers
Programming:
Guiding Principles
1.
2.
3.
4.
5.
6.
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)
“No Wrong Door”
1.
2.
3.
4.
5.
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)
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
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(COD TIP, in press)
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
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(COD TIP, in press)
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
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(COD TIP, in press)
Philosophical Differences:
Harm Reduction &
Abstinence
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
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Pitfalls of Abstinence-Oriented
Treatment
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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
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
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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)
Types of Program
Capability
 Addiction-Only
Services (AOS)
 Dual Diagnosis Capable (DDC)
 Dual Diagnosis Enhanced (DDE)
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
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Treatment
Models & Issues
Psychotic Disorders:
Counselor Recommendations
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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)
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)
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
Sequential, Parallel and
Integrated Treatment (3)
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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
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.)
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
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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
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(COD TIP, in press)
Essential Features of ACT
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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)
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
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(COD TIP, in press)
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)
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
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, recoveryoriented process
Phase III: vocational issues
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)
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
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Preparing Psychiatric Patients for
12-Step Meetings
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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
Cross-Training Issues
Resistances of credentialed professionals
 Resistances of non-credentialed staff
 Effective training designs
 Incentives
 Mandates
 Using training to facilitate system change
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