Transcript Document 7142209
Integrated Treatment for Adolescents with Mental Health and Substance Use Challenges
Presentation to: Consumer and Family Member Forum
Friday, December 8th, 2006
Kari Collins, LCSW Michael Gosser, LCSW, CADC Sonny Hatfield, LCSW
Kentucky Youth First Division of Mental Health and Substance Abuse 502-564-4456
Conceptual Challenges to Address
• • •
Most adolescents do not recognize their substance use as a problem and are being mandated to treatment (and are angry about it) Co-occurring problems (mental, trauma, legal) are the norm and often predate substance use Treatment has to take into account the multiple systems (peers, family, school, welfare, criminal justice) involved in their lives
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Conceptual Challenges to Address
•
Adolescents have less control of their lives and recovery environment than adults
•
Need to be creative in dealing with family and peer relationships because they are still central to the adolescent’s self identity and are not easily changed
•
Families often play a pivotal role, but vary in their ability and willingness to help
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Need for Services
• Some youth in Kentucky are in trouble.
– In 2005, there were an estimated 25,793 adolescents in the state that needed treatment for their substance related problems. Less than 10% are documented as having received treatment.
– Nationally, less than 50% stay in treatment 6 weeks, and 75% stay less than the 3 months recommended by NIDA.
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Need for Services (continued)
– Youth involved with the juvenile justice system are considerably more likely to have substance use problems than in the general population.
– Estimates range from 50%-90% of youth with substance use problems also have mental health disorders.
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Facts About Co-Occurring Disorders
• 43% receiving mental health services had been diagnosed with a co-occurring SUD. • CMHS (2001)national health services study • 13% of adolescents with significant emotional and behavior problems reported substance dependence. • SAMHSA 1994-96 National Household Survey • 62% of males and 82% of females entering SUD treatment had a co-occurring psychiatric disorder. • SAMHSA/ CSAT 1997-2002 study • 75-80 % of adolescents receiving inpatient substance abuse treatment have a coexisting mental disorder • NMHA, 2005 Cabinet for Health and Family Services
Reclaiming Futures
• RWJF launched national program and local pilots in 2002 to serve youth with SA and CO who were also involved in the justice system.
• The Vision: – More Treatment – Better Treatment – Beyond Treatment Cabinet for Health and Family Services
Reclaiming Futures –
Three things that work!
System Reform Treatment Improvement Community Engagement
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Reclaiming Futures Model
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System of Care
• Systems of Care is not a program — it is a philosophy of how care should be delivered.
• Systems of Care is an approach to services that recognizes – the importance of family, school and community, – seeks to promote the full potential of every child and youth by addressing their physical, emotional, intellectual, cultural and social needs.
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Continuum of Care vs. Systems of Care
Continuum of Care
Range of actual services/program elements and resources at varying levels of intensity
Systems of Care
Greater than the continuum, containing the service/program elements and resources
and
provisions for service coordination and integration.
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System of Care Core Values
1.
Child centered and family focused
, with the needs of the child and family dictating the types and mix of services and resources provided.
2.
Community based
, with the location of services, resource development, management and local decision making at the community level.
3.
Culturally competent
, with agencies, programs, services and resources that are responsive to the cultural, racial, and ethnic differences of the population they serve.
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System of Care Guiding Principles
1. A comprehensive array of services/ resources across domains of their lives 2. Individualized services/resources 3. Services within the least restrictive setting 4. Youth, families and caregivers should be full participants 5. Integrated services between child serving agencies and resources Cabinet for Health and Family Services
System of Care Guiding Principles
6. Service coordination (case management) 7. Early identification and intervention 8. Smooth transitions 9. Advocacy 10.Cultural differences and special needs Cabinet for Health and Family Services
Traditional Treatment Approaches
• Sequential – One disorder then the other • Parallel – Treated simultaneously by different professionals Cabinet for Health and Family Services
Integrated Treatment: Definition
• Treatment interventions for COD are combined within the context of a primary treatment relationship or service setting.
– It is a means of actively combining interventions intended to address substance abuse and mental disorders in order to treat both, related problems, and the whole person more effectively.
SAMHSA, TIP 42 Cabinet for Health and Family Services
Delivery of Services
(samhsa, TIP 42)
• Provide access • Complete a full assessment • Provide appropriate level of care • Achieve integrated treatment – Treatment planning and review – Psychopharmacotherapy • Provide comprehensive services – Supportive and Ancillary Wrap Services • Ensure continuity of care – Extended Care, Halfway Homes and other Residence Alternatives Cabinet for Health and Family Services
Achieving Integrated Treatment
• Beginning – Addiction Only • Advanced – COD Enhanced • Intermediate – COD capable • Fully Integrated Cabinet for Health and Family Services
Fully Integrated Treatment
• One program that provides treatment for both disorders.
• Mental and substance use disorders are treated by the same clinicians.
• The clinicians are trained in psychopathology, assessment, and treatment strategies for both disorders.
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Fully Integrated, cont.
• The focus is on preventing anxiety rather than breaking through denial.
• Emphasis is placed on trust, understanding, and learning.
• Treatment is characterized by a slow pace and a long-term perspective.
• Providers offer stagewise and motivational counseling.
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Fully Integrated, cont.
• Supportive clinicians are readily available.
• 12-Step groups are available to those who choose to participate and can benefit from participation.
• Pharmacotherapies are indicated according to clients' psychiatric and other medical needs Cabinet for Health and Family Services
Screening
• Purpose: – To identify adolescents who need a more comprehensive assessment for substance use disorders • Components: – Questions to uncover “red flags” or indicators of serious substance-related problems among adolescents – Include multiple domains including: substance use disorder severity, home life, psychiatric status, and school status preferably from more than one source.
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CRAFFT
CRAFFT
1. Have you ever ridden in a
C
ar driven by someone (including yourself) who was high or had been using alcohol or drugs? __ 2. Do you ever use alcohol or drugs to
R
elax, feel better about yourself, or fit in?
3. Do you ever use alcohol or drugs while you are by yourself yes __
A
lone?
4. Do you ever
F
orget things you did while using alcohol or drugs?
5. Do your
F
amily or
F
riends ever tell you that you should cut __ __ down on your drinking or drug use?
6. Have you ever gotten into
T
rouble while you were using alcohol or drugs?
__ __ no __ __ __ __ __ __ Scoring: 2 or more positive items indicate the need for further assessment.
The CRAFFT is intended specifically for adolescents. It draws upon adult screening instruments, covers alcohol and other drugs, and calls upon situations that are suited to adolescents Cabinet for Health and Family Services
Who can (and should) do a Screening?
• Health service providers • Juvenile justice workers • Educators • Community organizations (schools, health care, judiciary, vocational rehabilitation, religious organizations) • Other individuals associated with adolescents at risk Cabinet for Health and Family Services
Assessment
The comprehensive assessment, which is based on the initial screening, has several purposes: 1. To accurately identify those youth who need treatment 2. To further evaluate is a substance use disorder exists, and to what severity 3. To learn more about the nature of the youth’s substance-using behavior Cabinet for Health and Family Services
Assessment (continued)
4. To identify other problem areas (medical, psychological, nutrition, social, family, education, delinquent behavior) 5. Evaluate the extent to which the family can be involved (assessment and interventions) 6. Identify strengths of the adolescent 7. Develop a written report (including severity of the problem areas, corrective plan of action, and recommendations for services) Cabinet for Health and Family Services
Evidence Based Assessment Tool
The
Global Appraisal of Individual Needs (GAIN)
is a progressive and integrated family of instruments for: •initial screenings, brief interventions and referrals •standardized biopsychosocial clinical assessments for diagnosis, placement and treatment planning •monitoring of changes in clinical status, service utilization, and costs to society •subgroup and program level needs assessment and evaluation The GAIN has been used with both adolescents and adults and in outpatient, intensive outpatient, partial hospitalization, methadone, short term residential, long-term residential, therapeutic communities, and correctional programs.
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GAIN
• • •
GAIN-Short Screener (GAIN-SS)
screener – a two page, brief
The GAIN-Quick (GAIN-Q)
- a general assessment (11 14 pages) used to identify various life problems among adolescents and adults in the general population. It is designed for use by personnel in diverse settings (e.g. Employee Assistance Programs, Student Assistance Programs, health clinics, juvenile justice, criminal justice, etc.)
GAIN-Initial (GAIN-I)
a full bio-psycho-social that integrates research and clinical assessment to do assist with diagnosis, placement, individualized treatment planning, program evaluation and meets major reporting requirements. Cabinet for Health and Family Services
Effective Treatment Program Characteristics
• Assessment and Treatment Matching • Comprehensive integrated treatment approach • Family Involvement • Developmentally Appropriate • Engagement and Retention – Trust – Length of stay • Qualified Staff • Gender and Cultural Competence • Continuing Care • Treatment Outcomes Cabinet for Health and Family Services
Evidence Based Interventions
• Motivational Enhancement Therapy (MET) • Family-Based • Behavioral Therapy • Cognitive-Behavioral Therapy (CBT) • Community Reinforcement Approach Cabinet for Health and Family Services
Motivational Enhancement Therapy
• Stand-alone brief interventions OR • Integrated with other modalities • Client-centered approach for resolving ambivalence and planning for change • Demonstrates improved treatment commitment and reduction of substance use and risky behaviors • Developmentally appropriate with adolescents Cabinet for Health and Family Services
Family Based Interventions
• Structural-Strategic Family Therapy • Parent Management Training (PMT) • Functional Family Therapy (FFT) • Multisystemic Therapy (MST) • Multidimensional Family Therapy (MDFT) – All based on: • Family systems theory • Use of functional analysis for interventions that restructure interactions • Teaching parents behavioral principles and better monitoring skills to increase the adolescent’s pro-social behaviors, decrease substance use, improve family functioning, and hold treatment gains Cabinet for Health and Family Services
Purposes for Family Involvement
• Learn about child from family perspective • Mutual education and redefinitions • Define substance use in the family context • Establish/re-establish parental influence • To decrease family’s resistance to treatment • To assess interpersonal function of drug use Cabinet for Health and Family Services
Family Involvement, cont.
• To interrupt non-useful family behaviors • Identify and implement change strategies consistent with family’s interpersonal functioning and cultural identity • Provide assertion training for child and any high-risk siblings Cabinet for Health and Family Services
Behavioral Therapy Approaches
• Based on operant behavioral principles – Reward behaviors incompatible with drug use – Withhold rewards or apply sanctions for use or other negative behaviors targeted – Use of physical monitoring (urines, etc.) for close link of consequences • Use of individual approach and family involvement • Has demonstrated positive results for a number of problem areas Cabinet for Health and Family Services
Cognitive-Behavioral Therapy
• Based on learning theory • Has individual and group applicability • Has a number of manualized approaches • Uses MET • Uses functional analysis to target areas • Teaches coping strategies, problem-solving & communication skills (practice & homework) • Uses relapse-prevention and alternative activities strategies for avoiding substance use Cabinet for Health and Family Services
Behavioral Treatment Studies
• Interventions associated with reduced substance use and problems: – 12-Step Treatment – Behavioral Therapies – Family Therapies – Engagement and maintenance is associated with several interventions • case management, stepping down residential to OP, assertive aftercare Cabinet for Health and Family Services
Lessons from Behavioral Studies
• Family therapies were associated with less initial change but more change post active treatment • Effectiveness was associated with therapies that: – were manual-guided and had developmentally appropriate materials – involved more quality assurance and clinical supervision – achieved therapeutic alliance and early positive outcomes – successfully engaged adolescents in aftercare, support groups, positive peer reference groups, more supportive recovery environments Cabinet for Health and Family Services
Lessons from Behavioral Studies
• The effectiveness of group therapy was dependent on the composition of the group • The effectiveness of therapy was dependent on changes in the recovery environment and social risk • Effectiveness was not consistently associated with the amount of therapy over 6-12 weeks or type of therapy • As other therapies have improved, there is no longer the clear advantage of family therapy found in early literature reviews • Differences between conditions change over time, with many people fluctuating between use and recovery Cabinet for Health and Family Services
Community Reinforcement Therapy
• Combines principles & techniques derived from others (behavioral, CBT, MET, and family therapy) • Uses incentives to enhance treatment outcomes Cabinet for Health and Family Services
Specific Treatment Manuals
• Cannabis Youth Treatment (CYT) Series – Motivational Enhancement Therapy and Cognitive Behavioral Therapy: 5 Sessions – The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions of CBT – Family Support Network – The Adolescent Community Reinforcement Approach – Multidimensional Family Therapy Cabinet for Health and Family Services
Additional Adolescent Programs
• The Seven Challenges –
The Seven Challenges
®
Program
is designed for adolescent and young adult substance abusing or substance dependent individuals, to motivate a decision and commitment to change. It helps young people look at themselves, understand what it takes to give up a drug abusing lifestyle - and prepare for and attain success when they commit to such change.
The Seven Challenges is a comprehensive program that is developmentally appropriate, research based, culturally sensitive and holistic. Cabinet for Health and Family Services
The Seven Challenges
1. We decided to open up and talk honestly about ourselves and about alcohol and other drugs.
2. We looked at what we liked about alcohol and other drugs, and why we were using them.
3. We looked at our use of alcohol or other drugs to see if it has caused harm or could cause harm.
4. We looked at our responsibility and the responsibility of others for our problems.
5. We thought about where we seemed to be headed, where we wanted to go, and what we wanted to accomplish.
6. We made thoughtful decisions about our lives and about our use of alcohol and other drugs.
7. We followed through on our decisions about our lives and drug use. If we saw problems, we went back to earlier challenges and mastered them.
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Culturally Competent Treatment Programs
• Family (as defined by culture) seen as primary support system • Clinical decisions culturally driven • Dynamics within cross-cultural interactions discussed explicitly & accepted • Cultural knowledge build into all practice, programming & policy decisions • Providers explore youth’s level of assimilation/acculturation Cabinet for Health and Family Services
Culturally Competent Treatment Programs
• Respect for cultural differences • Creative outreach services to underserved • Awareness of different cultural views of treatment/help-seeking behaviors • Program staff work collaboratively with community support system • Treatment approaches build on cultural strengths & values of minorities • Ongoing diversity training for all staff • Providers are similar to youth of color served Cabinet for Health and Family Services
Level of Care Determination
• ASAM PPC-2R • Treatment matching • Long-term Outpatient Treatment – Greater effect for more severe social, family and employment problems (Friedman et.al 1993) – Better outcomes for adolescents with more sever psychiatric problems Cabinet for Health and Family Services
ASAM PPC 2R - Dimensions
• Acute Intoxication/Withdrawal • Biomedical Condition and Complications • Emotional, Behavioral or Cognitive – Co-morbidity • Dangerousness • Interference with addiction recovery • Social functioning • Ability for self-care • Course of illness • Readiness to Change • Relapse, Continued use • Recovery Environment Cabinet for Health and Family Services
ASAM PPC 2R – Levels of Care
• Early Intervention • Outpatient Treatment • Intensive Outpatient/Partial Hospitalization • Residential/Inpatient – Low intensity – Medium Intensity – High intensity • Medically Managed Intensive Inpatient Cabinet for Health and Family Services
Factors Affecting Treatment Placement
• Developmental Stages • Ethnicity • Gender • Co-occurring Disorders – Pharmacotherapy • Family Factors • Social and Community Factors – Peer influences – Environmental Influences – School Factors Cabinet for Health and Family Services
Other Services Needed
• Determine need for multidimensional services • Consider – Adolescent and family’s living conditions, – Other family issues/needs, – Other agencies already involved/needing to be involved, – What supports will be necessary and must be coordinated in order to support treatment efficacy Cabinet for Health and Family Services
Youth with Distinctive Treatment Needs
• Youth involved in the juvenile justice system – Diversion programs – Juvenile treatment/drug courts • Homeless and Precariously Housed Youth • Homosexual, Bisexual, and Transgendered Youth • Youth with Co-occurring Disorders – Physical Health Problems – Mental and Emotional Health Problems Cabinet for Health and Family Services