integrated co-occurring disorders treatment in practice · integrated co-occurring disorders...

P R E S E N T E D B Y A N D R E A R A Y M S , L M H C , C D P

A N D

W I L L I A M W A T E R S P S Y D , L M H C

Integrated Co-Occurring Disorders Treatment in Practice

Comprehensive Healthcare

https://www.youtube.com/watch?feature=player_detailpage&v=0eQ26m1KqHs

A short story…

Pasco Site opened in October 2012

Response to “gap” in community

Primary SUD service with access to MH

678 clients between November 2012 and April 2016

52.7% received mental health services

Pasco Office is unique…

Learning Objectives

The core principles of integrated co-occurring disorders treatment

Understand the Comprehensive Program (Pasco Site) model

How to effectively integrate medication management, therapy, group counseling and case management.

Integrating medical case management

The evidences based programs that are used, brief overview.

April 1 – MH and SUD under the Behavioral Health Organization

Senate Bill 6312… “An important reason for this change is to better coordinate care for people with co-occurring disorders.”

The state will fully integrate the financing and delivery of physical health services, mental health services and chemical dependency services in the Medicaid program through managed health care by 2020

Why integrate?

Integrated Co-Occurring Disorders Treatment

Resource: SAMSHA PowerPoint on Integrated Treatment for Co-Occurring Disorders

Our program is fundamentally based on the SAMSHA Integrated Treatment of Co-Occurring Disorders program.

Includes other EBP’s

CBT

Motivation Interviewing

IMR-Illness Management and Recovery

Practice Principles for Integrated Treatment for

Co-Occurring Disorders

Resource: SAMSHA PowerPoint on Integrated Treatment for Co-Occurring Disorders

Mental health and substance abuse treatment are integrated to meet the needs of people with co-occurring disorders

Integrated treatment specialists are trained to treat both substance use and serious mental illnesses

Co-occurring disorders are treated in a stage-wise fashion with different services provided at different stages

Motivational interventions are used to treat consumers in all stages, but especially in the persuasion stage

Practice Principles for Integrated Treatment for Co-Occurring Disorders

Resource: SAMSHA PowerPoint on Integrated Treatment for Co-Occurring Disorders

Substance abuse counseling, using a cognitive-behavioral approach, is used to treat consumers in the active treatment and relapse prevention stages

Multiple formats for services are available, including individual, group, self-help, and family

Medication services are integrated and coordinated with psychosocial services

Treatment is Integrated

Resource: SAMSHA PowerPoint on Integrated Treatment for Co-Occurring Disorders

Mental health and substance abuse treatment are evaluated and addressed

Same team

Same location

Same time

Treatment targets the individual needs of people with co-occurring disorders and is integrated on organizational and clinical levels

Treatment is in a Stage-Wise Fashion

Resource: SAMSHA PowerPoint on Integrated Treatment for Co-Occurring Disorders

Pre-contemplation — Engagement Assertive outreach, practical help (housing, entitlements, other), and an

introduction to individual, family, group, and self-help treatment formats

Contemplation and Preparation — Persuasion Education, goal setting, and building awareness of problem through

motivational counseling Action — Active treatment Counseling and treatment based on cognitive-behavioral techniques,

skills training, and support from families and self-help groups Maintenance — Relapse prevention Continued counseling and treatment based on relapse prevention

techniques, skill building, and ongoing support to promote recovery.

Integrated Treatment Recovery Model

Resource: SAMSHA PowerPoint on Integrated Treatment for Co-Occurring Disorders

Hope is critical

Services and treatment goals are consumer-driven

Unconditional respect and compassion for consumers is essential

Integrated treatment specialists are responsible for engaging consumers and supporting their recovery

Focus on consumers’ goals and functioning, not on adhering to treatment

Consumer choice, shared decision making, and consumer /family education are important

Integrated Treatment Recovery Model (continued)

Integrated treatment is associated with the following positive outcomes:

Reduced substance use

Improvement in psychiatric symptoms and functioning;

Decreased hospitalization

Increased housing stability

Fewer arrests and

Improved quality of life

-(Drake et al.,2001)

Summary: Core Principles of Integrated Treatment

Integrated Treatment for Co-Occurring Disorders is effective in the recovery process for consumers with co-occurring disorders

The goal of this evidence-based practice is to support consumers in their recovery process

In Integrated Treatment programs, the same practitioners, working in one setting, provide mental health and substance abuse interventions in a coordinated fashion

Consumers receive one consistent message about treatment and recovery

Diagnosis related to SUD

Bipolar Disorder Alcohol or cocaine, depending on manic or depressed

PTSD Alcohol, benzodiazepines and sleeping pills to find relief

ADHD Alcohol and/or stimulants and marijuana.

Anxiety Alcohol, benzodiazepines and occasionally cocaine to compensate for

anxiety.

OCD Marijuana and alcohol to slow things down

Depression Alcohol

Panic Disorder Benzodiazepines and alcohol

Schizophrenia Nicotine, caffeine and other stimulants temporarily relieve symptoms

Pasco Comprehensive

Built on integrating services, didn’t have to change service delivery

Spirit is in treatment of each condition as equally as important.

Here is how it looks…

Flow chart

Initial Assessment

A Substance Use Disorders Assessment and/or Mental Health Assessment is completed.

Use the Assessment process to determine treatment recommendations and placement.

In combination with…

The ASAM Criteria for placement in substances use disorders treatment and co-occurring disorders treatment.

Medication Management

Treatment included psychotropic medications if needed even in early recovery.

Engagement in treatment improved with medications

Symptoms reduced

Many of our referrals have come from a MAT (Medication Assissted Treatment) program

Integration with medical

Several clients have acute and/or chronic medical conditions

Advocated for getting set up with a primary care physician

Coordinated care with primary care

Receive emergency room admission information

EBP’s

Comprehensive uses EBP’s for youth and adults with mental health conditions and co-occurring substance use disorders and mental health.

Motivation and the Change Process

“Clients are not unmotivated! They either…are just motivated to engage in behaviors that others consider harmful and problematic or are not ready to begin behaviors we think would be helpful.”

“Motivation is best viewed as the client’s readiness to engage in and complete the various tasks outlined in the stages of change for a specific behavior change.”

CBT

Critical Tasks

CBT addresses several critical tasks that are essential to successful substance abuse treatment (Rounsaville and Carroll 1992).

Foster the motivation for abstinence. (Cost benefit analysis)

Teach coping skills.

Foster management of painful affects.

Change reinforcement contingencies.

Improve interpersonal functioning and enhance social supports.

Illness Management and Recovery

The Illness Management and Recovery (IMR) program is a step-by-step program that gives people information and skills to help them set and achieve personally meaningful recovery goals. It can be provided in an individual or group format.

Components of IMR

The IMR program includes an IMR orientation session that uses this sheet to review the goals and expectations of the program

Assistance in developing your personal definition of recovery

Assistance in identifying and pursuing your personal goals

Approximately ten to twelve months of weekly sessions (or five to six months of twice-weekly sessions) using a series of educational handouts

Active practice of skills during sessions and at home

Involvement of significant others to increase their understanding and support at least one IMR wrap-up session to help you sum up progress and make plans for the future

Outcomes

Outcomes have been related to reduced arrests, no psychiatric admissions and reduced hospitalizations.

Currently doing other outcome measurements during treatment to determine reduction in symptoms of trauma and depression.

Urine tests are another way we measure outcomes/progress in treatment.

Average of over 60% completion rates for treatment.

Introducing

William Waters, PsyD, LMHC

Therapist/Team Leader in Pasco

My experience as a case-study

From Chemical Dependency to Mental Health:

Transition of thinking

Translation of language

Shift in treatment

Humility and Heroes

Transition in thinking

With consideration of the brain - heroes

http://worditout.com/word-cloud/748000

Hero and Villain

Essential Goal of Integrated Care

“Health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity.”

Preamble to the Constitution of the World Health Organization 1946

Wellbeing encouragement roles differs between chemical dependency and mental health professionals

Translation in Language

Take time to do this with your organization You have to get on the same page

We still confuse each other

In language

What is the conceptualization

What we think is best treatment

But we are in the same room discussing it

Curriculum covered by the chemical dependency professional Mapping into mental health

Mapping into joint treatment

Example Curriculum for IOP

IOP Components OP Components

Considering Change: Consciousness Raising. Where am I

Effects of Drugs A Day in the Life

Educational Goals Physiological Effects of Alcohol and Drugs

Vocational Goals Expectations

Stages of Recovery Expressions of Concern

Anger and Communication Values

Relapse Prevention Pros and Cons

Family Education Relationships

Health & Wellness Roles

Drug Education Confidence and Temptation

Relapse Prevention Problem Solving

Attitudes and Beliefs Setting a Goal and Preparing to Change

Disputing Irrational Beliefs Review and Termination

Building Self-Attitude The Stages of Change

Spirituality Identifying Triggers

12- Steps and Self-Help Managing Stress

Managing Criticism

Managing Thoughts

Managing Cravings and Urges

New Ways to Enjoy Life

Example Conversion Table

Therapeutic Targets

1 – Drives

2 – Suffering

3 – Wise mind

4 – Values

5 – Resilience

6 – Development

http://www.asam.org/quality-practice/guidelines-and-consensus-documents/the-asam-criteria/about

The NET

Weighting Treatment

Shift in treatment

Yes we are treating anxiety, depression, PTSD

We are considering heavily the context for growth

Weighting treatment toward the NET and ASAM dimensions.

More than Diagnostic

After sadness, anxiety, and anger. Empty

The absence of negative affect and substance use does not guarantee happiness

A presence we want to restore and nurture (PERMA)

Enjoying positive emotion

Being engaged with the people you care about

Maintaining good relationships

Having meaning in life

Achieving work goals

Krentzman, A. R. (2013). Review of the application of positive psychology to substance use, addiction, and recovery research. Psychology of addictive behaviors, 27(1), 151-165.

Seligman, M. E. (2012). Flourish: A visionary new understanding of happiness and well-being. Simon and Schuster.

Case Examples

Case Study 1– Inpatient

Values and resilience (4 and 5)

Self, social, and career development

Case Study 2– Work release

Wise mind and suffering (2 and 3)

Mental health, career development, self

Case Study 3– CPS

Drives, resilience, and development (1, 5, and 6)

Social, biological, education, and self

Hindrances

Large requirement to change and adapt

Underlying maladaptive schemas Effects ability to experience and maintain wellbeing

Cognitive and Emotional Schemas

Core Needs

1. Secure attachments to others (includes safety, stability, nurturance, and acceptance)

2. Autonomy, competence, and sense of identity

3. Freedom to express valid needs and emotions

4. Spontaneity and play

5. Realistic limits and self-control

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. Guilford Press.

Traditionally Expected

Impaired Limits Under-development of adequate internal limits in regard to

reciprocity or self-discipline. Difficulty respecting the rights of others, cooperating,

keeping commitments, or meeting long-term goals. Present as selfish, spoiled, irresponsible, or narcissistic. They typically grew up in families that were overly

permissive and indulgent. As children, these patients were not required to follow the

rules that apply to everyone else, to consider others, or to develop self- control.

As adults they lack the capacity to restrain their impulses and to delay gratification for the sake of future benefits.

Shorey, R. C., Stuart, G. L., Anderson, S., & Strong, D. R. (2013). Changes in early maladaptive schemas after

residential treatment for substance use. Journal of clinical psychology, 69(9), 912-922.

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. Guilford Press.

Also Found

Unrelenting Standards/Hypercriticalness schema

A sense that one must strive to meet very high internalized standards, usually in order to avoid disapproval or shame.

The schema typically results in feelings of constant pressure and hypercriticalness toward oneself and others.

The schema typically presents as: (1) perfectionism

(2) rigid rules and “shoulds” in many areas of life, including unrealistically high moral, cultural, or religious standards

(3) preoccupation with time and efficiency.

Shorey, R. C., Stuart, G. L., Anderson, S., & Strong, D. R. (2013). Changes in early maladaptive schemas after

residential treatment for substance use. Journal of clinical psychology, 69(9), 912-922.

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. Guilford Press.

Conditioning

It is a Conditional schema hold out the possibility of hope. The individual might change the

outcome and avert the negative outcomes, at least temporarily. They often develop as attempt to get relief from the unconditional schemas.

Unrelenting Standards in response to Defectiveness. “If I can be perfect, then I will be worthy of love.”

Unrelenting Standards in response to Impaired Limits. Combat: “If I can be perfect, then I can control my impulses.”

Justify: “If I work really hard, then I can make allowance for my substance use.”

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. Guilford Press.

Coping Responses from Case Studies

Unrelenting/Standards/ Hypercriticalness Surrender - Case Study 1– Inpatient

Spends inordinate amounts of time trying to be perfect

Irrational Example: Attending 4 meetings a day, unintentionally neglecting other important modes of treatment, failure is unacceptable, burns out spinning wheels

Over-compensation - Case Study 2– Work release Does not care about standards at all—does tasks in a hasty, careless manner

Irrational Example: Attending meetings but does not pay attention, not allowing self to hope to change, uses substances with a feeling of justification, externalized locus of responsibility

Avoidant - Case Study 3– CPS Avoids or procrastinates in situations and tasks in which performance will be self/other’s judged

Irrational Example: Spending as much waking time as possible busy, in conflicts/drama, trying to fix relationships, highly distracted by others, self-sooth stress with substances

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. Guilford Press.

Summary

The story

Transition of thinking

Translation of language

Shift in treatment

Hindrances aside

What we are working on building with CDPs is wellbeing

Summary

Meaning and Addiction Recovery

Recovery is possible

Re-envision life

Self-discovery (activities and relationships are most important)

Pain of the past is worked through

Goals for the future are set and worked toward

Contact us

Andrea Ray – andrea.ray@comphc.org

William Waters – william.waters@comphc.org