integrating treatment for co-occurring disorders brought to you by:

Integrating Treatment for Co-Occurring Disorders

Brought to you by:

Presented By

TODAY’S PRESENTERSTODAY’S PRESENTERS

Cynthia Moreno TuohyExecutive Director

NAADAC, The Association for Addiction Professionals

Misti StorieEducation and Training Consultant

NAADAC, The Association for Addiction Professionals

TODAY’S PRESENTERSTODAY’S PRESENTERS

Tim Sheehan, Ph.D.Director of Institutional Effectiveness

Hazelden Graduate School of Addiction Studies

Mary Woods, RNC, LADC, MSHS

Chief Executive Officer

Westbridge Community Services

WEB CONFERENCE OBJECTIVESWEB CONFERENCE OBJECTIVES

Discuss the prevalence of co-occurring disorders in substance abuse treatment programs



Contrast co-occurring treatment with traditional addiction treatment




Give a rationale for integrated treatment





List instruments helpful for screening






Describe evidence-based therapies helpful in treating co-occurring disorders






Describe evidence-based therapies helpful in treating co-occurring disorders

Access new training programs available through NAADAC and Hazelden

Part One:Introduction to Introduction to Co-occurring Co-occurring DisordersDisorders

SCOPE OF PRACTICESCOPE OF PRACTICE

An Addiction Professional’s scope of practice varies with education, training and state requirements.

With over 300 people on line today, each practitioner should keep his or her scope of practice in mind as we conduct this presentation.

DEFINING CO-OCCURRING DEFINING CO-OCCURRING DISORDERSDISORDERS

50 to 75% of all clients who are receiving treatment for a substance use disorder also have another diagnosable mental health disorder.

Further, of all psychiatric clients with a mental health disorder, 25 to 50% of them also currently have or had a substance use disorder at some point in their lives.

Co-morbidity of Substance Use and Psychiatric Disorders

Among a sample of about 10,000 adults:

13.5% had an alcohol use disorder. Of those, 36.6% also had a psychiatric disorder.

6.1% had a drug use disorder. Of those, 53.1% also had a psychiatric disorder.

22.5% had a psychiatric disorder. Of those, 28.9% also had an alcohol or drug use disorder.


Source: Regier et al. 1990

Psychiatric Disorders in Addiction TreatmentTwo studies of Prevalence rates in addiction treatment settings had similar findings. Persons

with substance use disorders are also like to have mood and anxiety disorders.

Source: Cacciola et al, 2001; Ross, Glaser and Germanson 1988



0%

5%10%

15%

20%25%

30%

35%

40%45%

Mood Disorders Anxiety Disorders Post-TraumaticStress Disorders

AntisocialPersonalityDisorders

BorderlinePersonalityDisorders

Severe MentalIllness

Addiction Treatment Provider Estimates by Psychiatric Disorder

Mental health disorder (MHD): significant and chronic disturbances with “feelings, thinking, functioning and/or relationships that are not due to drug or alcohol use and are not the result of a medical illness”22

Bipolar disorder

Major depressive disorder

Schizophrenia

Obsessive-compulsive disorder

Social phobia

Borderline personality disorder

Posttraumatic stress disorder


Substance use disorder (SUD): a behavioral pattern of continual psychoactive substance use that can be diagnosed as either substance abuse or substance dependence


Co-occurring disorders (COD): the simultaneous existence of “one or more disorders relating to the use of alcohol and/or other drugs of abuse as well as one or more mental [health] disorders.”18


SEVERITY OF CO-OCCURRING SEVERITY OF CO-OCCURRING DISORDERSDISORDERS

Co-occurring mental health disorders are often placed on a continuum of severity.

Non-severe: early in the continuum and can include mood disorders, anxiety disorders, adjustment disorders and personality disorders.

Severe: include schizophrenia, bipolar disorder, schizoaffective disorder and major depressive disorder.

SEVERITY OF CO-OCCURRING SEVERITY OF CO-OCCURRING DISORDERSDISORDERS

The classification of “severe and non-severe” is based on a specific diagnosis and by state criteria for Medicaid qualification but can vary significantly based on severity of the disability and the duration of the disorder.

QUADRANTS OF CAREQUADRANTS OF CARE

Part Two:What is Co-occurring What is Co-occurring Treatment and How Treatment and How is It Different fromis It Different fromTraditional Addiction Traditional Addiction Treatment?Treatment?

MODELS OF TREATMENTMODELS OF TREATMENT

Clients with co-occurring disorders have historically received substance abuse treatment services in isolation from mental health treatment services.

As more research on co-occurring disorders began to be conducted, the many limitations this approach places on the client and his or her success in treatment began to surface.

A twenty-eight year-old-woman named Anita entered an addiction treatment center where she was assessed as having alcohol dependence. Six months earlier, Anita had been diagnosed with major depressive disorder and was prescribed medication by her family doctor. At the treatment facility, it was recommended that Anita be re-assessed and treated, if necessary, at a mental health clinic, located nearby in town. What model of treatment does this scenario represent?

single model of treatment sequential model of treatment parallel model of treatment integrated model of treatment


Single model of care - It was believed that once the “primary disorder" was treated effectively, the client’s substance use problem would resolve itself because drugs and/or alcohol were no longer needed to cope.

Sequential model of treatment - acknowledges the presence of co-occurring disorders but treats them one at a time.

Parallel model of treatment - mental health disorders are treated at the same time as co-occurring substance use disorders, only by separate treatment professionals and often at separate treatment facilities.


INTEGRATED MODEL OF TREATMENTINTEGRATED MODEL OF TREATMENT

Integrated model of treatment

an approach to treating co-occurring disorders that utilizes one competent treatment team at the same facility to recognize and address all mental health and substance use disorders at the same time.


The integrated model of treatment can best be defined by following seven components:

1) Integration



1) Integration

2) Comprehensiveness



1) Integration


3) Assertiveness



1) Integration


3) Assertiveness

4) Reduction of negative consequences



1) Integration


3) Assertiveness


5) Long-term perspective



1) Integration


3) Assertiveness



6) Motivation-based treatment



1) Integration


3) Assertiveness



6) Motivation-based treatment

7) Multiple psychotherapeutic modalities

BENEFITS OF AN INTEGRATED BENEFITS OF AN INTEGRATED MODEL OF CAREMODEL OF CARE

Benefits of an Integrated Model of Care

Reduced need for coordination




Reduced frustration for clients





Shared decision-making responsibilities






Families and significant others are included







Transparent practices help everyone involved share responsibility








Clients are empowered to treat their own illness and manage their own recovery








Clients are empowered to treat their own illness and manage their own recovery

The client and his/her family has more choice in treatment, more ability for self-management, and a higher satisfaction with care

One disorder does not necessarily present as “primary.”

There isn’t necessarily a causal relationship between co-occurring disorders.

These are co-occurring brain diseases that need to be treated simultaneously.

An integrated model of care assumes that:

CO-OCCURRING DISORDERS CO-OCCURRING DISORDERS INTERACTIONSINTERACTIONS

SCREENING AND ASSESSMENTSCREENING AND ASSESSMENT

Screening: The first phase of evaluation where the potential client is interviewed to determine if he or she is appropriate for that specific treatment facility and to determine the possible presence or absence of a substance use or mental health problem.

Assessment: The second phase of evaluation where a systematic interview is necessary to verify the potential presence of a mental health or substance use disorder detected during the screening process.



IntoxicationWithdrawalSubstance-induced disordersMotivational factorsFeelings, symptoms, and disorders

Complexities of Screening and Assessment

CO-OCCURRING DISORDERS CO-OCCURRING DISORDERS INTERACTIONSINTERACTIONS

Substances and Negative Emotions

The choice of screening measures depends on:

1) The skill of the screening professional

2) The cost of the screening materials

3) How simple the scale is to interpret and use across disciplines

4) Psychometric qualities

5) The relevance of screening to prevalent disorders

6) Movement from very sensitive (generic) measures to more specific measures


Integrated Assessment Process – 12 Steps

1. Engage the Client




2. Identify and Contact Collaterals





3. Screen for and Detect Co-occurring Disorders






4. Determine Quadrant and Locus of Responsibility







5. Determine Level of Care







5. Determine Level of Care

6. Determine Diagnosis



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







11. Determine Stage of Change

12. Plan Treatment


American Society of Addiction Medicine Patient Placement Criteria – 2nd Edition Revised (ASAM PPC-2R) dimensions of care

Dimension 1: Acute Intoxication and/or Withdrawal Potential

Dimension 2: Biomedical Conditions and Complications

Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications

Dimension 4: Readiness to Change

Dimension 5: Relapse, Continued Use or Continued Problem Potential

Dimension 6: Recovery/Living Environment

DETERMINING LEVEL OF CAREDETERMINING LEVEL OF CARE

Level I: Outpatient treatment.

Level II: Intensive outpatient treatment, including partial hospitalization.

Level III: Residential/medically monitored intensive inpatient treatment.

Level IV: Medically managed intensive inpatient treatment.

DETERMINING LEVEL OF CAREDETERMINING LEVEL OF CARE

EVIDENCE-BASED PRACTICESEVIDENCE-BASED PRACTICES

In most treatment addiction centers, the three primary evidence-based practices used are:

motivational enhancement therapy (MET)

cognitive-behavioral therapy (CBT)

twelve step facilitation (TSF)

All of these treatment models are widely used – often without formal training – by addiction professionals around the country and can be easily applied to clients suffering from co-occurring disorders.

EVIDENCE-BASED PRACTICESEVIDENCE-BASED PRACTICES

The Integrated Combined Therapies model combines these three EBPs (Evidence-Based Practices) into a stage-wise treatment plan whereby:

motivational enhancement therapy is first utilized to initiate change and engage the client in the therapeutic process;

cognitive-behavioral therapy is then used to help make change within the client; and

twelve step facilitation is essential to helping maintain

and sustain changes.

STAGES OF CHANGE/STAGES OF CHANGE/STAGES OF TREATMENTSTAGES OF TREATMENT

OTHER CONSIDERATIONSOTHER CONSIDERATIONS

Managing Medications

Involving the Family

Encouraging Participation in Peer-Support Recovery Programs

Collaboration with the Collaboration with the prescriberprescriber

Even though the prescriber is ultimately responsible for ensuring safety and effectiveness of pharmacotherapies, addiction professionals can also help in this effort.

Since addiction professionals tend to see the client more often, they are well-positioned to:

recognize danger signs (including recent psychoactive substance use)

recognize abnormal side effects

monitor and support medication compliance

MANAGING MEDICATIONSMANAGING MEDICATIONS

Pharmacotherapy can only work if medications are taken as prescribed.

Some clients with co-occurring disorders are required to manage a regimen of multiple medications each day.

Clients often have difficulty strictly adhering to a dosing schedule, making them more prone to relapse and hospitalization.

Clinicians can help prepare clients to manage their medications.

INVOLVING THE CLIENT’S FAMILYINVOLVING THE CLIENT’S FAMILY

It is a myth that people with co-occurring disorders are disconnected from their families.

Research has shown that outcomes for substance use and mental health disorders are improved, including fewer relapses, when families are actively engaged in the treatment process.

Unfortunately, family members of a client who has co-occurring disorders often experience considerable stress, heartbreak, and confusion.

Involving families in treatment

INVOLVING THE CLIENT’S FAMILYINVOLVING THE CLIENT’S FAMILY

Involving families in treatment Encourage family member involvement and develop a

collaborative relationship as early as possible in the treatment process

Use an evidence-based practice for family treatment

Encourage families to attend self-help groups such as Al-Anon and NAMI

Double Trouble in Recovery Mental Illness Anonymous Dual Disorders Anonymous Dual Recovery Anonymous Dual Diagnosis Anonymous

DUAL-RECOVERY MUTUAL SELF-HELPDUAL-RECOVERY MUTUAL SELF-HELP

Specific dual-recovery groups can provide essential peer support:

GUIDING PRINCIPLES OF RECOVERYGUIDING PRINCIPLES OF RECOVERY

There are many pathways to recovery.

Recovery is self-directed and empowering, involving personal recognition of the need for change and transformation.

Recovery exists on a continuum of improved health and wellness.

Recovery involves addressing discrimination and transcending shame and stigma.

Recovery is supported by peers and allies, and involves joining and rebuilding a life in the community.

Recovery is a reality.

(from CSAT’s Regional Recovery Meetings, May 2008)

Part ThreeResources and Resources and Training Training OpportunitiesOpportunities

CO-OCCURRING DISORDERS CO-OCCURRING DISORDERS PROGRAM from PROGRAM from Dartmouth/HazeldenDartmouth/Hazelden

Written by the faculty from the Dartmouth Medical School, CDP provides practical tools for implementing evidence-based, integrated treatment practices.

CO-OCCURRING DISORDERS CO-OCCURRING DISORDERS PROGRAM from PROGRAM from Dartmouth/HazeldenDartmouth/Hazelden

Clinical Administrator’s Guide Curriculum 1: Screening and Assessment Curriculum 2: Integrating Combined Therapies Curriculum 3: Cognitive-Behavioral Therapy Curriculum 4: Medication Management Curriculum 5: Family Program DVD A Guide for Living with Co-occurring Disorders

Components of CDP include:

Training and technical assistance is available for all components: Call 1-800-328-9000, ext. 4672 or e-mail [email protected]

NAADAC/HAZELDEN COURSE

Integrating Treatment for Co-occurring Disorders:

An Introduction to What Every Addiction Counselor Needs to Know

…is a skill-based training program that will help addiction counselors improve their ability to assist clients who have co-occurring disorders, within their scope of practice.

NAADAC/HAZELDEN COURSE

Through case studies, video presentations, interactive exercises and extensive written resources, participants learn:

• the many myths related to mental illness treatment• barriers to assessing and treating co-occurring disorders• relevant research and prevalence data• commonly encountered mental disorders• applicable screening and assessment instruments• issues surrounding medication management• coordinating with other mental health professionals• the integrated model of mental health and addiction treatment

services

NAADAC is now conductingthe Lifelong Learning Program: Integrating Treatment for Co-occurring Disorders: An Introduction to What Every Addiction Counselor Needs To Know

Check the NAADAC website for trainings coming to your area at www.naadac.org

Interested in hosting a training?

Contact: Diana Kamp [email protected]

Cynthia Moreno Tuohy [email protected]

NAADAC/HAZELDEN COURSENAADAC/HAZELDEN COURSE

Now available as a distance learning program!

Integrating Treatment for Co-Occurring Co-occurring Disorders: An Introduction to What Every Addiction Counselor Needs to Know.

Learn at your own pace through presentations, videos, case studies, and interactive exercises.

Available 24/7. $180.00

18 CEs from NAADAC; 6 CEs from APA

NAADAC/HAZELDEN COURSENAADAC/HAZELDEN COURSE

LEADERSHIP IN LEADERSHIP IN CO-OCCURRING DISORDERSCO-OCCURRING DISORDERS

Announcing the Focus on Integrated Recovery!A collaboration between:

•Dartmouth Psychiatric Research Center•Hazelden •NAADAC, the Association for Addiction Professionals•NAATP, the National Association of Addiction Treatment Providers•The National Council for Community Behavioral Healthcare •SAMHSA, the Substance Abuse and Mental Health Services Administration, and •WestBridge Community Services•Active discussions with other leaders

FOCUS ON INTEGRATED FOCUS ON INTEGRATED RECOVERYRECOVERY

Co-Occurring Leadership What you can expect from Focus on Integrated Recovery •Practical, evidence-based resources to aid in the integration of the substance use and mental health disorders professions

•Centralized source for consistent messaging about co-occurring disorders

•Ongoing mechanism to capture the learning and experiences from partners and constituents across the behavioral health spectrum

•Opportunities for in-person and distance education on co-occurring disorders

•Support for the September 2011 Recovery Month

•Collaboration on new initiatives: evidence-based scopes of practice, outcome measurement, workforce development

FOCUS ON INTEGRATED FOCUS ON INTEGRATED RECOVERYRECOVERY

Co-Occurring Leadership Where to find the Focus on Integrated Recovery

Communications begin during September, 2011 Recovery Month

National Public Relations efforts

E-mail campaigns

Focus on Integrated Recovery Website

Links on the partners’ websites

Recovery Month materials

Let us know what you think and how we can help!

contact Jon Hartman - [email protected]

August 18, 2011 - Strategies for Successful Test Taking

September 15, 2011 - Your Voice Counts: Advocacy and the NAADAC Political Action Committee

October 13, 2011 - Conflict Resolution for Clients and Professionals

November 17, 2011 - What's Next in Your Career? Recap and Highlights from the NAADAC Workforce Conference

December 15, 2011 - Clinical Supervision: Keys to Success

Register at: www.naadac.org/education or www.myaccucare.com/webinars

UPCOMING WEBINARS 2011UPCOMING WEBINARS 2011

Alcohol SBIRT: Integrating Evidence-based Practice Into Your Practice

Medication Assisted Recovery: What Every Addiction Professional Needs to Know

Build Your Business With the Department of Transportation Substance Abuse Professional (SAP) Qualification

Working with NAADAC to Express Your Professional Identity

Screening, Brief Intervention and Referral to Treatment (SBIRT)

Medicaid Expansion 2014 and Preparing to Bill for Medicaid

Understanding NAADAC’s Code of Ethics

Staying Informed: Trends of the Addiction Profession

Archived webinars located at: www.naadac.org/education or www.myaccucare.com/webinars

ARCHIVED WEBINARSARCHIVED WEBINARS

Time for discussion!

www.naadac.orgwww.bhevolution.orgwww.hazelden.org

www.westbridge.org

Providing solutions to improve the quality of life for communities by helping addictions professionals excel in their field through the use of information technology.

Visit us today! Call: (800) 324-7966Click: www.MyAccuCare.com

Clinical Administrative

Outcome Reporting

Billing

The education delivered in this webinar is FREE to all professionals.

2 CEs are FREE to NAADAC members and AccuCare subscribers who attend this webinar. Non-members of NAADAC or non-subscribers of AccuCare receive 2 CEs for $25.

If you wish to receive CE credit, you MUST download, complete and submit the “CE Quiz” that is located at:

www.myaccucare.com/webinars

www.naadac.org/education

A CE certificate will be emailed to you within 30 days.

Successfully passing the “CE Quiz” is the ONLY way to receive a CE certificate.

OBTAINING CE CREDITOBTAINING CE CREDIT

Thank you for participating!

www.naadac.orgwww.bhevolution.orgwww.hazelden.org

www.westbridge.orgwww.myaccucare.com

Misti - [email protected] - [email protected]

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