Post on 25-May-2020
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