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Integrated Treatment

Integrated Treatment. Suzanne Carrier, LCSW. Integrated treatment With Co-occurring Disorders Persons who have one or more substance-related disorders as well as one or more mental disorders. Prevalence of Co-Occurring disorders.

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Integrated Treatment

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  1. Integrated Treatment Suzanne Carrier, LCSW

  2. Integrated treatment With Co-occurring Disorders Persons who have one or more substance-related disorders as well as one or more mental disorders.

  3. Prevalence of Co-Occurring disorders • Seven to 10 million individuals in the U.S. have at least one mental disorder and at least one alcohol or drug disorder. • 41% to 65% of individuals with a lifetime substance use disorder also have a lifetime history of at least one mental disorder. Report to Congress,SAMHSA, 2002

  4. Prevalence of Co-Occurring Disorders • 51% of those with one or more lifetime mental disorders also have a lifetime history of at least one substance abuse disorder. • 43% of youth receiving mental health services in the United States have been diagnosed with co-occurring disorders. Report to Congress, SAMHSA 2002

  5. Problems associated with Co-Occurring MH & SA • More difficulty with symptoms management and abstinence due to interaction of both illnesses. • Higher rates of relapse in both illness. • Multiple losses.

  6. Problems associated with Co-Occurring MH & SA • Higher rates of medical problems • Higher incidence of self harm and violence • Higher rates of involvement with the Criminal Justice System • Higher rates of Homelessness • Multiple vulnerabilities/victimizations

  7. Parallels Between Mental Illness and Substance Abuse • Both have biological, psychological and social components • Both create shame and guilt • Both are stigmatized by society • Both are primary • Both are progressive • Both are chronic • Both are no fault illnesses • People can and do recover from both Kathleen Sciacca, 1997

  8. Four Quadrants of Co-occurring Disorders • Quadrant I – Less severe mental illness and substance use/Primary health care setting/ consultation • Quadrant II – More severe mental illness and less severe substance use/ Mental Health or Substance Abuse System/collaboration Report to Congress, 2002

  9. Four Quadrants of Co-Occurring Disorders • Quadrant III – More severe substance use and less severe Mental illness/ Mental Health or Substance Abuse System/Collaboration • Quadrant IV – More severe substance use and mental illness/ Mental Health System/ Integrated Services Report to Congress, 2002

  10. Less severe mental illness and substance abuse primary care more severe Mental Illness – less severe SA collaboration at either MH/SA more severe SA – less severe mental illness collaboraton either MH/SA more severe substance abuse and mental illness – mental health system integrated treatment

  11. Treatment optionsfor co-occurring disorders • Sequential Treatment– or treatment that addresses one illness before the other illness is addressed. • Parallel Treatment- or treatment where each illness is addressed at different locations, clinicians and/or programs.

  12. Limitations of Parallel Treatment • Different Treatment Providers have incompatible treatment philosophies • Clients slips between the cracks and receives no services because the client doesn’t “fit” into the existing program • Providers lack a common language and treatment methodology Mueser, Noordsy, Drake, Fox, 2003

  13. Limitation of Parallel Treatment • MH and SA treatments are not integrated into a cohesive treatment package • Treatment providers fail to communicate • Burden of integration falls on the client • There are funding and eligibility barriers Mueser, Noordsy, Drake, Fox, 2003

  14. Limitations of Sequential Treatment • The untreated disorder gets worse, making it impossible to stabilize one disorder without attending to the other • There is a lack of agreement as to which disorder should be treated first • It’s unclear when one Disorder has been treated successfully so that the other one can be treated. The client is not referred for further treatment Mueser, Noordsy,Drake, Fox, 2003

  15. Integrated treatment The interaction between the mental health and/or substance abuse clinician and the individual, which addresses both the substance abuse and mental health needs of the individual.

  16. Program Types • Addiction or Mental Health only services (AOP or MHOP). • Refers to programs that either by choice or lack of resources (staff or financial), cannot accommodate clients who are have co-occurring disorders and require ongoing treatment. ASAM, 2001, p. 10

  17. Program Types • Dual diagnosis Capable (DDC). • Programs that address co-occurring mental and substance-related disorders in their policies and procedures, assessment, treatment planning, program content and discharge planning. • These programs are geared toward either SA or MH but the staff has the ability to address the interaction between mental and substance-related disorders. ASAM, 2001

  18. Program Types • Dual Diagnosis Enhanced (DDE). • Programs that have a high level of integration of substance abuse and mental health treatment services on a staffing, services and program content level. They are able to provide unified SA and MH treatment to clients who are more symptomatic and/or functionally impaired as a result of the co-occurring disorders. ASAM, 2001

  19. Integrated Services • Clinicians provide services for both mental illness and substance use at the same time. • AOP, MHOP, DDC and DDE.

  20. Components of Integrated Dual Disorders Treatment • Knowledge about alcohol and drug use, as well as mental illnesses • Integrated services • Stage-wise Treatment • Assessment • Motivational Treatment • Substance Abuse Counseling SAMHSA's Co-occurring disorders, IDDT tool kit, 2003

  21. Clinicians know the effects of alcohol and drugs and their interactions with mental illness

  22. Treatments • Medication • Illness management • Cognitive behavioral therapy • Social supports • Family involvement and education • Social skills groups • Case Management • Refusal Skills • Psychiatric Rehabilitation

  23. Different Treatment Methodologies • Care vs. Confrontation • Abstinence-oriented vs. Abstinence-mandated • Deinstitutionalization vs. Recovery & Rehabilitation David Mee-Lee, M.D.

  24. Principles of Integrated Treatment • First and foremost is the simple fact that people of all ages who have co-occurring disorder are people first, fully deserving of respect. • At the same time, consumers, recovering persons and their families need to be involved in all aspects of their treatment and recovery. • People with co-occurring disorders can and do recover. • People with co-occurring disorders deserve access to the services they need to recovery. David Mee-Lee, 2006

  25. The eight research-derived and consensus-derived principles

  26. Co-occurring is an expectation, not an exception • all integrated programs are not the same; the national consensus four quadrant model for categorizing co-occurring disorders .

  27. Empathic, hopeful, integrated treatment relationships are one of the most important contributors to treatment success in any setting; • provision of continuous integrated treatment relationships is an evidence based best practice for individuals with the most severe combinations of psychiatric and substance difficulties

  28. Case management and care must be balanced with empathic detachment, expectation, contracting, consequences, and contingent learning for each client, and in each service setting

  29. . When psychiatric and substance disorders coexist, both disorders should be considered primary, and integrated dual (or multiple) primary diagnosis-specific treatment is recommended

  30. Both mental illness and addiction can be treated within the philosophical framework of a "disease and recovery model" (Minkoff, 1989) • with parallel phases of recovery • acute stabilization, • motivational enhancement, • active treatment, • relapse prevention • rehabilitation/recovery), in which interventions are not only diagnosis-specific, but also specific to phase of recovery and stage of change.

  31. Stage-wise Treatment • People go through a process over time to recover and different services are helpful at different stages of recovery.

  32. Stages of Change ‘Spiral View’

  33. Stages of Change: Client’s perspective? Action Maintenance “I’m ready to start” “How do I keep going?” Relapse Preparation “What went wrong? “I’ve got to do something” Contemplation “Maybe I have a problem”. Precontemplation “I don’t have a problem.”

  34. Stages of Change: Client’s View Relapse Event Return to old behavior: “I hadn’t planned for that!” Action ? “This is a lot of work.” Preparation Maintenance Admit problem: “ I need to do something. But what?” Integrate change: “I’ve got the hang of this. “ Contemplation Ambivalent: “Maybe there is a problem, but maybe not.” Precontemplation “There’s no problem!”

  35. Change: An Ideal MI Approach… Action Maintenance Affirm efforts and continue to explore ambivalence. Ask permission before giving advice, Monitor relapse risks. Help in getting support for change Preparation Recycle/Reoccurrence/ Relapse Plan treatment around client’s goals and ideas. Remain nonjudgmental, Learn from relapse and Resist demoralization Contemplation Avoid arguing. Explore Ambivalence Precontemplation Build rapport/ raise doubt

  36. Stages of change Group Therapy • Different Clients can be in different stages and in the same group. • Addressing the groups concern over what others are doing according to what stage they are in.

  37. Motivational Treatment Clinicians use specific listening and counseling skills Clients develop awareness, hopefulness, and motivation for recovery. This is important for consumers who are demoralized and not ready for substance abuse treatment.

  38. A client-focused semi-directive method for enhancing motivation to changeby exploring and resolving ambivalence about change

  39. Spirit of Motivational Interviewing • A genuine interest in the client’s experience and perspectives—empathy. • Empathy is essential. • An openness to a way of thinking and working that is collaborative, honors the client’s self-direction, and is more about drawing out positive change than forcing change.

  40. Our goal for the client is to face up to a problem; we do not need a confrontational therapeutic style to accomplish this.

  41. Resistance & Ambivalence • “Resistance” or “lack of motivation" is our treatment label for the client’s unresolved ambivalence; for example, a desire to stop using vs. a desire to continue using. • The client is stuck. This concept of ambivalence is key to an MI approach.

  42. Refusal Skills • Say No First • Suggest an Alternative • Request the Person Stop Asking • Avoid Making Excuses Brunette, 2003 Modified

  43. Sources of Support • Family and Friends • Providers • 12-Step Recovery, NA,AA and DRA • NAMI and KY-CAN

  44. Kenneth Minkoff: We have ten years of data showing the efficacy of integrated treatment.

  45. Suggested Resources BooksDunn, C. & Rollnick, S. (2003). Lifestyle Change. London:Mosby.Ingersoll, K. S., Wagner, C. C., & Gharib, S. (2000). Motivational Groups for Community Substance Abuse Programs. Richmond, VA: Mid-Atlantic Addiction Technology Transfer Center, Center for Substance Abuse Treatment (Mid-ATTC/CSAT )Miller, W. R. (Ed.) (1999). Enhancing motivation for change in substance abuse treatment. Treatment Improvement Protocol (TIP) Series, No. 35. Rockville, MD: Center for Substance Abuse Treatment.

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