Canadian Mental Health Association Ottawa Branch Integrated Treatment for Homeless Individuals with Co-occu

1. 1 Canadian Mental Health Association Ottawa Branch  Integrated Treatment for Homeless Individuals with Co-occurring Mental Health and Substance Use DisordersPSR/RPS Canada ConferenceOttawaSeptember 22nd, 2010 Andre Inkel MSW RSW Danny Lang BA Rob Anderson MACP Teresa Meulensteen MSW RSW

2. 2 Learning Objectives for the Session 1. To understand the prevalence of substance use disorder amongst individuals with severe mental illness (SMI) and the specific impact of substance use on individuals with SMI. 2. To understand the integrated treatment approach as a best practice in responding to the treatment needs of this population, in particular, the utilization of a “stages of change” and “stages of treatment” approach. 3. To experience alternative approaches in group treatment for individuals with co-occurring substance use and mental health disorders

3. 3 Reflective of best practice in the field: Best Practices Concurrent Mental Health and Substance Use Disorders (2001) Prepared by the Centre for Addiction and Mental Health for Health Canada. This publication is available on line at the following address: www.cds-sca.com Components of integrated treatment from: Mueser, K. T., Noodsy, D.L., Drake, R.E., & Fox, L., (2003). Integrated Treatment for Dual Disorders: A Guide to Effective Practice. New York: Guilford Press.

4. 4 Reflective of best practice in the field: TIP #42 Substance Abuse Treatment for Persons with Co-occurring Disorders And Substance Abuse Treatment For Persons With Co-Occurring Disorders In-service Training Substance Abuse and Mental Health Services Administration (SAMHSA) http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.74073

5. 5 Reflective of best practice in the field: Best Practices Treatment and Rehabilitation for Women with Substance Use Problems (2001) Health Canada. This document is available on the internet at: http://www.cds~sca.com OUT OF THE SHADOWS AT LAST Transforming Mental Health, Mental Illness and Addiction Services in Canada The Standing Senate Committee on Social Affairs, Science and Technology (May 2006). This document is available on the internet at: http://www.parl.gc.ca/39/1/parlbus/commbus/senate/com-e/soci-e/rep-e/pdf/rep02may06high-e.pdf Women, Mental Health and Mental Illness and Addiction in Canada: An Overview (2006). This document is available on the internet at: www.cwhn.ca

6. 6 Canadian Mental Health Association Ottawa: Our Historical Roots Serving the greater Ottawa area for over 50 years, founded 1953 2010 budget >$10.5 million/ 100+employees Funding from: Province of Ontario, City of Ottawa, United Way, donations

7. 7 REFERRAL GUIDELINES Clients must have a serious mental illness, as defined by the Ministry of Health (Diagnosis, Disability, Duration) Clients must be homeless or at imminent risk of becoming homeless. This means that the person is living in unstable housing, is engaging in behaviour that puts their housing at risk and/or where an eviction order could be served. Clients with multiple and complex needs and as a result are not able to formulate and/or implement their own community support plan without intensive support will be priorized

8. 8

9. 9 Why is CMHA in the business of addressing concurrent disorders?

10. 10 Rationale Substance use disorder is now acknowledged as a common co-morbid condition found within the population of those living with severe mental illness but given the heterogeneous nature of the population, lifetime prevalence rates may vary from under 20% to over 60% (Mueser, Noordsy, Drake, & Fox, 2003).

11. 11 Prevalence of concurrent disorders in Canada A reported 1.7% of the overall Canadian population or 435,000 people experienced a substance use and co-occurring mood or anxiety disorder in the previous 12 months co-occurrence of substance abuse/dependence for the population of individuals with mood or anxiety disorders (13% for women and 33% for men) co-occurrence rate of mood or anxiety disorders for individuals with substance abuse/dependence (24% for women and 13% for men) (Rush, Urbanski, Bassani, Castel, Cameron, Strike, Kimberly, & Somers, 2008).

12. 12 Epidemiologic Catchment Area (ECA) study 20,000 structured interviews in the general population, the lifetime prevalence rate was 13.5% for alcohol use disorder and 6.1% for drug use disorder (combined lifetime prevalence of 17%) (Regier, Farmer, Rae, Locke, Keither, Judd & Goodwin, 1990).

13. 13 Epidemiologic Catchment Area (ECA) study For individuals living with a mental illness the rates increased substantially: alcohol use disorder increased to 33.7% for those with schizophrenia and to 56.1% for those with bipolar disorders. Similarly, lifetime prevalence rates for drug use were much higher with 27.5% of those with schizophrenia and 33.6% of those with bipolar disorders having a drug use disorder. (Regier, Farmer, Rae, Locke, Keither, Judd & Goodwin, 1990).

14. 14 Other prevalence info….. Cannabis use was estimated to be estimated at 50% for individuals with co-occurring disorders In terms of nicotine addiction, rates of smoking amongst individuals with Schizophrenia are between 70%-80%, with 40% of people smoking more than 40 cigarettes a day (Horsfall, Cleary, Hunt & Walter, 2009). Recent client prevalence survey of tobacco use at CMHA Ottawa: 70% general clientele/85% CD clients

15. 15 Smoking continued…. Individuals with mental illness remain one of the largest groups of smokers, accounting for 44% to 46% of cigarettes sold in the United States. This equates to 180 billion cigarettes or $37 billion in tobacco industry sales annually (Prochaska, Hall & Bero. 2008)

16. 16 Who gets treatment? A recent US study (and there is no indication that a markedly different experience awaits the Canadian consumer) found in 2006 that adults with concurrent disorders reported the following treatment profiles: 39.6% received mental health treatment only 2.8 % received substance abuse treatment only 49.2% received no treatment at all, and only 8.4% received treatment for both their mental health and substance use disorder (Department of Health and Human Services, 2007, p. 86).

17. 17 Impact of untreated substance abuse on individuals with mental illness Typically associated with increased relapse and hospitalization, increased housing instability and homelessness, increased suicide risk, increased family/interpersonal conflict, increased financial problems, increased involvement with the criminal justice system, and increased risk of victimization (Drake et al., 2001).

18. 18 Socio-environmental Factors “Substance abuse and mental illness are not ‘medical’ diagnoses alone, but are also strongly influenced by socio-environmental factors that are an indication of deep social inequities and poverty “ (Drake et al., 2008)

19. 19 Poor housing can be fatal… A recent study comparing mortality rates among residents of emergency shelters, rooming houses and other marginal housing environments with different income percentiles in Canada concluded the probability of survival to age 75 for those living in the marginal housing environments was 32% for men and 60% for women (compared with 51% and 72% respectively for those in even the lowest income percentile). The most common causes of early death included mental health, substance abuse complications and smoking related diseases. (Hwang, Wilkens, Tjepkema, O’Campo, & Dunn, 2009, p. 1 of 9).

20. 20 Four research paradigms for concurrent disorders…… neuroscience-pharmacology model (this is a disease of the brain that can largely be addressed through pharmacology) cognitive-behavioral model (you can be motivated to change individual behaviour patterns) coercive treatment model (high vigilance and monitoring to thwart the perceived threat of unmanaged behaviour) recovery environment model (environment and social factors create opportunities for substance abuse in this population and thus should be the target for modification and intervention) (Drake & Wallach 2008, p. 190).

21. 21 The link between Concurrent Disorders & Homelessness

22. 22 Link between homelessness, mental illness, substance misuse and concurrent disorders is well documented: Variations across studies may reflect issues such as the use of different assessment tools and the use of different terminology[1]: In the US [2]: Rates of mental illness and substance misuse among females who are homeless increased from 14% in 1990 to 37% in 2000 (58% of homeless women had a substance use problem) Rates of mental illness and substance misuse for men increased from 23% in 1990 to 32% in 2000 (84% of homeless men had a substance use problem) In Vancouver [3]: In 2005, of 1,719 sheltered and street homeless, 23% reported having a mental illness and 49% reported an addiction [1] E. Susser, S. Conover and E.L. Struening, “Problems of Epidemiologic Method in Assessing the Type and Extent of Mental Illness Among Homeless Adults”, Hospital and Community Psychiatry 40, 3 (1989): pp. 261-265. [2] North, C.S., Eyrich, K.M., Pollio, D.E., and Spitznagel, E.L. Are rates of psychiatric disorders changing over time in the homeless population? American Journal of Public Health 94(1):103-108, 2004 [3] Social Planning and Research Council of BC, On Our Street and in Our Shelters….Results of the 2005 Greater Vancouver Homeless Count (Vancouver: Social Planning and Research Council of BC. 2005).

23. 23 In Ottawa [2] : 35% homeless single adult men reported problems related to alcohol use and 51% reported problems related to drug use. 39% of male youth reported alcohol problems and 68% of male youth reported drug us problems. 26% of homeless single adult women report problems due to alcohol use and 25% reported problems due to drug use. 34% of female youth reported problems with alcohol and 56% of female youth reported drug use problems. All groups reported high levels of depression and anxiety (44% of single adult women and 53% of female youth reported depression/ schizophrenia was reported by 8% of single women and 6% of single men) 10% reported a suicide attempt 97% of both male and female homeless youth surveyed reported using drugs on a regular basis [4] [2] From Homeless to Home: Learning from people who have been homeless in Ottawa. Ottawa, ON. Canada. University fo Ottawa, Centre for research on Education and Community services (2009). http://www.socialsciences.uottawa.ca/crecs/eng/documents/FromHomelesstoHomeEn-09-02-12.pdf [3] “Ottawa street Involved Youth Study-Highlights 2006” Thomas Sidney retrieved May 9th 2007 from http://www.operationgohome.ca/PDF/Ottawa%20Street-Involved%20Youth%20Study%202006.pdf

24. 24 Top Five reasons for ER visits by the Homeless and Others….

25. 25 Top Five reasons for Inpatient Hospitalization by the Homeless and Others….

26. 26 Detection- Strategies CAST A WIDE NET BE OVERINCLUSIVE MAINTAIN A HIGH INDEX OF WELCOMING AND EXPECTATION

27. 27 Integrated Treatment: CMHA OTTAWA

28. 28 Treatment of Concurrent Disorders Traditional approaches Sequential Parallel

29. 29 What are the Necessary Ingredients of Integrated Treatment?

30. 30

31. 31 A definition of Integrated Treatment (I.T.) The design and provision of a long-term, time- phased treatment plan using a planned sequence of techniques: That is: Responsive to the many changing symptoms and disorders of the patient. I.T. may be provided by a cross-trained clinician or team

32. 32 Why Integrated treatment ? Among those with co-occurring disorders: The commonest cause of psychiatric relapse is resumption of alcohol or drug USE, not necessarily abuse The commonest cause of relapse to alcohol or drug use is untreated psychiatric disorders, especially depression and anxiety Co–occurring Disorders: Overview COSIG teleconference, 10/7/04 Bert Pepper, MD, downloaded from http://coce.samhsa.gov/cod_resources/PDF/Co-OccurringDisordersOverview10-04.pdf

33. 33 Components of Integrated Treatment & How They Work Together Integration of services Comprehensiveness Assertiveness Harm Reduction Approach Long term perspective Motivational based treatment Availability of multiple bio-psycho-social interventions

34. 34 Integrated Treatment Approach at CMHA Ottawa Outreach / Case Management Extended Hours Support Nursing Psychiatry Concurrent Disorders Group Treatment Vocational Support RGI Housing Access Dual Diagnosis Brokerage Service DBT Treatment Health Promotion

35. 35 Integrated Treatment – CMHA Persons with concurrent disorders are not only accepted into the program, but targeted Coordination for our clients happens at the level of the case manager or outreach worker There are a multitude of treatment and support options, including, but not limited to, concurrent disorders groups and clinical interventions Motivational interviewing and stages of change form the basis of the approach A housing first philosophy based on harm reduction principles informs our housing practice Recovery is the over-arching goal for all interventions

36. 36 Integrated Treatment One Team One client One plan

37. 37 Integrated Treatment – Summary Statement In integrated treatment, our role is to cultivate change through the stages of change using motivational interviewing and harm reduction strategies. We need to have a long-term perspective and incorporate a multitude of treatment options and strategies. The overall progress of the person needs to be coordinated by the agency and recovery needs to be the over-arching goal.

38. 38 Concurrent Disorders Programme Two components to the Concurrent Disorder programme: First component of the program is the group treatment. Second component of the program is the Concurrent Disorder training.

39. 39 CMHA partners with community addiction / treatment agencies: Rideauwood Addictions and Family Services Maison Fraternite Addiction & Problem Gambling Services of Ottawa (SHCHC) The Men’s Project Inner City Health Royal Ottawa Hospital Health Care Group

40. 40 Clients in Concurrent Disorder Treatment Groups: September 2010 Total of 225 clients participate in 23 weekly group sessions All groups are open-ended , many are population specific, all are operated on site at CMHA with the exception of 4“in-reach” groups

41. 41

42. 42

43. 43

44. 44

45. 45

46. 46

47. 47 Levels of Treatment within the CD Program matched to Stages of Change Engagement/Persuasion Groups Active Treatment Groups Relapse Prevention Groups Peer Support Group

48. 48 Stages of Change Prochaska and DiClemente (1992) Pre-contemplation Contemplation Preparation Action Maintenance Termination

49. 49 “People are generally better persuaded by the reasons which they themselves have discovered than by those which have come into the minds of others” Pascal’s Pansees, 17th Century

50. 50 Stages of Treatment (Mueser et al.)

51. 51 Group Goals Engagement: To engage clients into integrated service. To establish a therapeutic working alliance based on trust with group facilitators and group members. Persuasion: To help clients develop an understanding of how substance use has affected their lives, to become motivated to work on reducing their use of substances, and, if desired, to achieve abstinence.  

52. 52 Engagement / Persuasion Groups Client profile: Marginalized men & women Homeless or at risk of losing housing Sex Work History of repeated Abuse and Trauma In and out of custody HIV, Hep C Heavy users; crack, cocaine, IV use, opiates, alcohol SMI’s-Mood disorders, Schizophrenia, Personality Disorders

53. 53

54. 54 Key Elements of Engagement/Persuasion Groups To meet clients where they are at by addressing their concerns and not imposing goals on them Provide a safe environment to discuss positive aspects of substance use, this often sets the stage to discuss negative consequences of use……ultimately the goal being to develop and nurture that interest in working on substance use issues Facilitators encourage clients to make links between their daily experiences and their drug/alcohol use Instillation of strengths and hope is essential

55. 55 Challenges of Engagement/Persuasion Groups Inconsistent attendance Lack of routine Previous negative group experience Forming positive connections Exploring ambivalence One step forward; three steps back Containment vs. flooding Setting group guidelines

56. 56 ACTIVE TREATMENT GROUPS Clients are more aware of the negative effects of substance use on their lives  Focus shifts to further reduction of substance use  Emphasis on learning strategies to maintain abstinence or to maintain a harm reduction plan. Education Group interaction

57. 57 Active Treatment Groups Developing a Relapse Prevention Plan Developing Social Skills Increasing Leisure and Recreational Activities Exploring Community Self Help Groups Goal Plans

58. 58 Active Treatment Groups Managing Cravings Problems with Sleep Coping with difficult feelings Trauma Dealing with Relapses

59. 59 Relapse Prevention Groups  Client engaged in treatment and has not met criteria for substance abuse or dependence for the past 6-12 months Focus is on recovery in all life domains Emphasis on maintenance and dealing with triggers

60. 60 Client Profile for Relapse Prevention Housed Increase in Financial stability Medical/psychiatric supports Integrated community supports Transitional social network

61. 61 Peer Support Group One of the focuses of this group is on leadership.   The members are shown communication skills and techniques to both enhance their communication as well as give each member the skills to effectively lead a group on their own. In this format the counselors also act as members allowing peers to take leadership of the group once skills are in place.   The goal is to have the counselors out of the room and allow the group to run itself.  

62. 62 Group Interventions and Tools Motivational Interviewing CBT Art therapy Psycho educational topics with discussion Pay off matrix/decisional balance Peer Support

63. 63 Client Feedback of Concurrent Disorder Groups Provides support Sense of humour Safe environment Socialize without drugs Acceptance Positive input Enjoyable Reduces shame Share emotions Improve creativity Relaxing Companionship Trying new things Caring Decreases isolation Makes me happier Feeling human

64. 64 Essential Attitudes and Values for Clinicians Who Work with Client Who Have Concurrent Disorders Desire and willingness to work with people who have concurrent disorders Appreciation of the complexity of CD Openness to new information Awareness of personal reactions and feelings Recognition of the limitations of one’s own personal knowledge and expertise Flexibility of approach

65. 65 Essential Attitudes……(cont’d) Recognition of the value of client input into treatment goals and receptivity to client feedback Patience, perseverance, and therapeutic optimism Ability to employ diverse theories, concepts, models, and methods Cultural competence

66. 66 Essential Attitudes ……..(cont’d) Belief that all individuals have strengths and are capable of growth and development Recognition of the rights of clients with CD, including the right and need to understand assessment results and the treatment plan From: Substance Abuse Treatment for Persons with Co-occurring Disorders A Treatment Improvement Protocol TIP # 42 US Department of Health and Human Services (SAMHSA) 2005

67. 67 EMPATHY MANTRA When individuals with mental illness and substance disorder are not following recommendations, they are doing their job It is our job to understand their job, to join them in it, and help them to do it better Their job involves coming to terms with the painful reality of having both mental illness and substance use disorder, wanting neither one, yet having to build an identity that involves treatment for both  (K. Minkoff)

68. 68 Quote “Persons with mental illness experience social problems frequently because they live in a world in which these problems are endemic, not just because they are mentally ill. Thus social problems become erroneouly simplified as psychiatric problems, resulting in the creation of overly simple interventions and policies to address complex phenomena” (Draine, Salzer, Culhane & Hadley, 2002, p. 565)

69. 69