Randi Tolliver, PhD, CADC Illinois Co-Occurring Center for Excellence

1. Integrated Dual Diagnosis TreatmentImplementation and Program Maintenance in Mental Health and Substance Abuse Settings Randi Tolliver, PhD, CADC Illinois Co-Occurring Center for Excellence

2. Training Objectives • Review Key Components of the Integrated Dual Diagnosis Treatment Model • Program Implementation • Organizational Issues • Programmatic Issues • Agency Infrastructure

3. Training Objectives • Program Evaluation • Agencies in Transition • Other Management & Staffing Considerations

4. SAMHSA Definition “Co-occurring disorders may include any combination of two or more substance abuse disorders and mental disorders identified in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). There are nospecific combinations of….disorders that are defined uniquely as co-occurring disorders.” In “A Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders”

5. Comorbidity of Substance Use and Specific AXIS I Psychiatric Disorders Any Substance Alcohol Diagnosis Other Drug Diagnosis Schizophrenia 47% 33.7% 27.5% ASPD 83.6% 73.6% 42% Anxiety disorders 23.7% 17.9% 11.9% Phobia 22.9% 17.3% 11.2% Panic disorder 35.8% 28.7% 16.7% OCD 32.8% 24% 18.4% Bipolar Disorder 60.7% 46.2% 40.7% Major depression 27.2% 16.5%* 18% Regier DA et al. JAMA. 1990(Nov 21);264(19):2511-2518

6. Evidence-Based Practice Two Directions in EBP • Evidence-Based Interventions: • EB Guidelines, EB Practices, Empirically- supported (validated) Treatments • Evidence-Based Process for decision-making: • EB Process, EB Individual Practice

7. Evidence-Based Guidelines(EBG) • Different methods for designing guidelines: global subjective judgment or consensus-based, outcomes based, preference based, expert opinion, evidence based • Importance of explicit, evidence-based process in developing guidelines

8. Evidence-Based Process • EB Process is a way of doing practice which involves an individualizing process whereby evidence is used to make collaborative decisions with clients and caregivers. (Mullen, 2004) • EB Process is the integration of best research evidence with clinical expertise and patient values (Sackett et al., 2000).

9. Quadrants of Care

10. Integrated Dual Diagnosis Services • Improve quality of life • Utilize biopsychosocial treatments • Promote consumer and family involvement in service delivery • Promote stable housing • Promote employment as an expectation • Promote hopeful interactions

11. Integrated Dual Diagnosis Services • Promote a recovery concept • Increase continuity of care • Increase consumer quality of life outcomes • Increase stable housing • Increase employment • Increase independent living

12. Integrated Dual Diagnosis TreatmentMultidisciplinary Team • Views all activities of life as part of the recovery process. • The Team provides each consumer with a variety of service professionals that can help in all aspects of life. • Members meet individually and as a group with each consumer and their support network (family, friends etc.) to discuss consumer’s progress and goals.

13. Stage-Wise Interventions • Individuals with dual disorders gain the most confidence with their ability to recover or develop independent living skills and to meet daily living needs when they experience incremental successes through stages of treatment and change. • Caregivers and professional service providers should utilize the four stages of treatment to guide every interaction with individuals who have dual disorders.

14. Access to Comprehensive Services • Programs offer comprehensive services because the recovery process occurs in the context of daily living. • Comprehensive Services Include: Housing/Residential Services Supported Employment Family Services Assertive Community Treatment or Intensive Case Management Case Management Integrated Substance Abuse and Mental Health Counseling Medical Services

15. Time-Unlimited Services • Consumers with dual disorders may experience cycles of relapse and recovery throughout their lives. • Consumers will achieve the highest quality of life when they have access to services all the time.

16. Assertive Outreach • Programs utilize assertive outreach to keep consumers engaged in relationships (service professional, family, friends) Service professionals who use assertive outreach: • Meet with their clients in the community • Meet regularly with clients • Offer practical assistance with daily needs and living skills.

17. Motivational Interviewing The role of Motivational Interviewing in IDDT: • Help consumers examine their ambivalence about their goals and strategies • Help consumers identify their goals for daily living • Help consumers develop strategies for achieving those goals

18. Substance Abuse Counseling • Consumers are provided counseling that promotes recovery skills during the Active Treatment or Relapse Prevention Stage of Treatment • In group treatment • Consumers can develop peer support • Consumers learn from each other

19. Group Treatment Agencies that offer group treatment: • Offer a menu of group treatment options • Offer group treatment options to all consumers who experience dual disorders

20. Family Psychoeducation • Social support plays a critical role in improving assessments and reducing relapse and hospitalization in persons with severe mental illness. • Family psychoeducational programs can be a powerful approach for improving substance abuse outcomes in clients with severe mental illness.

21. Participation in Alcohol & Drug Self-Help Groups • Social support plays an important role in reducing relapse for persons with dual disorders • Self-Help Groups provide consumers with opportunities to share and learn from others who experience dual disorders

22. Pharmacological Treatment • Medications are effective in the treatment of persons with severe mental illness and dual disorders • Medications are often most effective when accompanied by comprehensive integrated services and treatments.

23. Interventions to Promote Health Individuals with dual disorders are at risk for poor health including: • Hospitalization and emergency room visits • Suicide and violence • Infectious diseases • Complications resulting from chronic illnesses

24. Secondary Interventions for Non-Responders to Substance Abuse Treatment • Have a specific plan to identify individuals who are not responding to IDDT treatment • Questions to consider: • What are the criteria to identify non -responders? • What is the process for the secondary intervention? • How does this get followed up?

25. Delivery of Services Guiding Principles for Effective Treatment Adapted from SAMHSA Tip 42

26. Organizational Environment Common ground: • Values and principles • Guidelines • Outcome measures Differences: • Treatment philosophy • Treatment practice • Relationships • Vocabulary • Basic competencies

27. Organizational Change • Understanding the organization’s model • Multi-level organizations • Mutual and conflicting needs • Traditional versus innovative ways of communicating • Systems tend to resist substantial change Adapted from Hendrickson, E. L (2006)

28. Program Development • Utilize evidence-based or best practices • Utilize a competency-based perspective • Employ recovery support specialists • Develop a plan to address housing needs • Employ employment specialists

29. Program Development • Develop policy & procedures for program operations • Develop a clear understanding of target population • Develop a marketing strategy that will ensure adequate numbers of consumers are engaged

30. Program Development • Develop a realistic time frame for hiring and training staff • Establish a functional and clear admission and referral process • Allow easy accessibility to program services across the continuum of care

31. Necessary Infrastructure • Supervisor support for models or changes • Specific assessment instruments • Training protocol for providers • Implementation of treatment model • Utilization of outcome evaluation • Considerations of staff qualifications and training needs • Recognition of additional/other needs

32. Questions to Consider for Development and Implementation • Currently, which co-occurring treatment services are being offered to which consumers? • Where in the continuum of care are the services being offered? • Do current services demonstrate the qualities of “effective” services? • Do the services meet the needs of the community? SAMHSA Tip 42

33. Questions to Consider • What is the capacity of the agency to implement comprehensive, integrated services? • What are the core competencies needed for staff to provide effective services?

34. Implementation Challenges • Physician or psychiatrist staffing • Physical resources • Billing and reimbursement issues McGovern, Xie, et. al. (2006).

35. Implementation Challenges • Identifying and responding to gaps in workforce competencies, certifications, and licensure • Addressing increases in staff concern related to changes in roles and responsibilities • Addressing discrepancies in record keeping

36. Implementation Challenges • Addressing organizational structure and policies • Resolving differences in treatment philosophies • Establishing a cohesive multidisciplinary team

37. Program Evaluation • General Organization Index (GOI) • Integrated Dual Diagnosis Treatment (IDDT) Fidelity Scale • Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index

38. General Organizational Index • Program Philosophy • Eligibility/ Consumer Information • Penetration • Assessment • Individualized Treatment Plan • Individualized Treatment • Training

39. General Organizational Index • Supervision • Process Monitoring • Outcome Monitoring • Quality Assurance • Consumer Choice Regarding Service Provision

40. IDDT Fidelity Scale • Multidisciplinary Team • Stage-Wise Interventions • Access to Comprehensive DD Services • Time-Unlimited Services • Outreach • Motivational

41. IDDT Fidelity Scale • Substance Abuse Counseling • Group DD Treatment • Family Psychoeducation on DD • Participation in Alcohol & Drug Self-Help Groups • Pharmacological Treatment • Interventions to Promote Health • Secondary Interventions to Substance Abuse Treatment Non-Responders

42. Dual Diagnosis Capability in Addiction Treatment(DDCAT) Index • Program Structure • Program Milieu • Clinical Process: Assessment • Clinical Process: Treatment • Continuity of Care • Staffing • Training

43. DDCAT (3.2): 7 DIMENSIONS McGovern, Giard, et al. (2006).

44. Measuring Changes • Client Readiness for Change (Prochaska, DiClemente, and Norcoss, 1992) • Substance Abuse Treatment Scale (Mueser, Drake, Clark, Mchugo, Mercer- McFadden, Ackerson, 1995) • Stages of Change Readiness and Treatment Eagerness Scale (Miller & Tonigan, 1996)

45. Program Commitment Plan • Specific statements of services to be implemented • Identification of individual(s) to monitor implementation • Identification of ways to measure effectiveness of services • Method for implementing services Adapted from Hendrickson, E. L (2006)

46. Program Commitment Plan • Development of timeline for implementation • Process to determine effectiveness of plan implementation • Method for ongoing review and modification of the plan Adapted from Hendrickson, E. L (2006)

47. Agencies in Transition • Currently numerous agencies within Illinois are providing a level of dual diagnosis services • Organizational level • Program level • Provider level

48. Program Management • Ensure compliance with all licensure requirements • Develop policies and procedures for all program activities • Maintain effective working relations with other community agencies / Collaborate • Build consensus Adapted from Hendrickson, E. L (2006)

49. Program Management • Maintain systems that ensure consumers move through treatment services in the easiest manner • Manage data systems • Ensure all information needed by funding sources is provided accurately and on time Adapted from Hendrickson, E. L (2006)

50. Program Management • Ensure compliance with all licensure requirements • Develop policies and procedures for all program activities • Maintain effective working relations with other community agencies Adapted from Hendrickson, E. L (2006)