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Integrated Dual Diagnosis Treatment Implementation and Program Maintenance in Mental Health and Substance Abuse Settings Randi Tolliver, PhD, CADC Illinois Co-Occurring Center for Excellence Training Objectives Review Key Components of the Integrated Dual Diagnosis Treatment Model Program Implementation Organizational Issues Programmatic Issues Agency Infrastructure Training Objectives Program Evaluation Agencies Other in Transition Management & Staffing Considerations 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 no specific combinations of….disorders that are defined uniquely as co-occurring disorders.” In “A Report to Congress on the Prevention and Treatment of CoOccurring Substance Abuse Disorders and Mental Disorders” 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 Evidence-Based Practice Two Directions in EBP Evidence-Based • EB Guidelines, EB Practices, Empiricallysupported (validated) Treatments Evidence-Based • Interventions: Process for decision-making: EB Process, EB Individual Practice Evidence-Based Guidelines (EBG) Different methods for designing guidelines: global subjective judgment or consensusbased, outcomes based, preference based, expert opinion, evidence based Importance of explicit, evidence-based process in developing guidelines 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). Quadrants of Care 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 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 Integrated Dual Diagnosis Treatment Multidisciplinary 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. 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. Access to Comprehensive Services Programs offer comprehensive services because the recovery process occurs in the context of daily living. Comprehensive Services Include: Case Management Housing/Residential Services Integrated Substance Abuse and Mental Health Counseling Supported Employment Medical Services Family Services Assertive Community Treatment or Intensive Case Management 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. 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. 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 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 Group Treatment Agencies that offer group treatment: Offer Offer a menu of group treatment options group treatment options to all consumers who experience dual disorders 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. 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 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. 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 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? Delivery of Services Guiding Principles for Effective Treatment 1 Employ a wellness & recovery perspective 2 Adopt a multi-problem viewpoint 3 Develop a phased approach 4 Address real-life problems early 5 Plan for cognitive and functional impairments 6 Use support systems to maintain and extend treatment effectiveness Adapted from SAMHSA Tip 42 Organizational Environment Differences: Treatment philosophy Treatment practice Relationships Common ground: Values and principles Guidelines Outcome measures Vocabulary Basic competencies 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) 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 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 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 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 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 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? Implementation Challenges Physician or psychiatrist staffing Physical resources Billing and reimbursement issues McGovern, Xie, et. al. (2006). 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 Implementation Challenges Addressing organizational structure and policies Resolving differences in treatment philosophies Establishing a cohesive multidisciplinary team Program Evaluation General Organization Index (GOI) Integrated Dual Diagnosis Treatment (IDDT) Fidelity Scale Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index General Organizational Index 1. 2. 3. 4. 5. 6. 7. Program Philosophy Eligibility/ Consumer Information Penetration Assessment Individualized Treatment Plan Individualized Treatment Training General Organizational Index 8. 9. 10. 11. 12. Supervision Process Monitoring Outcome Monitoring Quality Assurance Consumer Choice Regarding Service Provision IDDT Fidelity Scale 1. 2. 3. 4. 5. 6. Multidisciplinary Team Stage-Wise Interventions Access to Comprehensive DD Services Time-Unlimited Services Outreach Motivational IDDT Fidelity Scale 7. 8. 9. 10. 11. 12. 13. 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 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index 1. 2. 3. 4. 5. 6. 7. Program Structure Program Milieu Clinical Process: Assessment Clinical Process: Treatment Continuity of Care Staffing Training DDCAT (3.2): 7 DIMENSIONS Dimension Content of items I Program Structure Program mission, structure and financing, format for delivery of mental health services. II Program Milieu Physical, social and cultural environment for persons with psychiatric problems. III Clinical Process: Assessment Processes for access and entry into services, screening, assessment & diagnosis. IV Clinical Process: Treatment Processes for treatment including pharmacological and psychosocial evidence-based formats. V Continuity of Care Discharge and continuity for both substance use and psychiatric services, peer recovery supports. VI Staffing Presence, role and integration of staff with mental health expertise, supervision process VII Training Proportion of staff trained and program’s training strategy for co-occurring disorder issues. McGovern, Giard, et al. (2006). Measuring Changes Client Readiness for Change (Prochaska, DiClemente, and Norcoss, 1992) Substance Abuse Treatment Scale (Mueser, Drake, Clark, Mchugo, MercerMcFadden, Ackerson, 1995) Stages of Change Readiness and Treatment Eagerness Scale (Miller & Tonigan, 1996) 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) 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) Agencies in Transition Currently numerous agencies within Illinois are providing a level of dual diagnosis services • • • Organizational level Program level Provider level 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) 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) 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) Effective Management The ability to communicate to all staff in a clear and timely manner the decisions made and the rationale for them The ability to successfully develop relationships with other community agencies The ability to operate both as an ally and loyal opposition when dealing with organizations the that have authority over the program. Adapted from Hendrickson, E. L (2006) Effective Management Understanding traditions, values, and ethics that clinicians and administrative staff follow Leadership Ensuring program survival Being able to listen and consider all staff input while being decisive when necessary Adapted from Hendrickson, E. L (2006) Essential Attitudes and Values for Providers of Co-Occurring Disorder Services • Awareness of personal reactions and feelings • Recognition of limitations of one’s own personal knowledge and expertise • Recognition of the value of consumer input into treatment goals and receptivity to client feedback TIP 42, Figure 3-7 Essential Attitudes and Values • Desire and willingness to work with individuals diagnosed with a co-occurring disorder • Appreciation of the complexity of co-occurring disorders • Cultural competence • Openness to new information • Ability to employ diverse theories, concepts, models, and methods TIP 42, Figure 3-7 Essential Attitudes and Values • Belief that all individuals have strengths and are capable of growth and development • Patience, perseverance, and therapeutic optimism • Recognition of the rights of consumers diagnosed with co-occurring disorders, including the right and need to understand assessment results and the treatment plan TIP 42, Figure 3-7 Additional Attributes • • • • • Flexibility Optimism Creativity Respectfulness Cooperativeness References • Evans, K. & Sullivan, J. M. (2001). Dual Diagnosis: Counseling the Mentally Ill Substance Abuser (2nd Ed.). New York: Guilford. • Gibbs, L.E. (2003). Evidence-based practice for the helping professions: A practical guide with integrated multimedia. Pacific Grove, CA: Brooks/Cole-Thompson Learning. • Hendrickson, E. L (2006). Designing, Implementing, and Managing Treatment Services for Individuals with Co-Occurring Mental Health and Substance Use Disorders: Blueprints for Action. Binghampton, NY: Haworth Press. References • Hendrickson, E. L. & Schmal, M. (1993). Dual Disorders Page, TIE Lines, 10 (3), 11. • McGovern, M. P., Giard, J., Brown, J., Comaty, J., & Riise, K. (2006). The Dual Diagnosis Capability in Addiction Treatment (DDCAT): A Toolkit for Enhancing Addiction Only Service (AOS) Programs and Dual Diagnosis Capable (DDC) Programs. Unpublished manuscript, Dartmouth Medical School. • McGovern, M.P., Xie, H., Segal, S. R., Siembab, L., & Drake, R. E. (2006). Addiction treatment services and co- occurring disorders: Prevalence estimates, treatment practices, and barriers. Journal of Substance Abuse Treatment (31), 276-275. References • Mullen, E. J. (2004). Facilitating practitioner use of evidence-based practice. In A. R. Roberts & K. Yeager (Eds.), Evidence-Based Practice Manual: Research and Outcome Measures in Health and Human Services. New York: Oxford University Press. • Regier, D. A., Farmer, M. E., Rae, D. S., et al. (1990). Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) Study. Journal of American Medical Association, 264, 2511-2518. References • Sackett, D.L., Richardson, W.S., Rosenberg, W. M. C., & Haynes, R. B. (2000). Evidence-Based Medicine: How to Practice and Teach Evidence Based Medicine (2nd ed.). London: Churchill-Livingstone.