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RSAT Training Tool: Co-occurring Disorders and Integrated Treatment Strategies Lisa Braude, PhD Niki Miller, M.S. CPS Advocates for Human Potential www.ahpnet.com 5/24/2017 2 Objectives ► Discuss the prevalence of CODs among RSAT clients and their impact on criminal behavior, addiction recovery and recidivism. Explain the importance of integrated substance abuse screening and assessment for co-occurring disorders and identify effective practices. ► List reasons to champion integrated treatment, educate clients on sustained recovery self management and link to community providers. ► 5/24/2017 3 Prevalence in Corrections Approximately 8.9 (4%) million adults in the U.S. have co-occurring disorders ► people in substance abuse treatment that have a mental health problem = 50% ► People in jails and prisons with substance problems = 65% ↑ ► people in prison who use substances also report a mental health problem = 74% ► people in jail with mental health disorders that also have a substance use problem= 76% 5/24/2017 4 Relevance to RSAT Programs RSAT staff should expect that cooccurring mental health problems will be the expectation and not the exception for offenders in substance abuse treatment. 5/24/2017 5 Practices and Principles Inmates have a legal right to treatment for medical conditions—including mental health disorder. Facilities are required to screen for mental health disorders and suicide risk and offer treatment to stabilize offenders who attempt suicide or have acute psychiatric symptoms. However, that legal right does not extend to treatment for substance use disorders. 5/24/2017 6 Relevance to RSAT Programs RSAT clients with CODs: • May already be diagnosed with a mental health disorder • May develop symptoms of a mental health disorder over time • May have symptoms that become more severe or improve over time • May have disorders that have gone undetected 5/24/2017 7 Relevance to RSAT Programs Signs of a co-occurring disorder that a correctional officer may notice: • • • • • • Seemingly intentional verbal disruptive outbursts Changes in inmate behavior over time The inmate may be an easy target for others Behavior may seem bazaar or out of the ordinary Withdrawing, self injury and internalizing Aggression or defensiveness resulting in restraint or seclusion 5/24/2017 8 Practices and Principles Basic competencies to deliver integrated RSAT treatment: ► ► ► Prevalence, signs, and symptoms of co-occurring disorders and ongoing screening and assessment Focus on interactions between mental and substance use disorders and how they affect recovery Integrated evidence-based interventions, team treatment approaches and community collaboration 5/24/2017 9 Relevance to RSAT Programs ► Collaboration ► Screening and assessment ► Integrated treatment interventions ► Case management and re-entry ► Peer and community-based support 5/24/2017 10 Module I: Signs and Symptoms Mental health disorders (mental illnesses) are conditions that can disrupt a person's thinking, feeling, mood, behavior, and ability to relate to others. ► can affect every area of a person’s life ► involve changes in the brain ► may respond to medications ► symptoms and severity fluctuate ► individual response to treatment approaches vary 5/24/2017 11 Signs and Symptoms Addiction is a chronic, condition with a high potential for relapse, characterized by compulsive drug seeking and use, despite harmful consequences. ► can affect every area of a person’s life ► involve changes in the brain ► may respond to medications ► symptoms and severity fluctuate ► individual response to treatment approaches vary 5/24/2017 12 Signs and Symptoms A “co-occurring disorder” is used to describe a simultaneous substance use disorder and mental health disorder. A mental disorder should be established independent of the substance use disorder, rather than symptoms resulting from substance use. 5/24/2017 13 Who Has a Co-Occuring Disorder? Marsha- age 42; Both children in placement. Used crack and alcohol for several years. Speaks about her time on the streets with pride and nostalgia. Cycles through periods of intense moods; rarely fully present during groups. She is either completely withdrawn or talking through the entire group without letting other participants speak. SUD Mental Illness Neither Co-occurring disorder? yes no 5/24/2017 14 Who Has a Co-Occuring Disorder? Brian – age 33; In college, began heavy cocaine use and binge drinking. Started having violent episodes with roommates and dropped out of school. Family found him living in an abandoned building. Remained homeless, was arrested for public nudity, drunk and disorderly, and shoplifting, etc. more than 25 times. Last time he hit an officer because he thought the police were imposters dressed as police officers. SUD Mental Illness Neither Co-occurring disorder? yes no 5/24/2017 15 Who Has a Co-Occuring Disorder? Steve- age 29; Self-injures—visible scarring on arms and shoulders. Psychiatric medications make it difficult to keep him awake during group. Reports he was raped by cell mate last time he was in jail. Attempted suicide during his second week out on parole by barbiturate overdose. Violated due to the presence of barbiturates in urine screen. SUD Mental Illness Neither Co-occurring disorder? yes no 5/24/2017 16 Screening Assessment for CODs Screening vs. Clinical assessment vs. Risk and needs assessment 5/24/2017 17 Screening Screening seeks to answer a “yes” or “no” question: Does the substance abuse client being screened show signs of a possible mental health problem? OR Does the mental health client being screened show signs of a possible substance abuse problem? 5/24/2017 18 Evidence-based Mental Health Screening Tools Description Modified MINI Screen (MMS) 22 Yes-No items that screen for anxiety and mood disorders, trauma exposure and PTSD, and non-affective psychoses 18 Yes-No items about current and past symptoms covering schizophrenia, depressive disorders, PTSD, phobias, intermittent explosive disorder, delusional Mental Health Screening Form III disorder, sexual and gender identity disorders, eating disorders, manic episode, (MHSF III) panic disorder, obsessive-compulsive disorder, pathological gambling, learning disorders, and mental retardation K6 Screening Scale Brief Mental Health Jail Screen (BMHJS) 5/24/2017 The tool consists of 6 items, each with a 0-4 point rating scale, that screen for general distress in the last 30 days (Kessler, et al., 2003). Maximum precision is in the clinical range of the scale, that is, for people with anxiety or mood disorders or non-affective psychoses whose level of functioning is seriously impaired. The BMHJS is a tool that takes less than 3 minutes; contains only 8 yes or no questions; is simple to incorporate into the booking process by corrections officers; is quickly administered. 19 Evidence-based Substance Use Screening Tools Description 16 items, 14 of them scoreable; most items tap symptoms of alcohol and Modified Simple Screening drug dependence, including prescription and over-the-counter Instrument for Substance Abuse medications, during the past six months. Several items tap lifetime and (MSSI-SA) current use problems for respondents and lifetime use problems for family members. CAGE Adapted to Include Drugs (CAGE-AID) Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) TCUDS-II 5/24/2017 A modified version of the CAGE screen for alcohol problems, the CAGEAID is a four-item conjoint screen for alcohol and substance abuse. The tool consists of seven items or questions regarding each of ten substances (a total of 70 questions) and one item or question about drug injection. A specific "substance involvement" (risk) score is calculated for each substance, and that score drives a recommendation for no intervention, brief intervention, or more intensive treatment for each substance. The Texas Christian University Drug Screen II (TCU-DSII) is a screening tool that enables corrections staff to quickly identify individuals who report heavy drug use or dependency and therefore might be eligible for treatment. Questions are based on the DSM-IV and the National Institute of Mental Health Diagnostic Interview Schedule. 20 Screening ► Detects mental health symptoms and looks at current substance use behavior ► Asks about past treatments, diagnoses and medications ► Identifies violent or suicidal tendencies/cognitive deficits- severe problems that may need immediate attention ► Determines who goes on for further assessment 5/24/2017 21 Risk and Need Assessment Risk assessments may act as preliminary screening flagging those in need of specific screens or assessments. They are designed to help determine: ► Level of security and housing assignment ► Programming priorities to reduce potential for disruptive behavior in the facility ► Programming priorities to reduce potential for a return to criminal behavior ► Weed out low risk individuals/identify highest risk offenders to target as the priority service recipients 5/24/2017 22 Clinical Assessment Clinical assessment: ► Nature/ severity of substance abuse/mental health problem ► History of symptoms-past treatments for both disorders; changes over time ► Baseline: current symptoms and functioning ► Readiness for change; client’s perception of need for change, ability to change- care preferences. ► Builds rapport- asks about client strengths, background, supports, limitations and cultural considerations. 5/24/2017 Evidence-based Clinical Assessment Title: Description: (GAIN) 120 minute standardized assessment for use in substance abuse diagnosis, placement, treatment planning, outcome monitoring, economic analysis, and/or program planning and identification of possible CODs The Psychiatric Research Interview for Substance and Mental Disorders (PRISM) Semi-Structured interview; Measures DSM-IV diagnoses on Axis I and II(Alcohol, Drug, Psychiatric Disorders); Differentiates the primary disorder from substance induced disorders or effects of withdrawal; 45-90 minutes to complete Global Appraisal of Individual Needs Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Tests adult psychopathology; 60-90 minutes to complete; 567 True/False Questions; 5 th grade reading level Personality Assessment Inventory (PAI) Tests adult psychopathology; 50-60 minutes to complete; 344 items; 22 non overlapping scales; 4th grade reading level Global Assessment of Functioning (GAF) Clinicians judgment of overall functioning; 100 point scale; 3 minutes to establish score; Higher score = healthier client The Addiction Severity Index (ASI) 5/24/2017 Semi-Structured Interview; Measures 7 substance-abusing problem areas; 50-60 minutes to complete; Past 30 day and lifetime problems are measured; 200 item; 7 subscales 24 Assessments Shortcomings of Forensic and Clinical Assessments: ► Actuarial tools, and they are standardized to serve a wide range of populations ► Weak cultural, ethnic, racial and gender-specific indicators ► Formulaic-may provide little opportunity to establish a connection with client 5/24/2017 25 Exercise Now that we have reviewed screening and assessment tools, let’s take a look at the profiles from Exercise I and re-consider each case for CODS. 5/24/2017 26 Who Has a Co-Occuring Disorder? Steve- Steve appears to be experiencing significant depression and should be fully assessed for mental health and suicide risk; he is also at-risk for sexual violence. He should be screened for substance abuse and assessed, if indicated. But, he may not have a substance use disorder. Steve may need treatment and support, but not for substance use, and, therefore not in the context of RSAT. 5/24/2017 27 Who Has a Co-Occuring Disorder? Marsha- Marsha shows signs of having a co-occurring disorder. She may be showing signs of bi-polar disorder should be referred for assessment by mental health clinician qualified to make a diagnosis. While she is in the RSAT program, it will be important to monitor her mood changes to see if they stabilize. She is also a long time crack and alcohol user and her symptoms may improve over time during a sustained period of sobriety, or may they may worsen. A team approach that includes mental health staff and periodic reassessment is best. 5/24/2017 28 Who Has a Co-Occuring Disorder? Brian – Brian’s profile points to a serious mental disorder and alcohol abuse or dependency. His paranoia may be symptoms of schizophrenia or another psychotic disorder. His use of alcohol indicates he probably has a co-occurring disorder. A comprehensive assessment is required, which will provide information about his level of stability and the severity of his drinking problem before the mental health and RSAT clinical team can determine if he is appropriate for the program. 5/24/2017 29 Module II: Best Practices for CODs ►Introduction to Integrated Treatment ►Proven and Promising Practices for Offenders with CODs 5/24/2017 30 Integrated Treatment Treatment approaches: ► ► ► Sequential=addressing the most serious illness first. Parallel=treating simultaneously but through separate systems of care. Integrated= a unified and comprehensive treatment program for clients with both. 5/24/2017 31 Integrated Treatment Core Principles of Integrated RSAT Programs: 1. 2. 3. 5/24/2017 Co-occurring disorders are prevalent -- screening, assessment and treatment planning should reflect this assumption Both co-occurring disorders are considered primary- how they interact is key to relapse prevention and recovery management Provider empathy, respect, and belief in capacity for recovery 32 Integrated Treatment 4. 5. 6. 5/24/2017 Individualized treatment and different treatment needs over the course of recovery Interventions are selected that have been shown to improve both disorders in criminal justice populations. Community re-integration and post-release supports = major factors in recovery 33 Integrated Treatment The Modified Therapeutic Community Setting ► Staff Readiness to Provide Integrated Treatment ► Agency Readiness to Provide Integrated Treatment ► Community Readiness Serve Re-entering RSAT Clients with MH Needs ► 5/24/2017 34 Modified Therapeutic Community Modifications to traditional TC model continued: ► ► ► ► ► incorporates increased flexibility shorter groups, less intense, less confrontation increased emphasis on orientation and instruction fewer sanctions, more explicit affirmation for achievements greater sensitivity to special developmental needs of the clients. 5/24/2017 35 Modified Therapeutic Community TCs are very applicable to people with CODs: ► ► ► ► ► ► Highly structured daily regimen fosters personal responsibility and self-reliance Self help culture Peers as role models; community as healing agent Regards change as gradual Specific focus on linking persons with CODs to peer recovery support community services. 5/24/2017 36 Integrated Treatment How have people with CODs been treated: ► ► ► ► ► separate funding streams SUD funding required abstinence-based programming different licensing and credentialing of providers and clinicians different eligibility guidelines and coverage for services different treatment philosophies/practices 5/24/2017 37 Integrated Treatment Mental health and substance abuse treatment mixed messages: abstinence-based vs. harm reduction ► confrontational vs. motivation ► no medication vs. medicate everyone The last decade both fields have begun to move toward strengths-based, client-centered, recovery oriented care. ► 5/24/2017 38 Exercise Exercise: Myths, Misconceptions and Facts about CODs Take a look at these common myths about people with CODs. Have any of these myths ever influenced your thinking? • Which ones may have influenced others in various service systems you deal with? • Which have the most influence on clients’ perceptions of themselves as persons in co-occurring recovery? 5/24/2017 39 Myths and Facts Myth: Just get to the root of your depression, then you won’t drink anymore. Fact: Experience and research show individuals with co-occurring disorders (COD) are at higher risk for: ► Relapsing ► Reoffending ► Homelessness ► Victimization Often MH problems precede SUDs in women and follow SUDs in men 5/24/2017 40 Myths and Facts Myth: Just stop using drugs and your psychological problems will take care of themselves. Fact: People with COD’s progress more rapidly from initial use to dependence, are less likely to complete treatment and adhere to medication regimes than those with only one disorder 5/24/2017 41 Myths and Facts Myth: People with co-occuring disorders are high-end consumers of services. Fact: The vast majority of people with CODs do not get any treatment. In fact, only 10% receive any treatment and 4% receive integrated treatment. 5/24/2017 42 Myths and Facts Myth: People with co-occurring disorders are very difficult to treat and require highly skilled staff with specialized training. Fact: Many practices are effective that do not require extensive training, such as: case management, supported employment, contingency management, r housing first programs and peer support/ recovery self-managment. 5/24/2017 43 Myths and Facts Myth: Offenders with co-occurring mental health disorders are violent and dangerous. Fact: According to the Bureau of Justice Assistance the rate of violent crimes among offenders with mental disorders is the same as for other offenders (2008). People with mental health disorders, however, are far more likely to be victims of violence. 5/24/2017 44 Selecting an Intervention Strategy Examples of effective CODs treatment approaches for RSAT programs: ►Cognitive Behavioral Therapy ►Psychiatric Medications ►Motivational Strategies ►Integrated Trauma CBT ►Illness Management and Recovery ►Assertive Community Treatment Teams 5/24/2017 45 Community Strategies Examples of effective community approaches for RSAT clients with CODs: ►Psychiatric Medication Management ►Assertive Community Treatment Teams ►Recovery Self Management/Peer Support ►Housing First ►Supported Employment 5/24/2017 46 Cognitive Behavioral Therapy ► ► ► ► ► ► Effective on substance use and mental health problems and on criminal thinking Target attitudes and behaviors; recognition and replacement of thinking errors & irrational and criminal thoughts Uses role plays, skill rehearsal and reinforcement Emphasizes personal responsibility Targets observable behaviors (e.g.: following jail/prison rules; using verbal skills vs. physical behaviors) May be facilitated by correctional program staff 5/24/2017 47 Medication Assisted Treatment Psychiatric Medication Management ► Benefits: Stabilizes psychiatric symptoms, provides relief to clients and can increase treatment engagement. ► Risks: Lack of continuity of care upon release, side effects, inmate refusal (forced medication by court order is ethically problematic) and mis-medication or overmedication. 5/24/2017 48 Medication Assisted Treatment Opiate Replacement Therapy ► Benefits: Stabilizes and manages withdrawal symptoms, reduces cravings, decreases potential for relapse and risks associated with IV drug use (HIV etc), increases medication adherence and treatment compliance. ► Risks: Lack of availability within facilities, costs, medication interactions, over reliance on meds rather than recovery supports, stigma. 5/24/2017 49 Motivational Strategies ► Goal is to motivate offenders in treatment to engage in treatment and comply with supervision requirements: ► ► ► ► Motivational Interviewing (MI): expansion of client intrinsic motivation, reinforces and encouragement target behavior Motivational Enhancement Therapy: combines MI, a review of assessment information, and 2-3 individual counseling sessions to build motivation and prepare clients for group counseling Contingency Management: system of pre-determined rewards used to acknowledge and reinforce target behavior (behavioral contracting; “carrot and stick”) Graduated Sanctions: swift and certain, on a continuum, with dismissal from program or return to custody as the end point 5/24/2017 50 Integrated Trauma CBT ► Teaches people with how to manage their triggers, new coping skills and about the connection between PSTD and SUDs ► ► ► ► Psycho-education on trauma Present day approach to PTSD symptom relief Especially effective component for women offenders Increases safety and self care; decreases unsafe behavior 5/24/2017 51 Assertive Community Treatment Assertive Community Treatment (ACT, FACT & IFCM) Customized, community-based services for people with CODs. Team approach to expanded access to services. ► ► ► ► ► ► Tailored to client’s current level of need Intensive case management 24 hours access to community supports The Social and Independent Living Skills (SILS) Friends and family enlisted to sustaining recovery Single point of contact for client IFCM is less expensive and equally effective option 5/24/2017 52 Illness Management & Recovery ► Teaches people with severe mental illness how to manage their disorder and how to work with treatment providers, friends, and family in achieving and sustaining recovery. ► ► ► ► ► Psychoeducation Behavioral tailoring The Social and Independent Living Skills (SILS) Wellness Recovery and Action Plan (WRAP) Peer support 5/24/2017 53 Implementing Integrated Treatment Treatment models are not mutually exclusive. Comprehensive treatment plans for RSAT clients with CODs may include several. Release planning approach: • What addition services does the client’s COD help them qualify for? • What benefit applications can be completed now? 5/24/2017 54 Community Strategies Release planning includes: ►Medication Management – 30 day supply, appointment with provider and source for payment ►Recovery Self Management training completed; connections to both AA/NA sponsor and MH peer program ►ACT Teams or Intensive Forensic Case Management in place ►Housing First programs or subsidized housing for people w/ CODs contacted ►Supported Employment programs; Goodwill, at Community MH Centers ►Providers identified, introduced and first post release appointment in place 5/24/2017 55 For more information on RSAT training and technical assistance visit: http://www.rsat-tta.com/Home or email Jon Grand, RSAT TA Coordinator at [email protected] 5/24/2017 56 Next Presentation Running Much Better Treatment Groups June 20, 2012, 2:00 PM EDT If a car’s not built right, the driver’s skills are secondary. The same goes for treatment groups and their clinicians. This webinar is about structural and operational fundamentals that largely determine the serviceability of any given treatment group, be it evidence-based and manualized, or TC-bred or home-made. Specifically, these fundamentals are the group’s membership criteria, operating structure, and learning content. At issue is why treatment staff must, and how they can, attend to these variables in order to avoid problems that even the best group therapists face too often and that many group therapists face all the time. Presenter: Fred Zackon 5/24/2017 57