Jim Cullen, M.S.W., Ph.D

1. The Practice Review: Approaches, skills and interventions in working with individuals with “complex needs” Jim Cullen, M.S.W., Ph.D Clinic Head/Manager, IGT Concurrent Disorders and Rainbow Services, Centre for Addiction and Mental Health. Assistant Professor, Faculty of Social Work, University of Toronto

2. Disclosures • Jim Cullen has previously received funding and support from the following sources: • Ontario Ministry of Health and Long Term Care • Government of Newfoundland and Labrador • Alberta Alcohol and Drug Abuse Commission/Ministry of Health • Ontario Ministry of Community and Social Services: Child Welfare Transformation Fund • Social Science and Humanities Research Council • Canadian Institute of Health Research • University of Toronto • Ryerson University • York University • University of Victoria • Ontario HIV Treatment Network • Centre for Addiction Research of British Columbia • North Bay General Hospital • City of Toronto • Toronto Hostel Training Association • Anishabe Health Services

3. What are people talking about when they use the term “complex” clients. • Clients that frustrate workers. • Clients that are multiple service users. • Clients that often have substance abuse and mental health challenges. • Clients that do not appear motivated are willing to change. What we are talking about are people……

4. Usually living with a Concurrent Disorder

5. A person with a mental health problem has a higher risk of having a substance use problem, just as a person with a substance use problem has an increased chance of having a mental health problem. People who have combined, or concurrent, substance use and mental health problems are said to have concurrent disorders.

6. Concurrent disorders can include combinations such as: • an anxiety disorder and a drinking problem • schizophrenia and cannabis dependence • borderline personality disorder and heroin dependence • depression and dependence on sleeping pills.

7. When do concurrent disorders begin? Mental health and substance use problems can begin at any time: from childhood to older age. Causes can include genetic, environmental and psychological factors. We often speak in terms of risk, but not prediction.

8. WHAT ARE THE SYMPTOMS OFCONCURRENT DISORDERS? Concurrent disorders is a term for any combination of mental health and substance use problems. There is no one symptom or group of symptoms that is common to all combinations. The combinations of concurrent disorders can be divided into five main groups: Substance abuse with; ) Mood and Anxiety; 2) Persistent and Severe; 3) Personality; 4) Eating Disorders 5) Trauma

9. • Some people who have a mental health problem may use substances to feel better. While substance use is very risky in such cases, it can help people forget their problems or relieve symptoms, at least in the short-term. People sometimes talk about using substances for “self-medication.”

10. Where do people get treatment? Most people with concurrent disorders have mild to moderate problems that can be treated in the community, but the referrals are barriers!!! People with severe problems may need specialized care for concurrent disorders.

11. What is integrated treatment? Clients with severe concurrent mental health and substance use problems may need integrated treatment. Integrated treatment is a way of making sure that treatment is smooth, co-ordinated and comprehensive for the client. It ensures that the client receives help not only with the concurrent disorders, but also in other life areas, such as housing and employment. e.g. Mental Health and Addiction Workers

12. Without proper screening how can we provide interventions that work? Screening and Assessment Tools 1st Stage; GAIN SS, any comprehensive addiction measure. 2nd Stage: PDSQ, ASI

13. So we know something is going on! Now I can just show I care, be client centred, express empathy and they will connect with me and everything will get better

14. Flash forward six months…. • I am frustrated • The client is lazy • They dropped out of service • We have barred them from service • They are in jail • They are in their 6th time in treatment • Why am I such a bad worker • The client is bad…..must be borderline!

15. We didn’t our approach work?Well what is the evidence about what works and are we doing it? So lets back up

16. Let’s start with definitions EBP (evidence Based practice)refers to preferential use of mental/addiction and behavioral health interventions for which systematic empirical research has provided evidence of statistically significant effectiveness as treatments for specific problems.

17. Best Practices refers specific mental/addiction and behavioral health interventions recommended by (usually government, colleges or other significant institutions) in which EBP literature has been reviewed and specific models selected based on context, funding constraints, culture etc.,

18. Promising Practicerefers mental/addiction and behavioral health interventions for which systematic empirical research has not been provided, but due to historical use, early data (client satisfaction questionnaires etc.), the interventions are used and monitored. • The inclusion of promising practice in our discourse was as a reaction to the push for EBP.

19. A Little History In recent years, EBP has been stressed by professional organizations and colleges such as the Ontario College of Physicians and Surgeons, Ontario College of Social Work and Social Service Workers, The College of Psychologists of Ontario, College of Nurses of Ontario, Ontario College of Pharmacists (and others) These institutions have also strongly encouraged their members to carry out investigations to provide evidence supporting or rejecting the use of specific interventions.

20. Prior to this movement however government funders began asking questions about what we were actually doing in our programs. • Pressure toward EBP has also come from public and private health insurance providers, which have sometimes refused coverage of practices, and even closed programs lacking in systematic evidence of usefulness.

21. Outcome evaluation took on a new life and programs were held accountable to produce results, not just “numbers served” • Funding contracts begun to include certain language that insisted on EBP being used. • Huge grass-roots reactions developed and funders revised the rigid criteria to include promising practice.

22. Many areas of professional practice, such as medicine, psychology, psychiatry, nursing, social work and so forth, have had periods in their pasts where practice was based on loose bodies of knowledge. Some of the knowledge was simply lore that drew upon the experiences of generations of practitioners, and much of it had no truly scientific evidence on which to justify various practices.

23. In the past this has often left the door open to dubious practice perpetrated by individuals who had no training at all in the domain, but who wished to convey the impression that they did for profit or other motives. • As the scientific method became increasingly recognized as the means to provide sound validation for such methods, it became clear that there needed to be a way of excluding these practitioners not only as a way of preserving the integrity of the field but also of protecting the public from harm.

24. Evidence based practice is an approach which tries to specify the way in which professionals or other decision-makers should make decisions by identifying such evidence that there may be for a practice, and rating it according to how scientifically sound it may be. Its goal is to eliminate unsound or excessively risky practices in favour of those that have better outcomes.

25. Evidence-based practice (EBP) involves complex and conscientious decision-making which is based not only on the available evidence but also on client characteristics, situations, and preferences. It recognizes that care is individualized and ever changing and involves uncertainties and probabilities.

26. EBP develops individualized guidelines of which best practices are devised to inform the improvement of whatever professional task is at hand. Evidence-based practice is a philosophical approach that is in opposition to some “ways of practice”. Examples of a reliance on "the way it was always done" can be found in almost every profession, even when those practices are contradicted by new and better information.

27. Recently some authors have redefined EBP in ways that add other factors to, the original emphasis on empirical research foundations. For example, EBP may be defined as treatment choices based not only on outcome research but also on practice wisdom (the experience of the clinician) and on family values (the preferences and assumptions of a client and his or her family or subculture).

28. Because conclusions about research results are made in a probabilistic manner, it is impossible to work with two simple categories of outcome research reports. Research evidence does not fall simply into "evidence-based" and "non-evidence-based" classes, but can be anywhere on a continuum from one to the other, depending on factors such as the way the study was designed and carried out.

29. The existence of this continuum makes it necessary to think in terms of "levels of evidence", or categories of stronger or weaker evidence that a treatment is effective. To classify a research report as strong or weak evidence for a treatment, it is necessary to evaluate the quality of the research as well as the reported outcome. • Evaluation of research quality can be a difficult task requiring meticulous reading of research reports and background information. It may not be appropriate simply to accept the conclusion reported by the researchers.

30. Systematic reviews help and guide us through the literature that would otherwise for many be overwhelming to assess.

31. So….what is a Systematic Review • A systematic review is a literature review focused on a single question which tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews are generally regarded as the highest level of evidence by professionals. An understanding of systematic reviews and how to implement them in practice is becoming mandatory for all professionals involved in the delivery of health and social service care.

32. It uses explicit methods to perform a thorough literature search and critical appraisal of individual studies to identify the valid and applicable evidence. It is often applied in the healthcare context, but is now being applied in many fields of research.

33. While many systematic reviews are based on an explicit quantitativemeta-analysis of available data, there has been strong critique of this rigid approach and now there are also qualitative reviews which nonetheless adhere to the standards for gathering, analyzing and reporting evidence.

34. The EPPI-Centre have been influential in developing methods for combining both qualitative and quantitative research in systematic reviews. • The Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) is part of the Social Science Research Unit at the Institute of Education, University of London. Its work is concerned with systematic reviews which use transparent and explicit methodologies for reviewing research evidence in order to be clear about what we know from research and how we know it.

35. Cochrane Collaboration • Many journals now publish systematic reviews, but the best-known source is the Cochrane Collaboration, a group of over 6,000 specialists in health care who systematically review randomized trials of the effects of treatments and, when appropriate, the results of other research. Cochrane reviews are published in the Cochrane Database of Systematic Reviews section of the Cochrane Library, which to date contains 2,893 complete reviews and 1,646 protocols.

36. http://www.cochrane.org/

37. Campbell Collaboration • The Cochrane Collaboration, which systematically reviews the effects of interventions in health care, is the Campbell Collaboration's sibling organization. • The Campbell Collaboration (C2) is a non-profit organization that applies a rigorous, systematic process to review the effects of interventions in the social, behavioral and educational arenas, in order to provide evidence-based information in the shape of systematic reviews.

38. The organization was founded in 1999, and held its first Colloquium in Philadelphia in February 2000. The idea was to develop an international network of social scientists in order to "produce, maintain and disseminate systematic reviews of research evidence on the effectiveness of social interventions". Its first Colloquium was held in Philadelphia in February 2000.

39. C2 has coordinating groups in education, crime and justice, and social welfare, and also has a methods group. • Campbell systematic reviews are published electronically in the C2 Register of Interventions and Policy Evaluations (C2-RIPE)

40. http://www.campbellcollaboration.org/

41. So what’s the evidence for Concurrent Across the board no matter what concurrent Symptoms: Do further assessment Use of self (success and pitfalls) Motivational Interviewing Contingency Management Community Reinforcement Cognitive Behavioural Approaches

42. Mood and Anxiety – CBT Mind over Mood, Interpersonal Group Therapy. • Personality – Dialectic Behaviour Therapy, CBT, Multi-systemic therapy • Trauma- 1st stage Seeking Safety, 2nd stage – Exposure Therapy/CBT • Psychotic Illness- life skills, art and recreation therapy, interpersonal group therapy, CBT.

43. But different agencies have different mandates To help you figure this out…..a practice review may be helpful.

44. So what’s a practice review?

45. A practice review is a systematic structure and method in which an organization or service reviews; • How do we provide service/treatment/support and does it match with our mandate. (e.g. our approach) (Inventory) • What does the current literature says about “what works”? (Literature review) • What are gaps between what we do and what the literature says works? (Comparative analysis) • 5. How do we address these gaps (Setting practice improvements)

46. Strengths • Practice reviews can occur at micro, mezzo and macro levels on any community that has agencies providing service. • They help to provide consistency, and helpful support based on knowledge in a comprehensive way. • Promotes knowledge exchange and sharing • With the creation of systematic reviews and other technology, access to evidence based treatments/approaches has greatly expanded.

47. Limitations • If done improperly can feel like evaluation. • Agencies can focus on just one “type” of evidence. • Mismatch between what evidence and available resources e.g. contingency management, supportive housing vs. shelters etc. • Different funders may have competing interests in what approach to use.

48. Review of Templates • Summary of Steps • Next steps flow chart • Inventory • Literature Review • Comparative Analysis • Setting Practice Improvements

49. What we have learned in working with complex clients from a practice review • Inconsistencies exist • The debate between labelling and “client centred” service. (symptoms vs. diagnosis) • Tools are invaluable (e.g. GAIN SS), we need to get a picture • Worker bias, knowledge transfer breakdown • Undervaluing of therapeutic alliance • Mental health vs. addiction stigma and bias (Ontario disability recent ruling) • There are approaches that work that we have not been using (contingency management)

50. Next steps for us • Providing funders (health authorities, networks etc) with evidence – knowledge transfer – advocacy etc. • Implementation of assessment tools across the spectrum (e.g. GAIN SS), Basis 32. • The need to establish outcome committee/measures etc. • Engagement of clients/patients/members – client feedback/focus groups.