Gaps in Service Towards Reaching Co-occurring Capability

1. Gaps in Service Towards Reaching Co-occurring Capability Anthony (AJ) Ernst, Ph.D. Ernst & Associates anthony.j.ernst@gmail.com

2. Bringing DDCAT to Tennessee 2009 – TN works with TN COD Advisory Committee and TN SA programs to explore DDCAT application 2009 – TN provides COD trainings and supports DDCAT program implementation 2010 – TN surveys program needs regarding DDCAT measures 2010 – TN provides training/support to address program needs/gaps

3. DDCAT INDEX RATINGS 1 - Addiction only (AOS) 2 - 3 - Dual Diagnosis Capable (DDC) 4 - 5 - Dual Diagnosis Enhanced (DDE)

4. ADDICTION ONLY SERVICES (AOS) Programs that either by choice or for lack of resources, cannot accommodate clients who have psychiatric illnesses that require ongoing treatment, however stable the illness and however well-functioning the client.

5. DUAL DIAGNOSIS CAPABLE (DDC) Programs that have a primary focus on the treatment of substance-related disorders, but are also capable of treating clients who have relatively stable diagnostic or sub-diagnostic co-occurring mental health problems related to an emotional, behavioral or cognitive disorder.

6. DUAL DIAGNOSIS ENHANCED (DDE) Programs that are designed to treat clients who have more unstable or disabling co-occurring mental disorders in addition to their substance-related disorders.

7. DDCAT/DDCMHT INDEX FIVE DIMENSIONS: TN Identified Gaps • PROGRAM STRUCTURE – mission statement • PROGRAM MILIEU – COD welcoming statement • CLINICAL PROCESS: ASSESSMENT • CLINICAL PROCESS: TREATMENT – treatment plan • CONTINUITY OF CARE – community continuity capacity, DRA/DTR meeting development • STAFFING – COD alumni support • TRAINING

8. PROGRAM STRUCTURE DDCAT I.A. Primary treatment focus as stated in mission statement Is the stated focus addiction only/MH only, primarily addiction/MH (with an acknowledgement of psychiatric problems/addiction problems) or dual diagnosis?

9. PROGRAM MILIEU DDCAT II.A. Routine expectation of and welcome to treatment for both disorders. What clients are expected and welcomed at your agency? How is this reflected in agency documents? (see handout)

10. CLINICAL PROCESS: TREATMENT DDCAT IV.A. Treatment plans Do treatment plans show an equivalent and integrated focus on both substance use and psychiatric disorders, or do they primarily focus on substance use or psychiatric issues only?

11. CLINICAL PROCESS: TREATMENT IV.B. Assess and monitor interactive courses of both disorders. Are changes and/or progress with status and symptoms of both psychiatric and substance use disorders followed (and noted)?

12. CLINICAL PROCESS: TREATMENT IV.D. Stage-wise treatment – ongoing Is stage of motivation assessed on an ongoing basis? Can treatment be revised based upon changes in motivation?

13. COD Treatment Plans: A Practical Approach • What can programs (and clinicians) do? • What can be done without a lot of money? • What can we do that looks across different combinations of co-occurring disorders?

14. The Transtheoretical Model STAGES OF CHANGE PRECONTEMPLATION > CONTEMPLATION > PREPARATION > ACTION > MAINTENANCE PROCESSES OF CHANGE COGNITIVE/EXPERIENTIAL BEHAVIORAL Consciousness Raising Self-Liberation Self-Revaluation Counter-conditioning Environmental Reevaluation Stimulus Control Emotional Arousal/Dramatic Relief Reinforcement Management Social Liberation Helping Relationships CONTEXT OF CHANGE (Levels of Change) Current Life Situation (Symptoms & situations level) Beliefs and Attitudes (Cognitions & beliefs level) Interpersonal Relationships (Interpersonal level) Social Systems (Family level)

15. Steps to “Staging” • Target a specific behavior (problem) as possible • Stage individual target behaviors • Match intervention processes to stage • If there is a failure in an individual’s progress in a targeted behavior, immediately evaluate for problems on other levels that may also need staging and intervention

16. Match intervention to target behavior and stage POSSIBLE INTERVENTIONS -Helping Relationships -Stimulus Control -Reinforcement Management

17. Match intervention to target behaviors and stage POSSIBLE INTERVENTIONS -Consciousness raising -Self-Reevaluation POSSIBLE INTERVENTIONS -Helping Relationships -Stimulus Control -Reinforcement Management

18. Interventions for target behaviors may shift over time POSSIBLE INTERVENTION -Self-Reevaluation POSSIBLE INTERVENTIONS -Helping Relationships -Stimulus Control -Reinforcement Management

19. The behaviors may be independent SUDs MH

20. One problem may precede another,as in this example SUDs MH

21. The problems may otherwise interact with each other MH SUDs

22. Outside factors may affect both substance use problems and mental health problems SUDs STRESS MH

23. And we have to be aware that triple diagnosis issues are never far away SUDs MH STRESS PHYSICAL ILLNESS

24. Target Behavior Assignment: Remember…- If we do not diagnose a problem properly, it is harder to treat. - With more problems interacting, diagnosis demands greater care and confirmation over time. -Assessment of the interaction of conditions is a necessary complement of diagnosis.

25. Measurement Issues • Multiple methods exist -SOCRATES, URICA, algorithms, ladders • Some methods are easier/harder to use • Variance in predictive utility by method • Variance in degree of separation among associated problem behaviors

26. Key Program Questions • What target behaviors should we measure? • When and how often should we measure? • What are the best measurements for our populations of interest?

27. Treatment Plan Case StudyFocus on specific targets within each problem behaviorThis may involve focus on a whole disorder or on individual symptoms within a disorder(see handout)

28. Example: Dimensions of problem behaviors suitable as targets for change • Frequency of behavior (how often) • Duration of behavior (how long) • Intensity of behavior (how much) • Context of behavior (where, with whom) • Purpose of behavior (why) • Consequences of behavior (what happens)

29. EXAMPLE TARGETS – BEHAVIOR TO DECREASE SUBSTANCE USE Frequency reduction Quantity reduction Duration reduction STAGING ISSUES Clients may be in different stages for different targets related to the same behavior

30. EXAMPLE TARGETS – BEHAVIOR TO DECREASE PANIC ATTACKS Frequency of occurrence Intensity of occurrence Duration of occurrence STAGING ISSUES Beliefs around causes Beliefs around medication use Family social system

31. EXAMPLE TARGETS – OF GENERAL BENEFIT FOR DUAL DIAGNOSIS SLEEP HYGIENE Setting a sleep schedule Decreasing caffeine consumption Adjusting the sleep environment STAGING ISSUES Beliefs about the utility of the interventions Family social system

32. CONTINUITY OF CARE DDCAT V.B. Capacity to maintain treatment continuity How is treatment terminated or continued? Is this equivalent for both addiction and psychiatric disorders?

33. CONTINUITY OF CARE DDCAT V.C. Focus on ongoing recovery issues for both disorders Are the disorders seen as acute or chronic, short-term or long-term, primary or secondary? How is recovery envisioned and planned?

34. COD Continuity of Care: Community Resource Coordination Groups Community Resource Coordination Groups (known as CRCGs) are local interagency groups, comprised of public and private providers and other community stakeholders who come together monthly to develop individual services plans for children, youth, and adults whose needs can be met only through interagency, community coordination and cooperation.

35. Community Resource Coordination Groups Model and Guiding Principles • All CRCG members should have the authority to commit services or resources for individuals and families referred to the CRCG • The role of a CRCG is to develop a coordinated strengths-based Individual Service Plan (ISP); an agreement for coordination of services developed in partnership with the individual or family. • Individuals referred are those who have encountered barriers or obstacles to getting their entire needs met through existing resources and whose needs can be met only through interagency cooperation. Prior to referring an individual, the referring agency will have explored services and resources within and outside the agency. • Each CRCG member is responsible for ensuring confidentiality for referred individuals and families. Members who represent an agency or organization should follow their agency’s/organization’s policies for confidentiality.

36. CONTINUITY OF CARE DDCAT V.D. Facilitation of self-help support groups for COD is documented Is the potential increased self-help linkage difficulty for the person with a psychiatric/substance use disorder anticipated and planned for? How is it dealt with?

37. Dual Recovery Anonymous Dual Recovery Anonymous™ is an independent, nonprofessional, Twelve Step, self-help membership organization for people with a dual diagnosis. Our goal is to help men and women who experience a dual illness. We are chemically dependent and we are also affected by an emotional or psychiatric illness. Both illnesses affect us in all areas of our lives; physically, psychologically, socially, and spiritually. http://draonline.org/

38. Double Trouble in Recovery Double Trouble in Recovery (DTR) is a Twelve Step fellowship of men and women who share their experience, strength and hope with each other so that they may solve their common problems and help others to recover from their particular addiction(s) and manage their mental disorder(s). • DTR is designed to meet the needs of the dually diagnosed, and is clearly for those having addictive substance problems as well as having been diagnosed with a psychiatric disorders. • We also address the problems and benefits associated with psychiatric medication; thus, we recognize that for many, having mental disorders represents Double Trouble in Recovery. http://www.doubletroubleinrecovery.org/

39. STAFFING DDCAT VI.E. Peer/Alumni supports are available with co-occurring disorders Are role models available for persons with co-occurring addiction and psychiatric disorders?

40. COD Alumni Support “Live” Sample Alumni Group • Free Alumni Group for all former residents (and their parents) of La Habra, Long Beach, and Whittier's Dual Diagnosis Programs • Thursday evenings at 8:00 PM at the Long Beach Facility http://www.centerfordiscovery.com/dualdiagnosisprogram/ourprogram/

41. COD Alumni Support “Live” Sample THE WATERSHED ALUMNI PROGRAMS For many of us, going home is sometimes the hardest part. The disease of addiction leaves our lives in shambles, which makes taking the first step in the right direction a very difficult one to choose. At The Watershed, we maintain contact with our patients long after their treatment has concluded. Our Alumni Services staff is dedicated to supporting those who have begun the journey of recovery. http://www.thewatershed.com/home.php

42. DDCAT, leading to a program that is... Welcoming Accessible Integrated Continuous and Comprehensive = “No Wrong Door” With a common goal of RECOVERY