Pacific Clinics’ Substance Abuse and Mental Health Services’ Henry van Oudheusden M.Div, MA, MSW, Corporate Director/Ex

1. Pacific Clinics’ Services to Children and Youth with Co-occurring Mental Health and Substance Use Disorders: From ‘Dual Diagnosis’ to Integrated ParallelFebruary 22, 2007CMHDA-Children’s System of Care Pacific Clinics’ Substance Abuse and Mental Health Services’ Henry van Oudheusden M.Div, MA, MSW, Corporate Director/Executive Director

2. We do a tremendous disservice when we speak of co-occurring disordered children and youth (aged 0-18) as though they were one homogenous group with identical treatment needs Labeling individuals as “Dually Diagnosed” or “Co-occurring Disordered” is clinically as gross and unhelpful as labeling someone as mentally ill. Clearer identification is essential to the creation of a helpful treatment plan and insuring positive and life giving outcomes.

3. Definition of Co-occurring Disorders for 12+ • Classic:Primary Clinical Axis I • Mental Health Disorder (ONSET BETWEEN 1.5-EARLY TEENS) as well as an unrelated Primary Clinical Axis I (ONSET ABUSE 10-11 AND DEPENDENCE MID TEENS) Substance Use Disorder. • Less Classic: Same as above but it doesn’t matter if one was ‘induced’ by the other, if they now co-exist independently and are each in need of clinical concern or treatment.

4. Not All Co-occurring Disordered Children are Alike: A COD Matrix • High Psychological (Psychotic or whenHigh Substance Abuse (abuse/dependence)the disorder is deemed severe) • High Substance (abuse/dependence)Low Psychological (Disorder does not cause major • lack of functioning in life domains) I II • Disruptive Disorder+Meth dependent Meth Dependent and Oppositional Defiant Conduct Disorder +Alcohol dependent Marijuana dependent and Adjustment Disorder • High Psychological Low Substance • Low SubstanceLow Psychological III IV • ADHD and 1x wk MJ use Attention-Deficit/Hyperactivity Disorder-NOS • Bi-Polar I and ‘occasional-non patterned Alcohol use weekend with friends • MJ use • Mental Health=System that deals with Psychological Disorders • Substance Abuse=System that deals with Substance Use Disorders • By Statute Mental Health cannot provide Substance Use treatmentservices and vice versa • Statutes are enforced by DMH and ADP State and County auditors

5. Progression of Mood Altering Substance Use 1980 & 2005 • Fetal Alcohol Spectrum Disorder---Substance use in-uterus • No Social (Isolated • Use Experimentation Use Use) Abuse Dependence • ------------ ------------------------- ------------------------------------------------------------- • 0-2 3-5 6-8 9-10 11-12 13-14 15-16 17 18 20 22 • 14 y/o-abuse • 15.5 y/o dependence • Anxiety disorders 3.8 • Attention Deficit Disorders-1.3-2.4 • Oppositional Defiant-5 • Conduct Disorder-5.6 Schizophrenia-effective disorders • Teen years and mid-thirties • Use: Most commonly used drug age 12+ in Feb-07 report: MJ/Prescription, Alcohol, and Meth. • Abuse: DMS IV • Dependence: DSM IV “Onset in the late 20’s 30’s and 40’s”

6. Definition of Terms • Utilizing ‘Dual Diagnosis’ and Integrated Parallel services, Pacific Clinics provides a developmentally appropriate continuum of treatment which is sensitive to the different needs of: infants (0-5), children (6-12), and adolescents (13-18). • ‘Dual Diagnosis’ Services are provided exclusively by mental health practitioners and seem most appropriate when the substance use is identified as “Low” according to the COD Matrix. • Mental health best and evidence based practices, such as Brief Strategic Family Therapy and Multi-Systemic Therapy, have positive outcomes and decrease substance even though they do not directly treat or qualify as substance abuse treatment. GUESS: When you include a lot of people-especially family in treatment-all aspects of the youth’s behavior improves. • Increasing Parenting skills: teaching parents how to teach their children refusal skills, coping skills decreases substance use . Positive parent interaction, communication skills, teaching parents how to engage child/youth in pro-social activities

7. More Definition of Terms • Integrated Parallel Treatment Services are provided by an interdisciplinary team made up of members from two different service delivery systems (Mental Health and Substance Abuse) and is utilized when the substance use is indicated as being “High” according to the COD Matrix. • When dependency is high and child/youth ‘cannot stop’, the parents/caregivers have lost control and the child responds better when treated by someone ‘who knows’. • When the parent needs treatment. • Creating a mutually respectful treatment team of professionals with different skill sets, core competencies, and treatment approaches that has as its goal: One Team with One Plan for One Person and Their Family.

8. “Dual Diagnosis” MH Treatment Child Treatment Matrix • High Substance Abuse High Substance Abuse • High Psychological Low Psychological I II • High Psychological Low Psychological • Low Substance Low Substance III IV • III and IV: When Mental Health can best provide ‘Dual Diagnosis’ Treatment: Family based treatment. e.g.. Multi-Family, Multi-System

9. Youth 12+ y/o Mental Health Needs • The reason cited most often for the latest treatment was: • “Felt depressed” 44.9%“Breaking rules or acting out” 22.4% “Thought about killing self or tried to kill self” 16.6% • “Tense or afraid” 14.9% • SAMHA 2004-Household Survey • DSM IV-R bias, mood altering substance use is not a rule-out for early childhood disorders.

10. What mental health can and does best. • Engage, engage and engage. The strength of mental health work is the Therapeutic Alliance • Involving different systems whenever possible: • Families • School • Pro-social Activities • Substance use decreases with parental involvement • Substance use decreases by 25% when youth involved in sports, youth groups • Case management/brokerage

11. Evidence-based Mental Health Clinical Practices Family Therapy • Multi-Sytemic Therapy • Scott Heneggeler • Intensive Family/Community Based Tx • Targets chronic, violent, or substance abusing offenders at high risk of out of home placements, and their families • Outcomes: • 25-70% Reduction Arrest Rates • 47-64% Reduction Out of Home Placement • Decrease MH Problems Juvenile Offenders

12. Evidence-based Mental Health Clinical Practices Family Therapy • Multi-Systemic Therapy cont. • Demonstrates strong outcomes • Fewer arrests • Fewer days of incarceration • Significantly less out of home placements • Improved family functioning • Less hard drug use • Average costs $4,500 per youth • Washington State Institute for Public Policy • The average size of the crime reduction effect -.31 • Net direct cost of the program per client $4,743 • Net benefits per participant $31,661 to $131,918

13. Evidence-based Clinical Practices Family Therapy • Brief Strategic Family Therapy • Jose Szapocznik PhD • Targets child/adolescents 8-17 years exhibiting, or at risk of behavior problems including substance abuse. • Outcomes: • Reduces Behavior Problems and Substance Abuse

14. Evidence-based Clinical Practices Family Therapy • Brief Strategic Family Therapy cont. • Average 12-15 sessions • Severe Conduct Disorder and Substance Abuse = 24-30 Sessions • Three Day Training, Two Day Booster, Monthly Phone/Video Consult (1 yr) • $18,000 to Implement

15. Evidence-based Clinical Practices Family Therapy • Multidimensional Family Therapy • Howard Liddle PhD • Targets Adolescents (11-18 years) with drug and behavior problems. • Selected and Indicated • Improvements in 1) Rates of drug Use, 2) Behavior Problems, 3) School Performance, 4) Family Functioning

16. When Mental Health Services Aren’t Enough: Difficulties in engaging the Client Moving from Dual Diagnosis to Integrated Treatment • When a substance use disorder is identified in treatment and the youth is: • Unwilling-defiant-denying • Unable-needs another level of care-or, due to environmental factors, can’t stay away from drugs/alcohol • What can a mental health clinician do?

17. Reach out to another system… The “system” that mental health needs to reach out to and include is child or adolescent substance abuse treatment Mental health’s difficulty is knowing how to engage and utilize this system of care They are often seen as ‘the others’ (“who don’t care and are a little rough”)

18. A typical Mental Health Therapist VS Substance Abuse Counselor misunderstanding .

19. The Co-occurring Disorders Child Treatment Matrix • High Substance Abuse High Substance Abuse • High Psychological Low Psychological I II • High PsychologicalLow Psychological • Low Substance Low Substance III IV • I and II:When Substance Abuse can best provide treatment. Substance abuse does not claim dual diagnosis treatment. Specializes in Detox and Long/short term stabilization.

20. What Substance Abuse Treatment can does best • Substance abuse treatment is diagnosis specific: treats 4 substance use diagnoses • Substance Intoxification • Substance Withdrawal • Substance Abuse • Substance Dependence • Is primarily available as an adult treatment modality • Has as a continuum of care: • Detox • Short/Long term residential • Day Rehabilitation • Outpatient • Aftercare

21. Cognitive Behavioral Therapy • Cognitive Behavioral Therapy is the most common evidence based practice used by substance abuse treatments statewide. • Inclusion of family is not yet standard practice statewide. • The ADP Outpatient Youth Treatment Protocols, developed in 2002-2003 are not fully implemented nor funded. • There is no detox protocol for persons younger than 18 and there are an inadequate number of beds for adolescent residential.

22. Blending Dual Diagnosis withIntegrated Parallel Treatment Matrix • High Substance Abuse High Substance Abuse • High Psychological Low Psychological I II • High Psychological Low Psychological • Low Substance Low Substance III IV Individual in I, II, III and IV can be treated by an interdisciplinary team employed by the same agency licensed and certified by DMH and ADPA or by and interdisciplinary team from 2 agencies who have decided to create One Team with One Plan for One Client

23. Integrated Treatment Services System Best Practice Multiple Systems One Person “Evidence based practices are necessary but not sufficient to meet the multiple and complex needs of people with co-occurring disorders. These individuals require a system-wide response” SAMHSA: Report to Congress on the Prevention and Treatment of Co-occurring Substance and Mental Health Disorders 2002

24. Multi-System Multi-Systemic Approach • Programs that are ‘system inclusive’ and address the multiple systems that affect the youth’s lives are by far the most successful and have the longest duration of positive outcomes. • Burrowclough et al. (2001), Grella, 2004. Minkoff, 2002 • We need researched best, evidence based practice and the systemic change that will nurture these practices. • Burrowclough et al. (2001), Drake 2004. Minkoff, 2002

25. Competing Systems with Differing Mandates, Concerns, and Interventions “One Team with One Plan for One Person” “ The ability to incorporate each of these components into treatment is critical for achieving the best possible outcome for clients with dual disorders, and inattention to any one component can undermine the overall effectiveness of a treatment program. A narrow focus on substance abuse (or mental health), and neglect of other important areas of functioning (e.g. housing, work, school, social relationships, quality of life) can make it difficult or impossible for clients to develop lifestyles worth living…..” Kim T. Mueser et al, Integrated Treatment for Dual Disorders, 2003

26. The more we know, the better able we are to focus and tailor treatment. • One size treatment does not fit all. • Often, one system of care is not enough to provide the treatment necessary for positive outcomes. • The better we are at wrapping an individual with services the more likely there will be positive outcomes.

27. What may not be possible on a Federal or State Level due to the restrictions of Block Grants May be possible on a County Level: The blending of entitlements: EPSDT and Drug MediCAL and/or encouraging and or demanding inter-agency cooperation

28. Integrated Treatment Approaches • Bridging the adolescent treatment gaps calls for the integration of a system change and best clinical practice. • Substance abuse and mental health services CAN be systemically integrated. • Other systems including, education, juvenile justice, 12 step, can integrated, albeit in a different way.

29. “…the expectation rather than the exception.” Department of Health and Human Services • There is Federal separation of services and funding • There is State separation of services and funding • There is often County separation of services and funding-where systems are integrated services improve. • Agencies have the ability to respond to consumer needs for integrated services by: blending funding sources so that they can fully implement integrated MH/SA assessments, developing one treatment plan for individuals with co-occurring disorders, develop interdisciplinary treatment teams, initiate ongoing staff cross-training/experiences, provide families with educational opportunities for MH and SA.

30. Need for Silo Change • That the integration of services is best practice and has positive outcomes for individuals with co-occurring disorders is not the question. • The Journal of Behavioral Health Services and Research 31:1 January-March 2004, • SAMHSA Report to Congress Nov. 2002 • Integrated Treatment for Dual Disorders, Kim Meuser et al. 2003, Kavanagh et Al. 2000 • Use of Inter-disciplinary teams • Onsite when 2 systems of care can be provided • When funding is blended

31. Clinical barriers to substance abuse treatment by mental health practitioners: • “Clinicians who work with people with co-occurring disorders must have sufficient knowledge of a discipline (substance abuse) in which they were not trained to be both comfortable and capable. While the fundamental approach to clinical education has not changed appreciably since 1910 (IOM 2000), the demands on clinicians have changed dramatically.” • SAMHSA: Report to Congress on the Prevention and Treatment of Co-occurring Substance and Mental Health Disorders Nov. 2002

32. Thank You

33. Finding EBPs • Office of the Surgeon General • http://www.surgeongeneral.gov/sgoffice.htm • Strengthening America’s Families • http://www.strengtheningfamilies.org • SAMHSA Model Programs • http://www.modelprograms.samhsa.gov • Promising Practices Network on Children, Families and Communities • http://www.promisingpractices.net

34. Finding EBPs • Evidence-Based Practices in Mental Health Services for Foster Youth – California Institute for Mental Health • http://www.cimh.org/downloads/Fostercaremanual.pdf • SAMHSA’s National Mental Health Information Center • http://www.mentalhealth.org/cmhs/communitysupport/toolkits/ • National Institute of Mental Health • http://www.nimh.nih.gov/publicat