hrf 2013 ppt keynote
DESCRIPTION
TRANSCRIPT
POSSIBILITIES FOR CHANGE
HARM REDUCTION & CONCURRENT DISORDERS
Stephanie Baker, MSW, RSWGuelph Wellington Drug Strategy
Harm Reduction Forum March 20th, 2013
OVERVIEW
• Importance & Relevance
• Barriers & Gaps
• Harm Reduction & CD
• CD Philosophy/Treatment
• Recommendations
IMPORTANCE & RELEVANCE
PREVALENCE AND OUTCOMES
CONCURRENT DISORDERS
Substance Use
Disorders
Mental Health
Disorders
Concurrent
Disorders
LIFE TIME PREVALENCE OF SUBSTANCE USE DISORDER FOR EACH
MENTAL HEALTH DISORDER
• Major Depression 27%• Any Anxiety Disorder 24%• BPD 23%• Schizophrenia 47%• Bipolar Disorder 56%• PTSD 30-75%• Eating Disorder 23-55%
(Skinner, 2005)
CONCURRENT DISORDERS ARE IMPORTANT BECAUSE…
• Poorer treatment outcomes than if person has either a MH disorder or a SA disorder alone
• Concurrent disorders affect many areas of a person’s life
• Individuals with concurrent disorders are in almost every treatment setting – they are the “expectation, NOT the exception”
RISKS ASSOCIATED WITH CD
• Suicide• Relapse• Violence• Prostitution• Victimization• Re-hospitalization• Financial problems• Loss of family/friends• Treatment non-compliance• Poor response to medication• Housing instability/homelessness• Medical problems (e.g. HIV, Hepatitis, STD, etc.)• Criminal involvement/legal problems/incarceration
RELATIONSHIP BETWEEN SA & MH
COMMON ELEMENTS• Both SA and MH can be chronic and recurring,
requiring immediate interventions and ongoing support
• SA and MH problems may be triggered by the same factors
• MH problems may influence the development of SA problems and SA problems may influence the development of MH problems
• Outcome of treatment for MH disorders is negatively affected by SA and vice versa
BARRIERS & GAPSCHALLENGES TO IMPLEMENTING BEST PRACTICE
TREATMENT BARRIERS
1.Structural Barriers: make it difficult for people with concurrent disorders to access appropriate treatment
2.Personal Barriers: characteristics of the person that prevents her/him from initiating or continuing with treatment for a concurrent disorder issue
(Mueser et al., 2003)
SYSTEMIC GAPS
• Present system of care in Canada is fragmented and compartmentalized • People accessing either system are often struggling with both issues
• Individuals are frequently treated for only one of their co-occurring disorders
• Few CD research studies considered harm reduction effects, most emphasize abstinence-related outcomes
• Most CD programs studied have been unsuccessful in bringing about substance use reductions
• Important need for research to assess the effects of harm-reduction programming on health improvements for individuals living with CD
(CCSA, 2009; O’Campo et al., 2009 )
OUTCOMES OF BARRIERS/GAPS
• Dissonance in philosophical perspectives regarding the “primary problem”
• Lack of coordination amongst service providers
• Inappropriate service provision
• Increased feelings of stigma
• Poorer treatment outcomes
HARM REDUCTION & CDHR IS INTEGRAL TO SUPPORTING
INDIVIDUALS & FAMILIES LIVING WITH CD
WHAT IS HARM REDUCTION?
•A philosophical approach applied in practice
•Often understood broadly - can encompass many variations of policies and programs •Intention is to support people in reducing negative consequences of use by moderating intake/switching to less harmful modes of use (e.g. methadone or needle exchange programs)
•A health-centered approach - implicitly and explicitly acknowledges the social determinants of health
FOCUS OF HARM REDUCTION
• A non-judgmental response
• Offers a direct point of contact
• Focuses on achievable improvements that can reduce adverse health and safety consequences
• Emphasizes measurable health, social, and economic outcomes as well as cost effectiveness of interventions
• A best practice treatment recommendation,
particularly for people with severe and persistent MI
PRINCIPLES OF HARM REDUCTION
•Pragmatic
•Respectful
•Prioritizes goals
•Maximizes intervention options
(James, 2007)
PHILOSOPHY OF HARM REDUCTION
• Respects people and their abilities
• Recognizes the ‘Stages of Change'
• Removes barriers to accessing programs and services
(James, 2007)
HARM REDUCTION MODEL
(RNAO, 2009)
CHALLENGES WITH HARM REDUCTION
1) Community resistance
2) The need to work with highly marginalized groups
3) Ensuring appropriate knowledge and training
4) Adequate resources to initiate and maintain initiatives
(James, 2007)
CD TREATMENTCD PHILOSOPHY IS HARM REDUCTION
QUADRANT MODEL
Specialized Addiction
INTEGRATED
Primary Care Specialized Mental Health
High Severity
High Severity
LowSeverity
(Skinner, 2005)
CD TREATMENT PHILOSOPHY
• Integrated treatment approach
• Promotes flexibility of goal choice
• Importance of working as a team
• Works with the person where s/he is at
• Offers individualized treatment planning
CD TREATMENT PHILOSOPHY
• No “wrong door”
• Motivational enhancement
• Goal of continued engagement
• Involves concerned significant others
• Minimization of treatment-related stress
• Offers flexible hours, duration, and location
STAGES OF CHANGE/MOTIVATIONAL TREATMENT
Stage of Change Characteristics Stage of Treatment
Tasks and Motivational Strategies
Outcome
Pre-Contemplation
~ Not thinking about change
~ Feeling of no control
~ Denial: does not believe it applies to self
~ Believes consequences are not serious
Pre-engagement
~ Outreach to establish contact with the person
~ Listen reflectively
~ Affirm
~ Person has no contact with mental health or substance use worker
Engagement ~ Give practical help for person’s
immediate concerns
~ Model open,
honest
communication
~ Express empathy
~ Person has assigned worker but no regular contact
(Connors et al., 2001; Mueser et al., 2003)
STAGES OF CHANGE/MOTIVATIONAL TREATMENT
Stage of Change Characteristics Stage of Treatment
Tasks and Motivational Strategies
Outcome
Contemplation ~ Weighing benefits and costs of behaviour
~ Proposed change
Early Planning/
Persuasion
~ Align with person’s
struggle (MH & SU)
~ Explore person’s
goals
~ Support person’s
desire to change
~ Person has regular contact but no reduction in substance use
Preparation ~ Experimenting with small changes
Late Planning/
Persuasion
~ Explore person’s concerns (MH & SU)
~ Develop discrepancies between the person’s goals and current behaviour
~ Identify options to help the person decide on a course of action
~ Plan social supports
~ Person discusses substance use in regular contact, and shows reduction in use for at least 30 days
(Connors et al., 2001; Mueser et al., 2003)
STAGES OF CHANGE/MOTIVATIONAL TREATMENT
Stage of Change Characteristics Stage of Treatment
Tasks and Motivational Strategies
Outcome
Action ~ Taking a definitive action to change
Early Active Treatment
~ Start action plan
~ Elicit change talk
~ Reward progress
~ Use slips as learning opportunities
~ Involve social supports
~ Develop specific action steps to work on target behaviours
~ Encourage self-efficacy
~ Person is engaged in treatment with the goal of abstinence or reduction, though s/he may still be using substances
Late Active Treatment
~ Continue to elicit change talk
~ Review/reinforce actions that are producing behaviour change
~ Review and identify new goals as person continues with change
~ Emphasize health alternatives
~ Identify examples of self-efficacy
~ Nurture and sustain
~ Person is engaged, and has achieved clear goals for changing his/her substance use for less than six months
(Connors et al., 2001; Mueser et al., 2003)
STAGES OF CHANGE/MOTIVATIONAL TREATMENT
Stage of Change Characteristics Stage of Treatment
Tasks and Motivational Strategies
Outcome
Maintenance ~ Maintaining new behaviour over time
Relapse Prevention
~ Keep focus on the person’s goals
~ Reinforce link between change behaviour and accomplishment of person’s goals
~ Identify continuing high-risk situations
~ Develop relapse prevention plans
~ Reinforce self-efficacy
~ Person is engaged and has achieved clear goals for changing his or her substance use for at least six months (occasional lapses may occur)
Relapse ~ Experiencing normal part of process of change
~ Usually feels demoralized
~ Focus on the successful part of the plan
~ Promote problem-solving
~ Encourage/assist the person to re-engage their efforts in the change process
~ Person discusses substance use in regular contact, and shows reduction in use for at least 30 days
(Connors et al., 2001; Mueser et al., 2003)
RECOMMENDATIONSCONSIDERATIONS FOR IMPROVED SUPPORT
WHY RESEARCH FOR HARM REDUCTION & CD IS
IMPORTANT
• People with CD have been excluded from mainstream psychiatric/addiction research and scientific trials
• Results in CD not being well understood
• Care provided may be inappropriate
• Interdisciplinary research is needed to contribute to a comprehensive understanding
(CCSA, 2009)
SUCCESSFUL PROGRAMS
• Client choice
• Positive interpersonal relationships
• Proactive multidisciplinary teams
• Housing provision
• Instrumental supports
• Flexible program policies(O’Campo et al., 2009)
RECOMMENDATIONS
1) Integration of harm reduction mental health service
2) Varied service components
3) Staff qualities
4) Education and information
5) Community development(Altenberg et al., 2003)
REFERENCES
Altenberg, J., Balian, R., Lunansky, L., Magee, W., & Welsh, S. (2003). Falling through the cracks: An evaluation of the need for integrated mental health services and harm reduction services, Toronto, ON: Wellesley Central Health Corporation.
Becker, M., Fortin, S., Nepinak, D., Noel, L., & Stopkewich, L. (Directors). (2012). Here at Home [Interactive Website]. Toronto, ON: National Film Board of Canada.
Canadian Centre on Substance abuse. (2009). Substance abuse in Canada: concurrent disorders. Ottawa, ON: Canadian Centre on Substance Abuse.
Connors, G., J., Donovan, D., M., & DiClemente, C., C. (2001). Substance abuse treatment and the stages of change: Selecting and planning interventions. New York, NY: The Guilford Press.
James, D. (2007). Harm Reduction: Policy Background Paper. Alberta Alcohol and Drug Abuse Commission. Alberta, CA: Alberta Health Services.
Mueser, K., Noordsy, D., Drake, R., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. New York, NY: The Guildford Press.
O’Campo, P., Kirst, M., Schaefer-McDaniel, N., Firestone, M., Scott, A., & McShane, K. (2009). Community- based services for homeless adults experiencing concurrent mental health and substance use disorders: A realist approach to synthesizing evidence, Journal of Urban Health, 86(6), 965-989.
Registered Nurses’ Association of Ontario. (2009) Supporting Clients on Methadone Maintenance Treatment. Toronto, Ontario. Registered Nurses’ Association of Ontario.
Skinner, W. J. (2005). Treating concurrent disorders: A guide for counselors. Toronto, ON: Centre for Addiction and Mental Health.
