treating addiction and other mental disorders cutting edge 2004 palmerston north, new zealand...

Treating Addiction and Other Mental Disorders

Cutting Edge 2004Palmerston North, New Zealand

September 3, 2004

Treating Addiction and Other Mental Disorders

Cutting Edge 2004Palmerston North, New Zealand

September 3, 2004

Joan E. Zweben, Ph.D.Joan E. Zweben, Ph.D.Executive Director: EBCRP and 14Executive Director: EBCRP and 14thth Street Clinic Street Clinic

Clinical Professor of Psychiatry; University of California, San Clinical Professor of Psychiatry; University of California, San FranciscoFrancisco

Joan E. Zweben, Ph.D.Joan E. Zweben, Ph.D.Executive Director: EBCRP and 14Executive Director: EBCRP and 14thth Street Clinic Street Clinic

Clinical Professor of Psychiatry; University of California, San Clinical Professor of Psychiatry; University of California, San FranciscoFrancisco

Systems IssuesSystems Issues

Have the elements of your systems Have the elements of your systems been aligned to create incentives and been aligned to create incentives and

not barriers?not barriers?

ObstacleObstacle

Providers are expected to collaborate to Providers are expected to collaborate to provide care, but government entities provide care, but government entities frequently do not communicate about frequently do not communicate about common issues. This leads to conflicting common issues. This leads to conflicting expectations and requirements.expectations and requirements.

Remedy: Explicit Policies Remedy: Explicit Policies

Do you have joint, interagency policy Do you have joint, interagency policy statement confirming commitment to, and statement confirming commitment to, and expectations for, treatment for persons with expectations for, treatment for persons with COD?COD?

Statement should clearly identify the Statement should clearly identify the impropriety of excluding persons with COD impropriety of excluding persons with COD from either treatment system or other from either treatment system or other service systems service systems

Licensing & CertificationLicensing & Certification

Naïve expectation that professional credentials Naïve expectation that professional credentials include proficiency in addressing substance abuseinclude proficiency in addressing substance abuse

No framework for specialized licensing and site No framework for specialized licensing and site certificationcertification

Overlapping and conflicting requirements between Overlapping and conflicting requirements between health services, mental health, alcohol/other drug, health services, mental health, alcohol/other drug, social services, criminal justice system, etc.social services, criminal justice system, etc.

Licensing & CertificationLicensing & Certification

Need comprehensive framework for Need comprehensive framework for program licensing and site certification, orprogram licensing and site certification, or

Specify programs that are exempt from Specify programs that are exempt from existing requirementsexisting requirements

Remove regulatory barriers that discourage Remove regulatory barriers that discourage providers from serving this population providers from serving this population

Create incentives through adequate Create incentives through adequate reimbursementreimbursement

Documentation NightmaresDocumentation NightmaresHave you streamlined documentation Have you streamlined documentation

requirements?requirements? Funding sources require different elements Funding sources require different elements

in the clinical chart, and have different audit in the clinical chart, and have different audit protocolsprotocols

Need for a universal chart to reduce extra Need for a universal chart to reduce extra work, save many trees, and allow consistent work, save many trees, and allow consistent data collection.data collection.

TrainingTraining Need mechanism to cross-train Need mechanism to cross-train

professionals and continuously develop professionals and continuously develop skill base of non-credentialed workersskill base of non-credentialed workers

Need to align all elements of the system to Need to align all elements of the system to promote mastery of content defined as promote mastery of content defined as important: intake process, treatment plan, important: intake process, treatment plan, staff evaluations, etc.staff evaluations, etc.

Need for regular clinical supervisionNeed for regular clinical supervision

Terminology: Common ConfusionsTerminology: Common Confusions Dual vs multiple disordersDual vs multiple disorders Medical comorbiditiesMedical comorbidities AOD and any coexisting psychiatric AOD and any coexisting psychiatric

disorderdisorder AOD and severe and persistent mental AOD and severe and persistent mental

illnessillness What is available in your community, and What is available in your community, and

for whom?for whom?

Barriers to Addressing Psychiatric DisordersBarriers to Addressing Psychiatric Disorders Mistrust professionalsMistrust professionals Don’t have good diagnosticiansDon’t have good diagnosticians Belief that TC or 12-step will fix everythingBelief that TC or 12-step will fix everything Enabling phobia vs individualized treatment Enabling phobia vs individualized treatment

planningplanning Resistance/misunderstanding about medsResistance/misunderstanding about meds Inappropriate expectations about time courseInappropriate expectations about time course Attitudes about chronic illness affect stance Attitudes about chronic illness affect stance

towards relapsetowards relapse

Barriers to Addressing AOD UseBarriers to Addressing AOD Use Failure to recognize and assessFailure to recognize and assess Minimize the role of AOD use; minimize the role Minimize the role of AOD use; minimize the role

of other mental disordersof other mental disorders Toxicology screens not readily availableToxicology screens not readily available Lack of understanding of and respect for the self-Lack of understanding of and respect for the self-

help systemhelp system Medications: some physicians overprescribe, Medications: some physicians overprescribe,

misprescribe, cloud the diagnosismisprescribe, cloud the diagnosis System barriersSystem barriers

Programming: Guiding PrinciplesProgramming: Guiding Principles1.1. Employ a recovery perspectiveEmploy a recovery perspective

2.2. Adopt a multi-problem viewpointAdopt a multi-problem viewpoint

3.3. Develop a phased approach to txDevelop a phased approach to tx

4.4. Address specific real-life problems early in txAddress specific real-life problems early in tx

5.5. Plan for the clients’ cognitive and functional Plan for the clients’ cognitive and functional impairmentsimpairments

6.6. Use support systems to maintain and extend Use support systems to maintain and extend treatment effectivenesstreatment effectiveness

(COD TIP, in (COD TIP, in press)press)

“No Wrong Door”“No Wrong Door”

1.1. Assessment, referral and tx planning must be Assessment, referral and tx planning must be consistent with this principleconsistent with this principle

2.2. Use creative outreach to promote engagementUse creative outreach to promote engagement3.3. Programs and staff may need to change Programs and staff may need to change

expectations and requirements to engage expectations and requirements to engage reluctant clientsreluctant clients

4.4. Tx plans based on client’s changing needsTx plans based on client’s changing needs5.5. Seamless system of care to provide continuity; Seamless system of care to provide continuity;

interagency cooperationinteragency cooperation (COD TIP, in (COD TIP, in

press)press)

Integrated Treatment for COD’SIntegrated Treatment for COD’S

Treatment at a single site, by cross-trained Treatment at a single site, by cross-trained cliniciansclinicians

Medications OK and monitored when Medications OK and monitored when possiblepossible

Appropriate adaptations for SMI: emphasis Appropriate adaptations for SMI: emphasis on reduction of harm, lowering anxiety, on reduction of harm, lowering anxiety, appropriate pacing, self help offered but not appropriate pacing, self help offered but not mandated mandated

(COD TIP, in press)(COD TIP, in press)

Basic Counselor CompetenciesBasic Counselor Competencies

Screen for COD; ability to refer for formal Screen for COD; ability to refer for formal diagnostic assessmentdiagnostic assessment

Form preliminary diagnostic impression to Form preliminary diagnostic impression to be verified by trained professionalbe verified by trained professional

Preliminary screening of danger to self or Preliminary screening of danger to self or othersothers

De-escalate client who is agitated, anxious, De-escalate client who is agitated, anxious, angry or otherwise vulnerableangry or otherwise vulnerable


Counselor Competencies, contCounselor Competencies, cont

Manage crisis, including threat of harm to Manage crisis, including threat of harm to self or othersself or others

Refer to mental health facility if appropriate Refer to mental health facility if appropriate and follow up to assure that services were and follow up to assure that services were receivedreceived

Coordinate care with mental health Coordinate care with mental health counselor; coordinate treatment planscounselor; coordinate treatment plans


Philosophical Differences:Harm Reduction &

Abstinence

Philosophical Differences:Harm Reduction &

Abstinence

Philosophical Divisions:Harm Reduction vs AbstinencePhilosophical Divisions:Harm Reduction vs Abstinence

Historical overviewHistorical overview Treatment outcome data; implicationsTreatment outcome data; implications Pitfalls of abstinence-oriented approachPitfalls of abstinence-oriented approach Pitfalls of harm reduction approachPitfalls of harm reduction approach Blended models: when and howBlended models: when and how Harborview Program, SeattleHarborview Program, Seattle

Pitfalls of Abstinence-Oriented TreatmentPitfalls of Abstinence-Oriented Treatment

Failure to assess motivation level before pushing Failure to assess motivation level before pushing abstinence commitmentabstinence commitment

Failure to understand factors promoting continued Failure to understand factors promoting continued useuse

Unrealistic timetablesUnrealistic timetables Power struggle vs clinical approachPower struggle vs clinical approach Failure to recognize fluctuating motivationFailure to recognize fluctuating motivation Inappropriate termination of treatmentInappropriate termination of treatment

Pitfalls of Harm Reduction ApproachPitfalls of Harm Reduction Approach Inappropriately low expectations for what Inappropriately low expectations for what

client can achieveclient can achieve Difficulty setting clear goalsDifficulty setting clear goals Reluctance to ask client to abstain Reluctance to ask client to abstain

completelycompletely Underestimate risks/lethalityUnderestimate risks/lethality Clinician alcohol and/or illicit drug useClinician alcohol and/or illicit drug use

Steps in the Assessment Process (2)Steps in the Assessment Process (2)

7. Determine disability and functional impairment7. Determine disability and functional impairment

8. Identify strengths and supports8. Identify strengths and supports

9. Identify cultural and linguistic needs and supports9. Identify cultural and linguistic needs and supports

10. Identify problem domains10. Identify problem domains

11. Determine stage of change11. Determine stage of change

12. Plan treatment12. Plan treatment(COD TIP, in (COD TIP, in

press)press)

Types of Program Capability Types of Program Capability

Addiction-Only Services (AOS)Addiction-Only Services (AOS) Dual Diagnosis Capable (DDC)Dual Diagnosis Capable (DDC) Dual Diagnosis Enhanced (DDE)Dual Diagnosis Enhanced (DDE)

Distinguishing Substance Abuse from Psychiatric DisordersDistinguishing Substance Abuse from Psychiatric Disorders Wait until withdrawal phenomena have Wait until withdrawal phenomena have

subsided (usually by 4 weeks)subsided (usually by 4 weeks) Physical exam, toxicology screensPhysical exam, toxicology screens History from significant othersHistory from significant others Longitudinal observations over timeLongitudinal observations over time Construct time lines: inquire about quality Construct time lines: inquire about quality

of life during drug free periodsof life during drug free periods

TreatmentModels & Issues

TreatmentModels & Issues

Psychotic Disorders:Counselor RecommendationsPsychotic Disorders:Counselor Recommendations Learn signs and sx of the disorderLearn signs and sx of the disorder Expect crises and have resourcesExpect crises and have resources Include education on the psychiatric condition and Include education on the psychiatric condition and

on medicationson medications Monitor medication, promote adherenceMonitor medication, promote adherence Provide frequent breaks, shorter mtgsProvide frequent breaks, shorter mtgs Use structure and support; avoid confrontationUse structure and support; avoid confrontation Present material in simple, concrete terms and use Present material in simple, concrete terms and use

multimedia toolsmultimedia tools (COD TIP, in press)(COD TIP, in press)

Sequential, Parallel and Integrated Treatment (1) Sequential, Parallel and Integrated Treatment (1)

SEQUENTIALSEQUENTIAL when abstinence is necessary for other when abstinence is necessary for other

interventions to be effectiveinterventions to be effective when psychiatric condition must be stabilizedwhen psychiatric condition must be stabilized when problem is severe in one area but mild in the when problem is severe in one area but mild in the

otherother (Ries 1993)(Ries 1993)

Sequential, Parallel and Integrated Treatment (2)Sequential, Parallel and Integrated Treatment (2)

PARALLEL TREATMENTPARALLEL TREATMENT when problem is severe in one area but mild in when problem is severe in one area but mild in

anotheranother clients with HIVclients with HIV

PROBLEMS:PROBLEMS: need to be highly functional to navigate systemsneed to be highly functional to navigate systems lack of coordinationlack of coordination

Sequential, Parallel and Integrated Treatment (3)Sequential, Parallel and Integrated Treatment (3)

Mental health and addiction care combined at Mental health and addiction care combined at one siteone site

Clinicians cross trained in both fieldsClinicians cross trained in both fields Unified case managementUnified case management Differences in philosophy reconciled within the Differences in philosophy reconciled within the

programprogram Useful for severe problems in several areasUseful for severe problems in several areas Flexibility promotes good conflict resolutionFlexibility promotes good conflict resolution

Integrated TreatmentIntegrated TreatmentPremise: treatment at a single site, featuring Premise: treatment at a single site, featuring

coordination of treatment philosophy, services and coordination of treatment philosophy, services and timing of intervention will be more effective than timing of intervention will be more effective than a mix of discrete and loosely coordinated servicesa mix of discrete and loosely coordinated services

Findings:Findings: decrease in hospitalizationdecrease in hospitalization lessening of psychiatric and substance abuse lessening of psychiatric and substance abuse

severityseverity better engagement and retention better engagement and retention

(Rosenthal et al, 1992, 1995, 1997; Hellerstein et al 1995.)(Rosenthal et al, 1992, 1995, 1997; Hellerstein et al 1995.)

What is Recovery:Mental Health PerspectiveWhat is Recovery:Mental Health Perspective

Recovery is recapturing a positive sense of Recovery is recapturing a positive sense of self in spite of the challenge of a psychiatric self in spite of the challenge of a psychiatric disabilitydisability

Recovery is actively self-managing one’s Recovery is actively self-managing one’s life and mental illnesslife and mental illness

Recovery is reclaiming social roles and a Recovery is reclaiming social roles and a life beyond the mental health systemlife beyond the mental health system

Specialized Treatment for SMI: Assertive Community TreatmentSpecialized Treatment for SMI: Assertive Community Treatment AOD and significant mental health disorderAOD and significant mental health disorder Severe and persistent mentally illSevere and persistent mentally ill Severe functional impairmentsSevere functional impairments Avoided or responded poorly to traditional Avoided or responded poorly to traditional

txtx Co-occurring homelessnesCo-occurring homelessnes Co-occurring criminal justice involvementCo-occurring criminal justice involvement


Essential Features of ACTEssential Features of ACT

Services provided in the community, frequently in Services provided in the community, frequently in client’s living environmentclient’s living environment

Assertive engagement, active outreachAssertive engagement, active outreach High intensity of servicesHigh intensity of services Small caseloadsSmall caseloads Continuous 24 hour responsibilityContinuous 24 hour responsibility Multidisciplinary teamMultidisciplinary team Close work with support systemClose work with support system Continuity of staffingContinuity of staffing


Modified Therapeutic Community (MTC)Modified Therapeutic Community (MTC)

Increased flexibility in activitiesIncreased flexibility in activities Decreased intensityDecreased intensity

Conflict resolution group, vs encounterConflict resolution group, vs encounter Shorter durationShorter duration More emphasis on instructionMore emphasis on instruction Increased role modelingIncreased role modeling

Greater individualizationGreater individualization


Harborview Recovery & Rehabilitation Program (HaRRP)Harborview Recovery & Rehabilitation Program (HaRRP)

Pre-phase program: Pre-phase program: case manager basedcase manager based focused around food, shelter and harm reductionfocused around food, shelter and harm reduction brief medication/money groups (Club Med)brief medication/money groups (Club Med) drop-in loungedrop-in lounge

(Richard K. Ries, (Richard K. Ries,

MD)MD)

HaRRP Stages (2)HaRRP Stages (2)

Phase I:Phase I: highly structured groups, 3x weekhighly structured groups, 3x week focus on recognition and acceptance of both focus on recognition and acceptance of both

psychiatric and substance abuse problemspsychiatric and substance abuse problems development of group processdevelopment of group process movement toward (but not requirement of) movement toward (but not requirement of)

sobrietysobriety

HaRRP Phases (3)HaRRP Phases (3)

Phase II:Phase II: participants have attained at least 3 months participants have attained at least 3 months

sobrietysobriety IIa: lower functioning but sober; more IIa: lower functioning but sober; more

activity based groupsactivity based groups IIb: can utilize more abstract, recovery-IIb: can utilize more abstract, recovery-

oriented processoriented processPhase III: vocational issues Phase III: vocational issues

Disability Benefit Management as a Treatment Intervention (1)Disability Benefit Management as a Treatment Intervention (1)

HARBORVIEW PROGRAM, SEATTLEHARBORVIEW PROGRAM, SEATTLE

Goals:Goals: 1) insure that $ went to food, shelter, basic 1) insure that $ went to food, shelter, basic needs; 2) increase treatment complianceneeds; 2) increase treatment compliance

computerized system with a range of levels of computerized system with a range of levels of controlcontrol

case managers disburse benefits in conjunction case managers disburse benefits in conjunction with treatment activitieswith treatment activities

(Ries & Comptois, 1997) (Ries & Comptois, 1997)

Benefit Management (2)Benefit Management (2) Payees (vs non-payees) were male, had diagnosis of Payees (vs non-payees) were male, had diagnosis of

schizophrenia, history of high inpatient utilizationschizophrenia, history of high inpatient utilization Higher current ratings of psychiatric symptoms, Higher current ratings of psychiatric symptoms,

substance use and functional disabilitysubstance use and functional disabilityThese characteristics usually predict poor compliance These characteristics usually predict poor compliance

and adverse outcomes, however:and adverse outcomes, however: Payees attended 2x number of outpt sessions and Payees attended 2x number of outpt sessions and

were no more likely to be currently homeless, were no more likely to be currently homeless, hospitalized or incarcerated; comparable to hospitalized or incarcerated; comparable to nonpayee groupnonpayee group

Preparing Psychiatric Patients for 12-Step MeetingsPreparing Psychiatric Patients for 12-Step Meetings

medication is compatible with recovery, but medication is compatible with recovery, but meetings are best selected carefullymeetings are best selected carefully

some meetings are more tolerant than others of some meetings are more tolerant than others of medication or eccentric behaviormedication or eccentric behavior

schizophrenics benefit from coaching on how to schizophrenics benefit from coaching on how to behave in meetingsbehave in meetings

12-step structure often beneficial; non-intrusive 12-step structure often beneficial; non-intrusive and stableand stable

Cross-Training IssuesCross-Training Issues

Resistances of credentialed professionalsResistances of credentialed professionals Resistances of non-credentialed staffResistances of non-credentialed staff Effective training designsEffective training designs IncentivesIncentives MandatesMandates Using training to facilitate system changeUsing training to facilitate system change