Integrating Treatment for Co-Occurring Disorders

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Integrating Treatment for Co-Occurring
Disorders Brought to you by
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Presented By
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Todays Presenters

Cynthia Moreno Tuohy Executive Director NAADAC,
The Association for Addiction Professionals
Misti Storie Education and Training
Consultant NAADAC, The Association for Addiction
Professionals
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Todays Presenters

Tim Sheehan, Ph.D. Director of Institutional
Effectiveness Hazelden Graduate School of
Addiction Studies
Mary Woods, RNC, LADC, MSHS Chief Executive
Officer Westbridge Community Services
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Web Conference Objectives

• Discuss the prevalence of co-occurring disorders
  in substance abuse treatment programs

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Web Conference Objectives

• Discuss the prevalence of co-occurring disorders
  in substance abuse treatment programs
• Contrast co-occurring treatment with traditional
  addiction treatment

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Web Conference Objectives

• Discuss the prevalence of co-occurring disorders
  in substance abuse treatment programs
• Contrast co-occurring treatment with traditional
  addiction treatment
• Give a rationale for integrated treatment

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Web Conference Objectives

• Discuss the prevalence of co-occurring disorders
  in substance abuse treatment programs
• Contrast co-occurring treatment with traditional
  addiction treatment
• Give a rationale for integrated treatment
• List instruments helpful for screening

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Web Conference Objectives

• Discuss the prevalence of co-occurring disorders
  in substance abuse treatment programs
• Contrast co-occurring treatment with traditional
  addiction treatment
• Give a rationale for integrated treatment
• List instruments helpful for screening
• Describe evidence-based therapies helpful in
  treating co-occurring disorders

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Web Conference Objectives

• Discuss the prevalence of co-occurring disorders
  in substance abuse treatment programs
• Contrast co-occurring treatment with traditional
  addiction treatment
• Give a rationale for integrated treatment
• List instruments helpful for screening
• Describe evidence-based therapies helpful in
  treating co-occurring disorders
• Access new training programs available through
  NAADAC and Hazelden

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• Part One

Introduction to Co-occurring Disorders
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Scope of Practice

• An Addiction Professionals scope of practice
  varies with education, training and state
  requirements.
• With over 300 people on line today, each
  practitioner should keep his or her scope of
  practice in mind as we conduct this presentation.

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DEFINING CO-OCCURRING DISORDERS

• 50 to 75 of all clients who are receiving
  treatment for a substance use disorder also have
  another diagnosable mental health disorder.
• Further, of all psychiatric clients with a mental
  health disorder, 25 to 50 of them also currently
  have or had a substance use disorder at some
  point in their lives.

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Defining Co-occurring Disorders

• Co-morbidity of Substance Use and Psychiatric
  Disorders
• Among a sample of about 10,000 adults
• 13.5 had an alcohol use disorder. Of those,
  36.6 also had a psychiatric disorder.
• 6.1 had a drug use disorder. Of those, 53.1
  also had a psychiatric disorder.
• 22.5 had a psychiatric disorder. Of those,
  28.9 also had an alcohol or drug use disorder.

Source Regier et al. 1990
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Defining Co-occurring Disorders

• Psychiatric Disorders in Addiction Treatment
• Two studies of Prevalence rates in addiction
  treatment settings had similar findings. Persons
  with substance use disorders are also like to
  have mood and anxiety disorders.

Source Cacciola et al, 2001 Ross, Glaser and
Germanson 1988
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Defining Co-occurring Disorders
Addiction Treatment Provider Estimates by
Psychiatric Disorder
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Defining Co-occurring Disorders

• Mental health disorder (MHD)
• significant and chronic disturbances with
  feelings, thinking, functioning and/or
  relationships that are not due to drug or alcohol
  use and are not the result of a medical illness22

• Social phobia
• Borderline personality disorder
• Posttraumatic stress disorder

• Bipolar disorder
• Major depressive disorder
• Schizophrenia
• Obsessive-compulsive disorder

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Defining Co-occurring Disorders

• Substance use disorder (SUD)
• a behavioral pattern of continual psychoactive
  substance use that can be diagnosed as either
  substance abuse or substance dependence

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Defining Co-occurring Disorders

• Co-occurring disorders (COD)
• the simultaneous existence of one or more
  disorders relating to the use of alcohol and/or
  other drugs of abuse as well as one or more
  mental health disorders.18

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Severity of Co-occurring Disorders

• Co-occurring mental health disorders are often
  placed on a continuum of severity.
• Non-severe early in the continuum and can
  include mood disorders, anxiety disorders,
  adjustment disorders and personality disorders.
• Severe include schizophrenia, bipolar disorder,
  schizoaffective disorder and major depressive
  disorder.

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Severity of Co-occurring Disorders

• The classification of severe and non-severe is
  based on a specific diagnosis and by state
  criteria for Medicaid qualification but can vary
  significantly based on severity of the disability
  and the duration of the disorder.

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Quadrants of Care
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• Part Two

What is Co-occurring Treatment and How is It
Different fromTraditional Addiction Treatment?
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Models of Treatment

• Clients with co-occurring disorders have
  historically received substance abuse treatment
  services in isolation from mental health
  treatment services.
• As more research on co-occurring disorders began
  to be conducted, the many limitations this
  approach places on the client and his or her
  success in treatment began to surface.

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Models of Treatment

• A twenty-eight year-old-woman named Anita entered
  an addiction treatment center where she was
  assessed as having alcohol dependence. Six months
  earlier, Anita had been diagnosed with major
  depressive disorder and was prescribed medication
  by her family doctor. At the treatment facility,
  it was recommended that Anita be re-assessed and
  treated, if necessary, at a mental health clinic,
  located nearby in town. What model of treatment
  does this scenario represent?
• single model of treatment
• sequential model of treatment
• parallel model of treatment
• integrated model of treatment

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Models of Treatment

• Single model of care - It was believed that once
  the primary disorder" was treated effectively,
  the clients substance use problem would resolve
  itself because drugs and/or alcohol were no
  longer needed to cope.
• Sequential model of treatment - acknowledges the
  presence of co-occurring disorders but treats
  them one at a time.
• Parallel model of treatment - mental health
  disorders are treated at the same time as
  co-occurring substance use disorders, only by
  separate treatment professionals and often at
  separate treatment facilities.

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Integrated Model of Treatment

• Integrated model of treatment
• an approach to treating co-occurring disorders
  that utilizes one competent treatment team at the
  same facility to recognize and address all mental
  health and substance use disorders at the same
  time.

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Integrated Model of Treatment

• The integrated model of treatment can best be
  defined by following seven components
• Integration

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Integrated Model of Treatment

• The integrated model of treatment can best be
  defined by following seven components
• Integration
• Comprehensiveness

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Integrated Model of Treatment

• The integrated model of treatment can best be
  defined by following seven components
• Integration
• Comprehensiveness
• Assertiveness

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Integrated Model of Treatment

• The integrated model of treatment can best be
  defined by following seven components
• Integration
• Comprehensiveness
• Assertiveness
• Reduction of negative consequences

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Integrated Model of Treatment

• The integrated model of treatment can best be
  defined by following seven components
• Integration
• Comprehensiveness
• Assertiveness
• Reduction of negative consequences
• Long-term perspective

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Integrated Model of Treatment

• The integrated model of treatment can best be
  defined by following seven components
• Integration
• Comprehensiveness
• Assertiveness
• Reduction of negative consequences
• Long-term perspective
• Motivation-based treatment

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Integrated Model of Treatment

• The integrated model of treatment can best be
  defined by following seven components
• Integration
• Comprehensiveness
• Assertiveness
• Reduction of negative consequences
• Long-term perspective
• Motivation-based treatment
• Multiple psychotherapeutic modalities

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Benefits of an Integrated Model of Care

• Benefits of an Integrated Model of Care
• Reduced need for coordination

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Benefits of an Integrated Model of Care

• Benefits of an Integrated Model of Care
• Reduced need for coordination
• Reduced frustration for clients

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Benefits of an Integrated Model of Care

• Benefits of an Integrated Model of Care
• Reduced need for coordination
• Reduced frustration for clients
• Shared decision-making responsibilities

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Benefits of an Integrated Model of Care

• Benefits of an Integrated Model of Care
• Reduced need for coordination
• Reduced frustration for clients
• Shared decision-making responsibilities
• Families and significant others are included

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Benefits of an Integrated Model of Care

• Benefits of an Integrated Model of Care
• Reduced need for coordination
• Reduced frustration for clients
• Shared decision-making responsibilities
• Families and significant others are included
• Transparent practices help everyone involved
  share responsibility

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Benefits of an Integrated Model of Care

• Benefits of an Integrated Model of Care
• Reduced need for coordination
• Reduced frustration for clients
• Shared decision-making responsibilities
• Families and significant others are included
• Transparent practices help everyone involved
  share responsibility
• Clients are empowered to treat their own illness
  and manage their own recovery

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Benefits of an Integrated Model of Care

• Benefits of an Integrated Model of Care
• Reduced need for coordination
• Reduced frustration for clients
• Shared decision-making responsibilities
• Families and significant others are included
• Transparent practices help everyone involved
  share responsibility
• Clients are empowered to treat their own illness
  and manage their own recovery
• The client and his/her family has more choice in
  treatment, more ability for self-management, and
  a higher satisfaction with care

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Co-occurring Disorders Interactions
An integrated model of care assumes that

• One disorder does not necessarily present as
  primary.
• There isnt necessarily a causal relationship
  between co-occurring disorders.
• These are co-occurring brain diseases that need
  to be treated simultaneously.

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SCREENING AND ASSESSMENT
Screening The first phase of evaluation where
the potential client is interviewed to determine
if he or she is appropriate for that specific
treatment facility and to determine the possible
presence or absence of a substance use or mental
health problem.
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SCREENING AND ASSESSMENT
Assessment The second phase of evaluation where
a systematic interview is necessary to verify the
potential presence of a mental health or
substance use disorder detected during the
screening process.
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SCREENING AND ASSESSMENT
Complexities of Screening and Assessment

• Intoxication
• Withdrawal
• Substance-induced disorders
• Motivational factors
• Feelings, symptoms, and disorders

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Co-occurring Disorders Interactions

• Substances and Negative Emotions

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SCREENING AND ASSESSMENT

• The choice of screening measures depends on
• The skill of the screening professional
• The cost of the screening materials
• How simple the scale is to interpret and use
  across disciplines
• Psychometric qualities
• The relevance of screening to prevalent disorders
• Movement from very sensitive (generic) measures
  to more specific measures

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SCREENING AND ASSESSMENT

• Integrated Assessment Process 12 Steps
• Engage the Client

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SCREENING AND ASSESSMENT

• Integrated Assessment Process 12 Steps
• Engage the Client
• Identify and Contact Collaterals

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SCREENING AND ASSESSMENT

• Integrated Assessment Process 12 Steps
• Engage the Client
• Identify and Contact Collaterals
• Screen for and Detect Co-occurring Disorders

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SCREENING AND ASSESSMENT

• Integrated Assessment Process 12 Steps
• Engage the Client
• Identify and Contact Collaterals
• Screen for and Detect Co-occurring Disorders
• Determine Quadrant and Locus of Responsibility

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SCREENING AND ASSESSMENT

• Integrated Assessment Process 12 Steps
• Engage the Client
• Identify and Contact Collaterals
• Screen for and Detect Co-occurring Disorders
• Determine Quadrant and Locus of Responsibility
• Determine Level of Care

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SCREENING AND ASSESSMENT

• Integrated Assessment Process 12 Steps
• Engage the Client
• Identify and Contact Collaterals
• Screen for and Detect Co-occurring Disorders
• Determine Quadrant and Locus of Responsibility
• Determine Level of Care
• Determine Diagnosis

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SCREENING AND ASSESSMENT

• Integrated Assessment Process 12 Steps
• Determine Disability and Functional Impairment

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SCREENING AND ASSESSMENT

• Integrated Assessment Process 12 Steps
• Determine Disability and Functional Impairment
• Identify Strengths and Supports

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SCREENING AND ASSESSMENT

• Integrated Assessment Process 12 Steps
• Determine Disability and Functional Impairment
• Identify Strengths and Supports
• Identify Cultural and Linguistic Needs and
  Supports

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SCREENING AND ASSESSMENT

• Integrated Assessment Process 12 Steps
• Determine Disability and Functional Impairment
• Identify Strengths and Supports
• Identify Cultural and Linguistic Needs and
  Supports
• Identify Problem Domains

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SCREENING AND ASSESSMENT

• Integrated Assessment Process 12 Steps
• Determine Disability and Functional Impairment
• Identify Strengths and Supports
• Identify Cultural and Linguistic Needs and
  Supports
• Identify Problem Domains
• Determine Stage of Change

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SCREENING AND ASSESSMENT

• Integrated Assessment Process 12 Steps
• Determine Disability and Functional Impairment
• Identify Strengths and Supports
• Identify Cultural and Linguistic Needs and
  Supports
• Identify Problem Domains
• Determine Stage of Change
• Plan Treatment

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DETERMINING LEVEL OF CARE

• American Society of Addiction Medicine Patient
  Placement Criteria 2nd Edition Revised (ASAM
  PPC-2R) dimensions of care
• Dimension 1 Acute Intoxication and/or Withdrawal
  Potential
• Dimension 2 Biomedical Conditions and
  Complications
• Dimension 3 Emotional, Behavioral or Cognitive
  Conditions and Complications
• Dimension 4 Readiness to Change
• Dimension 5 Relapse, Continued Use or Continued
  Problem Potential
• Dimension 6 Recovery/Living Environment

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DETERMINING LEVEL OF CARE

• Level I Outpatient treatment.
• Level II Intensive outpatient treatment,
  including partial hospitalization.
• Level III Residential/medically monitored
  intensive inpatient treatment.
• Level IV Medically managed intensive inpatient
  treatment.

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Evidence-Based Practices

• In most treatment addiction centers, the three
  primary evidence-based practices used are
• motivational enhancement therapy (MET)
• cognitive-behavioral therapy (CBT)
• twelve step facilitation (TSF)
• All of these treatment models are widely used
  often without formal training by addiction
  professionals around the country and can be
  easily applied to clients suffering from
  co-occurring disorders.

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Evidence-Based Practices

• The Integrated Combined Therapies model combines
  these three EBPs (Evidence-Based Practices) into
  a stage-wise treatment plan whereby
• motivational enhancement therapy is first
  utilized to initiate change and engage the client
  in the therapeutic process
• cognitive-behavioral therapy is then used to help
  make change within the client and
• twelve step facilitation is essential to helping
  maintain and sustain changes.

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STAGES OF CHANGE/STAGES OF TREATMENT
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STAGES OF CHANGE/STAGES OF TREATMENT
STAGES OF CHANGE/STAGES OF TREATMENT
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STAGES OF CHANGE/STAGES OF TREATMENT
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STAGES OF CHANGE/STAGES OF TREATMENT
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OTHER CONSIDERATIONS

• Managing Medications
• Involving the Family
• Encouraging Participation in Peer-Support
  Recovery Programs

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Collaboration with the prescriber

• Even though the prescriber is ultimately
  responsible for ensuring safety and effectiveness
  of pharmacotherapies, addiction professionals can
  also help in this effort.
• Since addiction professionals tend to see the
  client more often, they are well-positioned to
• recognize danger signs (including recent
  psychoactive substance use)
• recognize abnormal side effects
• monitor and support medication compliance

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MANAGING MEDICATIONS

• Pharmacotherapy can only work if medications are
  taken as prescribed.
• Some clients with co-occurring disorders are
  required to manage a regimen of multiple
  medications each day.
• Clients often have difficulty strictly adhering
  to a dosing schedule, making them more prone to
  relapse and hospitalization.
• Clinicians can help prepare clients
  to manage their medications.

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INVOLVING THE CLIENTS FAMILY
Involving families in treatment

• It is a myth that people with co-occurring
  disorders are disconnected from their families.
  
• Research has shown that outcomes for substance
  use and mental health disorders are improved,
  including fewer relapses, when families are
  actively engaged in the treatment process.
• Unfortunately, family members of a client who has
  co-occurring disorders often experience
  considerable stress, heartbreak, and confusion.

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INVOLVING THE CLIENTS FAMILY

• Involving families in treatment

• Encourage family member involvement and develop a
  collaborative relationship as early as possible
  in the treatment process
• Use an evidence-based practice for family
  treatment
• Encourage families to attend self-help groups
  such as Al-Anon and NAMI

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DUAL-RECOVERY MUTUAL SELF-HELP
Specific dual-recovery groups can provide
essential peer support

• Double Trouble in Recovery
• Mental Illness Anonymous
• Dual Disorders Anonymous
• Dual Recovery Anonymous
• Dual Diagnosis Anonymous

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GUIDING PRINCIPLES OF RECOVERY

• There are many pathways to recovery.
• Recovery is self-directed and empowering,
  involving personal recognition of the need for
  change and transformation.
• Recovery exists on a continuum of improved health
  and wellness.
• Recovery involves addressing discrimination and
  transcending shame and stigma.
• Recovery is supported by peers and allies, and
  involves joining and rebuilding a life in the
  community.
• Recovery is a reality.
• (from CSATs Regional Recovery Meetings, May 2008)

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• Part Three

Resources and Training Opportunities
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CO-OCCURRING DISORDERS PROGRAM from
Dartmouth/Hazelden
Written by the faculty from the
Dartmouth Medical School, CDP provides practical
tools for implementing evidence-based, integrated
treatment practices.
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CO-OCCURRING DISORDERS PROGRAM from
Dartmouth/Hazelden
Components of CDP include

• Clinical Administrators Guide  
• Curriculum 1 Screening and Assessment    
• Curriculum 2 Integrating Combined Therapies  
• Curriculum 3 Cognitive-Behavioral Therapy   
• Curriculum 4 Medication Management   
• Curriculum 5 Family Program    
• DVD A Guide for Living with Co-occurring
  Disorders

Training and technical assistance is available
for all components Call 1-800-328-9000, ext.
4672 or e-mail training_at_hazelden.org
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NAADAC/HAZELDEN COURSE
Integrating Treatment for Co-occurring Disorders
An Introduction to What Every Addiction
Counselor Needs to Know
is a skill-based training program that will help
addiction counselors improve their ability to
assist clients who have co-occurring disorders,
within their scope of practice.
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NAADAC/HAZELDEN COURSE

• Through case studies, video presentations,
  interactive exercises and extensive written
  resources, participants learn
• the many myths related to mental illness
  treatment
• barriers to assessing and treating co-occurring
  disorders
• relevant research and prevalence data
• commonly encountered mental disorders
• applicable screening and assessment instruments
• issues surrounding medication management
• coordinating with other mental health
  professionals
• the integrated model of mental health and
  addiction treatment services

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NAADAC/HAZELDEN COURSE

• NAADAC is now conductingthe Lifelong Learning
  Program Integrating Treatment for Co-occurring
  Disorders An Introduction to What Every
  Addiction Counselor Needs To Know
• Check the NAADAC website for trainings coming to
  your area at www.naadac.org

Interested in hosting a training? Contact
Diana Kamp dkamp_at_naadac.org Cynthia Moreno
Tuohy moreno_at_naadac.org
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NAADAC/HAZELDEN COURSE

• Now available as a distance learning program!
• Integrating Treatment for Co-Occurring
  Co-occurring Disorders
  An Introduction to What Every Addiction
  Counselor Needs to Know.
• Learn at your own pace through presentations,
  videos, case studies, and interactive exercises.
• Available 24/7. 180.00
• 18 CEs from NAADAC 6 CEs from APA

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Leadership in Co-Occurring Disorders

• Announcing the Focus on Integrated Recovery!
• A collaboration between
• Dartmouth Psychiatric Research Center
• Hazelden
• NAADAC, the Association for Addiction
  Professionals
• NAATP, the National Association of Addiction
  Treatment Providers
• The National Council for Community Behavioral
  Healthcare
• SAMHSA, the Substance Abuse and Mental Health
  Services Administration, and
• WestBridge Community Services
• Active discussions with other leaders

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Focus on Integrated recovery

• Co-Occurring Leadership
• What you can expect from Focus on Integrated
  Recovery
• Practical, evidence-based resources to aid in the
  integration of the substance use and mental
  health disorders professions
• Centralized source for consistent messaging about
  co-occurring disorders
• Ongoing mechanism to capture the learning and
  experiences from partners and constituents across
  the behavioral health spectrum
• Opportunities for in-person and distance
  education on co-occurring disorders
• Support for the September 2011 Recovery Month
• Collaboration on new initiatives evidence-based
  scopes of practice, outcome measurement,
  workforce development

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Focus on Integrated recovery

• Co-Occurring Leadership
• Where to find the Focus on Integrated Recovery
• Communications begin during September, 2011
  Recovery Month
• National Public Relations efforts
• E-mail campaigns
• Focus on Integrated Recovery Website
• Links on the partners websites
• Recovery Month materials
• Let us know what you think and how we can help!
• contact Jon Hartman - jhartman_at_hazelden.org

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UPCOMING WEBINARS 2011

• August 18, 2011 - Strategies for Successful Test
  Taking
• September 15, 2011 - Your Voice Counts Advocacy
  and the NAADAC Political Action Committee
• October 13, 2011 - Conflict Resolution for
  Clients and Professionals
• November 17, 2011 - What's Next in Your Career?
  Recap and Highlights from the NAADAC Workforce
  Conference
• December 15, 2011 - Clinical Supervision Keys to
  Success
• Register at www.naadac.org/education or
  www.myaccucare.com/webinars

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ARCHIVED WEBINARS

• Alcohol SBIRT Integrating Evidence-based
  Practice Into Your Practice
• Medication Assisted Recovery What Every
  Addiction Professional Needs to Know
• Build Your Business With the Department of
  Transportation Substance Abuse Professional (SAP)
  Qualification
• Working with NAADAC to Express Your Professional
  Identity
• Screening, Brief Intervention and Referral to
  Treatment (SBIRT)
• Medicaid Expansion 2014 and Preparing to Bill for
  Medicaid
• Understanding NAADACs Code of Ethics
• Staying Informed Trends of the Addiction
  Profession
• Archived webinars located at www.naadac.org/educa
  tion or www.myaccucare.com/webinars

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• Time for discussion!
• www.naadac.org
• www.bhevolution.org
• www.hazelden.org
• www.westbridge.org

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OBTAINING CE CREDIT

• The education delivered in this webinar is FREE
  to all professionals.
• 2 CEs are FREE to NAADAC members and AccuCare
  subscribers who attend this webinar. Non-members
  of NAADAC or non-subscribers of AccuCare receive
  2 CEs for 25.
• If you wish to receive CE credit, you MUST
  download, complete and submit the CE Quiz that
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• A CE certificate will be emailed to you within 30
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• Successfully passing the CE Quiz is the ONLY
  way to receive a CE certificate.

90

• Thank you for participating!
• www.naadac.org
• www.bhevolution.org
• www.hazelden.org
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• www.myaccucare.com
• Misti - misti_at_naadac.org
• Emily - ehaverty_at_orionhealthcare.com