1. BY CYNTHIA HOFFMAN, MFT www.cynthiahoffmanmft.com 1 Using Harm Reduction when working with SMI Populations

2. Presenter Biography www.cynthiahoffmanmft.com 2 Cynthia Hoffman, MFT is a psychotherapist in private practice. She also currently volunteers supervision to interns working in Community Mental Health settings. She has worked with severely mentally ill adults who use substances for over 13 years. She has worked in both community mental health settings and in private practice, practicing Harm Reduction. She is a also a member of the the Harm Reduction Therapy Centers Board of Directors. She has been practicing and teaching Harm Reduction Psychotherapy for over 13 years in both private practice and agency settings. www.cynthiahoffmanmft.com

3. Workshop Objective www.cynthiahoffmanmft.com 3 Objective: To familiarize the attendees with ACT and similar programs that work with homeless or previously homeless psychiatrically ill adults who have co-occurring substance use issues along with co- occurring medical illnesses and to identify the Harm Reduction techniques used with this population.

4. www.cynthiahoffmanmft.com 4 What is Assertive Community Treatment (ACT)? How the program works/History Who ACT serves Living situations Working with all providers: Benefits of ACT

5. How Act Works www.cynthiahoffmanmft.com 5 An ACT team is made up of multi-disciplinary staff that generally includes case managers, nurses, psychiatrist(s) and mental health clinicians. ACT operates from a “whatever it takes” philosophy and services are provided “in-vivo”. ACT programs were initially created to be a “hospital without walls”.

6. Who ACT serves www.cynthiahoffmanmft.com 6 Typical ACT clients may present with a variety of diagnoses including (but not limited to): Schizophrenia, Bipolar Disorder, Personality Disorders and Substance Abuse Disorders. Additionally, they are also likely to have health conditions, developmental disorders and environmental stressors. Many are homeless or formally homeless.

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8. Housing www.cynthiahoffmanmft.com 8 Clients in an ACT program may live in a variety of housing situations. Many are homeless or at least homeless for periods of time. Some live in supervised board & care homes and some may live independently in apartments or SRO’s (single room occupancy hotels). These housing situations often present barriers in treating clients from a harm reduction approach.

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10. Other Providers www.cynthiahoffmanmft.com 10 An essential component of an ACT program is the collaboration with other providers to ensure a strong continuum of care. payee services conservators housing staff hospital staff adjunct substance abuse services Helping to educate other providers on the benefits of a harm reduction approach can present challenges and is often met with resistance.

11. Benefits of ACT www.cynthiahoffmanmft.com 11 Studies show that substance use is reduced when wraparound case management along with providing social skills significantly reduces a clients substance use, sometimes by 50% Socialization, a sense of belonging Main focus of ACT is helping clients to improve their quality of life and develop meaningful activities

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13. Typical ACT client www.cynthiahoffmanmft.com 13 Adult 18 – 70 Average age approx 40 People of color Poor Former foster children Homeless or Minimally Housed

14. Why SMI populations drink and use www.cynthiahoffmanmft.com 14 People with mental illness use substances for a variety of reasons, including the relief of depression, anxiety, boredom or to relax and socialize (Addington & Duchak 1997, Fowler et al. 1998),Addington & Duchak 1997, Fowler et al. 1998),

15. Substances used: Alcohol Crack Speed Heroin Marijuana Prescription Drugs: i.e. Oxycontin, Klonopin www.cynthiahoffmanmft.com 15

16. INTENSIVE CASE MANAGEMENT PSYCHIATRIC INTERVENTIONS INDIVIDUAL SUPPORTIVE THERAPY GROUP THERAPY TEACHING SELF CARE INCENTIVES www.cynthiahoffmanmft.com 16 Interventions

17. Intensive Case Management www.cynthiahoffmanmft.com 17 Both short and long term goal setting (which includes goals that add meaningful activities to a clients life) Medical appointments Help with entitlements Communication with families Psychiatrist Case managers rotate 24 hour on call for off hours

18. Psychiatric Interventions www.cynthiahoffmanmft.com 18 ACT psychiatrist meets with the client as needed which could be from weekly to monthly. These appointments can be in the office, at the clients home or at a café. Collaborates WITH the client in developing an effective medication regimen, taking into account the substances a client uses. Discusses substance use and its effects when combined with medications May prescribe vitamins and/or behavioral interventions (CBT, DBT, etc) instead of or in conjunction with psychiatric meds

19. Individual and Group Therapy www.cynthiahoffmanmft.com 19 Individual Therapy is supportive and about teaching coping skills. Group Therapy is mostly psycho-educational and open-ended

20. “I’ve never had problems with drugs. I’ve had problems with the police.” Keith Richards www.cynthiahoffmanmft.com 20

21. Motivational Interviewing www.cynthiahoffmanmft.com 21 Whole package of Motivational Interviewing is complicated and there is much to learn. The spirit of MI is what’s essential. The Spirit of Motivational Interviewing Collaboration Evocation Autonomy Perception Curiosity Ethics Treats Resistance as thinking

22. Principles of Motivational Interviewing www.cynthiahoffmanmft.com 22 Express Empathy- Be affirming, help clients express their personal choice Develop Discrepancy – Develop the discrepancy between the clients goals and their current Behavior Roll with Resistance – Avoid Arguments – Know that resistance is a form of thinking about the issue Support Self Efficacy

23. Individual Therapy www.cynthiahoffmanmft.com 23 Supportive Client Centered Motivational Interviewing Individualized Personal Goals Quality of Life Issues Individualized Harm Reduction Strategies Identifying and helping client work towards goals that provide meaningful activities

24. Motivational Interviewing Whole package of Motivational Interviewing is complicated and there is much to learn. The spirit of MI is what’s essential. The Spirit of Motivational Interviewing Collaboration Evocation Autonomy Perception Curiosity Ethics Treats Resistance as thinking

25. Group Therapy www.cynthiahoffmanmft.com 25 Groups provided: Health Groups: Diabetes/High Blood Pressure Women’s/Men’s Groups Anger Management Socialization Groups – Lunch Group, Weekend Planning, Holiday Celebrations, Knitting, Walking, Music Group Art Therapy Seeking Safety

26. Group Therapy (continued) www.cynthiahoffmanmft.com 26  Harm Reduction. Includes topics:  Stages of change  Personal Goals  Family influence  Dealing with Feelings  Drug education including safer use

27. Teaching self care to SMI population Physical - wound care, dental, checking BP, blood sugar, liver panel regularly Psycho-education about physical health, psychiatric illness, substances used Prescribing vitamins i.e B6, statistics re: smi populations --50 to 80% Safe Injection, clean works and pipes, drinking water Diabetes and High Blood Pressure Education www.cynthiahoffmanmft.com 27

28. Incentives www.cynthiahoffmanmft.com 28 Incentives are offered for a variety of issues. They can be used to encourage someone to: o take a shower o attend a group o reduce use or o go on a substance use holiday Some examples of incentives used are: Food shopping Clothes or household items shopping Visits to a massage parlor Musical instruments A meal at a favorite restaurant

29. Incentives (cont) www.cynthiahoffmanmft.com 29 Some examples of incentives used are: Food shopping Clothes or household items shopping Visits to a massage parlor Musical instruments A meal at a favorite restaurant I

30. Sex www.cynthiahoffmanmft.com 30 Severely Mentally Ill and DD clients have sex. Oftentimes, alot of it. Provide Harm reduction education about sexual practices

31. Countertransference www.cynthiahoffmanmft.com 31 Many come to social because of family issues experienced when growing up. To experiences are likely to arise when working with clients. These should be recognized and discussed in individual supervision with the supervisor taking care not to act as therapist to the staff member.

32. Working with staff, burnout www.cynthiahoffmanmft.com 32 frustration at seeing these adults make bad choices Anger at the system The ACT Team Model allows for team members to help each other in a variety of ways i.e. going on outreach together, taking over if one person is ‘burnt out’ on a particular client

33. Challenges and Obstacles www.cynthiahoffmanmft.com 33 Funding Stress from everyone to keep clients out of the hospital even though the hospital might be what they need Growing acuity levels in clients while resources continue to shrink.

34. Contact us www.cynthiahoffmanmft.com cynthiahoffmanmft@yahoo.com www.cynthiahoffmanmft.com 34