Evidence Based Practice &Toolkits: Implementation of Integrated Dual Diagnosis Treatment (IDDT) Karin Kalk, Project Manager Marc Bono, PsyD, Trainer California Institute for Mental Health (Adapted from Presentation by Neal Adams, MD, MPH) Karin to start

Dual or Co-Occurring Disorders - a Definition Mental illness and substance use disorder occurring together in one person substance use disorders are common in people with severe mental illness mental illness is common in people with substance use disorders Dual disorders lead to worse outcomes and higher costs than single disorders Marc: In the U.S., the mental health and substance abuse administrative and treatment systems have traditionally been separate. However, people with mental illness commonly have substance use disorders, and likewise, people with substance use disorders commonly have mental illnesses. People who experience both disorders have a worse course of illness and worse outcomes than people with single disorders. People with dual disorders require costlier treatment than people with single disorders.

Co-Occurring Disorders High SA Low MI High MI Low SA Substance Abuse Mental Illness

Worse Outcomes Relapse of mental illness Treatment problems and hospitalization Violence, victimization, and suicidal behavior Homelessness and Incarceration Medical problems, HIV & Hepatitis risk behaviors and infection Family problems Increase service use and cost Now we will start to get at why we are here. What do you know about what happens to people who have severe mental illness when they use substances? (You may want to elicit suggestions from audience) This slide lists some of the difficult problems people with dual disorders face more frequently than people with single disorders. We’ll go over some of these in more detail in the next slides.

Integrated Dual Diagnosis Treatment - a Definition Treatment of substance use disorder and mental illness together same team same location same time other characteristics to be described later Emerging evidence based practice toolkits as a strategy for dissemination and implementation Developed for use in Mental Health Systems

Philosophic Underpinnings Comprehensive Recovery-Oriented Person-Centered Individualized

Interventions Motivational interviewing Cognitive behavioral counseling Group Interventions Social skills training Self-help groups Working with families Housing, employment, Psychopharmacology

Advantages of IDDT Comprehensive all aspects of treatment from screening to relapse prevention Substantial consensus of many experts that it is a useful approach. It incorporates many of the currently accepted techniques of substance abuse treatment including motivational interviewing stages of treatment, family psycho-education pharmacological advances

IDDT Advantages cont Provides guidelines reduce the wide variability of clinical practices Focuses attention on an important and very difficult population offers hope and assistance to stressed staff and clients Clinicians and administrators find it of immediate practical value

IDDT Advantages cont Virtually no practical alternative models parallel treatment in the substance abuse system has generally not been found to be feasible in California, although work continues on trying to overcome these barriers dual disorder adapted therapeutic community model is also supported by evidence but is not appropriate for all clients or those not willing to participate

Clinician Knowledge & Skills Knowledge about substances Knowledge and skills for stage-wise treatment outreach, practical help motivational counseling substance abuse counseling skills training self help referral family work infectious disease prevention and treatment Rehabilitation training skills

California IDDT Training & Evaluation Grant California Department of Mental Health has been awarded a SAMHSA grant to provide training for and evaluation of the implementation of integrated dual diagnosis treatment in four counties (eight sites) throughout the state. Neal Adams, MD, MPH, DMH Medical Director, PI: IDDT Toolkit Grant Karin’s slide

SAMHSA Toolkits Information about the EBP Individualized information for stakeholders, including consumers, family members and practitioners, administrators and pubic mental health authorities Implementation tips Basic curriculum Fidelity scales

Toolkit Issues: California Grant 3 general questions California project hopes to answer: Can the IDDT model be implemented with high fidelity in a variety of California sites typical of public mental health programs serving persons with severe mental illness? Is the Toolkit helpful? What else is important in making implementation work? Will client outcomes in our programs correlate with the fidelity of implementation of the IDDT model?

Counties Alameda Los Angeles Ventura Stanislaus

Organizational Change Changes at 5 levels health authority program leadership clinician/supervisor family consumer Each level has its own training and TA needs Because there is a history of separation of mental health and substance abuse services in the U.S., a significant amount of effort is required to make changes that allow integrated treatment to occur. There are 3 stages that systems go through to support a change to integrated treatment that we will go through in detail in a minutes. All the stakeholders involved in integrated treatment should be involved in making the change, including the state health authorities, program leaders, clinical leaders, families and consumers of services.

Tools for Design & Evaluation Fidelity Scale General Organizational Index Client Outcomes

Fidelity Scale Defines the IDDT program and its elements Operationalizes the principles of IDDT complex model cannot be tested component by component would require hundreds of studies fidelity scale based on expert consensus opinion “validated” fidelity scale should discriminate low from high fidelity programs correlate with outcomes ……..…see detailed Fidelity Scale The extent to which the IDDT fidelity scale is based on expert opinion can be seen by comparing the scale published in the Mueser et al book with the one currently being used as part of the SAMHSA project. Ohio has also made some significant changes in the version they are using.

Chart of Work Flow Flow of Client from system entry to recovery A ‘bird’s eye view’ Over generalized Clarify what IDDT elements apply when Eventually clinic will have its own chart of the IDDT Work Flow ………..see separate Work Flow Chart.

General Organizational Index General Organizational Index (OI) Similar to fidelity scale applies to all of the SAMHSA evidence-based practices Measures adherence to organizational practices believed to further successful organizational change and high quality treatment ……….see detailed General Organizational Index

GOI Items Program philosophy Eligibility/Client identification EBP commitment Eligibility/Client identification standardized screening Penetration % receiving EBP Assessment standardized assessment

GOI Items cont Individualized treatment plan Individualized treatment Training EBP for all practioners Supervision structured, weekly Process monitoring EBP implementation

GOI Items cont Outcome monitoring Quality Assurance substance use for IDDT Quality Assurance semi-annual review of EBP Client choice regarding service provision

Outcome Measures Alcohol Use Scale (AUS-R) Drug Use Scale (DUS-R) Measures alcohol use from abstinence – institutionalized dependence Drug Use Scale (DUS-R) Measures drug use from abstinence – institutionalized dependence Substance Abuse Treatment Scale (SATS) Assigns client to a level of treatment used in designing appropriate interventions Multnomah Community Abilities Scale (MCAS) 17 item validated level of functioning scale

Grant Activities Staff Training Implementation Activities Evaluation Monthly Education credits Syllabus Implementation Activities Sequenced with training topics Development of multi-disciplinary team Selection of clients for project Evaluation Initial, baseline fidelity evaluation – August Training on clinical evaluation tools – September Re-evaluation every six months

Perspective Developing a culture of learning, inquiry, quality and transformation multiple levels system administration clinicians Organizational focus not evaluation of staff performance 3 year vision

On to the fidelity scale…

IDDT Fidelity Items Multidisciplinary teams Integration of dual diagnosis specialist Stage-wise interventions Access to comprehensive services Time unlimited service Outreach Motivational Interviewing Substance abuse counseling Group dual diagnosis treatment Family psycho-education in dual diagnosis Participation in alcohol and drug self help groups Pharmacological treatment Interventions to promote health Secondary interventions for substance abuse treatment non-responders

Multidisciplinary Teams All clients targeted for IDDT receive care from a multidisciplinary team (MDT). An MDT consists of two or more of the following: a physician, a nurse, a case manager, or providers of ancillary rehabilitation services described in Item 3. 1 2 3 4 5 Traditional outpatient or brokered CM model; no team Minimal implementation of Multi discipline team (2 or three disciplines, low frequency of meeting, little integration) Partial Implementation of Multi discipline team (all three criteria are better than in “2” or one criterion done very well but others not) Nearly full of Multi- Discipline team (all three criteria met to Large degree) Full implementation team with Case managers, psychiatrist, nurses, residential staff, and vocational specialists work collaboratively on mental health; treatment team meetings daily; highly integrated.

Integration of Dual Diagnosis Specialist A DD specialist with at least 2 years of experience Works collaboratively with treatment team Experience can be in a variety of settings, preferably working with clients with a dual disorder 1 2 3 4 5 IDDT clients are referred to a separate substance abuse department within or outside the agency (e.g., referred to drug and alcohol staff) A substance specialist serves as a consultant to treatment team; does not attend meetings; is not involved in treatment Planning A substance abuse or DD specialist is a fully integrated member of the attends all team meetings; involved in treatment planning for IDDT clients; models IDDT skills and trains other staff in IDDT A DD specialist is a fully integrated clients; models IDDT skills and trains other staff in IDDT The team consists of multiple DD specialists with 2 years experience, fully integrated. They attend all team meetings; are involved in treatment clients; model IDDT skills and train other staff in IDDT

Stage-Wise Interventions All interventions (including ancillary rehabilitation services) are consistent with and determined by the client's stage of treatment or recovery. Concept of stages of treatment (or stages of change) include: Engagement, Motivation, Action, Relapse Prevention 1 2 3 4 5 Program does not use stages of treatment at all Minimal use of stages (no ratings, or not up to date, truncated or fuzzy stages, lack of interventions for each stage) Moderate use of stages (at least one element well implemented but not all three); or some staff use and others do not Consistent use of stages but at least one of the criteria not implemented fully A full range of interventions is available for all four stages and each client has a written up-to-date rating of current stage in treatment plan and is consistently reflected in progress notes

Stages of Change &Treatment Precontemplation -- Engagement outreach, practical help, crisis intervention Contemplation & Preparation -- Persuasion provide education, set goals, build awareness Action -- Active Treatment substance abuse counseling, medications, skills training, family and self-help groups Maintenance -- Relapse prevention relapse prevention plan, skills training, expand recovery to other areas of life

Access to Comprehensive Services To address a range of needs of clients targeted for IDDT, agency offers the following 5 rehab services: Residential service Supported employment Family psychoeducation Illness management and recovery Assertive community tx (ACT) or intensive case mgmt (ICM)

Access to Comprehensive Services cont 1 2 3 4 5 Access to related services identified in the client treatment plan None of the charts reviewed showed consideration of need for related services such as employment, illness mgmt or intensive case mgmt Some mention of related services in individual plan, but few services were actually accessed by the clients More related the treatment plan and they were usually Multiple identified. All were accessed, but not necessarily within 2 mos Multiple related related services treatment plan were accessed within 2 months residential/ housing services for DD clients -Housing specialist(s) -Wet-damp- dry housing No housing specialist available in county or program; limited or inadequate wet, damp, dry housing for DD clients Housing in county but not program; limited or inadequate wet, damp, for DD clients in program; full range of for DD specialist(s) in program; full range of wet, damp, dry clients; residential program affiliated with program

Time Unlimited Service Clients with DD are treated on a long-term basis with intensity modified according to need and degree of recovery. The following services are available on a time-unlimited basis: Substance abuse counseling Residential service Supported employment Family psychoeducation Illness management and recovery ACT or ICM

Time Unlimited Service cont Clients with DD are treated on a long-term basis with intensity modified according to need and degree of recovery. Services available on a time-unlimited basis: Substance abuse counseling Residential service Supported employment Family psychoeducation Illness management and recovery ACT or ICM 1 2 3 4 5 Overall program has a time limit. Program as a whole has no time limit but some of the services, such as particular groups are time limited. Neither program nor individual services have time limits or utilization limits per se, but some services are only offered some of the time. No time limits; services available at any time; but waiting lists exist. services available at any time; no waiting lists.

Outreach For all IDDT clients, but especially those in the engagement stage, IDDT program provides assertive outreach Characterized by some combination of meetings and practical assistance (e.g., housing assistance, medical care, crisis management, legal aid, etc.) in their natural living environments as a means of developing trust and a working alliance. Other clients continue to receive outreach as needed.

Outreach cont 1 2 3 4 5 Outreach: In situ aid for housing, medical, court and legal Outreach to engage clients initially and re-engage if stop attending Program is passive in recruitment and re-engagement; almost never uses in situ outreach mechanisms. Program makes initial attempts to engage but generally focuses efforts on most motivated clients; little or no in situ engagement Program staff frequently attempt in situ OR engagement outreach, but not both. Program staff frequently attempt BOTH in situ and engagement outreach (but it is not formally supported in policy, supervision and charting requirements). Policy, supervision, and charting requirements encourage in situ and engagement outreach. Over half the charts show evidence it has occurred when appropriate (e.g. when attendance is poor or a client has dropped out or if a client has court appearances).

Motivational Interviewing All interactions with DD clients are based on motivational interviewing that includes: Expressing empathy Developing discrepancy between goals and continued use Avoiding argumentation Rolling with resistance Instilling self-efficacy and hope

Motivational Interviewing cont 1 2 3 4 5 Motivational Interventions: Quantity Clinicians who treat IDDT clients use strategies. ≤20% of client charts reflect motivational interviewing approach (ie goals discrepancies, pay-off matrix); 21%- 40% of client charts reflect 41%- 60% of pay-off matrix) 61%- 79% of >80% of client Interviewing Qualitative No record of training on MI within past year Training on MI year but not all staff have attended Training for all staff on MI Year Training for all staff on MI year and staff interviews reflect use of MI Multiple trainings for all

Substance Abuse Counseling Clients who are in the action stage or relapse prevention stage receive substance abuse counseling aimed at: Teaching how to manage cues to use and consequences of use Teaching relapse prevention strategies Teaching drug and alcohol refusal skills Problem-solving skills training to avoid high-risk situations Challenging clients’ beliefs about substance use; and Coping skills and social skills training to deal with symptoms or negative mood states related to substance abuse

Substance Abuse Counseling cont 1 2 3 4 5 DDX counseling is not routinely provide Mental Health or Substance Abuse Counseling is provided by referral in a parallel or sequential model Mental Health or Substance Abuse Counseling is provide by the agency in specialized SA and or MH individual and/or group services Mental Health and Substance Abuse Counseling is provide by the agency in specialized integrated individual and/or group services Mental Health and Substance Abuse Counseling is provide by the agency in an integrated fashion throughout all aspects of programming as well as in specialized integrated individual and/or group

Group Dual Diagnosis Treatment All clients targeted for IDDT are offered a group treatment specifically designed to address both mental health and substance abuse problems, and approximately two-thirds are engaged regularly (e.g., at least weekly) in some type of group treatment. Groups could be family, persuasion, dual recovery, etc.

Group Dual Diagnosis Treatment cont 1 2 3 4 5 Group DD Treatment: DD clients are offered group treatment specifically designed to address both mental health and substance abuse problems <20% of DD clients regularly attend a DD group 20% - 34% of DD 35% - 49% of DD clients 50% - 65% >65% of DD Integrated group treatment for DD: health and substance abuse problems No groups are offered for DD clients Groups are offered for only one of the two disorders Separate groups are offered but not integration of the disorders in the groups groups for each disorder, but some integration occurs in the groups Integrated groups where both disorders are the focus of treatment

Family Psychoeducation in Dual Diagnosis Where available and if the client is willing, clinicians always attempt to involve family members (or long-term social network members) to give psychoeducation about DD and coping skills to reduce stress in the family, and to promote collaboration with the treatment team. 1 2 3 4 5 No identification of families or significant others for each client; or no outreach to families provided Minimum outreach to families provided: Materials on DD offered or sent Consultation with families around treatment decisions Moderate outreach: materials, consultation, some specific intervention, i.e. support group, coping skills training group. Partial implementation of an evidence-based family intervention for DD. Reviewers will look for evidence program is using an explicit evidence-based model Full implementation of an evidence-based family intervention for DD. Reviewers will look for evidence program is using an explicit evidence-based model.

Participation In Alcohol And Drug Self Help Groups Clinicians connect clients in the action stage or relapse prevention stage with substance abuse self-help programs in the community, such as: Alcoholics Anonymous (AA) Narcotics Anonymous (NA) Rational Recovery Double Trouble or Dual Recovery Proactive Self Help Groups & Liaison Staff have a working knowledge of the Self Help Groups they refer to Staff attend self help groups with clients Staff help clients to prepare and/or adjust to self help groups

Participation In Alcohol And Drug Self Help Groups cont 1 2 3 4 5 <20% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community 20% - 34% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community 35% - 49% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community 50% - 65% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community >65% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community No referral of dual-disorder clients in action or relapse prevention stages to self-help in community or at agency Occasional referral of dual-disorder clients in action or relapse prevention stages to self-help in community or at agency Routine referral but staff do not have a working knowledge of the self help programs Routine referral and staff has a working knowledge of the self help programs Routine referral and staff has a working knowledge of the self help programs and take proactive steps to assist clients in utilizing this resource including such things as mock groups or attending with the client

Pharmacological Treatment Physicians or nurses prescribing medications are trained in DD treatment and work with the client and the IDDT team to increase medication adherence; decrease the use of potentially addictive medications such as benzodiazepines; and offer medications such as clozapine, disulfiram, or naltrexone that may help to reduce addictive behavior. Five specific indicators are considered - do prescribers: Prescribe psychiatric medications despite active substance use Work closely with team/client Focus on increasing adherence Avoid benzodiazepines and other addictive substances Use clozapine, naltrexone, disulfiram

Pharmacological Treatment cont 1 2 3 4 5 All clients do not have ready access to psychiatric evaluation and treatment Clients have access to psychiatric evaluation and treatment but medications may be withheld for those with concurrent substance abuse; OR prescription of medications with abuse potential (e.g.enzodiazepines) is not controlled treatment, medications are not withheld, and are controlled; but prescribers have virtually no contact with treatment team and make no apparent efforts to Increase adherence are controlled; and prescribers have extensive contact with the treatment team and make apparent efforts to increase In addition to criteria in #4, prescribers actively consider naltrexone, disulfiram, clozapine, & other medications having some evidence base for use with persons with dual disorders

Interventions to Promote Health Efforts are made to promote health through encouraging clients to practice proper diet and exercise, find safe housing, and avoid high-risk behaviors and situations. Intent is to directly reduce the negative consequences of substance abuse using methods other than substance use reduction itself Typical negative consequences of substance abuse that are the focus of intervention include: physical effects social effects self-care and independent functioning, and use of substances in unsafe situations

Interventions to Promote Health cont 1 2 3 4 5 No explicit programmatic support for promoting health or reducing negative consequences of DD Program support for general health interventions such as diet and exercise but not for reducing the interventions and for reducing DD but interventions not used consistently (as documented in charts, protocols, and staff interviews) for general health DD but only individually (no such as trauma groups, smoking cessation groups, and needle exchange) Program supports reduction of DD and interventions are including interventions such as trauma groups, smoking cessation needle exchange)

Secondary Interventions for SA Treatment Non-responders Secondary interventions are more intensive (and expensive) interventions that are reserved for people who do not respond to basic outpatient IDDT. Program has a specific plan to identify treatment non-responders; evaluate them for secondary (i.e., more intensive) interventions; and link them with appropriate secondary interventions. Potential secondary interventions might include special medications that require monitoring; more intensive psychosocial interventions; or intensive monitoring, which is usually imposed by the legal system.

Secondary Interventions for SA Treatment Non-responders cont 1 2 3 4 5 Secondary interventions for non-responders. Diagnosis based (including trauma) Residential program Criminal-justice liaison Money management or payeeship Contingency management Outreach harm reduction approach for pre-contemplation clients Medications such as clozapine that require close monitoring Others if specified in tx plan No formal way of identifying non-responders Formal way of identifying non-responders but no specific interventions are in treatment plans for these clients Formal way of identifying and one to or two interventions are specified in treatment plans for these clients Formal way of identifying and three or four interventions are specified in treatment plans for these clients Formal way of identifying and five or more interventions are specified in treatment plans for these clients

Knowing is not enough; we must apply. Goethe