1. Treating Addiction and Other Mental Disorders Cutting Edge 2004 Palmerston North, New Zealand September 3, 2004 Joan E. Zweben, Ph.D. Executive Director: EBCRP and 14 th Street Clinic Clinical Professor of Psychiatry; University of California, San Francisco Joan E. Zweben, Ph.D. Executive Director: EBCRP and 14 th Street Clinic Clinical Professor of Psychiatry; University of California, San Francisco

2. Systems Issues Have the elements of your systems been aligned to create incentives and not barriers?

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

4. Remedy: Explicit Policies Do you have joint, interagency policy statement confirming commitment to, and expectations for, treatment for persons with COD? Do you have joint, interagency policy statement confirming commitment to, and expectations for, treatment for persons with COD? Statement should clearly identify the impropriety of excluding persons with COD from either treatment system or other service systems Statement should clearly identify the impropriety of excluding persons with COD from either treatment system or other service systems

5. Licensing & Certification Naïve expectation that professional credentials include proficiency in addressing substance abuse Naïve expectation that professional credentials include proficiency in addressing substance abuse No framework for specialized licensing and site certification No framework for specialized licensing and site certification Overlapping and conflicting requirements between health services, mental health, alcohol/other drug, social services, criminal justice system, etc. Overlapping and conflicting requirements between health services, mental health, alcohol/other drug, social services, criminal justice system, etc.

6. Licensing & Certification Need comprehensive framework for program licensing and site certification, or Need comprehensive framework for program licensing and site certification, or Specify programs that are exempt from existing requirements Specify programs that are exempt from existing requirements Remove regulatory barriers that discourage providers from serving this population Remove regulatory barriers that discourage providers from serving this population Create incentives through adequate reimbursement Create incentives through adequate reimbursement

7. Documentation Nightmares Have you streamlined documentation requirements? Funding sources require different elements in the clinical chart, and have different audit protocols Funding sources require different elements in the clinical chart, and have different audit protocols Need for a universal chart to reduce extra work, save many trees, and allow consistent data collection. Need for a universal chart to reduce extra work, save many trees, and allow consistent data collection.

8. Training Need mechanism to cross-train professionals and continuously develop skill base of non-credentialed workers Need mechanism to cross-train professionals and continuously develop skill base of non-credentialed workers Need to align all elements of the system to promote mastery of content defined as important: intake process, treatment plan, staff evaluations, etc. Need to align all elements of the system to promote mastery of content defined as important: intake process, treatment plan, staff evaluations, etc. Need for regular clinical supervision Need for regular clinical supervision

9. Terminology: Common Confusions Dual vs multiple disorders Dual vs multiple disorders Medical comorbidities Medical comorbidities AOD and any coexisting psychiatric disorder AOD and any coexisting psychiatric disorder AOD and severe and persistent mental illness AOD and severe and persistent mental illness What is available in your community, and for whom? What is available in your community, and for whom?

10. Barriers to Addressing Psychiatric Disorders Mistrust professionals Mistrust professionals Don’t have good diagnosticians Don’t have good diagnosticians Belief that TC or 12-step will fix everything Belief that TC or 12-step will fix everything Enabling phobia vs individualized treatment planning Enabling phobia vs individualized treatment planning Resistance/misunderstanding about meds Resistance/misunderstanding about meds Inappropriate expectations about time course Inappropriate expectations about time course Attitudes about chronic illness affect stance towards relapse Attitudes about chronic illness affect stance towards relapse

11. Barriers to Addressing AOD Use Failure to recognize and assess Failure to recognize and assess Minimize the role of AOD use; minimize the role of other mental disorders Minimize the role of AOD use; minimize the role of other mental disorders Toxicology screens not readily available Toxicology screens not readily available Lack of understanding of and respect for the self- help system Lack of understanding of and respect for the self- help system Medications: some physicians overprescribe, misprescribe, cloud the diagnosis Medications: some physicians overprescribe, misprescribe, cloud the diagnosis System barriers System barriers

12. Programming: Guiding Principles 1. Employ a recovery perspective 2. Adopt a multi-problem viewpoint 3. Develop a phased approach to tx 4. Address specific real-life problems early in tx 5. Plan for the clients’ cognitive and functional impairments 6. Use support systems to maintain and extend treatment effectiveness (COD TIP, in press)

13. “No Wrong Door” 1. Assessment, referral and tx planning must be consistent with this principle 2. Use creative outreach to promote engagement 3. Programs and staff may need to change expectations and requirements to engage reluctant clients 4. Tx plans based on client’s changing needs 5. Seamless system of care to provide continuity; interagency cooperation (COD TIP, in press) (COD TIP, in press)

14. Integrated Treatment for COD’S Treatment at a single site, by cross-trained clinicians Treatment at a single site, by cross-trained clinicians Medications OK and monitored when possible Medications OK and monitored when possible Appropriate adaptations for SMI: emphasis on reduction of harm, lowering anxiety, appropriate pacing, self help offered but not mandated Appropriate adaptations for SMI: emphasis on reduction of harm, lowering anxiety, appropriate pacing, self help offered but not mandated (COD TIP, in press)

15. Basic Counselor Competencies Screen for COD; ability to refer for formal diagnostic assessment Screen for COD; ability to refer for formal diagnostic assessment Form preliminary diagnostic impression to be verified by trained professional Form preliminary diagnostic impression to be verified by trained professional Preliminary screening of danger to self or others Preliminary screening of danger to self or others De-escalate client who is agitated, anxious, angry or otherwise vulnerable De-escalate client who is agitated, anxious, angry or otherwise vulnerable (COD TIP, in press)

16. Counselor Competencies, cont Manage crisis, including threat of harm to self or others Manage crisis, including threat of harm to self or others Refer to mental health facility if appropriate and follow up to assure that services were received Refer to mental health facility if appropriate and follow up to assure that services were received Coordinate care with mental health counselor; coordinate treatment plans Coordinate care with mental health counselor; coordinate treatment plans (COD TIP, in press)

17. Philosophical Differences: Harm Reduction & Abstinence

18. Philosophical Divisions: Harm Reduction vs Abstinence Historical overview Historical overview Treatment outcome data; implications Treatment outcome data; implications Pitfalls of abstinence-oriented approach Pitfalls of abstinence-oriented approach Pitfalls of harm reduction approach Pitfalls of harm reduction approach Blended models: when and how Blended models: when and how Harborview Program, Seattle Harborview Program, Seattle

19. Pitfalls of Abstinence-Oriented Treatment Failure to assess motivation level before pushing abstinence commitment Failure to assess motivation level before pushing abstinence commitment Failure to understand factors promoting continued use Failure to understand factors promoting continued use Unrealistic timetables Unrealistic timetables Power struggle vs clinical approach Power struggle vs clinical approach Failure to recognize fluctuating motivation Failure to recognize fluctuating motivation Inappropriate termination of treatment Inappropriate termination of treatment

20. Pitfalls of Harm Reduction Approach Inappropriately low expectations for what client can achieve Inappropriately low expectations for what client can achieve Difficulty setting clear goals Difficulty setting clear goals Reluctance to ask client to abstain completely Reluctance to ask client to abstain completely Underestimate risks/lethality Underestimate risks/lethality Clinician alcohol and/or illicit drug use Clinician alcohol and/or illicit drug use

21. Steps in the Assessment Process (2) 7. Determine disability and functional impairment 8. Identify strengths and supports 9. Identify cultural and linguistic needs and supports 10. Identify problem domains 11. Determine stage of change 12. Plan treatment (COD TIP, in press)

22. 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)

23. Distinguishing Substance Abuse from Psychiatric Disorders Wait until withdrawal phenomena have subsided (usually by 4 weeks) Wait until withdrawal phenomena have subsided (usually by 4 weeks) Physical exam, toxicology screens Physical exam, toxicology screens History from significant others History from significant others Longitudinal observations over time Longitudinal observations over time Construct time lines: inquire about quality of life during drug free periods Construct time lines: inquire about quality of life during drug free periods

24. Treatment Models & Issues

25. Psychotic Disorders: Counselor Recommendations Learn signs and sx of the disorder Learn signs and sx of the disorder Expect crises and have resources Expect crises and have resources Include education on the psychiatric condition and on medications Include education on the psychiatric condition and on medications Monitor medication, promote adherence Monitor medication, promote adherence Provide frequent breaks, shorter mtgs Provide frequent breaks, shorter mtgs Use structure and support; avoid confrontation Use structure and support; avoid confrontation Present material in simple, concrete terms and use multimedia tools Present material in simple, concrete terms and use multimedia tools (COD TIP, in press) (COD TIP, in press)

26. Sequential, Parallel and Integrated Treatment (1) SEQUENTIAL when abstinence is necessary for other interventions to be effective when abstinence is necessary for other interventions to be effective when psychiatric condition must be stabilized when psychiatric condition must be stabilized when problem is severe in one area but mild in the other (Ries 1993) when problem is severe in one area but mild in the other (Ries 1993)

27. Sequential, Parallel and Integrated Treatment (2) PARALLEL TREATMENT when problem is severe in one area but mild in another when problem is severe in one area but mild in another clients with HIV clients with HIVPROBLEMS: need to be highly functional to navigate systems need to be highly functional to navigate systems lack of coordination lack of coordination

28. Sequential, Parallel and Integrated Treatment (3) Mental health and addiction care combined at one site Mental health and addiction care combined at one site Clinicians cross trained in both fields Clinicians cross trained in both fields Unified case management Unified case management Differences in philosophy reconciled within the program Differences in philosophy reconciled within the program Useful for severe problems in several areas Useful for severe problems in several areas Flexibility promotes good conflict resolution Flexibility promotes good conflict resolution

29. Integrated Treatment Premise: treatment at a single site, featuring coordination of treatment philosophy, services and timing of intervention will be more effective than a mix of discrete and loosely coordinated services Findings: decrease in hospitalization decrease in hospitalization lessening of psychiatric and substance abuse severity lessening of psychiatric and substance abuse severity 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.)

30. What is Recovery: Mental Health Perspective Recovery is recapturing a positive sense of self in spite of the challenge of a psychiatric disability Recovery is recapturing a positive sense of self in spite of the challenge of a psychiatric disability Recovery is actively self-managing one’s life and mental illness Recovery is actively self-managing one’s life and mental illness Recovery is reclaiming social roles and a life beyond the mental health system Recovery is reclaiming social roles and a life beyond the mental health system

31. Specialized Treatment for SMI: Assertive Community Treatment AOD and significant mental health disorder AOD and significant mental health disorder Severe and persistent mentally ill Severe and persistent mentally ill Severe functional impairments Severe functional impairments Avoided or responded poorly to traditional tx Avoided or responded poorly to traditional tx Co-occurring homelessnes Co-occurring homelessnes Co-occurring criminal justice involvement Co-occurring criminal justice involvement (COD TIP, in press)

32. Essential Features of ACT Services provided in the community, frequently in client’s living environment Services provided in the community, frequently in client’s living environment Assertive engagement, active outreach Assertive engagement, active outreach High intensity of services High intensity of services Small caseloads Small caseloads Continuous 24 hour responsibility Continuous 24 hour responsibility Multidisciplinary team Multidisciplinary team Close work with support system Close work with support system Continuity of staffing Continuity of staffing (COD TIP, in press)

33. Modified Therapeutic Community (MTC) Increased flexibility in activities Increased flexibility in activities Decreased intensity Decreased intensity  Conflict resolution group, vs encounter  Shorter duration  More emphasis on instruction  Increased role modeling Greater individualization Greater individualization (COD TIP, in press)

34. Harborview Recovery & Rehabilitation Program (HaRRP) Pre-phase program: case manager based case manager based focused around food, shelter and harm reduction focused around food, shelter and harm reduction brief medication/money groups (Club Med) brief medication/money groups (Club Med) drop-in lounge drop-in lounge (Richard K. Ries, MD)

35. HaRRP Stages (2) Phase I: highly structured groups, 3x week highly structured groups, 3x week focus on recognition and acceptance of both psychiatric and substance abuse problems focus on recognition and acceptance of both psychiatric and substance abuse problems development of group process development of group process movement toward (but not requirement of) sobriety movement toward (but not requirement of) sobriety

36. HaRRP Phases (3) Phase II: participants have attained at least 3 months sobriety participants have attained at least 3 months sobriety IIa: lower functioning but sober; more activity based groups IIa: lower functioning but sober; more activity based groups IIb: can utilize more abstract, recovery- oriented process IIb: can utilize more abstract, recovery- oriented process Phase III: vocational issues

37. Disability Benefit Management as a Treatment Intervention (1) HARBORVIEW PROGRAM, SEATTLE Goals: 1) insure that $ went to food, shelter, basic needs; 2) increase treatment compliance computerized system with a range of levels of control computerized system with a range of levels of control case managers disburse benefits in conjunction with treatment activities case managers disburse benefits in conjunction with treatment activities (Ries & Comptois, 1997) (Ries & Comptois, 1997)

38. Benefit Management (2) Payees (vs non-payees) were male, had diagnosis of schizophrenia, history of high inpatient utilization Payees (vs non-payees) were male, had diagnosis of schizophrenia, history of high inpatient utilization Higher current ratings of psychiatric symptoms, substance use and functional disability Higher current ratings of psychiatric symptoms, substance use and functional disability These characteristics usually predict poor compliance and adverse outcomes, however: Payees attended 2x number of outpt sessions and were no more likely to be currently homeless, hospitalized or incarcerated; comparable to nonpayee group Payees attended 2x number of outpt sessions and were no more likely to be currently homeless, hospitalized or incarcerated; comparable to nonpayee group

39. Preparing Psychiatric Patients for 12-Step Meetings medication is compatible with recovery, but meetings are best selected carefully medication is compatible with recovery, but meetings are best selected carefully some meetings are more tolerant than others of medication or eccentric behavior some meetings are more tolerant than others of medication or eccentric behavior schizophrenics benefit from coaching on how to behave in meetings schizophrenics benefit from coaching on how to behave in meetings 12-step structure often beneficial; non-intrusive and stable 12-step structure often beneficial; non-intrusive and stable

40. Cross-Training Issues Resistances of credentialed professionals Resistances of credentialed professionals Resistances of non-credentialed staff Resistances of non-credentialed staff Effective training designs Effective training designs Incentives Incentives Mandates Mandates Using training to facilitate system change Using training to facilitate system change