THE INTEGRATED DUAL DIAGNOSIES PROGRAM OF VENTURA COUNTY BEHAVIORAL HEALTH Presented by Linda Gertso

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THE INTEGRATED DUAL DIAGNOSIES PROGRAM OF
VENTURA COUNTY BEHAVIORAL HEALTHPresented by
Linda Gertson, Ph.D.Behavioral Health Manager
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SOME CORE COMPETENCIES FOR STAFF WORKING WITH
CO-OCCURING SEVERE MENTAL ILLNESS AND ADDICTION

• Recognize that addiction is a disease
• Understand the neurobiology of stress and
  addiction
• Be aware that these disorders do not co-occur
  they interact. All elements of a treatment
  program should be based on this awareness
• Be familiar with the co-morbidity of trauma and
  addiction
• Know the difference between single event, acute
  trauma and early-onset, chronic trauma
• Understand trauma-informed approaches
• Be trained in Motivational Enhancement Techniques
• Conduct phase-oriented treatment
• Respect the philosophy and nature of 12 step
  programs

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ADDICTION IS A DISEASE

• Disease is defined as any deviation from or
  interruption of the normal structure or function
  of any part, organ, or system (or combination) of
  the body that is manifested by a characteristic
  set of symptoms and signs, and whose etiology,
  pathology, and prognosis may be known or
  unknown. Dorlands Illustrated Medical
  Dictionary, Twenty-Seventh Edition. Philadelphia
  Saunders, 1988.

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• Drugs kept me alive
• until I was ready to live
• Client with heroin addiction and trauma

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• PROGRAM
• OVERVIEW

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PROGRAM OVERVIEW

• Over 40 percent of the VCBH client population has
  co-occurring mental illness and substance use
  disorders.
• The interaction of mental illness and substance
  use disorders in this population was found to be
  associated with
• symptom severity
• hospitalizations
• incarcerations
• family conflict
• homelessness and other residential problems
• health problems
• medication non-compliance
• unemployment
• socio-economic status.

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PROGRAM OVERVIEW (continued)

• Chronology of the VCBH IDDT Program
• The Program was implemented in September 2005.
• The Program is evaluated every six months by an
  independent Program Evaluator.
• In September 2006 the Program was awarded a
  2,000,000 five-year SAMHSA grant to extend IDDT
  services to homeless individuals with
  co-occurring mental illness and substance use
  disorders.
• In September 2007 the Program was awarded the
  SAMHSA Science Service Award as one of four
  outstanding dual diagnosis programs in the US.

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PROGRAM OVERVIEW (continued)

• In a report to be published this December in the
  Journal of Psychiatric Rehabilitation titled
  Implementation of Integrated Dual Disorders
  Treatment in Eight California Programs, Program
  Evaluator Dr. Daniel Chandler stated Unlike the
  other counties who participated in this study,
  Ventura County created an IDDT team by hiring or
  transferring experienced dual disorders
  clinicians. In addition, the team leader used
  the (SAMHSA) fidelity scale as a template for
  designing and implementing the program.

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PROGRAM OVERVIEW (continued)

• According to Dr. Daniel Chandler The very high
  fidelity achieved by the Oxnard IDDT program (4.8
  of 5.0) is rare. And in the recent SAMHSA funded
  National Evidence-Based Practices study of
  different EBPs only two of 13 IDDT programs
  achieved high fidelity within three years. IDDT
  is a difficult model to implement because it
  requires a significant change in clinical
  practice and upgrading of clinical skills. The
  Oxnard program is the only IDDT program to have
  achieved high fidelity within six months.
  Reports from the National Project and from Ohio,
  where over 25 IDDT programs have been
  implemented, indicate a period of years is
  typical.

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• IDDT
• SERVICES

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IDDT SERVICES

• The IDDT Program provides integrated treatment
  for individuals with mental illness and
  co-occurring substance abuse.
• Between September 2005 and September 2009 the
  IDDT Team has conducted over 400 assessments.

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IDDT SERVICES (continued)

• What does the term integrated mean in the
  context of dual diagnosis INTEGRATED treatment?
• In this context integrated refers to the
  philosophy that both disorders (mental illness
  and substance misuse) must be treated
  simultaneously by one treatment team.
• It does not refer specifically to the integration
  of two different systems (e.g., a mental health
  program and a drug/alcohol program) but to the
  integration of treatment by a treatment team
  which understands the interaction of mental
  illness and addiction.

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IDDT SERVICES (continued)

• The Program rests on six evidenced-based
  elements
• accurate and thorough assessment
• client-centered recovery plans
• dual diagnosis counseling (individual therapy
  with licensed clinicians)
• integrated dual diagnosis groups
• appropriate psychopharmacology
• case management.

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IDDT SERVICES (continued)

• Integrated Assessment
• The clients attending the IDDT Program undergo a
  comprehensive integrated assessment that
  evaluates both their psychiatric symptoms and
  their use of addictive substances.
• The assessment is designed to assist clients in
  developing an understanding of how their
  disorders not only co-exist but how these
  disorders INTERACT.
• The assessment assists the client with
  clarifying how they perceive the advantages and
  disadvantages of using their substance(s) of
  choice.

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IDDT SERVICES (continued)

• Client-Centered Integrated Recovery Plans
  include
• the clients symptoms of both disorders and
  functional impairments
• the clients recovery goals as stated in their
  own words
• the clients strengths (including past
  accomplishments, motivations and attributes)
• barriers to successful recovery
• six-month objectives
• specific interventions agreed to by both the
  client and the staff
• community/family support
• discharge criteria and follow-up plan

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IDDT SERVICES (continued)

• Individual/Group/Family Sessions
• All clients participate in at least one group
  session per week and one individual session, as
  needed and/or requested.
• These sessions are designed to explore the
  disorders so that clients achieve a better
  understanding of their disorders and the
  interaction between the two.
• Each group is two hours in duration with the
  first hour consisting of educational material
  with handouts and the second hour for group
  discussion of personal issues.

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IDDT SERVICES (continued)

• In addition to the generic IDDT group clients
  can attend one or more of the following groups
• Trauma Group Due to the high co-morbidity
  between substance abuse and trauma, the IDDT
  program includes a specific group for clients
  with a history of sexual and/or physical abuse
  and other traumatic experiences. The program
  uses the manual Seeking Safety developed by Lisa
  Najavitz (an evidenced-based program endorsed by
  SAMHSA).
• Anger Management Group The program has
  implemented an evidenced-based Anger Management
  Group developed by SAMHSA.

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IDDT SERVICES (continued)

• Life Enhancement Training This group utilizes
  skills training similar to Dialetical Behavior
  Therapy developed by Marsha Linehan.

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IDDT SERVICES (continued)

• Case Management
• The case managers assist clients with
• access to health care
• money management
• housing
• benefits (such as General Relief, MediCal, SDI,
  and SSI)
• employment services
• social support services, including legal and
  family services.

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IDDT SERVICES (continued)

• Family Group The IDDT Program includes an
  education group for the clients family members
  and significant others. This group presents
  educational material related to co-occurring
  disorders and affords the participants an
  opportunity to discuss problems specific to their
  family/significant other situation.
• Participation in Alcohol/Drug Self-Help Groups
  Clients are strongly encouraged to attend 12-step
  programs and other peer support groups.

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IDDT SERVICES (continued)

• Peer Support Specialists
• The IDDT now has two peer support specialists
  (referred to as Recovery Coaches), one in Ventura
  and one in Oxnard.
• These individuals attend the groups, participate
  in staff meetings, conduct client
  outreach/engagement services and provide
  individual peer counseling.
• Students
• The program includes both psychology interns and
  practicum students. We also have two Research
  Assistants.

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• DEMOGRAPHICS

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DEMOGRAPHICS

• Clients Served in the IDDT Program
• (Data is for the Third Quarter of Fiscal Year
  08/09)
• Referral In Ox Vent East
• Self 52 58 83 Inpatient facility 6
  17 3
• Outpatient provider 9 5 4
• Other
• (case managers,
• assessment/triage) 33 20 10
• (OxOxnard VentVentura EastThousand Oaks
  Simi)

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DEMOGRAPHICS (continued)

• Clients Served in the IDDT Program (cont)
• Sex Ox Vent East
• Male 57 56 43
• Female 43 44 57
• Race
• White 59 79 93
• Hispanic 29 13 7
• Black 9 2 0
• Asian 0 0 0
• Other 3 6 0

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DEMOGRAPHICS (continued)

• Clients Served in the IDDT Program (cont)
• Language Ox Vent East
• English 97 96 97
• Spanish 3 4 3
• Primary Diagnosis
• Psychosis 17 13 23
• Depression 57 48 33
• Mood 9 29 40
• Anxiety 6 10 4

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• PROGRAM
• OUTCOMES

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PROGRAM OUTCOMES

• Stages of Treatment
• Clients who recover from dual disorders
  participate in the treatment process through a
  series of four stages
• engagement
• persuasion
• active treatment
• relapse prevention
• The goal of treatment is to assist clients with
  movement along this continuum of stages.

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Graph of Stage of Treatment Change over 12 Months

• This change is highly statistically significant

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PROGRAM OUTCOMES (continued)

• Stages of Change
• People who change maladaptive behaviors progress
  through a series of distinct stages
  precontemplation
• contemplation
• preparation
• action
• maintenance
• As with stages of treatment, the goal is to
  assist clients in movement along the continuum of
  the stages of change.

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Graph of Stage of Change Transitions over 12
Months

• This change is also highly statistically
  significant

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PROGRAM OUTCOMES (continued)

• Risk Reduction Factors (First 6 Months of
  Treatment)
• 80 of the clients in the IDDT Program avoided
  hospitalizations
• and incarcerations
• 80 reduced the frequency and/or amount of
  substances (if not totally clean and sober)
• 81 of the clients were compliant with their
  medication regimen
• Only 1 of the clients were never completely
  clean and sober (for a period of 30 continuous
  days) during the first 6 months of treatment

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Graph of Indicators of Reduced Risk Associated
with Treatment at 12 Months
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PROGRAM OUTCOMES (continued)

• Changes in Income Categories for
• 53 Clients Homeless at Program Entry
• Baseline Six Months
• Disability Income 5 persons 16 persons
• Average Disability
• Income 80.00 270.00
• Employment 0 persons 9 persons
• Mean Wage
• Increase Per
• Month 3,803.00 5,072.00

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Graph of Changes in Major Income Categories for
Clients Homeless at Time of Entry and at Six
Months

• All changes are statistically significant

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PROGRAM OUTCOMES (continued)

• The next graph shows how client self-rating of
  overall health status improved. In particular
  the percentage with poor health declined
  dramatically.

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Graph of Overall Self-Rating of Health

• Changes in Good and Poor are statistically
  significant

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PROGRAM OUTCOMES (continued)

• Mean Number of Days the Symptom was Experienced
  During the Previous 30 Days
• (All changes are statistically significant)
• Baseline Six Months
• Depression 17.3 11.7
• Anxiety 18.0 12.0
• Hallucinations 5.6 2.6
• Cognition 16.0 16.0
• Violent Behavior 5.2 1.6
• (comprehension/concentration/memory these
  mental functions can be impaired for an extended
  amount of time following abstinence)

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Graph of Mean Number of Symptoms (experienced
per day) at Baseline and Six Months
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PROGRAM OUTCOMESCLIENTS WITH TRAUMA HISTORY

• A significant body of research indicates a very
  high
• co-morbidity between substance use disorders and
  trauma. Incidence rates in our program are
• Males Females
• Childhood Physical
• Abuse 48 52
• Childhood Sexual
• Abuse 32 63
• Adult Abuse 13 78
• Abuse of Any Type 48 94

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Mean Beck Depression Scale Scores
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Mean Beck Anxiety Scale Scores
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Mean Beck Hopelessness Scale Scores
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Statistical significance of association between
number of group therapy or individual therapy
sessions and outcomes at six months (N99)

• Outcome Group Sessions Individual
  Visits Attend12-step
• Hospitalized in the Not Significant Significant
  Not Significant
• 6 months Positive Effect
• SATS improvement Not Significant Significant Not
  Significant
• Positive Effect
• Combined outcomes Not Significant Significant
  Not Significant
• Positive EffectCombined outcomes
  includes hospitalization, jail, never being
  clean, never being sober, relapsing. Each outcome
  was assigned a numeric value of 1, resulting in
  groups of 0, 1, 2, 3 and 4 outcomes having
  occurred (though in practice no one had 4).

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WHY VCBH IDDT WORKS(from our perspective!!)

• IDDT has been fully and successfully implemented
  in Ventura County as a result of
• Complete and continuous support of VCBH
  Administration
• Manager and staff with experience in dual
  diagnosis assessment and treatment WHO WERE FULLY
  COMMITTED TO SUCCESS OF THE PROGRAM (particularly
  in the Oxnard site)
• Immediate implementation of IDDT (during training
  rather than waiting for completion of training)
• Willingness to change and adapt

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WHY VCBH IDDT WORKS(from our perspective!!)

• Ongoing clinical supervision by an experienced
  dual diagnosis clinician
• Staff participation in the development of program
  forms, program development and outcome measures
• Advertisement of the program in behavioral health
  newsletters and other outlets
• Development of staff cohesiveness
• Groups composed of individuals in various Stages
  of Change and Treatment

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WHY VCBH IDDT WORKS(from our perspective!!)

• Inclusion of PTSD/trauma, anger management and
  LET groups
• Flexibility of staff schedules (e.g., evening
  groups)
• Groups conducted onsite and offsite
• Encouragement of client development of Dual
  Recovery Anonymous groups
• Inclusion of outcome measures
• Feedback to staff of client outcomes
• Use of outcome measures in for continuous program
  improvement

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WHAT NEEDS IMPROVEMENT?

• We need to decrease attrition rate. Many clients
  have disengaged from IDDT services prior to
  completion of the program. We hope that the
  inclusion of the Recovery Coaches will increase
  our ability to provide outreach to clients who
  have disengaged from the Program.
• Addiction is considered a chronic relapsing
  disease. Clients are at risk for relapse even
  following relatively long periods of abstinence.
  We are continuously making efforts to improve our
  understanding and treatment of this disease
  through intensification of treatment, analysis of
  our outcomes and participation in continuing
  education.

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CLIENT TESTIMONIALS

• Participating in group discussion in IDDT with
  other people facing the same problems
  homelessness, isolation, poverty, unemployment,
  depression and addiction has helped me feel
  less uniquely impaired.
• The IDDT Program has allowed me to learn a way
  of dealing with life on lifes terms.
• I know more about myself than I ever have.
• This program has helped me to be more aware of
  my problems and how to better mange them. It has
  also helped me to realize that I have the
  capacity to be a regular person.
• From my perspective, there is only one
  perspective. You have to treat both disorders at
  the same time.