Our client, not my client or yours: the benefits of a multiservice approach to the management of cli

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Our client, not my client or yours the benefits
of a multi-service approach to the management of
clients with an AOD problem

• Martin Jackson
• La Trobe University

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Aims of the Presentation

• To outline service providers and some of the
  features of clients that they see
• To outline commonalities of clients with a
  variety of problems (ABI, psychiatric, AOD etc),
  in particular, cognitive problems
• To discuss general ways of managing clients and
  propose that an interdisciplinary team is the
  best model

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Service Provider Clients

• Service providers such as disability services,
  psychiatric services, drug and alcohol services
  etc generally provide services to clients that
• meet the inclusion criteria
• do not meet any of the exclusion criteria
• the primary problem fits in with the service
  provision
• however, all services have clients with multiple
  problems, issues or disabilities
• clients with a number of ongoing significant
  issues are sometimes called complex clients or
  clients with complex needs

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Clients with complex needs

• A client with complex needs may be a person with
  several different conditions and issues
  contributing to their clinical presentation
• Conditions could include
• acquired brain injury
• psychiatric or psychological disorder
• substance use
• Issues could include
• psychosocial issues (family, environment etc)
• personality issues
• forensic issues

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Service providers and clients with complex needs

• Clients with complex or multiple needs may
  require or receive services from a number of
  providers including
• Disability services (abi)
• Alcohol and other drugs services
• Psychiatric services
• Justice/forensic services
• Medical services (GP)
• Specialist services (medical and community)

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Clients with complex or multiple needs

• What do they look like?
• What is the incidence of such clients?
• What is the prevalence of such clients?
• How aware are we of such clients?
• How do we manage them?

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A snapshot of arbias clients

• 541 clients received neuropsychological
  assessments for suspected ABI over a 12month
  period
• Only 5 of referrals were from other ABI service
  providers
• 93 clients were not diagnosed as having an ABI
• 286 clients had an active drug and alcohol issue
• 21 of clients were diagnosed with depression
• 21 of clients were diagnosed with psychotic
  symptoms

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Arbias/Depart of Justice Research

• Service providers are aware that their clients
  may have other disabilities
• However, they may not know the incidence or
  prevalence of other disabilities in their clients
  or the effects that these may have on outcome
• Arbias has been conducting a joint research
  project with the Department of Justice assessing
  the prevalence of ABI in a prisoner population

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Commonalities Across Disabilities

• Whether a person has a primary ABI, a drug and
  alcohol problem, a psychiatric disorder etc they
  are likely to have
• Cognitive problems
• Emotional problems
• Behavioural problems
• Cognitive problems are the most common

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Substance Related Cognitive Problems

• All neurotoxic substances have an acute
  intoxicating effect (and withdrawal effect) that
  affects cognition, usually in the areas of
  attention, memory and executive function
• All substances have the potential to produce an
  acute brain injury, generally related to
  overdoses and their secondary effects (hypoxia)
• Most substances (if not all) will produce an
  acquired brain injury in the long term

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Alcohol

• Memory difficulties
• Difficulty remembering recent events or recently
  learned information
• Achronogenesis - loss of time tags
• Retrieving information stored in memory
• Confabulation - a tendency to make up memories
• Preserved learned behaviour
• Executive difficulties
• Attention and concentration
• Planning, organisation, problem solving
• Complex, abstract and flexible thinking
• Self awareness and insight

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Benzodiazepines

• Short term cognitive effects
• Anterograde amnesia is common and severity is
  dose dependent, memory for information presented
  under the influence is impaired
• Verbal fluency, psychomotor speed, reaction time,
  attention, episodic memory, semantic memory
• Long term cognitive effects
• Impairment of concentration, attention,
  vigilance, speed of processing, sustained
  attention
• Visuospatial impairments (not seen in acute stage)

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Marijuana

• PET scans show increased cerebral blood flow
  (CBF) in paralimbic areas (orbital and mesial
  frontal lobes, temporal poles, cingulate and
  cerebellum) related to mood effects
• PET scans show decreased CBF in attentional
  network (parietal lobe, frontal lobe, thalamus,
  temporal cortex)
• Heavy use associated with impairments on tests of
  attentional/executive functions, reduced
  learning, perseveration of errors

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Solvents

• MRI scans - atrophy, white matter hyperintensity,
  hypointensity of basal ganglia and thalamus
• SPECT scans - a decrease in regional cerebral
  blood flow in the bilateral prefrontal cortex.
• Neuropathological and neuropsychological
  impairments are similar to those seen in
  subcortical dementias
• Neuropsychological studies have shown a wide
  range of cognitive impairments including
  processing speed, fine motor dysfunction,
  auditory discrimination, attention, memory,
  visuomotor function, psychosocial functioning
• Frontal hypoperfusion may related to
  amotivational syndrome

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Psychological and Psychiatric Related Cognitive
Problems

• Depression
• decreased blood flow in (left) prefrontal cortex,
  cingulate gyrus, basal banglia and right
  posterior cortex
• deficits in speed of processing, executive
  functioning, working memory, new learning, some
  visuospatial skills (face recognition)
• There is evidence that some deficits may remain
  once the person is no longer in a depressed mood

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Psychological and Psychiatric Related Cognitive
Problems

• Anxiety
• increased right hemisphere activity (PET)
  associated with panic, increased left hemisphere
  activity with worry, but quite variable
• amygdala, hippocampus (decreased volume),
  cingulate cortex, basal frontal cortex, right
  posterior cortex
• show biases in attention and memory
• variable deficits in speed of processing,
  executive functioning, working memory, new
  learning, some visuospatial skills
• deficits improve once the person is no longer
  anxious

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Psychological and Psychiatric Related Cognitive
Problems

• Schizophrenia
• enlarged lateral and third ventricles, loss of
  cortical thickness particularly in the temporal
  lobes, frontal lobes, basal ganglia
• deficits with attention, perception, executive
  functioning, memory difficulties

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Acquired Brain Injury Related Cognitive Problems

• Deficits differ depending on the aetiology of the
  problem (head injury, stroke etc)
• Generally there are deficits in
• attention speed of processing, divided
  attention, selective attention
• memory new learning and recall
• executive function planning and organising,
  problem solving, flexibility of thinking,
  abstract thinking, control, drive
• emotions and behaviour depression, anxiety,
  anger and aggression control

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Management of (complex) clients

• How do we respond to such clients?
• There has been a tendency in the past to refer a
  client to another service to deal with the
  problems (e.g. their problem is psychiatric not
  ABI)
• Is this helpful to the management of the client?
• DOA services have lead the way in trying to
  incorporate different aspects of a persons
  clinical presentation into their management by
  creating the ABI Clinician positions

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Management of (complex) clients

• There are two main ways providers could manage
  clients
• Keep them in-house and manage all the problems
  yourself
• Use a team approach of service providers

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In-house Management of Clients

• Advantages
• Minimises the number of different service
  providers involved
• More likely to have a consistent approach
• More likely to have better communication
• Would require wider training of staff and
  appropriate consultancy with other services

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In-house Management of Clients

• Disadvantages
• waters down expertise in staff who may become
  more generalist than specialist
• may reduce access to other services
• may increase the case management needs of the
  client
• staff may require a substantial amount of
  continuing education

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Team Approach to Managing Clients

• The two main team approaches that are used in
  rehabilitation services are
• the multidisciplinary team
• the interdisciplinary team
• The terms are often used interchangeably, but are
  actually different

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Multidisciplinary approach

• In this approach, each provider working with the
  client has their own goals and methods of
  achieving them
• There are usually few, if any, team goals
• Individual provider goals rarely take into
  account other providers goals or issues
• This is the most common approach used in
  practice, but has the most problems associated
  with it

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Multidisciplinary approach

• Problems
• inconsistent and incongruent goals and approaches
• higher probability of team friction
• higher probability of client/therapist and
  family/therapist relationship issues
• Less likelihood of good outcomes

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Interdisciplinary approach

• In this approach, the most important goals are
  team goals which all providers aim for within
  their own each speciality
• Each provider working with the client still has
  their own goals and methods of achieving them
• Individual provider goals always take into
  account the team goals, as well as other
  providers goals or issues
• This approach is generally not properly used in
  practice, but has the best outcomes associated
  with it

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Interdisciplinary approach

• Advantages
• consistent and congruent goals and approaches
• less probability of team friction
• less probability of client/therapist and
  family/therapist relationship issues
• can use the expertise of people from a variety of
  backgrounds
• generally has better outcomes

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Interdisciplinary approach

• Disadvantages
• it is time intensive, as it requires regular team
  meetings to monitor progress, make goals etc
• may be seen as a waste of time of people who
  primarily have a consulting role