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Adults with Dual Disorders in Contact with the Criminal Justice System

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Title: Adults with Dual Disorders in Contact with the Criminal Justice System


1
  • Adults with Dual Disorders in Contact with the
    Criminal Justice System
  • Holly Hills, Ph.D.
  • Wyoming Drug Court Conference
  • September 4, 2008

2
? Defining the Population of Persons with
Co-Occurring Disorders Typical Clinical
Presentations Systemic Variables that Impact Who
May be Served
3
Defining Co-Occurring Disorders
  • Co-occurring Disorders is used instead of dual
    diagnosis because clients often have more than
    two disorders.
  • Co-occurring Disorders typically defined as
  • a) at least one substance disorder, plus
  • b) at least one major mental disorder
  • -Major Depression -Bipolar Disorder
  • -Schizophrenia/psychotic disorders

4
Co-Occurring Disorders Prevalence
  • National Co-Morbidity Survey
  • Used representative national community sample
  • 30 had 12 month history of at least one
    DSM-III-R diagnosis
  • 52 of those with alcohol disorders at some point
    in their lifetime also had a history of at least
    one mental disorder

5
Co-Occurring Disorders Prevalence
  • National Co-Morbidity Survey
  • 59 of those with other drug disorders at some
    point in their lifetime also had a history of at
    least one mental disorder
  • Of those with lifetime co-occurrence, 84
    reported that their mental illness symptoms
    preceded their substance use disorder (Kessler et
    al., 1994)

6
Co-Occurring Disorders Prevalence
  • Prevalence of co-occurring disorders is even
    higher in public service systems (substance abuse
    treatment, mental health treatment, criminal
    justice, etc.) than in general population
  • Individuals with co-occurring disorders need to
    be thought of as the expectation, not the
    exception in such settings

7
Co-Occurring Disorders Risk Factors
  • Presence of a substance use disorder quadruples
    the risk of having a co-occurring mental disorder
  • Presence of a mental disorder triples the risk of
    having a co-occurring substance use disorder (ECA
    study, 1980-84)
  • Persons with any one substance use disorder have
    an increased risk for another substance disorder

8
Prevalence Data General Population
  • Epidemiologic Catchment Area Study
  • Presence of a mental disorder triples the risk of
    having a co-occurring substance use disorder
  • Presence of addictive disorder quadruples the
    risk of having a co-occurring mental disorder
  • Over 10 million adults in U.S. meet criteria for
    co-occurring disorders over twelve months

9
Co-Occurring Disorders Population Estimates
  • Using this definition, approximately 10 million
    people in the U.S. have co-occurring substance
    and mental disorders (SAMHSA, 1997)
  • When other mental disorders (anxiety disorders,
    personality disorders) are included, many more
    people can be considered to have co-occurring
    disorders.

10
How Many Offenders Have Co-occurring Disorders?
  • Rates of mental illness and substance use
    disorders in criminal justice settings are
    greater than those found in the general
    population
  • Rates of serious mental disorders in jails
  • 6.4 for males (Teplin, 1990)
  • 12.2 for females (GAINS, 2002)
  • Among jail detainees with a serious mental
    disorder
  • 72 have a co-occurring substance use disorder
    (Abram et al, 2001)

11
Prevalence of Mental Illness in Justice Settings
by Gender
  • Gender State Prison Jail Probation
  • Male 16 16 15
  • Female 24 23 22
  • Reported either a mental/emotional condition or
    an overnight stay in a mental hospital or
    program. (U.S. Department of Justice, 1999)

12
Persons with CODs in the Justice System
  • More likely to be homeless
  • Use a greater variety of services
  • More likely to be unemployed
  • More psychological impairment (including
    extensive trauma histories)

13
Relationships between Substance Abuse Mental
Disorders (Lehman et al.,1989)
  • 1. Acute and chronic substance use can produce
    psychiatric symptoms
  • 2. Substance withdrawal can cause psychiatric
    symptoms
  • 3. Substance use can mask psychiatric symptoms
  • 4. Psychiatric disorders can mimic symptoms
    associated with substance use
  • 5. Acute and chronic substance use can exacerbate
    psychiatric disorders
  • 6. Acute and chronic psychiatric disorders can
    exacerbate the recovery process from addictive
    disorders

14
Challenges in Addressing CODs
  • At risk for relapse
  • Criminality/criminal thinking
  • Housing needs
  • Transportation needs
  • Family reunification
  • Job skills deficits
  • Educational deficits
  • Stigma related to criminal history and SA and MH
    disorders
  • Scarce prevention and treatment resources

15
Outcomes Related to CODs
  • More rapid progression from initial use to
    substance dependence
  • Poor adherence to medication
  • Decreased likelihood of treatment completion
  • Greater rates of hospitalization
  • More frequent suicidal behavior
  • Difficulties in social functioning
  • Shorter time in remission of symptoms

16
Typical Clinical Presentations 33 year old
African-American male, history of hallucinations,
odd speech, poor hygiene, 10 year use of
significant alcohol, 15 year use of marijuana,
CSU x 3, Detox admissions x 5 in the past three
years multiple misdemeanant arrests 29 year old
Caucasian female, history of chronic crack
cocaine use, intermittent alcohol binges,
significant tearfulness, isolation, weight loss,
2 suicide attempts, multiple arrests
17
Systemic Variables that Impact Who May be
Served Priority Populations Primary
Diagnosis Assessment Skills / Capacity
Staffing Patterns / Job Classifications Access
to Psychotropic Medications Capacity for
Longitudinal Care
18
? Understanding Service Delivery Applying the
Quadrant Model Capacity to Serve Based on
Existing Available Resources Identifying Service
Gaps Understanding Populations of Persons with
COD who are Currently Most Underserved
19
Where are your agencies at in the service
spectrum?
III Less severe mental disorder/more
severe substance abuse disorder
IV More severe mental disorder/more
severe substance abuse disorder
High Severity
Alcohol and other drug abuse
I Less severe mental disorder/less
severe substance abuse disorder
II More severe mental disorder/less
severe substance abuse disorder
Mental Illness
Low Severity
High Severity
Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders, TIP 42
(2005)
20
  • Questions to Discuss with your Service Providers
    -
  • Where are the obvious service gaps in the
    system?
  • Are they related to the inability to serve
    specific diagnostic groups?
  • Are gaps related to missing elements in the
    treatment continuum?
  • Are all the pieces there, but is staff training /
    historical service patterns the impediment?

21
Strategies in Screening and Assessment
22
Twelve Steps in the Assessment Process (TIP42)
  • Engage Create a safe, private, nonjudgmental
    environment to build rapport determine cultural
    issues that may impact, importantly language
  • Five essential elements of engagement
  • Universal access (no wrong door)
  • Empathic Detachment
  • Person Centered Assessment
  • Cultural sensitivity
  • Trauma sensitivity

23
Twelve Steps in the Assessment Process (TIP42)
  • Identify collaterals
  • May be unwilling or unable to report their
    history accurately, obviously must be done with
    permission
  • Screen for COD
  • Safety issues related to acute intoxication and
    withdrawal
  • Present and past SU, related problems and
    disorders
  • Screen for MH safety issues (suicidality,
    violence, self-care, risk behaviors for HIV, Hep
    C or victimization)
  • Past and present MH disorders
  • Cognitive / Learning Deficits
  • Past and present victimization and trauma

24
Twelve Steps in the Assessment Process (TIP42)
  • Determine Quadrant
  • Quad I Less severe MH and SA Quad IV More
    severe MH and SU disorders
  • Severity of mental disorders are typically
    determined by diagnosis, severity of disability
    and duration of disability (6 mos)
  • Substance Abuse clinicians should be familiar
    with what criteria eligibility is established to
    be a MH priority client, may be eligible for
    services
  • Severity may be determined by using ASAM PPC-2R
    Dimension 3 or LOCUS

25
Twelve Steps in the Assessment Process (TIP42)
  • Level of care
  • ASAM ranges from 1. Acute intoxication to 6.
    Recovery
  • MH on Dimension 3. -- five areas suicide
    potential, interference with addiction recovery
    efforts, social functioning, ability for self
    care, and course of illness

26
Twelve Steps in the Assessment Process (TIP42)
  • Diagnosis
  • Determine history of past or current treatment of
    MH disorder existing stabilizing treatments
    should be maintained should accept this
    diagnosis presumptively, confirming with
    collaterals most important is to tie symptoms to
    specific life periods
  • Can use M.I.N.I. Plus, Timeline Follow Back, or
    SCID
  • Can use outlines of common DSM-IV disorders and
    inquire whether the symptoms were ever met, how
    treated, and success

27
Twelve Steps in the Assessment Process (TIP42)
  • Disabilities and Impairments
  • Cognitive capacities, social skills, need for
    special education
  • Capable of living independently?
  • Capable of supporting self financially?
  • Can engage in social relationships? Has social
    supports?
  • Level of intelligence? Memory impairments,
    learning disabilities, limited ability to read,
    write, understand? Problems with concentration,
    completing tasks?
  • Ability to use transportation, budgeting,
    self-care, ability to participate in treatment

28
Twelve Steps in the Assessment Process (TIP42)
  • Strengths and supports
  • Current strengths, skills, support in relation to
    managing their disorders
  • May focus on talents or interests, vocational
    skills, creative self expression
  • Areas connected to motivation for change
  • Important relationships, family or treatment
    staff
  • Previous treatment successes, what has worked?
  • Current successful attempts to manage symptoms

29
Twelve Steps in the Assessment Process (TIP42)
  • Cultural and linguistic needs
  • Not substantially different for the COD
    population but should consider
  • Fit in the treatment culture, conflicts in
    treatment
  • Cultural / linguistic service barriers
  • Literacy
  • Problem Domains
  • Medical, legal, social, vocational, family,
    social that impact treatment engagement and
    outcomes ASI does this
  • Identify contingencies that promote treatment
    adherence

30
Twelve Steps in the Assessment Process (TIP42)
  • Stage of Change
  • Interventions must be matched to stage of change
  • No problem / interest in change
    (precontemplation)
  • Might have a problem, may consider some change
    (contemplation)
  • Definitely believes they have a problem getting
    ready to change (preparation)
  • Working on changing actively, though perhaps
    slowly (action)
  • Achieved stability in this area trying to
    maintain status (maintenance)
  • Measures include SOCRATES, URICA
  • SATS is a case manager rated scale determining
    engagement in treatment (eight categories)
    covered in TIP 35

31
Twelve Steps in the Assessment Process (TIP42)
  • Plan Treatment
  • Treatment placement should be matched to the
    needs of the individual client
  • Concept of dual primary treatment
  • Focus is on integrated treatment planning,where
    intervention choices for each disorder are
    matched
  • Must take into account impact of other disorder
    on ability to comply with recommendations

32
Screening Assessment for Co-occurring
Disorders
  • All clients should be screened for both mental
    health and substance use disorders
  • Screening for mental health and substance abuse
    problems should be completed at the earliest
    possible point after involvement in the treatment
    system

33
Key Points Regarding Screening for Co-occurring
Disorders
  • Provide screening at different stages of
    treatment
  • Use similar or standardized screening instruments
    across different treatment settings
  • Information from prior screenings / assessments
    should be communicated across different points in
    the system

34
Screening
  • Should generate a yes or no response about
    the need for assessment
  • Should be connected to a protocol or cutting
    score recommendation for when an assessment
    should occur
  • Can be done by anyone without legal /
    professional constraints

35
Identification of Co-Occurring Disorders
  • Grisso and Underwood (2003) emphasize that
  • Instruments should not be used if there is no
    research on their reliability and validity
  • The greater the consequences of any decision
    that is based on the screen or assessment, the
    more important it is that valid and reliable
    measures be applied.

36
Screening and Detection
  • Mental Health Screening Form III
  • 18 yes / no questions that inquire about previous
    history of mental health treatment / contacts
    should be used as an interview method that can be
    inquired about re when did the problem begin,
    what was happening in your life at that time, did
    the problem begin before, during or after you
    were using substances?
  • Offers one screening question that addresses
    depression, PTSD, delusional disorder, gender
    identity disorder, manic episodes, panic
    disorder, obsessive /compulsive disorder,
    phobias, intermittent explosive disorder, eating
    disorders, pathological gambling, learning
    disorders / mental retardation.
  • Available in TIP 42

37
Methods for Assessment
  • M.I.N.I. / M.I.N.I. Plus / MINI kid
  • Format Structured interview intended to be
    administered by trained interviewers who do not
    have training in psychology or psychiatry
  • Takes 15-20 minutes to administer
  • Spanish version is available, computerized
    version is also available
  • Available on the internet at www.medical-outcome
    s.com at no charge for single use by clinicians /
    researchers

38
Methods for Assessment
  • Global Appraisal of Clinical Need (GAIN)
  • Format Structured interview method that covers
    treatment arrangements, substance abuse, mental
    health , physical health, legal, environmental,
    and vocational issues.
  • Takes 15- 30 min to administer 20 minutes to
    score
  • Cost Proprietary tools of Chestnut Health
    Systems. Currently considered in development, it
    can be used for evaluation and research at the
    cost of 1 under limited license.
  • Available from Chestnut Health Systems, Inc.
  • www.chestnut.org/li/gain

39
Treatment of CODs
  • Philosophy and Orientation
  • Expectation rather than Exception
  • No wrong door
  • Integration of Services
  • Integrated vs. Parallel vs. Serial
  • One multidisciplinary treatment team
  • Cross-Trained in SA and MH
  • Treats both disorders concurrently in one setting

40
Essential Integrated Treatment Components
  • No one correct model of care
  • Core components include
  • Standardized screening and assessment
  • Drug testing
  • Multidisciplinary treatment team, planning
  • Multidisciplinary case management
  • Long-term and stage-specific
  • Family/social network involvement
  • Appropriate psychopharmacology for MH

41
? Core Features in Delivering Treatment Services
to Persons with Co-Occurring Disorders Clinical
Practice Changes associated with Evidence-Based
Models (IDDT / CCISC)
42
  • Focus on Integrated Treatment
  • Drake (April, 2001) concludes that eight recent
    studies support the effectiveness of integrated
    dual diagnosis treatments for clients with severe
    mental illness and substance use disorders(pg.
    471).
  • Symptoms and behaviors positively influenced in
    these studies include substance abuse,
    psychiatric symptoms, quality of life ratings,
    rates of arrest and hospitalization, housing, and
    functional status.

43
Why Integrated Treatment?
  • Traditional, non-integrated approaches result in
    poorer outcomes
  • An integrated, multidisciplinary approach is
    needed
  • To achieve client retention and reduce burden
  • Focus is on person in a holistic sense
  • Providers are already working with these
    individuals AND can be more effective

44
CCISC Model Recommendations (Minkoff and Cline)
  • Welcoming
  • Accessible
  • Integrated
  • Continuous
  • Comprehensive
  • Consumer / Family Oriented

45
CCISC Model
  • Philosophy of Service
  • Comorbidity is the Expectation
  • Both disorders are considered as primary
  • Both are chronic relapsing illnesses
  • Acknowledge that readiness will vary
  • Need treatment to be lead by integrated staff
  • Need to have continuous relationship with
    providers

46
Definition of Integrated Service(Minkoff, 2001)
  • Treatment is
  • Diagnostically Specific
  • Phase Specific
  • Modified as Needed
  • Continuous Across Multiple Treatment Episodes

47
Principles of Service
  • Integration of Service
  • MH / SA
  • Acute and Long Term Care
  • Across Systems Children, Criminal Justice,
    Rehabilitation, Housing

48
Goals of Integrated Treatment(Drake, et al.,
1998)
  • Consider Disorders as Chronic
  • Take a Long Term Approach
  • Focus on Stabilization, Education,
    Self-Management
  • Employ a Team of Clinicians
  • Treat Both Disorders within the Same Program

49
Goals of Integrated Treatment(Drake, et al.,
1998)
  • Give Consistent Explanations
  • Offer a Coherent Prescription for Treatment
  • Reduce Conflict between Providers
  • Reduce Burden associated with 2 Programs
  • Reduce Opportunity for Conflicting Messages

50
More Questions to Discuss with your Providers
What models have you applied to your efforts at
developing integrated COD programs? Have you
defined yourselves as Dual Diagnosis Capable?
What significant changes in your service
delivery and record keeping have you
accomplished? What are the core features of
any integrated dual diagnosis treatment
programs that you are operating?
51
  • Moving toward Dual Diagnosis Capability
    Practice Elements Derived from the CCISC and IDDT
    models

52
Program Criteria Admission
  • Program does not exclude persons with an acute
    /recent history of severe/persistent MH disorders
    or an acute/recent history of substance abuse /
    dependence
  •  Admission criteria specifically allow for the
    inclusion of persons with COD (unless they
    REQUIRE immediate intensive service (CSU / Detox
    Svcs))

53
Program Criteria Admission
  • Persons are not excluded from admission based on
    their psychotropic medication history or current
    medication regimen, with limited exceptions.
  •  
  • Preadmission screening methods always assess for
    persons with COD
  • Standardized screening measures assess for both
    mental health and substance use disorders

54
Program Criteria Admission
  • Standardized screening measures assess for both
    mental health and substance use disorders
  •  
  • Standardized assessment methods or measures
    discuss the interaction of both MH and SU
    disorders
  • Stage of Change concepts are discussed /
    measured as a part of assessment process

55
Program Criteria Records
  • In the clinical record, diagnostic notation /
    impression / clinical summary, clearly identify
    by MH and SU diagnoses
  • Treatment plans describe goals and interventions
    for each identified mental health and substance
    use disorder
  • Progress notes indicate specific goals,
    behaviors, interventions for each diagnosis
    identified 

56
Program Criteria Records
  • Discharge plans explicitly discuss continuing
    care requirements for each mental health and
    substance use disorder continuity of care within
    a program is a primary goal
  •  
  • Clinical records integrate both mental health and
    substance use interventions in the same file

57
Program Criteria Treatment Quality
  • Manualized group interventions discuss the
    integration of mental health and substance use
    disorders.
  • Stage of Change concepts are discussed in
    progress notes, and in explicit therapeutic
    interventions Motivational Interviewing
    techniques specifically drive the interventions
  • Program uses specific contingency management
    strategies / methods to encourage treatment
    retention

58
Program Criteria Treatment Quality
  • Program employs drug testing procedures,
    routinely or as indicated
  • Program participants have access to self-help
    groups onsite OR are regularly transported to
    groups that specifically address COD (e.g., Dual
    Recovery / Double Trouble)

59
Program Criteria Staffing
  • Program staff includes persons onsite that have
    expertise / professional backgrounds in mental
    health and substance use disorders
  • Human resource policies and written training
    expectations focus on the acquisition of skills
    related to the treatment of persons with
    co-occurring disorders

60
Program Criteria Staffing
  • Interdisciplinary treatment team meetings occur
    regularly (at least monthly) and include staff
    with mental health and substance abuse
    professional backgrounds
  • Program staff communicate with other service
    providers, especially during episodes of acute
    care, encouraging their reconnection / continuity
    with long term care providers

61
Program Criteria Administrative
  • Program Mission Statement specifically welcomes
    persons with active co-occurring disorders
  • Program Policies and/or procedures specifically
    describe the treatment of persons with COD
  • Program literature discusses the admission or
    treatment of persons with COD

62
Program Criteria Administrative
  • The program has available written guidelines or
    procedures that describe strategies regarding use
    of psychopharmacological interventions in persons
    with COD
  •  MIS / data entry systems are employed that
    identify and track services delivered to persons
    with COD

63
Treating Persons with CODs Applying SAMHSA EBP
Toolkits -- Mental Health Perspective
  • Integrated Dual Diagnosis Treatment
  • General Organization Index (GOI)
  • IDDT Fidelity Scale

64
  • IDDT General Organization Index (GOI)
  • Measures the characteristics of an organization
    hypothesized to be related to its capacity to
    implement and sustain any EBP
  • Is intended to be a companion to the Fidelity
    tool
  • Is used as a self-assessment to monitor
    implementation (range 1 none to 5 full)
  • Is behaviorally anchored to measurable elements
    of practice
  • Is best conducted by independent evaluators
  • Requires multiple sources of information

65
  • IDDT General Organization Index (GOI)
  • Sources of Information
  • Interviews with staff
  • Observation of team meetings
  • Chart reviews
  • Observation of intervention

66
  • IDDT General Organization Index (GOI)
  • Domains
  • Program Philosophy
  • Eligibility / Client Identification
  • Penetration
  • Assessment
  • Individualized Treatment Plan
  • Individualized Treatment
  • Training

67
  • IDDT General Organization Index (GOI)
  • Domains
  • Supervision
  • Process Monitoring
  • Outcome Monitoring
  • Quality Assurance
  • Client Choice

68
  • IDDT IDDT Fidelity Scale
  • Domains
  • Multidisciplinary Team
  • Integrated substance abuse specialist
  • Stage-wise interventions
  • Access for IDDT Clients
  • Time-Unlimited Services
  • Outreach
  • Motivational Interventions

69
  • IDDT IDDT Fidelity Scale
  • Domains
  • Substance Abuse Counseling
  • Group DD Treatment
  • Family Psychoeducation on DD
  • Participation in SA self-help groups
  • Pharmacological Treatment
  • Interventions to Promote Health
  • Secondary interventions for SA treatment
    nonresponders

70
  • Available Frameworks and Tools
  • CMHS / Mental Health
  • CCISC Model (Minkoff and Cline)
  • COFIT, COMPASS, CODECAT
  • Designed to be used in either MH or SA settings,
    Focuses on Systems and Service Integration
  • Considered an Evidence Based Practice
  • Being evaluated through the COSIG grants

71
  • Available Frameworks and Tools
  • CSAT / Substance Abuse TIP 42
  • www.samhsa.gov
  • EBP lists (www.nrepp.samhsa.gov,
    www.nwattc.org www.scattc.org)

72
  • Use of CCISC Tools
  • (Minkoff Cline, 2000)
  • Using the CODECAT Clinician Self-Assessment of
    Competency
  • Using the COMPASS Agency Self-Survey
  • Using the COFIT for System Level Evaluation

73
Using the CODECATCan be used as a supervisor
evaluationor as an individual self-evaluation
Scores may be used to identify gaps in training
or as part of a supervisory process to identify
clinician strengths
74
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75
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76
COMPASS Agency Self-Survey
  • Recommended Method
  • Focus group structured interview
  • Represent a range of providers, 5-8 persons
  • Asked to evaluate services agency-wide that would
    be received by average or typical client
  • Range is rarely to consistently

77
COMPASS Agency Self-Survey
  • Philosophy These five items assess the extent to
    which an agency has an overall operating
    philosophy to assist clients with dual diagnoses.
    This can be documented or reflected in various
    forms, including program descriptions,
    orientation materials, mission statements,
    policies, and/or procedures.
  •  
  • Management Structure These eight items tap the
    degree to which organizational structures are
    organized to support integrated treatment of
    individuals with co-occurring disorders.
    Specific evidence of these structures includes
    budgeting and funding allocating processes,
    information systems, and billing structures.

78
COMPASS Agency Self-Survey
  • Access These five items tap the extent to which
    individuals with co-occurring disorders are
    welcomed or allowed to enter a treatment agency.
    Specific criteria include admission screening
    procedures, level of care determinations, and
    exclusionary criteria.
  •  
  • Identification/Detection of Co-occurring
    Disorders These five items measure the extent
    to which an agency can correctly determine if a
    client has a dual diagnosis. Evaluative criteria
    include urine screens and tools or checklists to
    detect substance use and mental health symptoms.
  •  
  • Assessment/Diagnosis These seven items
    determine the extent to which an agency can
    conduct an integrated, formal assessment of a
    clients mental health and substance abuse
    problems. Using an integrated assessment
    instrument, routinely filling it out and
    documenting both MH/SA conditions in client
    charts are assessed.

79
COMPASS Agency Self-Survey
  • Treatment Planning These five items assess the
    extent to which agencies treat each comorbid
    disorder as a primary problem. Criteria used to
    address competencies in this area include
    treatment plans, goals, objectives,
    interventions, and progress notes.
  •  
  • Treatment Content and Treatment Programming
    These thirteen items determine the extent to
    which an agencys treatment services are designed
    to address co-occurring disorders. Domains
    include whether dual diagnosis-informed
    interventions, educational materials, group
    programming, and treatment manuals are offered.

80
COMPASS Agency Self-Survey
  • Integrated Treatment Relationships These eight
    items tap competencies concerning offering
    continuous case management and interdisciplinary
    treatment teams that assist with recovery from
    both mental health and substance abuse problems.
  •  
  • Treatment Program Policies These four items
    gauge the extent to which an agency has
    established policies, contracts, and procedures
    for addressing treatment needs.
  •  
  • Psychopharmacology These seven items assess the
    degree to which the medication management
    process, in general, and the medical staff, in
    particular, consider both mental health and
    substance-related problems.

81
COMPASS Agency Self-Survey
  • Discharge Planning These seven items measure
    the degree to which an agency considers both the
    mental health and substance abuse treatment needs
    when they leave an agency treatment program.
  •  Integrated External Care Management These
    eight items determine the extent to which an
    agency links clients to additional community
    services outside of their agency. Evaluative
    criteria include referral resources and
    documentation, crisis response procedures, and
    inter-agency collaborative efforts.
  •  

82
COMPASS Agency Self-Survey
  • Staff Competency/Training These six items detail
    the degree to which agency staff members are
    prepared to assist clients with both of their
    disorders. Competency in this area may be
    documented in human resource policies, job
    descriptions, training materials, and performance
    reviews.
  • Specific Competencies These nine items tap
    agency dual diagnosis competencies to address
    issues related to culture, gender, age,
    developmental disability, trauma, or family.

83
COFIT - 100
  • The COFIT-100 has two key sections
  • Implementation (process) section
  • Outcomes section
  • Welcoming
  • Accessibility
  • Integration
  • Continuity
  • Comprehensiveness
  • Systems are likely to see progress in their
    implementation scores before seeing comparable
    progress in their outcome scores. There are 100
    items that are to be scored, giving a scoring
    range of 100 to 500.

84
  • Measuring Different Arenas
  • How do these tools fit together?
  • Service System
  • COFIT
  • Agency / Program
  • GOI and IDDT Fidelity Scale
  • COMPASS
  • Individual Clinician
  • CODECAT

85
Discussion Questions on Admitting Persons with
CODs
  • Will you accept persons with diagnoses of
    schizophrenia, schizoaffective disorder, major
    depression, bipolar disorder
  • Will you accept anyone with a severe and
    persistent mental illness regardless of their
    medication use / treatment history?
  • Will you accept persons with active substance
    dependence?
  • Will you accept persons with a self reported
    history of an active substance use problem?

86
Discussion on Admitting Persons with CODs
  • Will you admit persons with a recent history of
    psychiatric hospitalization, homelessness,
    housing instability, use of crisis services /CSU
    admissions?
  • Do you routinely take persons who have had
    numerous treatment contacts but who have not been
    successfully engaged in treatment? How is this
    addressed in this program?

87
Additional Techniques in the Treatment of Persons
with Co-Occurring Disorders
88
Key Techniques from TIP 42
  • Provide Motivational Enhancement consistent with
    Stage of Change
  • Employ contingency management techniques
  • Use Cognitive-Behavioral Techniques
  • Use Relapse Prevention Techniques
  • Use Repetition and Skill Building
  • Engage in mutual self help groups

89
Motivational Techniques Miller and Rollnick,
2002
  • Guiding Principles
  • Express Empathy
  • Develop Discrepancy
  • Roll with Resistance
  • Support Self Efficacy

90
Motivational Techniques Miller and Rollnick,
2002
  • Utilizing Motivational Enhancement Approaches
  • TIP 42 Figure 5-2

91
  • Utilizing Motivational Enhancement Approaches
  • Precontemplation
  • How would you express concern about their
    disorder(s)?
  • State nonjudgmentally that substance abuse / mood
    disorder is a problem/
  • Agree to disagree about the severity of their
    problems
  • Explore their perceptions of their problems
  • Emphasize your wish to help and their need to
    return

92
  • Utilizing Motivational Enhancement Approaches
  • Contemplation
  • Elicit both positive and negative aspects of
    their SA / MI
  • Make clear discrepancies between their values and
    actions
  • Offer a psychological evaluation / trial of
    abstinence
  • Preparation
  • Acknowledge the significance of their decision to
    seek treatment
  • Explain that relapse should not disrupt your
    relationship
  • Help them decide on appropriate, achievable
    action for a problem associated with one of their
    CODs
  • Action
  • Encourage and support
  • Acknowledge the painful aspects

93
  • Utilizing Motivational Enhancement Approaches
  • Maintenance
  • Anticipate and address difficulties
  • Support their resolve
  • Recognize the struggle
  • Relapse
  • Determine / explore what can be learned
  • Express concern
  • Support continue treatment seeking
  • Explore ability / efficacy in overcoming relapse

94
  • Motivational Enhancement Intervention
  • Group Treatment For Substance Abuse
  • Velasquez, M.M., et al. (2001)

95
  • Relapse Prevention
  • Overview of SAMM Concepts and Skills (TIP 42)
  • Overcoming Addiction Skills Training for People
    with Schizophrenia
  • Lisa Roberts, Andrew Shaner, Thad Eckman
    (1999)

96
  • Cognitive Behavioral Interventions
  • Seeking Safety by Lisa Najavits
  • Criminal Conduct and Substance Abuse Treatment by
    K. Wanberg and H. Milkman

97
  • Skill Building
  • Social Skills Training for Schizophrenia A
    Step by Step Guide
  • Bellack, Mueser, Gingerich, and Agresta (1997)

98
  • Continuity of Care
  • What does it mean in this population?
  • What essential knowledge / skills would you like
    clients to come to you with?
  • What are your priorities in an initial phase of
    treatment?
  • What are challenges do you anticipate?

99
Creating a Vision of Fully Integrated Treatment
(Drake et al., 1998)
  • What service elements can you identify as
    currently in place in your service setting?
  • What elements of your service delivery offerings
    need to be modified?
  • What are the gaps / challenges that are going to
    be the most difficult to confront?

100
CCISC Strategies for Implementation
  • Design policies to support integrated scopes of
    practice and treatment documentation within each
    funding stream / license
  • Identify initial clinician competency goals
  • Develop system wide training plan,
    Train-the-trainer, and available technical
    assistance
  • Address service system gaps related to
    available EBPs, consumer and family involvement,
    available service array

101
CCISC Strategies for Implementation
  • Develop a Structure for integrated system
    planning and implementation
  • Develop a consensus vision and an a
    collaborative plan of action
  • Agree to proceed with implementation within
    existing resources strategizing on how to
    incentivize participation
  • Utilize four quadrant model
  • Gather consensus for all programs to move to DD
    Capability

102
CCISC Strategies for Implementation
  • Develop structures for care coordination between
    MH and SA providers
  • Disseminate EBP and Consensus Best Practice
    guidelines
  • Identify priorities for BP implementation
    starting with welcoming, removing access
    barriers, integrated screening and data capture

103
Web Resources
  • www.samhsa.gov -- for TIP 42 and Co-occurring
    Center for Excellence links
  • Co-Occurring Disorders Web-based Curriculum
  • www.fmhi.usf.edu (follow the prompts for online
    education)
  • Brief Psychoeducational Manual on COD available
    at
  • www.fmhi.usf.edu/sparc/statement.html

104
Web Resources
  • Further information on Seeking Safety Manual at
  • www.seekingsafety.org
  • Further information on Trauma Recovery and
    Empowerment (TREM)
  • www.communityconnectionsdc.org/trauma

105
Web Resources
  • www.scattc.org
  • www.aacap.org/publications/factsfam/schizo.htm
  • www.surgeongeneral.gov/library/mentalhealth
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