Integrated Treatment for Adolescents with Mental Health and Substance Use Challenges

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Integrated Treatment for Adolescents with Mental
Health and Substance Use Challenges

• Presentation to Consumer and Family Member
  Forum
• Friday, December 8th, 2006

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Kari Collins, LCSWMichael Gosser, LCSW,
CADCSonny Hatfield, LCSW

• Kentucky Youth First
• Division of Mental Health and Substance Abuse
• 502-564-4456
• Kari.Collins_at_ky.gov
• Michael.Gosser_at_ky.gov
• Sonny.Hatfield_at_ky.gov

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(No Transcript)
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Conceptual Challenges to Address

• Most adolescents do not recognize their substance
  use as a problem and are being mandated to
  treatment (and are angry about it)
• Co-occurring problems (mental, trauma, legal) are
  the norm and often predate substance use
• Treatment has to take into account the multiple
  systems (peers, family, school, welfare, criminal
  justice) involved in their lives

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Conceptual Challenges to Address

• Adolescents have less control of their lives and
  recovery environment than adults
• Need to be creative in dealing with family and
  peer relationships because they are still central
  to the adolescents self-identity and are not
  easily changed
• Families often play a pivotal role, but vary in
  their ability and willingness to help

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Need for Services

• Some youth in Kentucky are in trouble.
• In 2005, there were an estimated 25,793
  adolescents in the state that needed treatment
  for their substance related problems. Less than
  10 are documented as having received treatment.
• Nationally, less than 50 stay in treatment 6
  weeks, and 75 stay less than the 3 months
  recommended by NIDA.

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Need for Services (continued)

• Youth involved with the juvenile justice system
  are considerably more likely to have substance
  use problems than in the general population.
• Estimates range from 50-90 of youth with
  substance use problems also have mental health
  disorders.

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Facts About Co-Occurring Disorders

• 43 receiving mental health services had been
  diagnosed with a co-occurring SUD.
• CMHS (2001)national health services study
• 13 of adolescents with significant emotional and
  behavior problems reported substance dependence.
• SAMHSA 1994-96 National Household Survey
• 62 of males and 82 of females entering SUD
  treatment had a co-occurring psychiatric
  disorder.
• SAMHSA/ CSAT 1997-2002 study
• 75-80 of adolescents receiving inpatient
  substance abuse treatment have a coexisting
  mental disorder
• NMHA, 2005

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Reclaiming Futures

• RWJF launched national program and local pilots
  in 2002 to serve youth with SA and CO who were
  also involved in the justice system.
• The Vision
• More Treatment
• Better Treatment
• Beyond Treatment

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Reclaiming Futures

• Three things that work!
• System Reform
• Treatment Improvement
• Community Engagement

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Reclaiming Futures Model
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System of Care

• Systems of Care is not a program it is a
  philosophy of how care should be delivered. 
• Systems of Care is an approach to services that
  recognizes
• the importance of family, school and community,
• seeks to promote the full potential of every
  child and youth by addressing their physical,
  emotional, intellectual, cultural and social
  needs.  

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Continuum of Care vs. Systems of Care

• Continuum of Care
• Range of actual services/program elements and
  resources at varying levels of intensity

• Systems of Care
• Greater than the continuum, containing the
  service/program elements and resources and
  provisions for service coordination and
  integration.

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System of Care Core Values

• 1. Child centered and family focused, with the
  needs of the child and family dictating the types
  and mix of services and resources provided.
• 2. Community based, with the location of
  services, resource development, management and
  local decision making at the community level.
• 3. Culturally competent, with agencies,
  programs, services and resources that are
  responsive to the cultural, racial, and ethnic
  differences of the population they serve.

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System of Care Guiding Principles

• A comprehensive array of services/ resources
  across domains of their lives
• 2. Individualized services/resources
• 3. Services within the least restrictive setting
• 4. Youth, families and caregivers should be full
  participants
• 5. Integrated services between child serving
  agencies and resources

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System of Care Guiding Principles

• Service coordination (case management)
• Early identification and intervention
• Smooth transitions
• Advocacy
• Cultural differences and special needs

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Traditional Treatment Approaches

• Sequential
• One disorder then the other
• Parallel
• Treated simultaneously by different professionals

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Integrated Treatment Definition

• Treatment interventions for COD are combined
  within the context of a primary treatment
  relationship or service setting.
• It is a means of actively combining interventions
  intended to address substance abuse and mental
  disorders in order to treat both, related
  problems, and the whole person more effectively.
• SAMHSA, TIP 42

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Delivery of Services(samhsa, TIP 42)

• Provide access
• Complete a full assessment
• Provide appropriate level of care
• Achieve integrated treatment
• Treatment planning and review
• Psychopharmacotherapy

• Provide comprehensive services
• Supportive and Ancillary Wrap Services
• Ensure continuity of care
• Extended Care, Halfway Homes and other Residence
  Alternatives

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Achieving Integrated Treatment

• Beginning
• Addiction Only
• Intermediate
• COD capable

• Advanced
• COD Enhanced
• Fully Integrated

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Fully Integrated Treatment

• One program that provides treatment for both
  disorders.
• Mental and substance use disorders are treated by
  the same clinicians.
• The clinicians are trained in psychopathology,
  assessment, and treatment strategies for both
  disorders.

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Fully Integrated, cont.

• The focus is on preventing anxiety rather than
  breaking through denial.
• Emphasis is placed on trust, understanding, and
  learning.
• Treatment is characterized by a slow pace and a
  long-term perspective.
• Providers offer stagewise and motivational
  counseling.

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Fully Integrated, cont.

• Supportive clinicians are readily available.
• 12-Step groups are available to those who choose
  to participate and can benefit from
  participation.
• Pharmacotherapies are indicated according to
  clients' psychiatric and other medical needs

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Screening

• Purpose
• To identify adolescents who need a more
  comprehensive assessment for substance use
  disorders
• Components
• Questions to uncover red flags or indicators of
  serious substance-related problems among
  adolescents
• Include multiple domains including substance use
  disorder severity, home life, psychiatric status,
  and school status preferably from more than one
  source.

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CRAFFT

• CRAFFT yes no
• Have you ever ridden in a Car driven by someone
  (including
• yourself) who was high or had been using alcohol
  or drugs? __ __
• 2. Do you ever use alcohol or drugs to Relax,
  feel better about
• yourself, or fit in? __ __
• 3. Do you ever use alcohol or drugs while you are
  by yourself
• Alone? __ __
• 4. Do you ever Forget things you did while using
  alcohol or
• drugs? __ __
• 5. Do your Family or Friends ever tell you that
  you should cut
• down on your drinking or drug use? __ __
• 6. Have you ever gotten into Trouble while you
  were using
• alcohol or drugs? __ __
• Scoring 2 or more positive items indicate the
  need for further assessment.
• The CRAFFT is intended specifically for
  adolescents. It draws upon adult screening
  instruments, covers alcohol and other drugs, and
  calls upon situations that are suited to
  adolescents

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Who can (and should) do a Screening?

• Health service providers
• Juvenile justice workers
• Educators
• Community organizations (schools, health care,
  judiciary, vocational rehabilitation, religious
  organizations)
• Other individuals associated with adolescents at
  risk

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Assessment

• The comprehensive assessment, which is based on
  the initial screening, has several purposes
• To accurately identify those youth who need
  treatment
• To further evaluate is a substance use disorder
  exists, and to what severity
• To learn more about the nature of the youths
  substance-using behavior

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Assessment (continued)

1. To identify other problem areas (medical,
   psychological, nutrition, social, family,
   education, delinquent behavior)
2. Evaluate the extent to which the family can be
   involved (assessment and interventions)
3. Identify strengths of the adolescent
4. Develop a written report (including severity of
   the problem areas, corrective plan of action, and
   recommendations for services)

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Evidence Based Assessment Tool

• The Global Appraisal of Individual Needs (GAIN)
  is a progressive and integrated family of
  instruments for
• initial screenings, brief interventions and
  referrals
• standardized biopsychosocial clinical assessments
  for diagnosis, placement and treatment planning
• monitoring of changes in clinical status, service
  utilization, and costs to society
• subgroup and program level needs assessment and
  evaluation
• The GAIN has been used with both adolescents and
  adults and in outpatient, intensive outpatient,
  partial hospitalization, methadone, short-term
  residential, long-term residential, therapeutic
  communities, and correctional programs.

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GAIN

• GAIN-Short Screener (GAIN-SS) a two page, brief
  screener
• The GAIN-Quick (GAIN-Q) - a general assessment
  (11-14 pages) used to identify various life
  problems among adolescents and adults in the
  general population. It is designed for use by
  personnel in diverse settings (e.g. Employee
  Assistance Programs, Student Assistance Programs,
  health clinics, juvenile justice, criminal
  justice, etc.)
• GAIN-Initial (GAIN-I) - a full bio-psycho-social
  that integrates research and clinical assessment
  to do assist with diagnosis, placement,
  individualized treatment planning, program
  evaluation and meets major reporting
  requirements.

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Effective Treatment Program Characteristics

• Assessment and Treatment Matching
• Comprehensive integrated treatment approach
• Family Involvement
• Developmentally Appropriate

• Engagement and Retention
• Trust
• Length of stay
• Qualified Staff
• Gender and Cultural Competence
• Continuing Care
• Treatment Outcomes

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Evidence Based Interventions

• Motivational Enhancement Therapy (MET)
• Family-Based
• Behavioral Therapy
• Cognitive-Behavioral Therapy (CBT)
• Community Reinforcement Approach

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Motivational Enhancement Therapy

• Stand-alone brief interventions OR
• Integrated with other modalities
• Client-centered approach for resolving
  ambivalence and planning for change
• Demonstrates improved treatment commitment and
  reduction of substance use and risky behaviors
• Developmentally appropriate with adolescents

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Family Based Interventions

• Structural-Strategic Family Therapy
• Parent Management Training (PMT)
• Functional Family Therapy (FFT)
• Multisystemic Therapy (MST)
• Multidimensional Family Therapy (MDFT)
• All based on
• Family systems theory
• Use of functional analysis for interventions that
  restructure interactions
• Teaching parents behavioral principles and better
  monitoring skills to increase the adolescents
  pro-social behaviors, decrease substance use,
  improve family functioning, and hold treatment
  gains

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Purposes for Family Involvement

• Learn about child from family perspective
• Mutual education and redefinitions
• Define substance use in the family context
• Establish/re-establish parental influence
• To decrease familys resistance to treatment
• To assess interpersonal function of drug use

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Family Involvement, cont.

• To interrupt non-useful family behaviors
• Identify and implement change strategies
  consistent with familys interpersonal
  functioning and cultural identity
• Provide assertion training for child and any
  high-risk siblings

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Behavioral Therapy Approaches

• Based on operant behavioral principles
• Reward behaviors incompatible with drug use
• Withhold rewards or apply sanctions for use or
  other negative behaviors targeted
• Use of physical monitoring (urines, etc.) for
  close link of consequences
• Use of individual approach and family involvement
• Has demonstrated positive results for a number of
  problem areas

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Cognitive-Behavioral Therapy

• Based on learning theory
• Has individual and group applicability
• Has a number of manualized approaches
• Uses MET
• Uses functional analysis to target areas
• Teaches coping strategies, problem-solving
  communication skills (practice homework)
• Uses relapse-prevention and alternative
  activities strategies for avoiding substance use

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Behavioral Treatment Studies

• Interventions associated with reduced substance
  use and problems
• 12-Step Treatment
• Behavioral Therapies
• Family Therapies
• Engagement and maintenance is associated with
  several interventions
• case management, stepping down residential to OP,
  assertive aftercare

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Lessons from Behavioral Studies

• Family therapies were associated with less
  initial change but more change post active
  treatment
• Effectiveness was associated with therapies that
• were manual-guided and had developmentally
  appropriate materials
• involved more quality assurance and clinical
  supervision
• achieved therapeutic alliance and early positive
  outcomes
• successfully engaged adolescents in aftercare,
  support groups, positive peer reference groups,
  more supportive recovery environments

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Lessons from Behavioral Studies

• The effectiveness of group therapy was dependent
  on the composition of the group
• The effectiveness of therapy was dependent on
  changes in the recovery environment and social
  risk
• Effectiveness was not consistently associated
  with the amount of therapy over 6-12 weeks or
  type of therapy
• As other therapies have improved, there is no
  longer the clear advantage of family therapy
  found in early literature reviews
• Differences between conditions change over time,
  with many people fluctuating between use and
  recovery

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Community Reinforcement Therapy

• Combines principles techniques derived from
  others (behavioral, CBT, MET, and family therapy)
• Uses incentives to enhance treatment outcomes

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Specific Treatment Manuals

• Cannabis Youth Treatment (CYT) Series
• Motivational Enhancement Therapy and Cognitive
  Behavioral Therapy 5 Sessions
• The Motivational Enhancement Therapy and
  Cognitive Behavioral Therapy Supplement 7
  Sessions of CBT
• Family Support Network
• The Adolescent Community Reinforcement Approach
• Multidimensional Family Therapy

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Additional Adolescent Programs

• The Seven Challenges
• The Seven Challenges Program is designed for
  adolescent and young adult substance abusing or
  substance dependent individuals, to motivate a
  decision and commitment to change. It helps young
  people look at themselves, understand what it
  takes to give up a drug abusing lifestyle - and
  prepare for and attain success when they commit
  to such change.The Seven Challenges is a
  comprehensive program that is developmentally
  appropriate, research based, culturally sensitive
  and holistic.

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The Seven Challenges

• 1. We decided to open up and talk honestly about
  ourselves and about alcohol and other drugs.
• 2. We looked at what we liked about alcohol and
  other drugs, and why we were using them.
• 3. We looked at our use of alcohol or other drugs
  to see if it has caused harm or could cause harm.
• 4. We looked at our responsibility and the
  responsibility of others for our problems.
• 5. We thought about where we seemed to be headed,
  where we wanted to go, and what we wanted to
  accomplish.
• 6. We made thoughtful decisions about our lives
  and about our use of alcohol and other drugs.
• 7. We followed through on our decisions about our
  lives and drug use. If we saw problems, we went
  back to earlier challenges and mastered them.

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Culturally Competent Treatment Programs

• Family (as defined by culture) seen as primary
  support system
• Clinical decisions culturally driven
• Dynamics within cross-cultural interactions
  discussed explicitly accepted
• Cultural knowledge build into all practice,
  programming policy decisions
• Providers explore youths level of
  assimilation/acculturation

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Culturally Competent Treatment Programs

• Respect for cultural differences
• Creative outreach services to underserved
• Awareness of different cultural views of
  treatment/help-seeking behaviors
• Program staff work collaboratively with community
  support system
• Treatment approaches build on cultural strengths
  values of minorities
• Ongoing diversity training for all staff
• Providers are similar to youth of color served

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Level of Care Determination

• ASAM PPC-2R
• Treatment matching
• Long-term Outpatient Treatment
• Greater effect for more severe social, family and
  employment problems (Friedman et.al 1993)
• Better outcomes for adolescents with more sever
  psychiatric problems

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ASAM PPC 2R - Dimensions

• Acute Intoxication/Withdrawal
• Biomedical Condition and Complications
• Emotional, Behavioral or Cognitive
• Co-morbidity
• Dangerousness
• Interference with addiction recovery
• Social functioning
• Ability for self-care
• Course of illness

• Readiness to Change
• Relapse, Continued use
• Recovery Environment

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ASAM PPC 2R Levels of Care

• Early Intervention
• Outpatient Treatment
• Intensive Outpatient/Partial Hospitalization
• Residential/Inpatient
• Low intensity
• Medium Intensity
• High intensity
• Medically Managed Intensive Inpatient

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Factors Affecting Treatment Placement

• Developmental Stages
• Ethnicity
• Gender
• Co-occurring Disorders
• Pharmacotherapy
• Family Factors
• Social and Community Factors
• Peer influences
• Environmental Influences
• School Factors

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Other Services Needed

• Determine need for multidimensional services
• Consider
• Adolescent and familys living conditions,
• Other family issues/needs,
• Other agencies already involved/needing to be
  involved,
• What supports will be necessary and must be
  coordinated in order to support treatment
  efficacy

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Youth with Distinctive Treatment Needs

• Youth involved in the juvenile justice system
• Diversion programs
• Juvenile treatment/drug courts
• Homeless and Precariously Housed Youth
• Homosexual, Bisexual, and Transgendered Youth
• Youth with Co-occurring Disorders
• Physical Health Problems
• Mental and Emotional Health Problems