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Gaps in Service Towards Reaching Co-occurring

Capability

Anthony (AJ) Ernst, Ph.D.Ernst & Associatesanthony.j.ernst@gmail.com

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Bringing DDCAT to Tennessee

2009 – TN works with TN COD Advisory Committee and TN SA programs to explore DDCAT application

2009 – TN provides COD trainings and supports DDCAT program implementation

2010 – TN surveys program needs regarding DDCAT measures

2010 – TN provides training/support to address program needs/gaps

DDCAT INDEX RATINGS

1 - Addiction only (AOS)2 -3 - Dual Diagnosis Capable

(DDC)4 -5 - Dual Diagnosis Enhanced

(DDE)

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ADDICTION ONLY SERVICES (AOS)

Programs that either by choice or for lack of resources, cannot accommodate clients who have psychiatric illnesses that require ongoing treatment, however stable the illness and however well-functioning the client.

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DUAL DIAGNOSIS CAPABLE (DDC)

Programs that have a primary focus on the treatment of substance-related disorders, but are also capable of treating clients who have relatively stable diagnostic or sub-diagnostic co-occurring mental health problems related to an emotional, behavioral or cognitive disorder.

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DUAL DIAGNOSIS ENHANCED (DDE)

Programs that are designed to treat clients who have more unstable or disabling co-occurring mental disorders in addition to their substance-related disorders.

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DDCAT/DDCMHT INDEX FIVE DIMENSIONS: TN Identified Gaps

PROGRAM STRUCTURE – mission statement PROGRAM MILIEU – COD welcoming

statement CLINICAL PROCESS: ASSESSMENT CLINICAL PROCESS: TREATMENT – treatment

plan CONTINUITY OF CARE – community continuity

capacity, DRA/DTR meeting development STAFFING – COD alumni support TRAINING

PROGRAM STRUCTURE

DDCAT I.A. Primary treatment focus as

stated

in mission statement

Is the stated focus addiction only/MH only,

primarily addiction/MH (with an

acknowledgement of psychiatric

problems/addiction problems) or dual

diagnosis?

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PROGRAM MILIEU

DDCAT II.A. Routine expectation of and welcome to treatment for both

disorders.

What clients are expected and welcomed at your agency?

How is this reflected in agency documents?

(see handout)

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CLINICAL PROCESS: TREATMENT

DDCAT IV.A. Treatment plans

Do treatment plans show an equivalent and

integrated focus on both substance use and

psychiatric disorders, or do they primarily focus on substance use or

psychiatric issues only?

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CLINICAL PROCESS: TREATMENT

IV.B. Assess and monitor interactive courses of both disorders.

Are changes and/or progress with status and symptoms of both

psychiatric and substance use disorders followed

(and noted)?

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CLINICAL PROCESS: TREATMENT

IV.D. Stage-wise treatment – ongoing

Is stage of motivation assessed on an ongoing basis?

Can treatment be revised based upon changes in motivation?

COD Treatment Plans: A Practical Approach

What can programs (and clinicians) do?

What can be done without a lot of money?

What can we do that looks across different combinations of co-occurring disorders?

The Transtheoretical Model

STAGES OF CHANGE

PRECONTEMPLATION > CONTEMPLATION > PREPARATION > ACTION > MAINTENANCE

PROCESSES OF CHANGE

COGNITIVE/EXPERIENTIAL BEHAVIORALConsciousness Raising Self-LiberationSelf-Revaluation Counter-conditioningEnvironmental Reevaluation Stimulus ControlEmotional Arousal/Dramatic Relief Reinforcement ManagementSocial Liberation Helping Relationships

CONTEXT OF CHANGE (Levels of Change)

Current Life Situation (Symptoms & situations level)Beliefs and Attitudes (Cognitions & beliefs level)Interpersonal Relationships (Interpersonal level)Social Systems (Family level)

Steps to “Staging”

1. Target a specific behavior (problem) as possible

2. Stage individual target behaviors

3. Match intervention processes to stage

4. If there is a failure in an individual’s progress in a targeted behavior, immediately evaluate for problems on other levels that may also need staging and intervention

Match intervention to target behavior and stage

BEHAVIOR

PRECONTEMPLATION

STAGE

CONTEMPLATION

STAGE

PREPARATION

STAGE

ACTION

STAGE

MAINTENANCE

STAGE

QUIT

DRINKNG X

POSSIBLE INTERVENTIONS-Helping Relationships-Stimulus Control-Reinforcement Management

Match intervention to target behaviors and stage

BEHAVIOR

PRECONTEMPLATION

STAGECONTEMPLATION

STAGE

PREPARATION

STAGE

ACTION

STAGE

MAINTENANCE

STAGE

Quit

Drinking X

Manage

Bi-Polar Mood

Disorder

X

POSSIBLE INTERVENTIONS-Consciousness raising-Self-Reevaluation

POSSIBLE INTERVENTIONS-Helping Relationships-Stimulus Control-Reinforcement Management

Interventions for target behaviors may shift over time

BEHAVIOR

PRECONTEMPLATION

STAGE

CONTEMPLATION

STAGE

PREPARATION

STAGE

ACTION

STAGE

MAINTENANCE

STAGE

Quit

Drinking X

Manage

Bi-Polar Mood

Disorder

X

POSSIBLE INTERVENTION-Self-Reevaluation

POSSIBLE INTERVENTIONS-Helping Relationships-Stimulus Control-Reinforcement Management

MHSUDs

The behaviors may be independent

MHSUDs

One problem may precede another,as in this example

MH SUDs

The problems may otherwise interact with each other

STRESS

MH

SUDs

Outside factors may affect both substance use problems and mental health problems

STRESSMH

SUDs

PHYSICALILLNESS

And we have to be aware that triple diagnosis issues are never far away

Target Behavior Assignment: Remember…

- If we do not diagnose a problem properly, it is harder to treat.

- With more problems interacting, diagnosis demands greater care and confirmation over time.

-Assessment of the interaction of conditions is a necessary complement of diagnosis.

Measurement Issues

Multiple methods exist -SOCRATES, URICA, algorithms, ladders

Some methods are easier/harder to use

Variance in predictive utility by method

Variance in degree of separation among associated problem behaviors

Key Program Questions

What target behaviors should we measure?

When and how often should we measure?

What are the best measurements for our populations of interest?

Treatment Plan Case Study

Focus on specific targets within each problem behavior

This may involve focus on a whole disorder or on individual

symptoms within a disorder

(see handout)

Example: Dimensions of problem behaviors suitable as targets for change

Frequency of behavior (how often)

Duration of behavior (how long)

Intensity of behavior (how much)

Context of behavior (where, with whom)

Purpose of behavior (why)

Consequences of behavior (what happens)

EXAMPLE TARGETS – BEHAVIOR TO DECREASE

SUBSTANCE USEFrequency reductionQuantity reductionDuration reduction

STAGING ISSUESClients may be in different stages for

different targets related to the same behavior

EXAMPLE TARGETS – BEHAVIOR TO DECREASE

PANIC ATTACKSFrequency of occurrenceIntensity of occurrenceDuration of occurrence

STAGING ISSUESBeliefs around causes

Beliefs around medication useFamily social system

EXAMPLE TARGETS – OF GENERAL BENEFIT FOR DUAL DIAGNOSIS

SLEEP HYGIENESetting a sleep schedule

Decreasing caffeine consumptionAdjusting the sleep environment

STAGING ISSUESBeliefs about the utility of the interventions

Family social system

CONTINUITY OF CARE

DDCAT V.B. Capacity to maintain treatment continuity

How is treatment terminated or continued?Is this equivalent for both addiction and

psychiatric disorders?

CONTINUITY OF CARE

DDCAT V.C. Focus on ongoing recovery issues for both disorders

Are the disorders seen as acute or chronic, short-term or long-term,

primary or secondary? How is recovery envisioned and planned?

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COD Continuity of Care: Community Resource Coordination Groups

Community Resource Coordination Groups (known

as CRCGs) are local interagency groups,

comprised of public and private providers and

other community stakeholders who come together

monthly to develop individual services plans for

children, youth, and adults whose needs can be

met only through interagency, community

coordination and cooperation.

Community Resource Coordination Groups Model and Guiding Principles

All CRCG members should have the authority to commit services or resources for individuals and families referred to the CRCG

The role of a CRCG is to develop a coordinated strengths-based Individual Service Plan (ISP); an agreement for coordination of services developed in partnership with the individual or family.

Individuals referred are those who have encountered barriers or obstacles to getting their entire needs met through existing resources and whose needs can be met only through interagency cooperation. Prior to referring an individual, the referring agency will have explored services and resources within and outside the agency.

Each CRCG member is responsible for ensuring confidentiality for referred individuals and families. Members who represent an agency or organization should follow their agency’s/organization’s policies for confidentiality.

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CONTINUITY OF CARE

DDCAT V.D. Facilitation of self-help support groups for COD is

documented

Is the potential increased self-help linkage difficulty for the person with a

psychiatric/substance use disorder anticipated and planned for?

How is it dealt with?

Dual Recovery Anonymous

Dual Recovery Anonymous™ is an independent, nonprofessional, Twelve Step, self-help membership organization for people with a dual diagnosis. Our goal is to help men and women who experience a dual illness. We are chemically dependent and we are also affected by an emotional or psychiatric illness. Both illnesses affect us in all areas of our lives; physically, psychologically, socially, and spiritually.

http://draonline.org/

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Double Trouble in Recovery

Double Trouble in Recovery (DTR) is a Twelve Step fellowship of men and women who share their experience, strength and hope with each other so that they may solve their common problems and help others to recover from their particular addiction(s) and manage their mental disorder(s).

DTR is designed to meet the needs of the dually diagnosed, and is clearly for those having addictive substance problems as well as having been diagnosed with a psychiatric disorders.

We also address the problems and benefits associated with psychiatric medication; thus, we recognize that for many, having mental disorders represents Double Trouble in Recovery.

http://www.doubletroubleinrecovery.org/38

STAFFING

DDCAT VI.E. Peer/Alumni supports are available with co-occurring

disorders

Are role models available for persons with co-occurring addiction and

psychiatric disorders?

COD Alumni Support

“Live” Sample Alumni Group Free Alumni Group for all former residents

(and their parents) of La Habra, Long Beach, and Whittier's Dual Diagnosis Programs

Thursday evenings at 8:00 PM at the Long Beach Facility

http://www.centerfordiscovery.com/dualdiagnosisprogram/ourprogram/

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COD Alumni Support

“Live” SampleTHE WATERSHED ALUMNI PROGRAMSFor many of us, going home is sometimes the

hardest part. The disease of addiction leaves our lives in shambles, which makes taking the first step in the right direction a very difficult one to choose. At The Watershed, we maintain contact with our patients long after their treatment has concluded. Our Alumni Services staff is dedicated to supporting those who have begun the journey of recovery.

http://www.thewatershed.com/home.php41

DDCAT, leading to a program that is...

Welcoming

Accessible

Integrated

Continuous

and

Comprehensive

= “No Wrong Door”

With a common goal of RECOVERY