Integrated TreatmentIntegrated Treatment

Suzanne Carrier, LCSWSuzanne Carrier, LCSW

Integrated treatmentIntegrated treatment

With Co-occurring Disorders With Co-occurring Disorders

Persons who have one or more Persons who have one or more substance-related disorders as substance-related disorders as

well as one or more mental well as one or more mental disorders.disorders.

Report to Congress,SAMHSA, 2002Report to Congress,SAMHSA, 2002

Prevalence of Co-Occurring Prevalence of Co-Occurring disordersdisorders

• Seven to 10 million individuals in the Seven to 10 million individuals in the U.S. have at least one mental U.S. have at least one mental disorder and at least one alcohol or disorder and at least one alcohol or drug disorder.drug disorder.

• 41% to 65% of individuals with a 41% to 65% of individuals with a lifetime substance use disorder also lifetime substance use disorder also have a lifetime history of at least one have a lifetime history of at least one mental disorder.mental disorder.

Report to Congress, SAMHSA 2002Report to Congress, SAMHSA 2002

Prevalence of Co-Occurring Prevalence of Co-Occurring DisordersDisorders

• 51% of those with one or more 51% of those with one or more lifetime mental disorders also have a lifetime mental disorders also have a lifetime history of at least one lifetime history of at least one substance abuse disorder.substance abuse disorder.

• 43% of youth receiving mental health 43% of youth receiving mental health services in the United States have services in the United States have been diagnosed with co-occurring been diagnosed with co-occurring disorders.disorders.

Problems associated with Co-Problems associated with Co-Occurring MH & SAOccurring MH & SA

• More difficulty with symptoms More difficulty with symptoms management and abstinence due to management and abstinence due to interaction of both illnesses.interaction of both illnesses.

• Higher rates of relapse in both illness.Higher rates of relapse in both illness.

• Multiple losses.Multiple losses.

Problems associated with Co-Problems associated with Co-Occurring MH & SAOccurring MH & SA

• Higher rates of medical problemsHigher rates of medical problems

• Higher incidence of self harm and Higher incidence of self harm and violenceviolence

• Higher rates of involvement with the Higher rates of involvement with the Criminal Justice SystemCriminal Justice System

• Higher rates of HomelessnessHigher rates of Homelessness

• Multiple vulnerabilities/victimizationsMultiple vulnerabilities/victimizations

Kathleen Sciacca, 1997Kathleen Sciacca, 1997

Parallels Between Mental Parallels Between Mental Illness and Substance AbuseIllness and Substance Abuse• Both have biological, psychological and social Both have biological, psychological and social

componentscomponents• Both create shame and guiltBoth create shame and guilt• Both are stigmatized by societyBoth are stigmatized by society• Both are primaryBoth are primary• Both are progressiveBoth are progressive• Both are chronicBoth are chronic• Both are no fault illnessesBoth are no fault illnesses

•People can and do recover from People can and do recover from bothboth

Report to Congress, 2002Report to Congress, 2002

Four Quadrants of Co-occurring Four Quadrants of Co-occurring DisordersDisorders

• Quadrant I – Less severe mental Quadrant I – Less severe mental illness and substance use/Primary illness and substance use/Primary health care setting/ consultationhealth care setting/ consultation

• Quadrant II – More severe mental Quadrant II – More severe mental illness and less severe substance illness and less severe substance use/ Mental Health or Substance use/ Mental Health or Substance Abuse System/collaborationAbuse System/collaboration

Report to Congress, 2002Report to Congress, 2002

Four Quadrants of Co-Four Quadrants of Co-Occurring DisordersOccurring Disorders

• Quadrant III – More severe substance Quadrant III – More severe substance use and less severe Mental illness/ use and less severe Mental illness/ Mental Health or Substance Abuse Mental Health or Substance Abuse System/CollaborationSystem/Collaboration

• Quadrant IV – More severe substance Quadrant IV – More severe substance use and mental illness/ Mental Health use and mental illness/ Mental Health System/ Integrated ServicesSystem/ Integrated Services

Less severe mental illness and substance Less severe mental illness and substance abuseabuse

primary careprimary care

more severe Mental Illness – less severe SAmore severe Mental Illness – less severe SA

collaboration at either MH/SAcollaboration at either MH/SA

more severe SA – less severe mentalmore severe SA – less severe mental

illness illness collaboraton either MH/SAcollaboraton either MH/SA

more severe substance abuse and more severe substance abuse and mental illnessmental illness – mental – mental

health systemhealth system

integrated treatmentintegrated treatment

Treatment optionsTreatment optionsfor co-occurring disordersfor co-occurring disorders

• Sequential Treatment– or treatment Sequential Treatment– or treatment that addresses one illness before the that addresses one illness before the other illness is addressed.other illness is addressed.

• Parallel Treatment- or treatment Parallel Treatment- or treatment where each illness is addressed at where each illness is addressed at different locations, clinicians and/or different locations, clinicians and/or programs.programs.

Mueser, Noordsy, Drake, Fox, 2003Mueser, Noordsy, Drake, Fox, 2003

Limitations of Parallel Limitations of Parallel TreatmentTreatment

• Different Treatment Providers have Different Treatment Providers have incompatible treatment philosophiesincompatible treatment philosophies

• Clients slips between the cracks and Clients slips between the cracks and receives no services because the receives no services because the client doesn’t “fit” into the existing client doesn’t “fit” into the existing programprogram

• Providers lack a common language Providers lack a common language and treatment methodologyand treatment methodology

Mueser, Noordsy, Drake, Fox, 2003Mueser, Noordsy, Drake, Fox, 2003

Limitation of Parallel Limitation of Parallel TreatmentTreatment• MH and SA treatments are not integrated MH and SA treatments are not integrated

into a cohesive treatment packageinto a cohesive treatment package

• Treatment providers fail to communicateTreatment providers fail to communicate

• Burden of Burden of integrationintegration falls on the client falls on the client

• There are funding and eligibility barriersThere are funding and eligibility barriers

Mueser, Noordsy,Drake, Fox, 2003Mueser, Noordsy,Drake, Fox, 2003

Limitations of Sequential Limitations of Sequential TreatmentTreatment

• The untreated disorder gets worse, making The untreated disorder gets worse, making it impossible to stabilize one disorder it impossible to stabilize one disorder without attending to the otherwithout attending to the other

• There is a lack of agreement as to which There is a lack of agreement as to which disorder should be treated firstdisorder should be treated first

• It’s unclear when one Disorder has been It’s unclear when one Disorder has been treated successfully so that the other one treated successfully so that the other one can be treated. The client is not referred can be treated. The client is not referred for further treatmentfor further treatment

Integrated treatmentIntegrated treatment

The interaction between the mental The interaction between the mental health health

and/or substance abuse clinician and and/or substance abuse clinician and the the

individual, which addresses both theindividual, which addresses both the

substance abuse and mental health substance abuse and mental health needsneeds

of the individual.of the individual.

ASAM, 2001, p. 10ASAM, 2001, p. 10

Program TypesProgram Types

• Addiction or Mental Health only Addiction or Mental Health only services (AOP or MHOP).services (AOP or MHOP).

• Refers to programs that either by Refers to programs that either by choice or lack of resources (staff or choice or lack of resources (staff or financial), cannot accommodate financial), cannot accommodate clients who are have co-occurring clients who are have co-occurring disorders and require ongoing disorders and require ongoing treatment.treatment.

ASAM, 2001ASAM, 2001

Program TypesProgram Types

• Dual diagnosis Capable (DDC).Dual diagnosis Capable (DDC).

• Programs that address co-occurring mental Programs that address co-occurring mental and substance-related disorders in their and substance-related disorders in their policies and procedures, assessment, policies and procedures, assessment, treatment planning, program content and treatment planning, program content and discharge planning. discharge planning.

• These programs are geared toward either SA These programs are geared toward either SA or MH but the staff has the ability to address or MH but the staff has the ability to address the interaction between mental and the interaction between mental and substance-related disorders.substance-related disorders.

ASAM, 2001ASAM, 2001

Program TypesProgram Types

• Dual Diagnosis Enhanced (DDE).Dual Diagnosis Enhanced (DDE).

• Programs that have a high level of Programs that have a high level of integration of substance abuse and mental integration of substance abuse and mental health treatment services on a staffing, health treatment services on a staffing, services and program content level. They services and program content level. They are able to provide unified SA and MH are able to provide unified SA and MH treatment to clients who are more treatment to clients who are more symptomatic and/or functionally impaired symptomatic and/or functionally impaired as a result of the co-occurring disorders.as a result of the co-occurring disorders.

Integrated ServicesIntegrated Services

• Clinicians provide services for both Clinicians provide services for both mental illness and substance use at mental illness and substance use at the same time.the same time.

• AOP, MHOP, DDC and DDE.AOP, MHOP, DDC and DDE.

SAMHSA's Co-occurring disorders, ISAMHSA's Co-occurring disorders, IDDT tool kit, 2003DDT tool kit, 2003

Components of Integrated Dual Components of Integrated Dual Disorders TreatmentDisorders Treatment

• Knowledge about alcohol and drug Knowledge about alcohol and drug use, as well as mental illnessesuse, as well as mental illnesses

• Integrated servicesIntegrated services

• Stage-wise TreatmentStage-wise Treatment

• AssessmentAssessment

• Motivational TreatmentMotivational Treatment

• Substance Abuse CounselingSubstance Abuse Counseling

Clinicians know the effects of alcohol Clinicians know the effects of alcohol and drugs and their interactions with and drugs and their interactions with mental illnessmental illness

TreatmentsTreatments

• MedicationMedication• Illness managementIllness management• Cognitive behavioral therapyCognitive behavioral therapy• Social supportsSocial supports• Family involvement and educationFamily involvement and education• Social skills groupsSocial skills groups• Case ManagementCase Management• Refusal SkillsRefusal Skills• Psychiatric RehabilitationPsychiatric Rehabilitation

David Mee-Lee, M.D.David Mee-Lee, M.D.

Different Treatment Different Treatment MethodologiesMethodologies

• Care vs. ConfrontationCare vs. Confrontation

• Abstinence-oriented vs. Abstinence-Abstinence-oriented vs. Abstinence-mandatedmandated

• Deinstitutionalization vs. Recovery & Deinstitutionalization vs. Recovery & RehabilitationRehabilitation

David Mee-Lee, 2006David Mee-Lee, 2006

Principles of Integrated Principles of Integrated TreatmentTreatment• First and foremost is the simple fact that people First and foremost is the simple fact that people

of all ages who have co-occurring disorder are of all ages who have co-occurring disorder are people first, fully deserving of respect.people first, fully deserving of respect.

• At the same time, consumers, recovering persons At the same time, consumers, recovering persons and their families need to be involved in all and their families need to be involved in all aspects of their treatment and recovery.aspects of their treatment and recovery.

• People with co-occurring disorders can and do People with co-occurring disorders can and do recover.recover.

• People with co-occurring disorders deserve People with co-occurring disorders deserve access to the services they need to recovery.access to the services they need to recovery.

The eight research-derived and The eight research-derived and consensus-derived principlesconsensus-derived principles

• Co-occurring is an expectation, not Co-occurring is an expectation, not an exceptionan exception

• all integrated programs are not the all integrated programs are not the same; the national consensus four same; the national consensus four quadrant model for categorizing co-quadrant model for categorizing co-occurring disordersoccurring disorders

.

• Empathic, hopeful, integrated Empathic, hopeful, integrated treatment relationships are one of the treatment relationships are one of the most important contributors to most important contributors to treatment success in any setting; treatment success in any setting;

• provision of continuous integrated provision of continuous integrated treatment relationships is an evidence treatment relationships is an evidence based best practice for individuals based best practice for individuals with the most severe combinations of with the most severe combinations of psychiatric and substance difficultiespsychiatric and substance difficulties

• Case management and care must be Case management and care must be balanced with empathic detachment, balanced with empathic detachment, expectation, contracting, expectation, contracting, consequences, and contingent consequences, and contingent learning for each client, and in each learning for each client, and in each service settingservice setting

• . . When psychiatric and substance When psychiatric and substance disorders coexist, both disorders disorders coexist, both disorders should be considered primary, and should be considered primary, and integrated dual (or multiple) primary integrated dual (or multiple) primary diagnosis-specific treatment is diagnosis-specific treatment is recommendedrecommended

• Both mental illness and addiction can Both mental illness and addiction can be treated within the philosophical be treated within the philosophical framework of a "disease and recovery framework of a "disease and recovery model" (Minkoff, 1989) model" (Minkoff, 1989)

• with parallel phases of recovery with parallel phases of recovery – acute stabilization, acute stabilization, – motivational enhancement, motivational enhancement, – active treatment, active treatment, – relapse preventionrelapse prevention– rehabilitation/recovery), in which rehabilitation/recovery), in which

interventions are not only diagnosis-interventions are not only diagnosis-specific, but also specific to phase of specific, but also specific to phase of recovery and stage of change.recovery and stage of change.

Stage-wise TreatmentStage-wise Treatment

• People go through a process over People go through a process over time to recover and different services time to recover and different services are helpful at different stages of are helpful at different stages of recovery.recovery.

Stages of Change ‘Spiral Stages of Change ‘Spiral View’View’

PrecontemplationPrecontemplation““I don’t have a problem.”I don’t have a problem.”

ContemplationContemplation““Maybe I have a problem”.Maybe I have a problem”.

PreparationPreparation““I’ve got to do something”I’ve got to do something”

ActionAction““I’m ready to start”I’m ready to start”

MaintenanceMaintenance““How do I keep going?”How do I keep going?”

RelapseRelapse““What went wrong?What went wrong?

Stages of Change: Client’s Stages of Change: Client’s perspective?perspective?

MaintenanceMaintenance

ContemplationContemplation

ActionAction

PreparationPreparation

PrecontemplationPrecontemplation

Stages of Change: Client’s ViewStages of Change: Client’s View

Relapse EventRelapse Event

““There’s no problem!”There’s no problem!”

Ambivalent: “Maybe Ambivalent: “Maybe there is a problem, there is a problem, but maybe not.”but maybe not.”

Admit problem: “ I Admit problem: “ I need to do need to do

something. But something. But what?”what?”

““This is a lot This is a lot of work.”of work.”

Integrate Integrate change: “I’ve change: “I’ve got the hang got the hang

of this. “of this. “

Return to old behavior:Return to old behavior:““I hadn’t plannedI hadn’t planned

for that!”for that!”?

PrecontemplationPrecontemplationBuild rapport/ raise doubtBuild rapport/ raise doubt

ContemplationContemplation

Change: An Change: An IdealIdeal MI Approach… MI Approach…

Avoid arguing. Explore AmbivalenceAvoid arguing. Explore Ambivalence

PreparationPreparationPlan treatment around Plan treatment around

client’s goals and ideas.client’s goals and ideas.

ActionActionAffirm efforts and continue toAffirm efforts and continue toexplore ambivalence.explore ambivalence.Ask permission before giving Ask permission before giving advice, advice,

MaintenanceMaintenanceMonitor relapse risks.Monitor relapse risks.

Help in getting support Help in getting support for changefor change

RelapseRelapseRemain nonjudgmental, Remain nonjudgmental, Learn from relapse and Learn from relapse and Resist demoralizationResist demoralization

Recycle/Reoccurrence/Recycle/Reoccurrence/

Stages of change Group Stages of change Group TherapyTherapy

• Different Clients can be in different Different Clients can be in different stages and in the same group.stages and in the same group.

• Addressing the groups concern over Addressing the groups concern over what others are doing according to what others are doing according to what stage they are in.what stage they are in.

Motivational TreatmentMotivational Treatment

Clinicians use specific listening and Clinicians use specific listening and counseling skills counseling skills

Clients develop awareness, hopefulness, Clients develop awareness, hopefulness, and motivation for recovery. and motivation for recovery.

This is important for consumers who are This is important for consumers who are demoralized and not ready for demoralized and not ready for substance abuse treatment.substance abuse treatment.

A client-focusedA client-focused

semisemi-directive method for -directive method for enhancing motivation to changeenhancing motivation to change

by exploring and resolving by exploring and resolving ambivalence about changeambivalence about change

Spirit of Motivational InterviewingSpirit of Motivational Interviewing

• A genuine interest in the client’s experience A genuine interest in the client’s experience and perspectives—and perspectives—empathy.empathy.

• EmpathyEmpathy is essential. is essential.

• An An opennessopenness to a way of thinking and to a way of thinking and working that is working that is collaborativecollaborative, honors the , honors the client’s client’s self-directionself-direction, and is more about , and is more about drawing out positive changedrawing out positive change than forcing than forcing

change.change.

Our Our goalgoal for the client is to face up to a for the client is to face up to a problem; problem;

we do not need a confrontational therapeutic we do not need a confrontational therapeutic stylestyle to accomplish this. to accomplish this.

•Resistance & AmbivalenceResistance & Ambivalence

• “ “Resistance” or “lack of motivation" Resistance” or “lack of motivation" is our treatment label for the client’s is our treatment label for the client’s

unresolved unresolved ambivalence;ambivalence; for example, for example, a desire to stop using vs. a desire to a desire to stop using vs. a desire to

continue using.continue using.

• The client is stuck. This concept of The client is stuck. This concept of ambivalence is key to an MI ambivalence is key to an MI

approach. approach.

Brunette, 2003 ModifiedBrunette, 2003 Modified

Refusal SkillsRefusal Skills

• Say No FirstSay No First

• Suggest an AlternativeSuggest an Alternative

• Request the Person Stop AskingRequest the Person Stop Asking

• Avoid Making ExcusesAvoid Making Excuses

Sources of SupportSources of Support

• Family and FriendsFamily and Friends

• ProvidersProviders

• 12-Step Recovery, NA,AA and DRA12-Step Recovery, NA,AA and DRA

• NAMI and KY-CANNAMI and KY-CAN

Kenneth Minkoff:Kenneth Minkoff:

We have ten years of data showing the We have ten years of data showing the efficacy of integrated treatment.efficacy of integrated treatment.

BooksBooksDunn, C. & Rollnick, S. (2003). Dunn, C. & Rollnick, S. (2003). Lifestyle Change.Lifestyle Change. London:Mosby.London:Mosby.

Ingersoll, K. S., Wagner, C. C., & Gharib, S. (2000). Ingersoll, K. S., Wagner, C. C., & Gharib, S. (2000). Motivational Groups for Community Substance Abuse Motivational Groups for Community Substance Abuse Programs. Richmond, VA: Mid-Atlantic Addiction Programs. Richmond, VA: Mid-Atlantic Addiction Technology Transfer Center, Center for Substance Abuse Technology Transfer Center, Center for Substance Abuse Treatment (Mid-ATTC/CSAT )Treatment (Mid-ATTC/CSAT )

Miller, W. R. (Ed.) (1999). Enhancing motivation for Miller, W. R. (Ed.) (1999). Enhancing motivation for change in substance abuse treatment. Treatment change in substance abuse treatment. Treatment Improvement Protocol (TIP) Series, No. 35. Rockville, Improvement Protocol (TIP) Series, No. 35. Rockville, MD: Center for Substance Abuse Treatment. MD: Center for Substance Abuse Treatment.

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