gaps in service towards reaching co-occurring capability
DESCRIPTION
Gaps in Service Towards Reaching Co-occurring Capability. Anthony (AJ) Ernst, Ph.D. Ernst & Associates [email protected]. Bringing DDCAT to Tennessee. 2009 – TN works with TN COD Advisory Committee and TN SA programs to explore DDCAT application - PowerPoint PPT PresentationTRANSCRIPT
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Gaps in Service Towards Reaching Co-occurring
Capability
Anthony (AJ) Ernst, Ph.D.Ernst & [email protected]
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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
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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
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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?
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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?
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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)
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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
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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
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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
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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
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MHSUDs
The behaviors may be independent
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MHSUDs
One problem may precede another,as in this example
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MH SUDs
The problems may otherwise interact with each other
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STRESS
MH
SUDs
Outside factors may affect both substance use problems and mental health problems
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STRESSMH
SUDs
PHYSICALILLNESS
And we have to be aware that triple diagnosis issues are never far away
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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.
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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
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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?
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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)
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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)
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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
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EXAMPLE TARGETS – BEHAVIOR TO DECREASE
PANIC ATTACKSFrequency of occurrenceIntensity of occurrenceDuration of occurrence
STAGING ISSUESBeliefs around causes
Beliefs around medication useFamily social system
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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
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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?
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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.
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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?
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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
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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?
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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
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DDCAT, leading to a program that is...
Welcoming
Accessible
Integrated
Continuous
and
Comprehensive
= “No Wrong Door”
With a common goal of RECOVERY