integrated treatment for adolescents with mental health and substance use challenges presentation...

Integrated Treatment for Adolescents with Mental Health and

Substance Use Challenges

Presentation to: Consumer and Family Member

Forum

Friday, December 8th, 2006

Kari Collins, LCSWMichael Gosser, LCSW, CADC

Sonny Hatfield, LCSW

Kentucky Youth FirstDivision of Mental Health and Substance Abuse

[email protected]

[email protected]@ky.gov

mailto:[email protected]



Cabinet for Health and Family Services

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


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 adolescent’s self-identity and are not easily changed

• Families often play a pivotal role, but vary in their ability and willingness to help


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.


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.


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


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


Reclaiming Futures –

Three things that work!

System Reform

Treatment Improvement

Community Engagement


Reclaiming Futures Model


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.


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.


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.


System of Care Guiding Principles

1. 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


System of Care Guiding Principles

6. Service coordination (case management)

7. Early identification and intervention

8. Smooth transitions

9. Advocacy

10.Cultural differences and special needs


Traditional Treatment Approaches

• Sequential– One disorder then the other

• Parallel– Treated simultaneously by different professionals


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


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


Achieving Integrated Treatment

• Beginning– Addiction Only

• Intermediate– COD capable

• Advanced– COD Enhanced

• Fully Integrated


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.


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.


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


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.


CRAFFTCRAFFT yes no1. 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


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


Assessment

The comprehensive assessment, which is based on the initial screening, has several purposes:

1. To accurately identify those youth who need treatment

2. To further evaluate is a substance use disorder exists, and to what severity

3. To learn more about the nature of the youth’s substance-using behavior


Assessment (continued)

4. To identify other problem areas (medical, psychological, nutrition, social, family, education, delinquent behavior)

5. Evaluate the extent to which the family can be involved (assessment and interventions)

6. Identify strengths of the adolescent

7. Develop a written report (including severity of the problem areas, corrective plan of action, and recommendations for services)


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.


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.


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


Evidence Based Interventions

• Motivational Enhancement Therapy (MET)

• Family-Based

• Behavioral Therapy

• Cognitive-Behavioral Therapy (CBT)

• Community Reinforcement Approach


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


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 adolescent’s pro-social behaviors, decrease substance use, improve family functioning, and hold treatment gains


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 family’s resistance to treatment

• To assess interpersonal function of drug use


Family Involvement, cont.

• To interrupt non-useful family behaviors

• Identify and implement change strategies consistent with family’s interpersonal functioning and cultural identity

• Provide assertion training for child and any high-risk siblings


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


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


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


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


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


Community Reinforcement Therapy

• Combines principles & techniques derived from others (behavioral, CBT, MET, and family therapy)

• Uses incentives to enhance treatment outcomes


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


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.


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.


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 youth’s level of assimilation/acculturation


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


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


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


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


Factors Affecting Treatment Placement

• Developmental Stages• Ethnicity• Gender• Co-occurring Disorders

– Pharmacotherapy

• Family Factors• Social and Community Factors

– Peer influences– Environmental Influences– School Factors


Other Services Needed

• Determine need for multidimensional services

• Consider – Adolescent and family’s 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


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

integrated treatment for adolescents with mental health and substance use challenges presentation...

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