minority fellowship program: co-occurring mental …...minority fellowship program co-occurring...
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Minority Fellowship ProgramCo-Occurring Mental and Substance Use Disorders Webinar
Substance Abuse and Mental Health Services AdministrationU.S. Department of Health and Human Services
Minority Fellowship Program TrainingWebinar • April 3, 2019
Disclaimer
The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the
Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S.
Department of Health and Human Services.
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Co-Occurring Disorders Overview
A. Kathleen Burlew, Ph.D.Professor Emeritus
Department of PsychologyUniversity of Cincinnati
Minority Fellowship Program TrainingWebinar • April 3, 2019
Opening
Edith
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Co-occurring comorbid
The occurrence of two disorders or illnesses in the same person at the same time.
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Sequential Comorbid
Time difference between the initial occurrence of one disorder and the initial occurrence of the other
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Quiz Yourself (Question 1)
The National Survey on Drug Use and Health (NSDUH) interviewed over 68,000 households. According to the 2017 NSDUH, 46.6 million Americans met criteria for a mental disorder. What percent do you think have a substance use disorder?
Is the correct response• 9 %• 18%• 28%• 38%
The correct answer is 18%
Source:Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/
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Quiz Yourself (Question 2)
According to the 2017 NSDUH, 18.7 million adults age 18+ had a substance use disorder (SUD). What percent of those had a mental health disorder?
Is the correct response: • 20%• 30%• 45%• 60%
The correct answer is 45%
Source:Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/
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Quiz Yourself (Question 3) Prevalence of Co-occurring disorders
According to the NSDUH, how many American adults met criteria for a co-occurring substance abuse and mental disorder?
Is the correct response: • 3 million• 8.5 million• 13 million• 18.2 million
The correct answer is 8.5 million
Source:Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www. samhsa.gov/data/
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Quiz Yourself (Question 4): Co-Occurring Disorders
Which of these disorders does NOT occur more frequently among individuals with substance use disorders than the general population? a. generalized anxiety disorder b. panic disorderc. post-traumatic stress disorderd. depression e. bipolar disorderf. attention-deficit hyperactivity disorder (ADHD)g. psychotic illnessh. borderline personality disorderi. antisocial personality disorderj. all of these occur more frequently in individuals with substance use disorders than the
general population
The correct answer is ALL OF THESE.
Reference: https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders/introduction
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Racial/Ethnic Differences (Adults)
Study: Collaborative Psychiatric Epidemiology StudiesSample: 20,013 adults ages 18 years or older
Percent meeting criteria for lifetime co-occurring disorder• Whites (8.2%)• Latinos (5.8%)• Blacks (5.4%)• Asians (2.1%)
Asians: Dysthymia (DSM IV) and agoraphobia
Mericle, A., Ta, V., Holck, P., & Arria, A (2012). Prevalence, Patterns, and Correlates of Co-Occurring Substance Use and Mental Disorders in the US: Variations by Race/Ethnicity. Comprehensive Psychiatry, 53 (6). 657-665.
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Racial/Ethnic Differences (Adolescents)
Sample: 9,030 youthAges: 12-17
• Blacks, Latinos, and mixed-race adolescents were more likely than Whites to have co-occurring internalizing problems (major depression, general anxiety, traumatic stress, and risk ofsuicidality in the past year).
• Blacks and AN/AI were less likely than Whites to have externalizing problems or combined internalizing and externalizing problems (conduct disorder and ADHD).
Chisholm, C., Mulatu, M., & Brown, J. (2009). Racial/ethnic disparities in the patterns of co-occurring mental health problems in adolescents in substance abuse treatment.Journal of Substance Abuse Treatment 37 203–210
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Perspectives Regarding Causality
Approaches• Secondary substance abuse
models• Secondary psychopathology
theories• Common Factors Theory
Chicken and egg
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Secondary Substance Abuse
PRIMARYPrimary psychiatric illnesses lead to substance use disorders.
SECONDARY
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Secondary Psychopathology Theories
PRIMARYSubstance use leads to or triggers a psychiatric disturbance that would not otherwise have developed.
Gobbi, Atkin et al (February 13, 2019). Association of Cannabis Use in Adolescence and Risk of Depression, Anxiety, and Suicidality in Young Adulthood: A Systematic Review and Meta-analysis. JAMA Psychiatry. Published online doi:10.1001/jamapsychiatry.2018.4500
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Substance/Medication Induced Disorders
Substance/medication-induced mental disorders are mental problems that develop in people who did not have mental health problems before using substances, and include:
• Substance-induced psychotic disorders• Substance-induced bipolar and related disorders• Substance-induced depressive disorders• Substance-induced anxiety disorders• Substance-induced obsessive-compulsive and related disorders• Substance-induced sleep disorders• Substance-induced sexual dysfunctions• Substance-induced delirium• Substance-induced neurocognitive disorders
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Common Factors
A third factor independently increases the risk of both psychiatric illness and substance use.Examples
○ Genetic vulnerabilities○ Trauma○ Stress○ Childhood experiences
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What constitutes an integrated approach?
“An integrated approach…… identifies and evaluates each disorder concurrently and provides treatment as appropriate for each patient’s particular constellation of disorder……. (individuals) entering treatment for psychiatric illnesses should be screened for substance use disorders and vice versa .”
Reference: NIDA. (2018, February 27). Common Comorbidities with Substance Use Disorders. Retrieved from https://www.drugabuse.gov/publications/on 2019, March 24.https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders/introduction
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Diagnostic Assessment Tools
• Structured Clinical Interview for DSM (SCID 5)• PRISM• Global Assessment of Individual Needs (GAIN)
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Brief Assessment of Patient/Family Perception of Health Problems
• What do you think caused your problem? • Do you have an explanation for why it started when it did? • What does your sickness do to you; how does it works? • How severe is your sickness? How long do you expect it to last? • What problems has your sickness caused you? • What do you fear about your sickness? • What kind of treatment do you think you should receive? • What are the most important results you hope to receive from this
treatment?
Originally developed by Tripp-Reimer, Brink, & Saunders (1984) and later updated in Belief and Traditions that impact the Latino Healthcare https://www.medschool.lsuhsc.edu/physiology/docs/Belief%20and%20Traditions%20that%20impact%20the%20Latino%20Healthcare.pdf
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Other Cultural Issues in Assessment
Race/Ethnicity and Psychiatric Diagnoses• Blacks more likely to be diagnosed with schizophrenia and less likely to be
diagnosed with mood disorders (Burlew, Enoch-Morris,Camphina-Capote, 1998).
• Advantage of structured assessment instruments
Substance Use DiagnosesDifferences in endorsement of substance use symptomsWu LT, Pan JJ, Blazer DG, Tai B, Stitzer ML, Woody,GE. (2010)
Measurement EquivalenceTrauma Symptom Checklist
Ghee, A., Johnson, C., & Burlew, A.K., (2010) Measurement Equivalence of the Trauma Symptom Checklist-40 for African American and Caucasian Female Substance Abusers. Journal of Aggression, Maltreatment & Trauma, 19: 8, 820-838
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Treatment Challenges
• Few integrated treatments are available.1. Seeking Safety: PTSD and substance abuse2. Real Men are Safe (REMAS): HIV prevention and substance abuse.
• Impact of Health Disparities Issues– Differences in access to care– Access to Recovery Capital
• Treatment providers trained in either substance use or mental disorders and focus on that area.
• Attending adequately to contextual factors
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Other Treatment Issues
• Advantage of providing culturally adapted or culturally tailored interventions– Gordon Hall (meta-analysis)– REMAS (HIV risk reduction among substance users (Calsyn, Burlew, et al., 2013 )
• Program capacity to match services to client’s stage of treatment(engagement, motivation, active treatment, recovery)
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Summary
• Co-occurring disorders are widespread.• Evidence suggests racial/ethnic differences in co-occurring
disorders.• An integrated approach includes the evaluation and treatment
of each disorder along with addressing cultural issues.• Cultural factors are present in assessment and treatment
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Kathleen Burlew Contact Information
A. Kathleen Burlew, PhD.Professor EmeritusDepartment of PsychologyUniversity of Cincinnati
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Healthy Minds, Healthy Bodies, Healthy Communities:Perspectives from the Arab American Community
Carolynn Dougherty, MA, LPCBehavior Health Clinical Supervisor
Arab Community Center for Economic & Social Services (ACCESS) Community Health and Research Center
Minority Fellowship Program TrainingWebinar • April 3, 2019
Who are Arab Americans?
The Elias Zainea family left Damascus, Syria in 1897 (Courtesy of Joe Zainea)
Arab Americans In Michigan: Demographics (Country of Origin)
United States33%
Iraq20%
Lebanon22%
Yemen17%
Other8%
Country of Origin, Arab Adults, Michigan, 2016
United States Iraq Lebanon Yemen Other
Arab Americans In Michigan: Demographics (Household Income by percent)
< $25,00048%
$25,000 -$49,999
20%
$50,000+ 32%
HOUSEHOLD INCOME BY PERCENT
< $25,000 $25,000 - $49,999 $50,000+
Arab Americans In Michigan: Demographics (Age by percent)
18 - 4459%45 - 64
30%
65+11%
AGE BY PERCENT
18 - 44 45 - 64 65+
General Health Status
*Source: CDC Health Indicators; Gallup Healthways Well Being Index; 2012 CDC - Morbidity and Mortality Weekly Report (MMWR); Preliminary Report, Refugee Health Study, Oakland University ; National Institutes of Mental Health Statistics
Observations
• High rates of PTSD• Inevitable link between PTSD and Substance Use• Study on Arab American Pathways to Treatment• Comorbidities amplified by acculturation• Language and culture can be a barrier to westernized
treatment
Source: Arfken, Cynthia & Berry, Alec & Owens, Darlene. (2009). Pathways for Arab Americans to Substance Abuse Treatment in Southeastern Michigan. Journal of Muslim Mental Health. 4. 31-46.
Risk Factors and Culture
Acculturation
• Weather• Lack of Transportation• Language• Mental Health
• Sedentary Lifestyle• Unhealthy Diet• Risky Behaviors
Number of substances of abuse by level of acculturation
Level of AcculturationOne Substance of
Abuse(N = 121)
Two or More Substances of Abuse
(N = 26)
N (%) N (%) n (%)
Low 21 14.3 21 17.4 0 0
Moderate 71 48.3 62 51.2 9 34.6
High 55 37.4 38 31.4 17 65.4Level of acculturation was defined by birth in the US, 10 or more years in the US and fluency with English
Source: Arfken, Cynthia & Kubiak, Sheryl & Farrag, Mohamed. (2009). Acculturation and Polysubstance Abuse in Arab-American Treatment Clients. Transcultural psychiatry. 46. 608-22.
Employability & Mental Health
The ACCESS Model
Healthy Minds: Behavioral Health
Counseling programs, support groups, substance abuse treatment
programs, psychosocial rehabilitation, victims of crime
Healthy Bodies:Physical Health
Physicals, disease screenings, mobile and dental clinic, OB/GYN,
laboratory services, pharmacy
Healthy Communities:Public Health
Substance abuse, domestic violence, infectious disease,
healthcare enrollment, research, refugee health, WIC,
child/adolescent
65+ programs offering culturally and linguistically sensitive services to a diverse clientele
INTEGRATION: Person-Centered Care
Meet the patient where they are at and when they are ready
Our role is to address social determinants of health
Multidisciplinary approach
• One Stop Shop – Co-location
• Cross Training over departments
• Loyalty to agency, not just the program
Co-Located & Collaborative Quality Care Processes
The Power of Peers
• Cultural Humility
• Focus on Empowerment
• Social Mobilization
Empowerment
ACCESS Client: Percent Improvement in Health Outcomes
26.3
33.9
54.9
64.3
28.7
36.842.6
70.867
31.3
0
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Overall Health Functioning in EverydayLife
Serious PsychologicalDistress
Not using Tobaccoanymore
Attending school orEmployed
Baseline Follow up
Carolynn Dougherty Contact Information
Carolynn E. Dougherty, M.A., LPCBehavior Health Clinical SupervisorArab Community Center for Economic & Social Services (ACCESS) Community Health and Research Center
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Evidence Based Practice: Supported Employment
Zandia Lawson, MSW, LSWMental Health Administrator
Employment and Work Incentives/Benefits PlanningOhio Mental Health and Addictions Services
Minority Fellowship Program TrainingWebinar • April 3, 2019
Work and Recovery
• Most people want to work and see work as an essential part of their recovery!
• Working may prevent entry into disability system or allow people to transition off benefits.
• Employment plays a central role in any individual’s mental wellbeing and quality of life.
• Work plays an important role in financial independence, personal status, and allows individuals participate in their community.
• Working can help people feel better, alleviate poverty, reduce stigma in society.
What is IPS?
• Individual Placement and Support (IPS) is a model of supported employment for people with serious mental illness and co-occurring substance use disorders. IPS supported employment helps people living with behavioral health conditions work at regular jobs of their choosing. Although variations of supported employment exist, IPS refers to the evidence-based practice of supported employment.
• IPS was originally studied and validated with people with serious mental illness, including people with co-occurring substance use disorders.
• IPS is based on 8 principles.
IPS Core Principles
• Zero Exclusion - eligibility is based on client choice• Competitive employment is the goal• Personalized work incentives/benefits planning is provided• Rapid job search• Employment specialists build employer relationships• Follow-along supports are continuous • Client preferences are honored • Supported employment is integrated with treatment
Zero Exclusion
• Program eligibility is based on client choice. No one is excluded who wants to participate.
• Clients are not excluded because they are not “ready” or because of lack of prior work history, hospitalization history, substance use, symptoms, or other characteristics.
Competitive Employment is the goal
• Anyone can apply to jobs
• Pay at least minimum wage/same pay as coworkers with similar duties
• There are no artificial time limits imposed by the social service agency
Personalized Work Incentives/Benefits Planning Is Provided
• Benefits planning and guidance help clients make informed decisions about work.
• Employment specialists help clients obtain personalized, understandable, and accurate information about their Social Security, Medicaid, and other government benefits.
Rapid Job Search
• Job search starts soon after a client expresses interest in working.
• IPS programs use a rapid job search approach to help job seekers obtain jobs. The first face-to-face contact with the employer occurs within 30 days of program entry.
• Pre-employment assessments are kept to a minimum.
Employment Specialists Build Employer Relationships
• Each specialist makes at least 6, in-person contacts with hiring managers each week.
• Employment specialists systematically visit employers, who are selected based on the client’s preferences, to learn about their business needs and hiring preferences.
Follow-Along Supports Are Continuous
• Employment specialists continue to stay in regular contact with client’s and, when appropriate, the employer without arbitrary time limits.
• Job supports are individualized and continue for as long as each client wants and needs the support.
Client Preferences Are Important
Job seeking is based on client preferences, strengths, and work experiences, not on a pool of jobs that are available.
IPS Is Integrated with Mental Health Treatment
• IPS programs are integrated with mental health treatment teams. Employment specialists attach to 1 or 2 mental health treatment teams. In many mental health organizations, employment specialists are attached to Assertive Community Treatment (ACT) and Integrated Dual Disorders Treatment (IDDT) teams.
• Employment specialists coordinate services with treatment team members, including, case managers, therapists, prescribers, and other community providers, for example vocational rehabilitation and housing programs.
Key Players in the IPS Model
• Client
• Employment specialists
• Case managers
• Counselors, Prescribers
• Work Incentives/Benefits Counselor
• VR Counselor
Work and Recovery
In 2014, NAMI, the National Alliance on Mental Illness, completed a report, Road to Recovery: Employment and Mental Illness. The report concluded by stating “mental illness should no longer sentence people to poverty. People living with mental illness want to work, frequently can work, and models have been developed to help them succeed.”
Work and Recovery (con't)
• IPS Supported Employment is a model that has proveneffectiveness with individuals with serious mental illness,including people with co-occurring substance use disorders.
• People with co-occurring mental illness and substance usedisorders do want to work and can work in integratedcompetitive employment with the right services and supports.
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Resources
The IPS Employment Center
NAMI Road To Recovery (PDF)
SAMHSA Integrated Treatment for Co-Occurring Disorders Evidence-Based Practices (EBP) KIT
Zandia Lawson Contact Information
Zandia Lawson, MSW, LSWMental Health AdministratorEmployment and Work Incentives/Benefits PlanningOhio Mental Health and Addictions Services
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Practical Approaches for Providers
Mindy L. VanceBureau Chief
Bureau of Support Services Ohio Mental Health and Addictions Services
Minority Fellowship Program TrainingWebinar • April 3, 2019
Background
• Historically, marginalized groups and individuals of lower socio-economic status have experienced:– Higher rates of health related issues– Lower rates of access to services, specifically diversity competent
services– Lower treatment outcomes– Milburn, Beatty, & Lopez (2019)
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Background (con't)
• Within behavioral health itself, we have two systems that lendthemselves to inequity:– Community Behavioral Health System– Private Behavioral Health System
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History, Experience, and Perception Matters
• According to Milburn et al,. (2019), to begin the process of reducing inequity, “it is critical to build, support, and sustain a health workforce of well-informed, competent leaders, researchers, and practitioners committed to this complex and challenging work” (p. 1).
• In order to build this workforce, we need to:– Increase diversity– Reduce implicit and explicit bias– Provide culturally appropriate person-centered services– Develop a thorough understanding of the history and power of privilege and it’s impact on
communities and individuals.– Understand that perception matters – Enhance our empathetic reasoning skills– Recognize that it is complicated
• Additionally, we need to learn to say “maybe I am not the best person to help this individual.”
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History, Experience, and Perception Matters (con't)
Personal & Environmental Factors
• Cultural Identity• Stigma• Recognition of Mental Health
Problems• Social Networks• Gender Differences• Financial Factors
– Memon, Taylor, Mohebati, Sundin,Cooper, Scanlon, & de Visser, (2016).
Relationship between Individual & Provider
• Waiting Times (differences with mentalhealth and substance use disorders)
• Language• Communication• Power Dynamics• Responding to Needs• Cultural Naivety, discrimination, &
Insensitivity with mental health andsubstance use disorders
• Awareness of Services– Memon, Taylor, Mohebati, Sundin, Cooper,
Scanlon, & de Visser, (2016).
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How Therapists Drive Away Minority Clients (Psychology Today 2013) Monnica T Williams Ph.D.
• Racist remarks by therapists– “I don’t see you as Black. I just see you as a regular person.”
• I’ve commented previously on this type of remark (see my article on circularstereotypes). It tells the client that the therapist finds the client odd or irregular insome way, due to their Blackness. It is as if something is wrong with being a personof color and the therapist is going above and beyond the call of duty to politelyignore inconvenient differences.
– “I’m not sure we need to focus on race or culture to understand yourdepression.”
• This illustrates the therapist’s own discomfort with the idea that racism andmental health are linked (Chae et al., 2011; Chao et al., 2012). Furthermore, how canthe therapist possibly know if racism is cause the of the client’s mental healthproblem when s/he won’t even take the time to listen and learn? The client quicklydiscovers this therapist will not take him/her seriously.
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How Therapists Drive Away Minority Clients (Psychology Today 2013) Monnica T Williams Ph.D. (con't)
Racist remarks by therapists– “If Black people just worked harder, they could be successful like other
people.”• This shows that the therapist has uncritically accepted the pathological stereotype
that African Americans are just plain lazy. By extension, the client is also lazy andwould be successful and happy with a bit of good hard work. It also ignores socialforces, such as institutionalized racism and other barriers that make it harder forminorities to be successful.
– “Don’t be too sensitive about the racial stuff. I didn’t mean anythingbad/offensive.”
• Gotcha. The therapist made a racist remark and this client was brave enough to call itout. Does the client get an apology from the therapist or even a discussion of theoccurrence? No, in a typical blame-the-victim fashion, the client is accused of beinghypersensitive. After all, the therapist meant well. Right.
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Service Linkage
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Service Linkage (2)
1. Ask the individual what they want and need2. Provide them with information to make an informed choice;
are they interested in mental health, substance use disorder,or co-occurring treatment and recovery services– Look locally
• Community Association
– Seek out advocacy organizations• Urban League
– Build a list of diversity based practitioners• Networking
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Service Linkage (3)
• MFP participants, please professionally market yourself with communityassociations, advocacy organizations, and professional database services such asPsychology Today along with the services you provide including co-occurringservices.
• When I searched African American Psychologists in Columbus, Ohio 40 AfricanAmerican professionals and their contact information were listed.
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References
• Chae, D. H., Lincoln, K. D., & Jackson, J. S. (2011). Discrimination, attribution, and racial group identification: Implications forpsychological distress among Black Americans in the National Survey of American Life (2001-2003). American Journal ofOrthopsychiatry, 81(4), 498-506.
• Chou, T., Asnaani, A., & Hofmann, S. G. (2012). Perception of racial discrimination and psychopathology across three U.S.ethnic minority groups. Cultural Diversity and Ethnic Minority Psychology, 18(1), 74-81.
• Constantine, M.G. (2007). Racial Microaggressions Against African American Clients in Cross-Racial Counseling Relationships.Journal of Counseling Psychology, 54(1), 1-16.
• Memon, A., Taylor, K., Mohebati, L. M., Sundin, J. Cooper, M., Scanlon, T., & de Visser, R. (2016). Perceived barriers to accessingmental health services among black and minority ethnic (BME) communities: a qualitative study in Southeast England. BMJOpen, 6(11), 1-9.
• Milburn, N. G., Beatty, L., & Lopez, S. A. (2019). Understanding, unpacking, and eliminating health disparities: A prescription forhealth equity promotion through behavioral and psychological research—an introduction. Cultural Diversity and EthnicMinority Psychology, 25(1), 1–5.
• Sue, D. W., et al. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist,62(4), 271-286.
• Terwilliger, J. M., Bach, N., Bryan, C., & Williams, M. T. (2013). Multicultural versus Colorblind Ideology: Implications for MentalHealth and Counseling. In Psychology of Counseling, A. Di Fabio, ed., Nova Science Publishers. ISBN-13: 978-1-62618-410-7.
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Mindy Vance Contact Information
Mindy L. VanceBureau ChiefBureau of Support Services Ohio Mental Health and Addictions Services
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Thank You
SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.
www.samhsa.gov1-877-SAMHSA-7 (1-877-726-4727)
1-800-487-4889 (TDD)
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