Transcript NIMH Co-Occurring Disorders Curriculum

Court-Based Interventions and
Co-Occurring Disorders
Florida Partners in Crisis 2012 Annual
Conference and Justice Institute
Orlando, Florida, July 13, 2012
Presented by Roger H. Peters, Ph.D., University of South Florida, and
Fred C. Osher, M.D., Council of State Governments Justice Center
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Workshop Outline
I.
II.
III.
IV.
V.
VI.
Overview of workshop
Integrated screening and assessment
Modifications to court program
structure and treatment
Clinical Considerations: Principles of
care for CODs
Linking to EBP’s in the community
Q&A
2
(GAINS Center, 2004;
Steadman et al., 2009)
Co-Occurring Substance Use
Disorders
74% of state prisoners with mental
problems also have substance abuse or
dependence problems
(U.S. Department of Justice, 2006)
4
Persons with CODs
Repeatedly cycle through the criminal justice
and treatment systems
 Experience problems when not taking
medications, not in treatment, experiencing
mental health symptoms, using alcohol or drugs
 Small amounts of alcohol or drugs may trigger
recurrence of mental health symptoms
 Antisocial beliefs similar to other offenders
 More criminal risk factors than other offenders

5
Conceptual Model of COD Treatment
Services in Specialty Courts
Select High Risk Population
• Co-occurring disorders
• Higher levels of risk and need
Optimize the Treatment Process
Blended Screening and
Assessment Strategies
Specialized
Supervision
Judicial hearings
Community
supervision
• Matching to treatment and
supervision (by risk and need)
• Address special needs
• Continuing care (post-graduation)
COD Treatment
Integrated treatment services
Cognitive-behavioral treatment
Medications
Contingency management
MET/motivational interventions
Relapse prevention
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Integrated Screening and Assessment
• Routine screening for both sets of disorders
• Identify acute symptoms
• Focus on areas of functional impairment that
would prevent effective drug court participation
• Examine longitudinal interaction of disorders
• Assess participant motivation
Brief Jail
Mental
Health
Screen
Global
Appraisal
of Need
(GAIN-SS)
Mental
Health
Screening
Instruments
Mental
Health
Screening
Form-III
MINIScreen
8
Global
Appraisal of
Need
(GAIN-SS)
TCU Drug
Screen - II
Substance
Use
Screening
Instruments
ASIAlcohol and
Drug Abuse
sections
Simple
Screening
instrument
(SSI)
9
Features of COD Treatment
•
•
•
•
Highly structured treatment services
Destigmatize mental illness
Focus on symptom management vs. cure
Education regarding individual diagnoses
and interactive effects of CODs
• “Criminal thinking” groups
• Basic life management and problem-solving
skills
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COD Program Phases
• Orientation
• Relapse prevention/transition
• Intensive treatment
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Treatment Modifications - I
• Higher staff-to-participant ratio
• Increased length of services:
• Pace of treatment slower
• Flexible progression through treatment allowed
• Ongoing tracking and case monitoring
• Extended exit and re-entry policies
• Treatment may last for more than one year
Treatment Modifications - II
• Integrated treatment to address MH and SA issues
• More emphasis on education and support rather
than compliance and sanctions
• Motivational interventions in both group and
individual settings
• Cognitive and memory enhancement strategies
• Case management and outreach services
• Focus on housing, employment, medication needs
Modifying Treatment for
Cognitive Impairment
•
•
•
•
•
Minimize need for abstraction (e.g.,
use concrete, specific scenarios)
Have demonstrate skills
Keep instructions brief
Use audiovisual aids
Keep role plays short and focused
(Bellack, 2003)
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Program Modifications for CODs
• Supplementary services (COD treatment
groups, medication clinic, case
management/crisis intervention)
• Tracks within specialty court programs
• COD dockets
• Transfer between drug courts, mental
health courts, COD dockets
• Extended program duration (e.g., 18 mos.)
• Blended screening and assessment
• Specialized supervision teams 15
Other Modifications for CODs
• Community partnerships for COD/MH services
• Recovery-oriented treatment planning and case
management
• Dually credentialed staff
• Focus on incentives and non-punitive sanctions
• Specialized supervision teams
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Modifying Court Hearings
• More frequent court hearings may be needed
• Hearings provide a good opportunity to recognize
and reward positive behavioral change
• Less formal, smaller, more private
• Greater interaction between judge and participants
• Include mental health professionals
Community Supervision and CODs
•
•
•
•
•
•
Specialized caseloads (MH/COD)
Smaller caseloads (e.g., < 45)
Sustained and specialized officer training
Active engagement in SA and MH treatment
Dual focus on treatment and surveillance
Specialized caseloads more effective w CODs
- Lower rates of revocation, arrest, incarceration
- Better linkage with community treatment services
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Community Supervision and CODs
• Problem-solving approach
- Higher revocation threshold
- Wide range of incentives and sanctions
- Flexibly apply sanctions
- Avoid sanctions that remove participants
from treatment
• Relationship quality important (trust,
caring-fairness, avoid punitive stance) –
“firm but fair”
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(See Skeem et al., 2006, 2009)
Court Based Interventions:
Clinical Considerations

Fred Osher, M.D.
Awareness: Consequences of
Co-occurring Disorders
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
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Increased vulnerability to relapse and
rehospitalization
More psychotic symptoms
Inability to manage finances
Housing instability and homelessness
Noncompliance with medications and treatment
Increased vulnerability to HIV infection and
hepatitis
Medical Complications of Co-Occurring
Substance Use: HIV and Hepatitis B and C
25%
20%
15%
10%
5%
0%
Seroprevalnce Rates in SMI
Sample
HIV (N=931)
HBV (N=751)
HCV(N=751)
Rosenberg et al., A J Public Health, 2001
Persons with Substance Use
Disorders had
 2.95 (1.25-6.86) increased
chance of having HIV
 1.74 (1.20-2.51) increased
chance of having HBV
 2.42 (1.62-3.63) chance of
having HCV
Consequences of Co-occurring
Disorders (cont.)
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Lower satisfaction with familial relationships
Increased family burden
Violence
Return to Incarceration
Increased depression and suicidality
Higher service utilization and costs
Principles of care
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Integrated treatment
Screening, Assessment, and
Individualized Treatment Planning
Assertiveness
Close monitoring
Longitudinal perspective
Harm reduction
Stages of change
Stable living situation
Cultural competency and consumer
Optimism
centeredness
1. Integrated treatment

Traditional models of treatment for dual disorders
results in poor outcomes
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
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
no treatment -- high utilization of E.R., jails, hospitals
sequential treatment
parallel treatment -- burden of integration on individual
Fragmentation
Integrated treatment associated with better
outcomes in SMI and perhaps non-SMI
Past Year Mental Health Care and Treatment for Adults Aged 18 or Older with Both
Serious Mental Illness and Substance Use Disorder
Source: NSDUH (2008)
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FIDELITY TO DUAL DIAGNOSIS
PRINCIPLES
2. Screening, Assessment, and Individualized
Treatment Planning Definition: Screening

A formal process of testing to determine whether a client
does or does not warrant further attention at the current time
in regard to a particular disorder and, in this context, the
possibility of a co-occurring substance or mental disorder.

The screening process for co-occurring disorders (COD)
seeks to answer a “yes” or “no” question: Does the substance
abuse [or mental health] client being screened show signs of
a possible mental health [or substance abuse] problem?

Note that the screening process does not necessarily identify
what kind of problem the person might have, or how serious it
might be, but determines whether or not further assessment
is warranted.
A Framework for Prioritizing Target Population
Low Criminogenic Risk
Medium to High Criminogenic Risk
(low)
(med/high)
Low Severity of
Substance Abuse
Substance Dependence
(med/high)
(low)
Low Severity
of
Mental Illness
(low)
Serious
Mental Illness
Serious
Mental Illness
(med/high)
Low Severity
of
Mental Illness
(low)
Group 1
I–L
CR: low
SA: low
MI: low
Group 2
II – L
CR: low
SA: low
MI: med/high
Group 3
III – L
CR: low
SA: med/high
MI: low
Low Severity of
Substance Abuse
Substance Dependence
(med/high)
(low)
Serious
Mental Illness
(med/high)
Low Severity
of
Mental Illness
(low)
(med/high)
Low Severity
of
Mental Illness
(low)
Group 4
IV – L
CR: low
SA: med/high
MI: med/high
Group 5
I–H
CR: med/high
SA: low
MI: low
Group 6
II – H
CR: med/high
SA: low
MI: med/high
Group 7
III – H
CR: med/high
SA: med/high
MI: low
Council of State Governments Justice Center
Serious
Mental Illness
(med/high)
Group 8
IV – H
CR: med/high
SA: med/high
MI: med/high
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2. Screening, Assessment, and Individualized
Treatment Planning Definition: Assessment


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A basic assessment consists of gathering key information
and engaging in a process with the client that enables the
counselor/therapist to understand the client’s readiness for
change, problem areas, COD diagnosis, disabilities, and
strengths.
An assessment typically involves a clinical examination of
the functioning and well-being of the client and includes a
number of tests and written and oral exercises. The COD
diagnosis is established by referral to a psychiatrist or
clinical psychologist.
Assessment of the COD client is an ongoing process that
should be repeated over time to capture the changing nature
of the client’s status.
Individualized Treatment Planning Steps
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1. Evaluate pressing needs
2. Determine motivation to address
substance use/mental health problems
3. Select target behaviors for change
4. Determine interventions/conditions to achieve
desired goals
5. Choose measures to evaluate the
intervention
6. Select follow-up times to review the plan.
3. Assertiveness


Responsibility of systems to support
outreach and engagement services
Successful interventions:


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“go wherever the client is”
In-reach to institutional settings
work with family, landlords and employers
Forensic Assertive Community Treatment
(FACT)
4. Close monitoring
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Intensive supervision needed until stable
Sometimes coercive, always persuasive
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
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representative payeeship
mandatory substance abuse treatment
urine testing
The essence of court-based interventions
5. Longitudinal perspective

Mental health, substance use disorders, and
disease are chronic, relapsing conditions

Treatment occurs continuously over years

Progress measured over time

What is the courts role in the recovery
trajectory
6. Harm reduction strategies

Assume:
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continuum from abstinenceproblematic use
abuse/dependence
reducing quantity/frequency of use decreases
likelihood of negative consequences
Provide alternatives to traditional abstinence
only philosophies
More likely to engage those who don’t yet
have abstinence as a goal
Tough concept in drug court context
7. Stages of change

Engagement - connecting people to treatment

Persuasion - convincing engaged clients to
accept treatment

Active treatment - range of behavioral,
psychoeducational and medical interventions

Relapse prevention - prevention and
management of relapses
COURSE OF ATTAINING STABLE
REMISSION
(Drake et al, 1997)
are
Grap
QuickTim
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hics deco
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100
90
80
Recovered
70
Relapse Prevention
Percent
60
Late Active Treatment
50
Early Active Treatment
40
Late Persuasion
30
Early Persuasion
20
Engagement
10
Pre-engagement
0
0 mo.
6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.
Assessment Point
8. Stable living situation


Not having a home makes assessment difficult and
protracted
Range of safe, affordable housing options are
necessary
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safe havens or low demand residences for engagement and
persuasion
alcohol and drug free housing during active treatment and
relapse prevention
Separate conditions and treatment from housing
Flexibility and tolerance required to retain people in
housing
9. Cultural competency and
consumer centeredness

Seek to understand - don’t assume a
shared set of values or impose one’s own

Respect cultural differences

Value the consumer’s point of view
10. Optimism

Critical ingredient for recovery

Hope as an antidote to despair
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Must have courage to connect with the reality of despair
Share belief that because the problems are severe, the
person deserves help
Create a vision of what a hopeful outcome might be
Peer supervision and training to bolster staff
optimism
Integrating Treatment with Supervision
Transformation: Integrated Public HealthPublic Safety Court Strategies
(NIDA 2006)
Communitybased
treatment
Close
supervision
Blends functions of
criminal justice and
treatment systems to
optimize outcomes
Opportunity to avoid
incarceration or
criminal record
Consequences for
noncompliance are
certain and immediate
Questions for Discussion
What is the capacity of your community behavioral health
providers to serve the target population and willingness to
partner with the court diversion efforts?
What is the quality of behavioral health services available to
the target population?
What is the priority given to criminal justice involved clients
for community behavioral services?
Q&A
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