Transcript RSAT Training Tool: Co-occurring Disorders and Integrated

RSAT Training Tool:
Co-occurring Disorders
and Integrated
Treatment Strategies
Lisa Braude, PhD
Niki Miller, M.S. CPS
Advocates for Human Potential
www.ahpnet.com
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Objectives
►
Discuss the prevalence of CODs among RSAT
clients and their impact on criminal behavior,
addiction recovery and recidivism.
Explain the importance of integrated substance
abuse screening and assessment for co-occurring
disorders and identify effective practices.
► List reasons to champion integrated treatment,
educate clients on sustained recovery self
management and link to community providers.
►
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Prevalence in Corrections
Approximately 8.9 (4%) million adults in the
U.S. have co-occurring disorders
► people
in substance abuse treatment that have a
mental health problem = 50%
► People in jails and prisons with substance
problems = 65% ↑
► people in prison who use substances also report a
mental health problem = 74%
► people in jail with mental health disorders that
also have a substance use problem= 76%
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Relevance to RSAT Programs
RSAT staff should expect that cooccurring mental health problems will be
the expectation and not the exception for
offenders in substance abuse treatment.
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Practices and Principles
Inmates have a legal right to treatment for
medical conditions—including mental health
disorder. Facilities are required to screen for
mental health disorders and suicide risk and
offer treatment to stabilize offenders who
attempt suicide or have acute psychiatric
symptoms. However, that legal right does not
extend to treatment for substance use disorders.
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Relevance to RSAT Programs
RSAT clients with CODs:
• May already be diagnosed with a mental health
disorder
• May develop symptoms of a mental health disorder
over time
• May have symptoms that become more severe or
improve over time
• May have disorders that have gone undetected
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Relevance to RSAT Programs
Signs of a co-occurring disorder that a correctional
officer may notice:
•
•
•
•
•
•
Seemingly intentional verbal disruptive outbursts
Changes in inmate behavior over time
The inmate may be an easy target for others
Behavior may seem bazaar or out of the ordinary
Withdrawing, self injury and internalizing
Aggression or defensiveness resulting in restraint or
seclusion
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Practices and Principles
Basic competencies to deliver integrated RSAT
treatment:
►
►
►
Prevalence, signs, and symptoms of co-occurring
disorders and ongoing screening and assessment
Focus on interactions between mental and substance
use disorders and how they affect recovery
Integrated evidence-based interventions, team
treatment approaches and community collaboration
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Relevance to RSAT Programs
► Collaboration
► Screening
and assessment
► Integrated treatment interventions
► Case management and re-entry
► Peer and community-based support
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Module I: Signs and Symptoms
Mental health disorders (mental illnesses) are
conditions that can disrupt a person's thinking,
feeling, mood, behavior, and ability to relate to
others.
► can
affect every area of a person’s life
► involve changes in the brain
► may respond to medications
► symptoms and severity fluctuate
► individual response to treatment approaches vary
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Signs and Symptoms
Addiction is a chronic, condition with a high
potential for relapse, characterized by
compulsive drug seeking and use, despite
harmful consequences.
► can
affect every area of a person’s life
► involve changes in the brain
► may respond to medications
► symptoms and severity fluctuate
► individual response to treatment approaches vary
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Signs and Symptoms
A “co-occurring disorder” is used to describe a
simultaneous substance use disorder and
mental health disorder.
A mental disorder should be established
independent of the substance use disorder,
rather than symptoms resulting from substance
use.
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Who Has a Co-Occuring Disorder?
Marsha- age 42; Both children in placement. Used crack and
alcohol for several years. Speaks about her time on the streets
with pride and nostalgia. Cycles through periods of intense
moods; rarely fully present during groups. She is either
completely withdrawn or talking through the entire group
without letting other participants speak.
 SUD
 Mental Illness
 Neither
Co-occurring disorder? yes  no 
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Who Has a Co-Occuring Disorder?
Brian – age 33; In college, began heavy cocaine use and binge
drinking. Started having violent episodes with roommates and
dropped out of school. Family found him living in an abandoned
building. Remained homeless, was arrested for public nudity,
drunk and disorderly, and shoplifting, etc. more than 25 times.
Last time he hit an officer because he thought the police were
imposters dressed as police officers.
 SUD
 Mental Illness
 Neither
Co-occurring disorder? yes  no 
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Who Has a Co-Occuring Disorder?
Steve- age 29; Self-injures—visible scarring on arms and
shoulders. Psychiatric medications make it difficult to keep him
awake during group. Reports he was raped by cell mate last time
he was in jail. Attempted suicide during his second week out on
parole by barbiturate overdose. Violated due to the presence of
barbiturates in urine screen.
 SUD
 Mental Illness
 Neither
Co-occurring disorder? yes  no 
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Screening Assessment for CODs
Screening
vs.
Clinical assessment
vs.
Risk and needs assessment
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Screening
Screening seeks to answer a “yes” or “no”
question:
Does the substance abuse client being screened
show signs of a possible mental health problem?
OR
Does the mental health client being screened
show signs of a possible substance abuse
problem?
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Evidence-based Mental Health
Screening Tools
Description
Modified MINI Screen
(MMS)
22 Yes-No items that screen for anxiety and mood disorders, trauma exposure
and PTSD, and non-affective psychoses
18 Yes-No items about current and past symptoms covering schizophrenia,
depressive disorders, PTSD, phobias, intermittent explosive disorder, delusional
Mental Health Screening Form III
disorder, sexual and gender identity disorders, eating disorders, manic episode,
(MHSF III)
panic disorder, obsessive-compulsive disorder, pathological gambling, learning
disorders, and mental retardation
K6 Screening Scale
Brief Mental Health Jail Screen
(BMHJS)
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The tool consists of 6 items, each with a 0-4 point rating scale, that screen for
general distress in the last 30 days (Kessler, et al., 2003). Maximum precision is
in the clinical range of the scale, that is, for people with anxiety or mood
disorders or non-affective psychoses whose level of functioning is seriously
impaired.
The BMHJS is a tool that takes less than 3 minutes; contains only 8 yes or no
questions; is simple to incorporate into the booking process by corrections
officers; is quickly administered.
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Evidence-based Substance Use
Screening Tools
Description
16 items, 14 of them scoreable; most items tap symptoms of alcohol and
Modified Simple Screening
drug dependence, including prescription and over-the-counter
Instrument for Substance Abuse medications, during the past six months. Several items tap lifetime and
(MSSI-SA)
current use problems for respondents and lifetime use problems for family
members.
CAGE Adapted to Include
Drugs
(CAGE-AID)
Alcohol, Smoking, and
Substance Involvement
Screening Test
(ASSIST)
TCUDS-II
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A modified version of the CAGE screen for alcohol problems, the CAGEAID is a four-item conjoint screen for alcohol and substance abuse.
The tool consists of seven items or questions regarding each of ten
substances (a total of 70 questions) and one item or question about drug
injection. A specific "substance involvement" (risk) score is calculated for
each substance, and that score drives a recommendation for no
intervention, brief intervention, or more intensive treatment for each
substance.
The Texas Christian University Drug Screen II (TCU-DSII) is a screening
tool that enables corrections staff to quickly identify individuals who report
heavy drug use or dependency and therefore might be eligible for
treatment. Questions are based on the DSM-IV and the National Institute
of Mental Health Diagnostic Interview Schedule.
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Screening
► Detects
mental health symptoms and looks at
current substance use behavior
► Asks about past treatments, diagnoses and
medications
► Identifies violent or suicidal tendencies/cognitive
deficits- severe problems that may need
immediate attention
► Determines who goes on for further assessment
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Risk and Need Assessment
Risk assessments may act as preliminary screening flagging those in need of specific screens or assessments.
They are designed to help determine:
► Level of security and housing assignment
► Programming priorities to reduce potential for
disruptive behavior in the facility
► Programming priorities to reduce potential for a
return to criminal behavior
► Weed out low risk individuals/identify highest risk
offenders to target as the priority service recipients
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Clinical Assessment
Clinical assessment:
► Nature/
severity of substance abuse/mental
health problem
► History of symptoms-past treatments for both
disorders; changes over time
► Baseline: current symptoms and functioning
► Readiness for change; client’s perception of need
for change, ability to change- care preferences.
► Builds rapport- asks about client strengths,
background, supports, limitations and cultural
considerations.
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Evidence-based Clinical Assessment
Title:
Description:
(GAIN)
120 minute standardized assessment for use in substance abuse diagnosis, placement,
treatment planning, outcome monitoring, economic analysis, and/or program planning
and identification of possible CODs
The Psychiatric Research Interview for
Substance and Mental Disorders (PRISM)
Semi-Structured interview; Measures DSM-IV diagnoses on Axis I and II(Alcohol, Drug,
Psychiatric Disorders); Differentiates the primary disorder from substance induced
disorders or effects of withdrawal; 45-90 minutes to complete
Global
Appraisal of Individual Needs
Minnesota Multiphasic Personality Inventory-2
(MMPI-2)
Tests adult psychopathology; 60-90 minutes to complete; 567 True/False Questions; 5 th
grade reading level
Personality Assessment Inventory (PAI)
Tests adult psychopathology; 50-60 minutes to complete; 344 items; 22 non overlapping
scales; 4th grade reading level
Global Assessment of Functioning (GAF)
Clinicians judgment of overall functioning; 100 point scale; 3 minutes to establish score;
Higher score = healthier client
The Addiction Severity Index (ASI)
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Semi-Structured Interview; Measures 7 substance-abusing problem areas; 50-60
minutes to complete; Past 30 day and lifetime problems are measured; 200 item; 7
subscales
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Assessments
Shortcomings of Forensic and Clinical
Assessments:
► Actuarial
tools, and they are standardized to serve
a wide range of populations
► Weak cultural, ethnic, racial and gender-specific
indicators
► Formulaic-may provide little opportunity to
establish a connection with client
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Exercise
Now that we have reviewed screening and
assessment tools, let’s take a look at the profiles
from Exercise I and re-consider each case for
CODS.
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Who Has a Co-Occuring Disorder?
Steve- Steve appears to be experiencing significant depression
and should be fully assessed for mental health and suicide risk;
he is also at-risk for sexual violence. He should be screened for
substance abuse and assessed, if indicated. But, he may not
have a substance use disorder. Steve may need treatment and
support, but not for substance use, and, therefore not in the
context of RSAT.
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Who Has a Co-Occuring Disorder?
Marsha- Marsha shows signs of having a co-occurring disorder.
She may be showing signs of bi-polar disorder should be referred
for assessment by mental health clinician qualified to make a
diagnosis. While she is in the RSAT program, it will be important
to monitor her mood changes to see if they stabilize. She is also
a long time crack and alcohol user and her symptoms may
improve over time during a sustained period of sobriety, or may
they may worsen. A team approach that includes mental health
staff and periodic reassessment is best.
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Who Has a Co-Occuring Disorder?
Brian – Brian’s profile points to a serious mental disorder and
alcohol abuse or dependency. His paranoia may be symptoms of
schizophrenia or another psychotic disorder. His use of alcohol
indicates he probably has a co-occurring disorder. A
comprehensive assessment is required, which will provide
information about his level of stability and the severity of his
drinking problem before the mental health and RSAT clinical
team can determine if he is appropriate for the program.
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Module II: Best Practices for CODs
►Introduction
to Integrated Treatment
►Proven and Promising Practices for
Offenders with CODs
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Integrated Treatment
Treatment approaches:
►
►
►
Sequential=addressing the most serious illness first.
Parallel=treating simultaneously but through
separate systems of care.
Integrated= a unified and comprehensive treatment
program for clients with both.
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Integrated Treatment
Core Principles of Integrated RSAT Programs:
1.
2.
3.
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Co-occurring disorders are prevalent -- screening,
assessment and treatment planning should
reflect this assumption
Both co-occurring disorders are considered
primary- how they interact is key to relapse
prevention and recovery management
Provider empathy, respect, and belief in capacity
for recovery
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Integrated Treatment
4.
5.
6.
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Individualized treatment and different treatment
needs over the course of recovery
Interventions are selected that have been shown
to improve both disorders in criminal justice
populations.
Community re-integration and post-release
supports = major factors in recovery
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Integrated Treatment
The Modified Therapeutic Community Setting
► Staff Readiness to Provide Integrated
Treatment
► Agency Readiness to Provide Integrated
Treatment
► Community Readiness Serve Re-entering RSAT
Clients with MH Needs
►
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Modified Therapeutic Community
Modifications to traditional TC model continued:
►
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►
►
►
incorporates increased flexibility
shorter groups, less intense, less confrontation
increased emphasis on orientation and instruction
fewer sanctions, more explicit affirmation for
achievements
greater sensitivity to special developmental needs of
the clients.
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Modified Therapeutic Community
TCs are very applicable to people with CODs:
►
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Highly structured daily regimen
fosters personal responsibility and self-reliance
Self help culture
Peers as role models; community as healing agent
Regards change as gradual
Specific focus on linking persons with CODs to peer
recovery support community services.
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Integrated Treatment
How have people with CODs been treated:
►
►
►
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separate funding streams
SUD funding required abstinence-based programming
different licensing and credentialing of providers and
clinicians
different eligibility guidelines and coverage for services
different treatment philosophies/practices
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Integrated Treatment
Mental health and substance abuse treatment
mixed messages:
abstinence-based vs. harm reduction
► confrontational vs. motivation
► no medication vs. medicate everyone
The last decade both fields have begun to move toward
strengths-based, client-centered, recovery oriented
care.
►
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Exercise
Exercise: Myths, Misconceptions and Facts
about CODs
Take a look at these common myths about people with CODs.
Have any of these myths ever influenced your thinking?
• Which ones may have influenced others in various service
systems you deal with?
• Which have the most influence on clients’ perceptions of
themselves as persons in co-occurring recovery?
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Myths and Facts
Myth: Just get to the root of your depression, then
you won’t drink anymore.
Fact: Experience and research show individuals with
co-occurring disorders (COD) are at higher risk for:
► Relapsing
► Reoffending
► Homelessness
► Victimization
Often MH problems precede SUDs in women and
follow SUDs in men
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Myths and Facts
Myth: Just stop using drugs and your psychological
problems will take care of themselves.
Fact: People with COD’s progress more rapidly from
initial use to dependence, are less likely to complete
treatment and adhere to medication regimes than
those with only one disorder
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Myths and Facts
Myth: People with co-occuring disorders are
high-end consumers of services.
Fact: The vast majority of people with CODs do
not get any treatment. In fact, only 10% receive
any treatment and 4% receive integrated
treatment.
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Myths and Facts
Myth: People with co-occurring disorders are very
difficult to treat and require highly skilled staff with
specialized training.
Fact: Many practices are effective that do not require
extensive training, such as: case management,
supported employment, contingency management, r
housing first programs and peer support/ recovery
self-managment.
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Myths and Facts
Myth: Offenders with co-occurring mental health
disorders are violent and dangerous.
Fact: According to the Bureau of Justice Assistance the
rate of violent crimes among offenders with mental
disorders is the same as for other offenders (2008).
People with mental health disorders, however, are far
more likely to be victims of violence.
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Selecting an Intervention Strategy
Examples of effective CODs treatment
approaches for RSAT programs:
►Cognitive
Behavioral Therapy
►Psychiatric Medications
►Motivational Strategies
►Integrated Trauma CBT
►Illness Management and Recovery
►Assertive Community Treatment Teams
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Community Strategies
Examples of effective community approaches for
RSAT clients with CODs:
►Psychiatric
Medication Management
►Assertive Community Treatment Teams
►Recovery Self Management/Peer Support
►Housing First
►Supported Employment
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Cognitive Behavioral Therapy
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Effective on substance use and mental health problems and
on criminal thinking
Target attitudes and behaviors; recognition and replacement
of thinking errors & irrational and criminal thoughts
Uses role plays, skill rehearsal and reinforcement
Emphasizes personal responsibility
Targets observable behaviors (e.g.: following jail/prison rules;
using verbal skills vs. physical behaviors)
May be facilitated by correctional program staff
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Medication Assisted Treatment
Psychiatric Medication Management
►
Benefits: Stabilizes psychiatric symptoms, provides
relief to clients and can increase treatment
engagement.
►
Risks: Lack of continuity of care upon release, side
effects, inmate refusal (forced medication by court
order is ethically problematic) and mis-medication or
overmedication.
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Medication Assisted Treatment
Opiate Replacement Therapy
►
Benefits: Stabilizes and manages withdrawal
symptoms, reduces cravings, decreases potential for
relapse and risks associated with IV drug use (HIV
etc), increases medication adherence and treatment
compliance.
►
Risks: Lack of availability within facilities, costs,
medication interactions, over reliance on meds rather
than recovery supports, stigma.
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Motivational Strategies
►
Goal is to motivate offenders in treatment to engage in
treatment and comply with supervision requirements:
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Motivational Interviewing (MI): expansion of client intrinsic
motivation, reinforces and encouragement target behavior
Motivational Enhancement Therapy: combines MI, a review of
assessment information, and 2-3 individual counseling sessions to
build motivation and prepare clients for group counseling
Contingency Management: system of pre-determined rewards
used to acknowledge and reinforce target behavior (behavioral
contracting; “carrot and stick”)
Graduated Sanctions: swift and certain, on a continuum, with
dismissal from program or return to custody as the end point
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Integrated Trauma CBT
►
Teaches people with how to manage their triggers, new
coping skills and about the connection between PSTD
and SUDs
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Psycho-education on trauma
Present day approach to PTSD symptom relief
Especially effective component for women offenders
Increases safety and self care; decreases unsafe behavior
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Assertive Community Treatment
Assertive Community Treatment (ACT, FACT & IFCM)
Customized, community-based services for people with
CODs. Team approach to expanded access to services.
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Tailored to client’s current level of need
Intensive case management
24 hours access to community supports
The Social and Independent Living Skills (SILS)
Friends and family enlisted to sustaining recovery
Single point of contact for client
IFCM is less expensive and equally effective option
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Illness Management & Recovery
►
Teaches people with severe mental illness how to
manage their disorder and how to work with treatment
providers, friends, and family in achieving and
sustaining recovery.
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Psychoeducation
Behavioral tailoring
The Social and Independent Living Skills (SILS)
Wellness Recovery and Action Plan (WRAP)
Peer support
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Implementing Integrated Treatment
Treatment models are not mutually exclusive.
Comprehensive treatment plans for RSAT clients
with CODs may include several.
Release planning approach:
• What addition services does the client’s COD
help them qualify for?
• What benefit applications can be completed
now?
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Community Strategies
Release planning includes:
►Medication
Management – 30 day supply, appointment with
provider and source for payment
►Recovery Self Management training completed;
connections to both AA/NA sponsor and MH peer program
►ACT Teams or Intensive Forensic Case Management in place
►Housing First programs or subsidized housing for people w/
CODs contacted
►Supported Employment programs; Goodwill, at Community MH
Centers
►Providers identified, introduced and first post release
appointment in place
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For more information on RSAT training and
technical assistance visit:
http://www.rsat-tta.com/Home
or email Jon Grand, RSAT TA Coordinator at
[email protected]
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Next Presentation
Running Much Better Treatment Groups
June 20, 2012, 2:00 PM EDT
If a car’s not built right, the driver’s skills are secondary. The same goes for treatment groups and
their clinicians. This webinar is about structural and operational fundamentals that largely
determine the serviceability of any given treatment group, be it evidence-based and manualized, or
TC-bred or home-made. Specifically, these fundamentals are the group’s membership criteria,
operating structure, and learning content. At issue is why treatment staff must, and how they can,
attend to these variables in order to avoid problems that even the best group therapists face too
often and that many group therapists face all the time.
Presenter: Fred Zackon
7/17/2015
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