Transcript Staging - MyPrevention.org

Gaps in Service Towards Reaching
Co-occurring Capability
Anthony (AJ) Ernst, Ph.D.
Ernst & Associates
[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
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Addiction only (AOS)
Dual Diagnosis Capable (DDC)
Dual Diagnosis Enhanced (DDE)
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 substancerelated disorders.
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DDCAT/DDCMHT INDEX FIVE
DIMENSIONS: TN Identified Gaps
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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
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?
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?
The Transtheoretical Model
STAGES OF CHANGE
PRECONTEMPLATION > CONTEMPLATION > PREPARATION > ACTION > MAINTENANCE
PROCESSES OF CHANGE
COGNITIVE/EXPERIENTIAL
Consciousness Raising
Self-Revaluation
Environmental Reevaluation
Emotional Arousal/Dramatic Relief
Social Liberation
BEHAVIORAL
Self-Liberation
Counter-conditioning
Stimulus Control
Reinforcement Management
Helping Relationships
CONTEXT OF CHANGE (Levels of Change)
Current Life Situation
Beliefs and Attitudes
Interpersonal Relationships
Social Systems
(Symptoms & situations level)
(Cognitions & beliefs level)
(Interpersonal level)
(Family level)
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
Match intervention to target behavior
and stage
PRECONTEMPLATION
STAGE
CONTEMPLATION
STAGE
PREPARATION
STAGE
BEHAVIOR
ACTIO
N
STAGE
QUIT
DRINKNG
X
POSSIBLE INTERVENTIONS
-Helping Relationships
-Stimulus Control
-Reinforcement Management
MAINTENANC
E
STAGE
Match intervention to target behaviors
and stage
PRECONTEMPLATION
STAGE
CONTEMPLATION
STAGE
PREPARATION
STAGE
ACTION
STAGE
MAINTENANCE
STAGE
BEHAVIOR
Quit
Drinking
Manage
Bi-Polar
Mood
Disorder
X
X
POSSIBLE INTERVENTIONS
-Consciousness raising
-Self-Reevaluation
POSSIBLE INTERVENTIONS
-Helping Relationships
-Stimulus Control
-Reinforcement Management
Interventions for target behaviors may shift
over time
PRECONTEMPLATION
STAGE
CONTEMPLATION
STAGE
PREPARATION
STAGE
ACTION
STAGE
MAINTENANCE
STAGE
BEHAVIOR
Quit
Drinking
Manage
Bi-Polar
Mood
Disorder
X
X
POSSIBLE INTERVENTION
-Self-Reevaluation
POSSIBLE INTERVENTIONS
-Helping Relationships
-Stimulus Control
-Reinforcement Management
The behaviors may be independent
SUDs
MH
One problem may precede another,
as in this example
SUDs
MH
The problems may otherwise interact
with each other
MH
SUDs
Outside factors may affect both substance
use problems and mental health problems
SUDs
STRESS
MH
And we have to be aware that triple
diagnosis issues are never far away
SUDs
MH
STRESS
PHYSICAL
ILLNESS
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.
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
Key Program Questions
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What target behaviors should we measure?

When and how often should we measure?

What are the best measurements for our
populations of interest?
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)
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)
EXAMPLE TARGETS – BEHAVIOR TO
DECREASE
SUBSTANCE USE
Frequency reduction
Quantity reduction
Duration reduction
STAGING ISSUES
Clients may be in different stages for different targets
related to the same behavior
EXAMPLE TARGETS – BEHAVIOR TO
DECREASE
PANIC ATTACKS
Frequency of occurrence
Intensity of occurrence
Duration of occurrence
STAGING ISSUES
Beliefs around causes
Beliefs around medication use
Family social system
EXAMPLE TARGETS – OF GENERAL
BENEFIT FOR DUAL DIAGNOSIS
SLEEP HYGIENE
Setting a sleep schedule
Decreasing caffeine consumption
Adjusting the sleep environment
STAGING ISSUES
Beliefs about the utility of the interventions
Family social system
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?
CONTINUITY OF CARE
DDCAT V.C. Focus on ongoing recovery
issues for both disorders
Are the disorders seen as acute or chronic, shortterm or long-term, primary or secondary?
How is recovery envisioned and planned?
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
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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.
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?
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.
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http://www.doubletroubleinrecovery.org/
STAFFING
DDCAT VI.E. Peer/Alumni supports are
available with co-occurring
disorders
Are role models available for persons with cooccurring addiction and psychiatric disorders?
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/ourprog
ram/
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COD Alumni Support
“Live” Sample
THE WATERSHED ALUMNI PROGRAMS
For 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.
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http://www.thewatershed.com/home.php
DDCAT, leading to a program that is...
Welcoming
Accessible
Integrated
Continuous
and
= “No Wrong Door”
Comprehensive
With a common goal of RECOVERY