Training - DHSS

Training - DHSS

Cultural Clashes in CoOccurring Disorders and What To Do About It David Mee-Lee, M.D. www.DMLMD.com Philosophical Clashes - Polarized on Presenting Problem 3 Ds Deadly Disease

Denial Detachment 3Ps Psychiatric Disorders Psychopharmacology Process Philosophical Clashes - Different Theories, Treatments 1. Addiction vs Mental Health System

3 Ds and 3 Ps - implications for medication, staff credentials, attitudes towards physicians, role of staff and team, data gathering, 12 Step programs Philosophical Clashes - Different Theories, Treatments 2. Integrated vs Parallel or Sequential Hybrid programs - staffing difficulties; numbers of

patients and variability, but one-stop treatment Parallel programs - use of existing programs and staff, but more difficult to case manage Philosophical Clashes - Different Theories, Treatments 3. Care versus Confrontation Mental health - care, support, understanding, passivity

Addiction - accountability, behavior change Philosophical Clashes - Different Theories, Treatments 4. Abstinence-oriented versus Abstinencemandated Treatment as a process, not an event Respective roles in both approaches Philosophical Clashes

- Different Theories, Treatments 5. Deinstitutionalization versus Recovery and Rehabilitation Role of least restrictive setting Role for individualized treatment with continuum of care Minkoff, 1991) (Ken

Every Door is the Right Door People with co-occurring disorders: individuals who have at least one mental disorder as well as an alcohol or drug use disorder. While these disorders may interact differently in any one personat least one disorder of each type can be diagnosed independently of the other (In A Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders)

SAMHSA Report to Congress Co-occurring disorders may include any combination of two or more substance abuse disorders and mental disorders identified in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). There are no specific combinations of.disorders that are defined uniquely as co-occurring disorders.

Underlying Principles 1. Firstly people of all ages with co-occurring disorders are people first, fully deserving of respect 2. At same time, consumers, recovering persons and their families need be involved in all aspects of their treatment and recovery 3. People with co-occurring disorders can and do recover. Be optimistic about prospects for achieving stability and recovery,

provide long-term support needed to maintain their progress Recovery in Addiction Recovery is the process through which severe alcohol and other drug problems (here defined as those problems meeting DSM-IV criteria for substance abuse or substance dependence) are resolved in tandem with the

development of physical, emotional, ontological (spirituality, life meaning), relational and occupational health. (White, W. & Kurtz, E. (2005). The Varieties of Recovery Experience. Chicago, IL. Great Lakes Addiction Technology Transfer Center. Posted at http//:www.glattc.org) Recovery in Mental Health Recovery occurs when people with mental illness

discover, or rediscover, their strengths and abilities for pursuing personal goals and develop a sense of identity that allows them to grow beyond their mental illness (Pat Deegan, a consumer leader and psychologist with schizophrenic disorder defines recovery from serious mental illness) Underlying Principles (cont.) 4. People with co-occurring disorders deserve access to

services they need to recover. To put these beliefs into practice, development of this report has been guided by following principles: Ensure development of system in which any door is the right door to receive treatment for co-occurring disorders. This means people with co-occurring disorders can enter any appropriate agency in service system and be provided or referred to appropriate

services Underlying Principles (cont.) Develop client-centered, individualized treatment plans based on accurate assessment of person's condition and degree of service coordination he or she requires. Family members must be involved in treatment, where appropriate

Ensure maximum feasible degree of integration for individuals with most serious substance abuse disorders and mental disorders Underlying Principles (cont.) Provide prevention and treatment services that are culturally competent, age, sexuality and gender appropriate and that reflect diversity in

community Promote expansion and enhancement of service providers capabilities to treat individuals of all ages who have co-occurring substance abuse disorders and mental disorders Underlying Principles (cont.) 5. Not recommending creation of separate system

of care for people with dual diagnosis. Indeed, people with co-occurring disorders must be able to receive treatment in mainstream systems of care that are well-prepared to support their recovery 6. Formation of partnerships should be developed at all levels, from national to community and neighborhood, for developing/enhancing seamless systems of care that allow people to move freely between and among entire constellation of services

What to Do About Philosophical Clashes? - Person-Centered Services Assessment:

(ASAM PPC-2R, 2001) 1. Acute Intoxication and/or Withdrawal Potential 2. Biomedical Conditions and Complications 3. Emotional, Behavioral or Cognitive Conditions Complications 4. Readiness to Change 5. Relapse/Continued Use, Continued Problem

6. Recovery Environment and Potential Individualized Treatment Patient/Participant Assessment BIOPSYCHOSOCIAL Dimensions

Progress Treatment Response Problems/Priorities Proximal Outcomes e.g Build alliance working with Session Rating Scale (SRS) Multidimensional Assessment

Outcome Rating Scale (ORS) Plan Intensity of Service Modalities and Levels of Service (Clinical and wrap-around services) Biopsychosocial Treatment

Treatment Matching - Modalities Motivate - Dimension 4 Manage All Six Dimensions Medication Dimensions 1, 2, 3, 5 Meetings Dimensions 2, 3, 4, 5, 6 Monitor - All Six Dimensions Treatment Levels of Service I

Outpatient Treatment II Intensive Outpatient and Partial Hospitalization III Residential/Inpatient Treatment IV Medically-Managed Intensive

Inpatient Treatment People and Personnel Clashes and Solutions Collaborative, concurrent interdisciplinary team Vulnerabilities inhibiting team cohesiveness Team communication

Staff-program match Stress of working with multiple vulnerabilities People and Personnel Clashes and Solutions (cont.) Tolerance To listen to anothers opinion Open-mindedness To give up old views Patience To explore before jumping to diagnosis Education To learn more about SUD and MH

Serenity To realize we dont have all the answers Policy and Program Clashes and Solutions - Program Issues Mission of the program, department, institution or agency

Equal emphasizes both mental health and addictions issues Admission criteria and patient mix - what can staff/program manage Policy and Program Clashes and Solutions - Program Issues (cont.) Terminology and treatment tools e.g., disorientated;

reformed alcoholic Non-cognitive, activity groups e.g., time use charts; collages Groups education about dual identity and feelings groups to learn to cope Policy and Program Clashes and Solutions

- Program Issues (cont.) Family involvement; systems work and continuing care Self/mutual help groups - preparation for AA/NA mainstreaming; MICA and Dual Diagnosis Anonymous; Dual Recovery Anonymous Staff composition reflects training proportionate to programs clientele

Policy and Program Clashes and Solutions - Payment Issues Person- centered funding of services based on priorities in all assessment dimensions Move from medical necessity (withdrawal, biomedical, psychiatric severity), to multidimensional severity

requiring interventions in any/all six dimensions Policy and Program Clashes and Solutions - Payment Issues (cont.) Fund case management to allow proactive, not reactive treatment

Turf battles between mental health and addiction services (often more neglected of the two systems due to fewer numbers of clients and/or stigma) Data to Identify Gaps Systems issues cannot change quickly. Each

incident of inefficient or inadequate care can be a data point that promotes systems change Finding efficient ways to gather data as it happens in daily care of clients can provide hope, direction for change Data to Identify Gaps (cont.) PLACEMENT SUMMARY

Level of Care/Service Indicated Level of Care/Service Received Data to Identify Gaps (cont.) PLACEMENT SUMMARY Reason for Difference - Circle only one number -- 1. Level of care or Service not available; 2. Provider judgment; 3. Client preference; 4. Client is on waiting list for appropriate level/service; 5. Level of care or Service available, but no

payment source; 6. Geographic inaccessibility etc. David Mee-Lee, M.D. www.DMLMD.com

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