TIPS & TOPICS

Volume 4, No.3
June 2006

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– Until Next Time

Welcome to the June edition of TIPS and TOPICS (TNT). We won’t call it the June/July issue even though you are receiving it in the first few days of July. You will however receive a combined July/August edition sometime in August – as is our custom in the summer.

SAVVY

The website for the Substance Abuse and Mental Health Services Administration’s Co-Occurring Center for Excellence (SAMHSA COCE) was launched on February 14, 2005 as a rich resource on co-occurring disorders. As a Senior Fellow for the COCE, I was notified that the COCE website was recently updated on June 8.

Tips:

• TIP 1: Check the COCE Web site to tap the updates and other resources on co-occurring disorders (COD).

Central to the COCE approach is a series of overview papers addressing key COD topic areas. The overview papers summarize the science base for each topic addressed, and make recommendations for practice, systems, and State and local laws and regulations which support treatment and prevention systems as appropriate. Three overview papers are now available in print and PDF format. Two additional overview papers are available in PDF format (clearance for printing is pending) from the COCE website.  (http://www.coce.samhsa.gov/cod_resources /index_right_2.aspx?obj=77) 

No. 1 – Definitions and Terms Relating to Co- Occurring Disorders – Available now in PDF and printed copies
It is essential to use a common language to develop consensus on how to address the needs of persons with co-occurring disorders. This paper provides definitions of terms associated with substance- related disorders, mental disorders, co-occurring disorders, and programs.

No. 2 – Screening, Assessment, and Treatment Planning for Persons with Co-Occurring Disorders – Available now in PDF and printed copies
Clients with co-occurring disorders are best served through an integrated screening, assessment, and treatment planning process that addresses both substance use and mental disorders, each in the context of the other. This paper discusses the purpose, appropriate staffing, protocols, methods, advantages and disadvantages, and processes for integrated screening, assessment, and treatment planning for persons with COD as well as systems issues and financing.

No. 3 – Overarching Principles To Address the Needs of Persons With Co-Occurring Disorders – Available now in PDF and printed copies
Principles, by their nature, are consistent with a concern for the well-being of the client and his or her loved ones. This overview paper outlines 12 overarching principles for working with persons with co-occurring disorders. These principles are intended to help guide, but not define, systemic and clinical responses.

No. 5 – Addressing Co-Occurring Disorders in Non- Traditional Service Settings – Available now in PDF only
Settings outside the substance abuse and mental health system, or settings where service missions do not include a primary focus on COD but where persons with COD are likely to be seen, are the focus of this overview paper. These include primary health, public safety and criminal justice, and social service settings. These settings should be prepared to identify and effectively respond to persons with COD.

No. 6 – Understanding Evidence-Based Practices for Co-Occurring Disorders – Available now in PDF only
The advantages of employing evidence-based practices are now widely acknowledged across the medical, substance abuse, and mental health fields. This paper discusses evidence-based practices and their use in treating persons with co-occurring disorders, discusses how evidence is used to determine if a given practice should be labeled as evidence based, and gives some brief examples.

Other COD Resources on the COCE website:

>>COCE Products – Presentations – A new expert presentation is now available
http://www.coce.samhsa.gov/cod_resources /index_right_3.aspx?obj=82

>>ATTC Resources and Publications – A new link has been updated to provide access to a new edition of Psychotherapeutic Medications 2006: What Every Counselor Should Know – The language has been modified to increase readability for a larger audience, and in keeping with the goal of updating the brochure annually, several new medications are included.
(http://www.coce.samhsa.gov/cod_resources /index.aspx?obj=23)

>> Policy Academy States Products – Five new action plans have been added for the States of Arkansas, Delaware, Pennsylvania, Montana and New Mexico (http://www.coce.samhsa.gov/cod_resources /index.aspx?obj=26)

>> COD Federal
(http://www.coce.samhsa.gov/cod_resources /index_right3.aspx?obj=31):
**New HRSA Cultural Competence Web Page
**NIMH Study to Help Depressed Patients Become Symptom-Free
For more information, e-mail coce@samhsa.hhs.gov or call (301) 951-3369.

• TIP 2: The American Society of Addiction Medicine Patient Placement Criteria, Second Edition, Revised (ASAM PPC-2R) describes three types of programs for people with COD. These program types can be established at any level of care.

The first COCE overview paper on definitions and terms included terms associated with programs. While the original ASAM PPC-2R descriptions were of programs within the addiction treatment continuum of care, the COCE expanded the program descriptions. The paper referenced definitions that should be used with mental health as well as addiction programs. While the ASAM Criteria describes Addiction-Only Services (AOS) programs, there are no criteria for who belongs in an AOS program. Dual Diagnosis Capable (DDC) is considered the base level that should exist to at least evaluate a client for COD and case manage a person if a COD is present. Here is more detail on the three types of programs:

A. Programs that offer Addiction-Only Services (AOS) or Mental Health-Only Services (MHO)
Cannot accommodate people with COD who require ongoing treatment, however stable the co-occurring illness and however well functioning the individual. The policies and procedures typically do not accommodate COD: For example, individuals on psychotropic medications generally are not accepted in addiction programs; or in mental health programs, people still using substances are told to return when thirty days sober. Coordination or collaboration between mental health and addiction services are not routinely present.

B. Dual Diagnosis Capable (DDC) Programs
* Dual Diagnosis Capable (DDC) programs routinely accept individuals who have co occurring mental and substance related disorders.
* DDC programs can meet such clients’ needs so long as the co-occurring disorder is sufficiently stabilized and the individuals are capable of independent functioning to such a degree that the co-occurring disorder does not interfere with participation in treatment.
* DDC programs address COD in their policies and procedures, assessment, treatment planning, program content, and discharge planning.
* They have arrangements in place for coordination and collaboration between addiction and mental health services.
* They also can provide addiction treatment consultation; or psychopharmacologic monitoring and psychological assessment and consultation on site; or by well-coordinated consultation off-site.

C. Dual Diagnosis Enhanced (DDE) Programs
* DDE programs can accommodate persons with COD where both disorders are unstable to the extent that integrated addiction and mental health services are needed.
* DDE programs are staffed by psychiatric and mental health clinicians as well as addiction treatment professionals. Cross training is provided to all staff. Such programs tend to have relatively high ratios of staff to clients and provide close monitoring of clients who demonstrate both addiction and mental health instability and disability.
* DDE programs have policies, procedures, assessment, treatment planning and discharge planning that accommodate more acute clinical presentations and crises in people with COD.
* Dual diagnosis-specific and mental health symptom management groups are incorporated into addiction treatment. Motivational enhancement therapies are more likely to be available (particularly in outpatient settings.)

References

Mee-Lee D, Shulman GD, Fishman M, Gastfriend DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for the Treatment of Substance- Related Disorders, Second Edition-Revised (ASAM PPC-2R). Chevy Chase, MD: American Society of Addiction Medicine, Inc.

See Pages 7-11 for more detail on Co-Occurring Disorders.

SKILLS

What kind of program and service do you provide? Is your agency AOS or MHO, DDC, or DDE? Here are a couple of tips to help you evaluate that more.

Tips:

• Review your rules and policies about medication and/or substance use to increase access to people with COD, rather than to exclude them.

Many people with COD show up for treatment on benzodiazepines or narcotic analgesic medication.

What do addiction programs often do?

They do one of two things: send the person away and refuse admission; or begin immediate detoxification whether the person wants to do that or not. If a client presents to you on medication, which you believe to be detrimental to the client (e.g., benzodiazepines in a person with addiction illness) you are right to be concerned.

What would be a more effective approach?

Admit them to the program. Good assessment and treatment cannot really be done before a person is actually admitted to a program. This is a person who needs assessment and treatment, not a plan based on a policy and procedure.

The purpose of admission is:
(1) taking a careful history from the person and/or the family;
(2) assessing over time whether the person has a co- occurring disorder or not;
(3) engaging the client in a plan to collaborate with the prescribing physician;
(4) working with the client’s stage of readiness to detox off the medication and try other medication or non-medication methods.
This is not an all-inclusive list.

These are all challenging issues. This is what treatment in a DDC or DDE program encompasses. It does not exclude the client from the very assessment and treatment planning they need.

Similarly, mental health programs often ignore the substance use problems and focus just on the mental health problem.
For example- The clinician stabilizes an intoxicated, suicidal, impulsive, depressed client; sends them out with a Major Depressive Disorder diagnosis; and next sends them to a psychiatrist who prescribes an antidepressant.

What’s missing in this approach?

> An assessment of the substance-induced depression.
> Engaging the person into exploring substance use problems.

• Rather than focus on referring the person to appropriate co-occurring disorders resources, re-frame your thinking and terminology to focus on linking the person to all the services they need.

Oklahoma, like many states and counties, is examining and improving their infrastructure to better address the needs of people with COD. I was interested to hear them raise the following point: In moving towards “every door being the right door” or “no wrong door”, we have to change how we respond when a person walks into a treatment program which may lack all the services needed for that person or population.

What is often our first impulse? Either to give the person a different number to call, or to make an appointment with someone else a few days or weeks away. We hope they make it, but at least we did the right thing and gave them a referral. So thus we soothe ourselves that we have done all we can.

A few years ago I called AT&T to enquire about a service; I thought I had the correct number. As soon as the service representative realized I had called the wrong service number, she did not merely tell me to hang up and call the correct number. While I was still on the phone and could hear what she was doing, she called the correct number, explained to the different service representative what I was wanting, then introduced me, and passed me over to get my question correctly answered. I know we are not offering voice mail, call-waiting or conference calling services. But I got better linking service than the people who reach out to us- those often psychotic and/or intoxicated. And I wasn’t even psychotic (I don’t think).

If you or your agency is still thinking in terms of referral, you may still be an AOS or MHO program. Start talking about ways you can at least become a DDC service, one that at a minimum can link people to get their needs met, even if you cannot provide integrated services- yet!

SOUL

I just returned from an invitation-only conference, which examined current research and clinical applications to facilitate the client process of change in substance abuse treatment. Carlo DiClemente, Ph.D., one of the originators of the Transtheoretical Model (TTM) of Stages of Change, invited us to make a presentation in twenty minutes or less. When you are challenged to distill the recommendations you would give for incorporating stages of change in clinical work, there is no room for fluff or waffling. It is not a bad way to discover what you really believe about any subject, not just stages of change.
It is cliché to say the more you know, the more you realize you don’t know. But again that was my experience there as I sat around the table with American and international researchers and clinicians. I think I made a good contribution, and I know I certainly learnt a lot from them. You often don’t know what you don’t know. Putting aside all the research validity questions (about whether you can really categorize people into neat stages of Precontemplation, Contemplation, Preparation and Action) there is something really useful about thinking of stages of change in your personal and professional life. In this month’s Stump the Shrink you will see how different counselors can view stages of change differently depending on one’s view of the world. That’s in the clinical and professional world.

But in my personal life, I find it useful too. Before beating on yourself for not sticking to the diet or exercise plan you vowed to do, you might just own the fact that you are more in Contemplation (ambivalent) than you thought. Re-look at your commitment and reasons to change (or not) and renew your choice. Perhaps you may decide you really don’t want to get started yet.

This can apply to significant others and family too. Instead of feeling frustrated at others who don’t do what you think is important, remember they might be in Precontemplation (don’t think there is a problem – that what you think is important is not necessarily on their radar screen). You could yell at their resistance and unthoughfulness, but you may need to raise their awareness of what is going on for you, then make a request of them.

When my college-student daughter was living at home in her teen years, I was continually frustrated with her wasting electricity by leaving lights and air- conditioning on when she would go out. Nagging didn’t work. It just didn’t seem to propel her to Action in turning lights off. So I started putting Post- It notes on her mirror (one place I was sure she would look at). The notes weren’t reminder notes. They were “User Fee” notes, stating the amount to be deducted from her allowance for whatever length of time the air-conditioning was left on. “12 hours of air conditioning – $2.00.” (I don’t know what it actually costs to leave the AC on for 12 hours).

Even if it didn’t raise her consciousness all the way to Action, I felt better. If she left the electricity on, then she was choosing to spend part of her allowance on my electricity budget. She was far more at Action for keeping her money than in submitting herself to my fruitless nagging. And you thought stages of change was just for clients!

STUMP THE SHRINK

The email below was not intended as a Stump the Shrink question, but raises good points anyway. (The reader is referring to the April 2006 edition of TNT.) 

Reader Comment:

Hi Dr. Mee-Lee:

As always I appreciated your recent Tips and Topics. I wanted to comment on the table with the stages of change and the levels of care. In that context I think it’s important to frame the “level of service” as a key component of the treatment plan. How do we strategically match the patient to a level of service that will enhance and reinforce the stage- based treatment plan objective and activities. The way the table is designed makes me concerned providers will make concrete level of service decisions based solely on stage of change. Realizing stage of change addresses multiple issues, as you defined later in your article, shows it’s not as concrete as the table defines. It also reflects that stage of change on an issue that may be perceived as unrelated to recovery could be a key component in engaging the client in service.

The other continuous challenge regarding stage of change for providers continues to be their own personal bias on “recovery” and making the stage assessment from that. For example; two therapists look at a client. One therapist has strong roots in a 12 step model, the other more “eclectic”. The patient hasn’t used in 2 months, is attending group, complying with the treatment plan. The eclectic counselor views him in “action”.

Same client, but the “12 step model” counselor says he’s in pre-contemplation. Why? He refuses to attend meetings and says he now has control over his use, “if I wasn’t in control I wouldn’t have been able to quit”. Seems like stage of change should be based on the client’s perception of recovery. Of course a counselor can’t do that if they don’t see that the client’s view of recovery is as relevant. So what is the baseline definition specific to substance use/dependency we should use when assessing stage of change? Abstinence, “recovery”, desire for help??

This wasn’t intended to be a “stump the shrink”

Scott Boyles
Program Administrative Officer
Montana Addictive and Mental Disorders Division
Chemical Dependency Bureau
406-444-9408

Response:

Hi Scott:

Thanks for your comments with points well taken.

I understand your concerns about the table, especially if taken out of context with the clinical caveats I mentioned. It is the danger of trying to get one point across that can be misunderstood if not seen in its entirety. The main point I was trying to make was that when people are in early stages of change, the motivational enhancement strategies should be done in less intensive levels of care, and not more intensive levels- as is often the practice in the field. For example, it is difficult to test out and have the client do their own research on the “just cutting back” treatment plan when they are in a residential program. Or it is hard to have them try the “I have strong willpower, no AA” treatment plan if in a program where everyone is expected to attend and appreciate AA.

Your next point about assessing stage of change is important too. What I usually say is that if the client is there talking to you in treatment, then they are in the Action stage for something e.g., staying out of jail; getting their kids back; keeping their job. They may be in Contemplation or Precontemplation as regards to what WE think they should work on e.g., abstinence, recovery etc. But of course we should start with where THEY are at, not where WE think they should be at.

Thanks for your feedback.

David

Until Next Time

See you next month for a combined July/August edition of TNT.
David