Adults with Dual Disorders in Contact with the Criminal Justice System

1

• Adults with Dual Disorders in Contact with the
  Criminal Justice System
• Holly Hills, Ph.D.
• Wyoming Drug Court Conference
• September 4, 2008

2
? Defining the Population of Persons with
Co-Occurring Disorders Typical Clinical
Presentations Systemic Variables that Impact Who
May be Served
3
Defining Co-Occurring Disorders

• Co-occurring Disorders is used instead of dual
  diagnosis because clients often have more than
  two disorders.
• Co-occurring Disorders typically defined as
• a) at least one substance disorder, plus
• b) at least one major mental disorder
• -Major Depression -Bipolar Disorder
• -Schizophrenia/psychotic disorders

4
Co-Occurring Disorders Prevalence

• National Co-Morbidity Survey
• Used representative national community sample
• 30 had 12 month history of at least one
  DSM-III-R diagnosis
• 52 of those with alcohol disorders at some point
  in their lifetime also had a history of at least
  one mental disorder

5
Co-Occurring Disorders Prevalence

• National Co-Morbidity Survey
• 59 of those with other drug disorders at some
  point in their lifetime also had a history of at
  least one mental disorder
• Of those with lifetime co-occurrence, 84
  reported that their mental illness symptoms
  preceded their substance use disorder (Kessler et
  al., 1994)

6
Co-Occurring Disorders Prevalence

• Prevalence of co-occurring disorders is even
  higher in public service systems (substance abuse
  treatment, mental health treatment, criminal
  justice, etc.) than in general population
• Individuals with co-occurring disorders need to
  be thought of as the expectation, not the
  exception in such settings

7
Co-Occurring Disorders Risk Factors

• Presence of a substance use disorder quadruples
  the risk of having a co-occurring mental disorder
• Presence of a mental disorder triples the risk of
  having a co-occurring substance use disorder (ECA
  study, 1980-84)
• Persons with any one substance use disorder have
  an increased risk for another substance disorder

8
Prevalence Data General Population

• Epidemiologic Catchment Area Study
• Presence of a mental disorder triples the risk of
  having a co-occurring substance use disorder
• Presence of addictive disorder quadruples the
  risk of having a co-occurring mental disorder
• Over 10 million adults in U.S. meet criteria for
  co-occurring disorders over twelve months

9
Co-Occurring Disorders Population Estimates

• Using this definition, approximately 10 million
  people in the U.S. have co-occurring substance
  and mental disorders (SAMHSA, 1997)
• When other mental disorders (anxiety disorders,
  personality disorders) are included, many more
  people can be considered to have co-occurring
  disorders.

10
How Many Offenders Have Co-occurring Disorders?

• Rates of mental illness and substance use
  disorders in criminal justice settings are
  greater than those found in the general
  population
• Rates of serious mental disorders in jails
• 6.4 for males (Teplin, 1990)
• 12.2 for females (GAINS, 2002)
• Among jail detainees with a serious mental
  disorder
• 72 have a co-occurring substance use disorder
  (Abram et al, 2001)

11
Prevalence of Mental Illness in Justice Settings
by Gender

• Gender State Prison Jail Probation
• Male 16 16 15
• Female 24 23 22
• Reported either a mental/emotional condition or
  an overnight stay in a mental hospital or
  program. (U.S. Department of Justice, 1999)

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Persons with CODs in the Justice System

• More likely to be homeless
• Use a greater variety of services
• More likely to be unemployed
• More psychological impairment (including
  extensive trauma histories)

13
Relationships between Substance Abuse Mental
Disorders (Lehman et al.,1989)

• 1. Acute and chronic substance use can produce
  psychiatric symptoms
• 2. Substance withdrawal can cause psychiatric
  symptoms
• 3. Substance use can mask psychiatric symptoms
• 4. Psychiatric disorders can mimic symptoms
  associated with substance use
• 5. Acute and chronic substance use can exacerbate
  psychiatric disorders
• 6. Acute and chronic psychiatric disorders can
  exacerbate the recovery process from addictive
  disorders

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Challenges in Addressing CODs

• At risk for relapse
• Criminality/criminal thinking
• Housing needs
• Transportation needs
• Family reunification

• Job skills deficits
• Educational deficits
• Stigma related to criminal history and SA and MH
  disorders
• Scarce prevention and treatment resources

15
Outcomes Related to CODs

• More rapid progression from initial use to
  substance dependence
• Poor adherence to medication
• Decreased likelihood of treatment completion
• Greater rates of hospitalization
• More frequent suicidal behavior
• Difficulties in social functioning
• Shorter time in remission of symptoms

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Typical Clinical Presentations 33 year old
African-American male, history of hallucinations,
odd speech, poor hygiene, 10 year use of
significant alcohol, 15 year use of marijuana,
CSU x 3, Detox admissions x 5 in the past three
years multiple misdemeanant arrests 29 year old
Caucasian female, history of chronic crack
cocaine use, intermittent alcohol binges,
significant tearfulness, isolation, weight loss,
2 suicide attempts, multiple arrests
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Systemic Variables that Impact Who May be
Served Priority Populations Primary
Diagnosis Assessment Skills / Capacity
Staffing Patterns / Job Classifications Access
to Psychotropic Medications Capacity for
Longitudinal Care
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? Understanding Service Delivery Applying the
Quadrant Model Capacity to Serve Based on
Existing Available Resources Identifying Service
Gaps Understanding Populations of Persons with
COD who are Currently Most Underserved
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Where are your agencies at in the service
spectrum?
III Less severe mental disorder/more
severe substance abuse disorder
IV More severe mental disorder/more
severe substance abuse disorder
High Severity
Alcohol and other drug abuse
I Less severe mental disorder/less
severe substance abuse disorder
II More severe mental disorder/less
severe substance abuse disorder
Mental Illness
Low Severity
High Severity
Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders, TIP 42
(2005)
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• Questions to Discuss with your Service Providers
  -
• Where are the obvious service gaps in the
  system?
• Are they related to the inability to serve
  specific diagnostic groups?
• Are gaps related to missing elements in the
  treatment continuum?
• Are all the pieces there, but is staff training /
  historical service patterns the impediment?

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Strategies in Screening and Assessment
22
Twelve Steps in the Assessment Process (TIP42)

• Engage Create a safe, private, nonjudgmental
  environment to build rapport determine cultural
  issues that may impact, importantly language
• Five essential elements of engagement
• Universal access (no wrong door)
• Empathic Detachment
• Person Centered Assessment
• Cultural sensitivity
• Trauma sensitivity

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Twelve Steps in the Assessment Process (TIP42)

• Identify collaterals
• May be unwilling or unable to report their
  history accurately, obviously must be done with
  permission
• Screen for COD
• Safety issues related to acute intoxication and
  withdrawal
• Present and past SU, related problems and
  disorders
• Screen for MH safety issues (suicidality,
  violence, self-care, risk behaviors for HIV, Hep
  C or victimization)
• Past and present MH disorders
• Cognitive / Learning Deficits
• Past and present victimization and trauma

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Twelve Steps in the Assessment Process (TIP42)

• Determine Quadrant
• Quad I Less severe MH and SA Quad IV More
  severe MH and SU disorders
• Severity of mental disorders are typically
  determined by diagnosis, severity of disability
  and duration of disability (6 mos)
• Substance Abuse clinicians should be familiar
  with what criteria eligibility is established to
  be a MH priority client, may be eligible for
  services
• Severity may be determined by using ASAM PPC-2R
  Dimension 3 or LOCUS

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Twelve Steps in the Assessment Process (TIP42)

• Level of care
• ASAM ranges from 1. Acute intoxication to 6.
  Recovery
• MH on Dimension 3. -- five areas suicide
  potential, interference with addiction recovery
  efforts, social functioning, ability for self
  care, and course of illness

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Twelve Steps in the Assessment Process (TIP42)

• Diagnosis
• Determine history of past or current treatment of
  MH disorder existing stabilizing treatments
  should be maintained should accept this
  diagnosis presumptively, confirming with
  collaterals most important is to tie symptoms to
  specific life periods
• Can use M.I.N.I. Plus, Timeline Follow Back, or
  SCID
• Can use outlines of common DSM-IV disorders and
  inquire whether the symptoms were ever met, how
  treated, and success

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Twelve Steps in the Assessment Process (TIP42)

• Disabilities and Impairments
• Cognitive capacities, social skills, need for
  special education
• Capable of living independently?
• Capable of supporting self financially?
• Can engage in social relationships? Has social
  supports?
• Level of intelligence? Memory impairments,
  learning disabilities, limited ability to read,
  write, understand? Problems with concentration,
  completing tasks?
• Ability to use transportation, budgeting,
  self-care, ability to participate in treatment

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Twelve Steps in the Assessment Process (TIP42)

• Strengths and supports
• Current strengths, skills, support in relation to
  managing their disorders
• May focus on talents or interests, vocational
  skills, creative self expression
• Areas connected to motivation for change
• Important relationships, family or treatment
  staff
• Previous treatment successes, what has worked?
• Current successful attempts to manage symptoms

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Twelve Steps in the Assessment Process (TIP42)

• Cultural and linguistic needs
• Not substantially different for the COD
  population but should consider
• Fit in the treatment culture, conflicts in
  treatment
• Cultural / linguistic service barriers
• Literacy
• Problem Domains
• Medical, legal, social, vocational, family,
  social that impact treatment engagement and
  outcomes ASI does this
• Identify contingencies that promote treatment
  adherence

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Twelve Steps in the Assessment Process (TIP42)

• Stage of Change
• Interventions must be matched to stage of change
• No problem / interest in change
  (precontemplation)
• Might have a problem, may consider some change
  (contemplation)
• Definitely believes they have a problem getting
  ready to change (preparation)
• Working on changing actively, though perhaps
  slowly (action)
• Achieved stability in this area trying to
  maintain status (maintenance)
• Measures include SOCRATES, URICA
• SATS is a case manager rated scale determining
  engagement in treatment (eight categories)
  covered in TIP 35

31
Twelve Steps in the Assessment Process (TIP42)

• Plan Treatment
• Treatment placement should be matched to the
  needs of the individual client
• Concept of dual primary treatment
• Focus is on integrated treatment planning,where
  intervention choices for each disorder are
  matched
• Must take into account impact of other disorder
  on ability to comply with recommendations

32
Screening Assessment for Co-occurring
Disorders

• All clients should be screened for both mental
  health and substance use disorders
• Screening for mental health and substance abuse
  problems should be completed at the earliest
  possible point after involvement in the treatment
  system

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Key Points Regarding Screening for Co-occurring
Disorders

• Provide screening at different stages of
  treatment
• Use similar or standardized screening instruments
  across different treatment settings
• Information from prior screenings / assessments
  should be communicated across different points in
  the system

34
Screening

• Should generate a yes or no response about
  the need for assessment
• Should be connected to a protocol or cutting
  score recommendation for when an assessment
  should occur
• Can be done by anyone without legal /
  professional constraints

35
Identification of Co-Occurring Disorders

• Grisso and Underwood (2003) emphasize that
• Instruments should not be used if there is no
  research on their reliability and validity
• The greater the consequences of any decision
  that is based on the screen or assessment, the
  more important it is that valid and reliable
  measures be applied.

36
Screening and Detection

• Mental Health Screening Form III
• 18 yes / no questions that inquire about previous
  history of mental health treatment / contacts
  should be used as an interview method that can be
  inquired about re when did the problem begin,
  what was happening in your life at that time, did
  the problem begin before, during or after you
  were using substances?
• Offers one screening question that addresses
  depression, PTSD, delusional disorder, gender
  identity disorder, manic episodes, panic
  disorder, obsessive /compulsive disorder,
  phobias, intermittent explosive disorder, eating
  disorders, pathological gambling, learning
  disorders / mental retardation.
• Available in TIP 42

37
Methods for Assessment

• M.I.N.I. / M.I.N.I. Plus / MINI kid
• Format Structured interview intended to be
  administered by trained interviewers who do not
  have training in psychology or psychiatry
• Takes 15-20 minutes to administer
• Spanish version is available, computerized
  version is also available
• Available on the internet at www.medical-outcome
  s.com at no charge for single use by clinicians /
  researchers

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Methods for Assessment

• Global Appraisal of Clinical Need (GAIN)
• Format Structured interview method that covers
  treatment arrangements, substance abuse, mental
  health , physical health, legal, environmental,
  and vocational issues.
• Takes 15- 30 min to administer 20 minutes to
  score
• Cost Proprietary tools of Chestnut Health
  Systems. Currently considered in development, it
  can be used for evaluation and research at the
  cost of 1 under limited license.
• Available from Chestnut Health Systems, Inc.
• www.chestnut.org/li/gain

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Treatment of CODs

• Philosophy and Orientation
• Expectation rather than Exception
• No wrong door
• Integration of Services
• Integrated vs. Parallel vs. Serial
• One multidisciplinary treatment team
• Cross-Trained in SA and MH
• Treats both disorders concurrently in one setting

40
Essential Integrated Treatment Components

• No one correct model of care
• Core components include
• Standardized screening and assessment
• Drug testing
• Multidisciplinary treatment team, planning
• Multidisciplinary case management
• Long-term and stage-specific
• Family/social network involvement
• Appropriate psychopharmacology for MH

41
? Core Features in Delivering Treatment Services
to Persons with Co-Occurring Disorders Clinical
Practice Changes associated with Evidence-Based
Models (IDDT / CCISC)
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• Focus on Integrated Treatment
• Drake (April, 2001) concludes that eight recent
  studies support the effectiveness of integrated
  dual diagnosis treatments for clients with severe
  mental illness and substance use disorders(pg.
  471).
• Symptoms and behaviors positively influenced in
  these studies include substance abuse,
  psychiatric symptoms, quality of life ratings,
  rates of arrest and hospitalization, housing, and
  functional status.

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Why Integrated Treatment?

• Traditional, non-integrated approaches result in
  poorer outcomes
• An integrated, multidisciplinary approach is
  needed
• To achieve client retention and reduce burden
• Focus is on person in a holistic sense
• Providers are already working with these
  individuals AND can be more effective

44
CCISC Model Recommendations (Minkoff and Cline)

• Welcoming
• Accessible
• Integrated
• Continuous
• Comprehensive
• Consumer / Family Oriented

45
CCISC Model

• Philosophy of Service
• Comorbidity is the Expectation
• Both disorders are considered as primary
• Both are chronic relapsing illnesses
• Acknowledge that readiness will vary
• Need treatment to be lead by integrated staff
• Need to have continuous relationship with
  providers

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Definition of Integrated Service(Minkoff, 2001)

• Treatment is
• Diagnostically Specific
• Phase Specific
• Modified as Needed
• Continuous Across Multiple Treatment Episodes

47
Principles of Service

• Integration of Service
• MH / SA
• Acute and Long Term Care
• Across Systems Children, Criminal Justice,
  Rehabilitation, Housing

48
Goals of Integrated Treatment(Drake, et al.,
1998)

• Consider Disorders as Chronic
• Take a Long Term Approach
• Focus on Stabilization, Education,
  Self-Management
• Employ a Team of Clinicians
• Treat Both Disorders within the Same Program

49
Goals of Integrated Treatment(Drake, et al.,
1998)

• Give Consistent Explanations
• Offer a Coherent Prescription for Treatment
• Reduce Conflict between Providers
• Reduce Burden associated with 2 Programs
• Reduce Opportunity for Conflicting Messages

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More Questions to Discuss with your Providers
What models have you applied to your efforts at
developing integrated COD programs? Have you
defined yourselves as Dual Diagnosis Capable?
What significant changes in your service
delivery and record keeping have you
accomplished? What are the core features of
any integrated dual diagnosis treatment
programs that you are operating?
51

• Moving toward Dual Diagnosis Capability
  Practice Elements Derived from the CCISC and IDDT
  models

52
Program Criteria Admission

• Program does not exclude persons with an acute
  /recent history of severe/persistent MH disorders
  or an acute/recent history of substance abuse /
  dependence
•  Admission criteria specifically allow for the
  inclusion of persons with COD (unless they
  REQUIRE immediate intensive service (CSU / Detox
  Svcs))

53
Program Criteria Admission

• Persons are not excluded from admission based on
  their psychotropic medication history or current
  medication regimen, with limited exceptions.
•  
• Preadmission screening methods always assess for
  persons with COD
• Standardized screening measures assess for both
  mental health and substance use disorders

54
Program Criteria Admission

• Standardized screening measures assess for both
  mental health and substance use disorders
•  
• Standardized assessment methods or measures
  discuss the interaction of both MH and SU
  disorders
• Stage of Change concepts are discussed /
  measured as a part of assessment process

55
Program Criteria Records

• In the clinical record, diagnostic notation /
  impression / clinical summary, clearly identify
  by MH and SU diagnoses
• Treatment plans describe goals and interventions
  for each identified mental health and substance
  use disorder
• Progress notes indicate specific goals,
  behaviors, interventions for each diagnosis
  identified 

56
Program Criteria Records

• Discharge plans explicitly discuss continuing
  care requirements for each mental health and
  substance use disorder continuity of care within
  a program is a primary goal
•  
• Clinical records integrate both mental health and
  substance use interventions in the same file

57
Program Criteria Treatment Quality

• Manualized group interventions discuss the
  integration of mental health and substance use
  disorders.
• Stage of Change concepts are discussed in
  progress notes, and in explicit therapeutic
  interventions Motivational Interviewing
  techniques specifically drive the interventions
• Program uses specific contingency management
  strategies / methods to encourage treatment
  retention

58
Program Criteria Treatment Quality

• Program employs drug testing procedures,
  routinely or as indicated
• Program participants have access to self-help
  groups onsite OR are regularly transported to
  groups that specifically address COD (e.g., Dual
  Recovery / Double Trouble)

59
Program Criteria Staffing

• Program staff includes persons onsite that have
  expertise / professional backgrounds in mental
  health and substance use disorders
• Human resource policies and written training
  expectations focus on the acquisition of skills
  related to the treatment of persons with
  co-occurring disorders

60
Program Criteria Staffing

• Interdisciplinary treatment team meetings occur
  regularly (at least monthly) and include staff
  with mental health and substance abuse
  professional backgrounds
• Program staff communicate with other service
  providers, especially during episodes of acute
  care, encouraging their reconnection / continuity
  with long term care providers

61
Program Criteria Administrative

• Program Mission Statement specifically welcomes
  persons with active co-occurring disorders
• Program Policies and/or procedures specifically
  describe the treatment of persons with COD
• Program literature discusses the admission or
  treatment of persons with COD

62
Program Criteria Administrative

• The program has available written guidelines or
  procedures that describe strategies regarding use
  of psychopharmacological interventions in persons
  with COD
•  MIS / data entry systems are employed that
  identify and track services delivered to persons
  with COD

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Treating Persons with CODs Applying SAMHSA EBP
Toolkits -- Mental Health Perspective

• Integrated Dual Diagnosis Treatment
• General Organization Index (GOI)
• IDDT Fidelity Scale

64

• IDDT General Organization Index (GOI)
• Measures the characteristics of an organization
  hypothesized to be related to its capacity to
  implement and sustain any EBP
• Is intended to be a companion to the Fidelity
  tool
• Is used as a self-assessment to monitor
  implementation (range 1 none to 5 full)
• Is behaviorally anchored to measurable elements
  of practice
• Is best conducted by independent evaluators
• Requires multiple sources of information

65

• IDDT General Organization Index (GOI)
• Sources of Information
• Interviews with staff
• Observation of team meetings
• Chart reviews
• Observation of intervention

66

• IDDT General Organization Index (GOI)
• Domains
• Program Philosophy
• Eligibility / Client Identification
• Penetration
• Assessment
• Individualized Treatment Plan
• Individualized Treatment
• Training

67

• IDDT General Organization Index (GOI)
• Domains
• Supervision
• Process Monitoring
• Outcome Monitoring
• Quality Assurance
• Client Choice

68

• IDDT IDDT Fidelity Scale
• Domains
• Multidisciplinary Team
• Integrated substance abuse specialist
• Stage-wise interventions
• Access for IDDT Clients
• Time-Unlimited Services
• Outreach
• Motivational Interventions

69

• IDDT IDDT Fidelity Scale
• Domains
• Substance Abuse Counseling
• Group DD Treatment
• Family Psychoeducation on DD
• Participation in SA self-help groups
• Pharmacological Treatment
• Interventions to Promote Health
• Secondary interventions for SA treatment
  nonresponders

70

• Available Frameworks and Tools
• CMHS / Mental Health
• CCISC Model (Minkoff and Cline)
• COFIT, COMPASS, CODECAT
• Designed to be used in either MH or SA settings,
  Focuses on Systems and Service Integration
• Considered an Evidence Based Practice
• Being evaluated through the COSIG grants

71

• Available Frameworks and Tools
• CSAT / Substance Abuse TIP 42
• www.samhsa.gov
• EBP lists (www.nrepp.samhsa.gov,
  www.nwattc.org www.scattc.org)

72

• Use of CCISC Tools
• (Minkoff Cline, 2000)
• Using the CODECAT Clinician Self-Assessment of
  Competency
• Using the COMPASS Agency Self-Survey
• Using the COFIT for System Level Evaluation

73
Using the CODECATCan be used as a supervisor
evaluationor as an individual self-evaluation
Scores may be used to identify gaps in training
or as part of a supervisory process to identify
clinician strengths
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COMPASS Agency Self-Survey

• Recommended Method
• Focus group structured interview
• Represent a range of providers, 5-8 persons
• Asked to evaluate services agency-wide that would
  be received by average or typical client
• Range is rarely to consistently

77
COMPASS Agency Self-Survey

• Philosophy These five items assess the extent to
  which an agency has an overall operating
  philosophy to assist clients with dual diagnoses.
  This can be documented or reflected in various
  forms, including program descriptions,
  orientation materials, mission statements,
  policies, and/or procedures.
•  
• Management Structure These eight items tap the
  degree to which organizational structures are
  organized to support integrated treatment of
  individuals with co-occurring disorders.
  Specific evidence of these structures includes
  budgeting and funding allocating processes,
  information systems, and billing structures.

78
COMPASS Agency Self-Survey

• Access These five items tap the extent to which
  individuals with co-occurring disorders are
  welcomed or allowed to enter a treatment agency.
  Specific criteria include admission screening
  procedures, level of care determinations, and
  exclusionary criteria.
•  
• Identification/Detection of Co-occurring
  Disorders These five items measure the extent
  to which an agency can correctly determine if a
  client has a dual diagnosis. Evaluative criteria
  include urine screens and tools or checklists to
  detect substance use and mental health symptoms.
•  
• Assessment/Diagnosis These seven items
  determine the extent to which an agency can
  conduct an integrated, formal assessment of a
  clients mental health and substance abuse
  problems. Using an integrated assessment
  instrument, routinely filling it out and
  documenting both MH/SA conditions in client
  charts are assessed.

79
COMPASS Agency Self-Survey

• Treatment Planning These five items assess the
  extent to which agencies treat each comorbid
  disorder as a primary problem. Criteria used to
  address competencies in this area include
  treatment plans, goals, objectives,
  interventions, and progress notes.
•  
• Treatment Content and Treatment Programming
  These thirteen items determine the extent to
  which an agencys treatment services are designed
  to address co-occurring disorders. Domains
  include whether dual diagnosis-informed
  interventions, educational materials, group
  programming, and treatment manuals are offered.

80
COMPASS Agency Self-Survey

• Integrated Treatment Relationships These eight
  items tap competencies concerning offering
  continuous case management and interdisciplinary
  treatment teams that assist with recovery from
  both mental health and substance abuse problems.
•  
• Treatment Program Policies These four items
  gauge the extent to which an agency has
  established policies, contracts, and procedures
  for addressing treatment needs.
•  
• Psychopharmacology These seven items assess the
  degree to which the medication management
  process, in general, and the medical staff, in
  particular, consider both mental health and
  substance-related problems.

81
COMPASS Agency Self-Survey

• Discharge Planning These seven items measure
  the degree to which an agency considers both the
  mental health and substance abuse treatment needs
  when they leave an agency treatment program.
•  Integrated External Care Management These
  eight items determine the extent to which an
  agency links clients to additional community
  services outside of their agency. Evaluative
  criteria include referral resources and
  documentation, crisis response procedures, and
  inter-agency collaborative efforts.
•  

82
COMPASS Agency Self-Survey

• Staff Competency/Training These six items detail
  the degree to which agency staff members are
  prepared to assist clients with both of their
  disorders. Competency in this area may be
  documented in human resource policies, job
  descriptions, training materials, and performance
  reviews.
• Specific Competencies These nine items tap
  agency dual diagnosis competencies to address
  issues related to culture, gender, age,
  developmental disability, trauma, or family.

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COFIT - 100

• The COFIT-100 has two key sections
• Implementation (process) section
• Outcomes section
• Welcoming
• Accessibility
• Integration
• Continuity
• Comprehensiveness
• Systems are likely to see progress in their
  implementation scores before seeing comparable
  progress in their outcome scores. There are 100
  items that are to be scored, giving a scoring
  range of 100 to 500.

84

• Measuring Different Arenas
• How do these tools fit together?
• Service System
• COFIT
• Agency / Program
• GOI and IDDT Fidelity Scale
• COMPASS
• Individual Clinician
• CODECAT

85
Discussion Questions on Admitting Persons with
CODs

• Will you accept persons with diagnoses of
  schizophrenia, schizoaffective disorder, major
  depression, bipolar disorder
• Will you accept anyone with a severe and
  persistent mental illness regardless of their
  medication use / treatment history?
• Will you accept persons with active substance
  dependence?
• Will you accept persons with a self reported
  history of an active substance use problem?

86
Discussion on Admitting Persons with CODs

• Will you admit persons with a recent history of
  psychiatric hospitalization, homelessness,
  housing instability, use of crisis services /CSU
  admissions?
• Do you routinely take persons who have had
  numerous treatment contacts but who have not been
  successfully engaged in treatment? How is this
  addressed in this program?

87
Additional Techniques in the Treatment of Persons
with Co-Occurring Disorders
88
Key Techniques from TIP 42

• Provide Motivational Enhancement consistent with
  Stage of Change
• Employ contingency management techniques
• Use Cognitive-Behavioral Techniques
• Use Relapse Prevention Techniques
• Use Repetition and Skill Building
• Engage in mutual self help groups

89
Motivational Techniques Miller and Rollnick,
2002

• Guiding Principles
• Express Empathy
• Develop Discrepancy
• Roll with Resistance
• Support Self Efficacy

90
Motivational Techniques Miller and Rollnick,
2002

• Utilizing Motivational Enhancement Approaches
• TIP 42 Figure 5-2

91

• Utilizing Motivational Enhancement Approaches
• Precontemplation
• How would you express concern about their
  disorder(s)?
• State nonjudgmentally that substance abuse / mood
  disorder is a problem/
• Agree to disagree about the severity of their
  problems
• Explore their perceptions of their problems
• Emphasize your wish to help and their need to
  return

92

• Utilizing Motivational Enhancement Approaches
• Contemplation
• Elicit both positive and negative aspects of
  their SA / MI
• Make clear discrepancies between their values and
  actions
• Offer a psychological evaluation / trial of
  abstinence
• Preparation
• Acknowledge the significance of their decision to
  seek treatment
• Explain that relapse should not disrupt your
  relationship
• Help them decide on appropriate, achievable
  action for a problem associated with one of their
  CODs
• Action
• Encourage and support
• Acknowledge the painful aspects

93

• Utilizing Motivational Enhancement Approaches
• Maintenance
• Anticipate and address difficulties
• Support their resolve
• Recognize the struggle
• Relapse
• Determine / explore what can be learned
• Express concern
• Support continue treatment seeking
• Explore ability / efficacy in overcoming relapse

94

• Motivational Enhancement Intervention
• Group Treatment For Substance Abuse
• Velasquez, M.M., et al. (2001)

95

• Relapse Prevention
• Overview of SAMM Concepts and Skills (TIP 42)
• Overcoming Addiction Skills Training for People
  with Schizophrenia
• Lisa Roberts, Andrew Shaner, Thad Eckman
  (1999)

96

• Cognitive Behavioral Interventions
• Seeking Safety by Lisa Najavits
• Criminal Conduct and Substance Abuse Treatment by
  K. Wanberg and H. Milkman

97

• Skill Building
• Social Skills Training for Schizophrenia A
  Step by Step Guide
• Bellack, Mueser, Gingerich, and Agresta (1997)

98

• Continuity of Care
• What does it mean in this population?
• What essential knowledge / skills would you like
  clients to come to you with?
• What are your priorities in an initial phase of
  treatment?
• What are challenges do you anticipate?

99
Creating a Vision of Fully Integrated Treatment
(Drake et al., 1998)

• What service elements can you identify as
  currently in place in your service setting?
• What elements of your service delivery offerings
  need to be modified?
• What are the gaps / challenges that are going to
  be the most difficult to confront?

100
CCISC Strategies for Implementation

• Design policies to support integrated scopes of
  practice and treatment documentation within each
  funding stream / license
• Identify initial clinician competency goals
• Develop system wide training plan,
  Train-the-trainer, and available technical
  assistance
• Address service system gaps related to
  available EBPs, consumer and family involvement,
  available service array

101
CCISC Strategies for Implementation

• Develop a Structure for integrated system
  planning and implementation
• Develop a consensus vision and an a
  collaborative plan of action
• Agree to proceed with implementation within
  existing resources strategizing on how to
  incentivize participation
• Utilize four quadrant model
• Gather consensus for all programs to move to DD
  Capability

102
CCISC Strategies for Implementation

• Develop structures for care coordination between
  MH and SA providers
• Disseminate EBP and Consensus Best Practice
  guidelines
• Identify priorities for BP implementation
  starting with welcoming, removing access
  barriers, integrated screening and data capture

103
Web Resources

• www.samhsa.gov -- for TIP 42 and Co-occurring
  Center for Excellence links
• Co-Occurring Disorders Web-based Curriculum
• www.fmhi.usf.edu (follow the prompts for online
  education)
• Brief Psychoeducational Manual on COD available
  at
• www.fmhi.usf.edu/sparc/statement.html

104
Web Resources

• Further information on Seeking Safety Manual at
• www.seekingsafety.org
• Further information on Trauma Recovery and
  Empowerment (TREM)
• www.communityconnectionsdc.org/trauma

105
Web Resources

• www.scattc.org
• www.aacap.org/publications/factsfam/schizo.htm
• www.surgeongeneral.gov/library/mentalhealth