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Integrated Treatment for Adolescents with Mental Health and Substance Use Challenges


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Title: Integrated Treatment for Adolescents with Mental Health and Substance Use Challenges

Integrated Treatment for Adolescents with Mental
Health and Substance Use Challenges
  • Presentation to Consumer and Family Member
  • Friday, December 8th, 2006

Kari Collins, LCSWMichael Gosser, LCSW,
CADCSonny Hatfield, LCSW
  • Kentucky Youth First
  • Division of Mental Health and Substance Abuse
  • 502-564-4456

(No Transcript)
Conceptual Challenges to Address
  • Most adolescents do not recognize their substance
    use as a problem and are being mandated to
    treatment (and are angry about it)
  • Co-occurring problems (mental, trauma, legal) are
    the norm and often predate substance use
  • Treatment has to take into account the multiple
    systems (peers, family, school, welfare, criminal
    justice) involved in their lives

Conceptual Challenges to Address
  • Adolescents have less control of their lives and
    recovery environment than adults
  • Need to be creative in dealing with family and
    peer relationships because they are still central
    to the adolescents self-identity and are not
    easily changed
  • Families often play a pivotal role, but vary in
    their ability and willingness to help

Need for Services
  • Some youth in Kentucky are in trouble.
  • In 2005, there were an estimated 25,793
    adolescents in the state that needed treatment
    for their substance related problems. Less than
    10 are documented as having received treatment.
  • Nationally, less than 50 stay in treatment 6
    weeks, and 75 stay less than the 3 months
    recommended by NIDA.

Need for Services (continued)
  • Youth involved with the juvenile justice system
    are considerably more likely to have substance
    use problems than in the general population.
  • Estimates range from 50-90 of youth with
    substance use problems also have mental health

Facts About Co-Occurring Disorders
  • 43 receiving mental health services had been
    diagnosed with a co-occurring SUD.
  • CMHS (2001)national health services study
  • 13 of adolescents with significant emotional and
    behavior problems reported substance dependence.
  • SAMHSA 1994-96 National Household Survey
  • 62 of males and 82 of females entering SUD
    treatment had a co-occurring psychiatric
  • SAMHSA/ CSAT 1997-2002 study
  • 75-80 of adolescents receiving inpatient
    substance abuse treatment have a coexisting
    mental disorder
  • NMHA, 2005

Reclaiming Futures
  • RWJF launched national program and local pilots
    in 2002 to serve youth with SA and CO who were
    also involved in the justice system.
  • The Vision
  • More Treatment
  • Better Treatment
  • Beyond Treatment

Reclaiming Futures
  • Three things that work!
  • System Reform
  • Treatment Improvement
  • Community Engagement

Reclaiming Futures Model
System of Care
  • Systems of Care is not a program it is a
    philosophy of how care should be delivered. 
  • Systems of Care is an approach to services that
  • the importance of family, school and community,
  • seeks to promote the full potential of every
    child and youth by addressing their physical,
    emotional, intellectual, cultural and social

Continuum of Care vs. Systems of Care
  • Continuum of Care
  • Range of actual services/program elements and
    resources at varying levels of intensity
  • Systems of Care
  • Greater than the continuum, containing the
    service/program elements and resources and
    provisions for service coordination and

System of Care Core Values
  • 1. Child centered and family focused, with the
    needs of the child and family dictating the types
    and mix of services and resources provided.
  • 2. Community based, with the location of
    services, resource development, management and
    local decision making at the community level.
  • 3. Culturally competent, with agencies,
    programs, services and resources that are
    responsive to the cultural, racial, and ethnic
    differences of the population they serve.

System of Care Guiding Principles
  • A comprehensive array of services/ resources
    across domains of their lives
  • 2. Individualized services/resources
  • 3. Services within the least restrictive setting
  • 4. Youth, families and caregivers should be full
  • 5. Integrated services between child serving
    agencies and resources

System of Care Guiding Principles
  • Service coordination (case management)
  • Early identification and intervention
  • Smooth transitions
  • Advocacy
  • Cultural differences and special needs

Traditional Treatment Approaches
  • Sequential
  • One disorder then the other
  • Parallel
  • Treated simultaneously by different professionals

Integrated Treatment Definition
  • Treatment interventions for COD are combined
    within the context of a primary treatment
    relationship or service setting.
  • It is a means of actively combining interventions
    intended to address substance abuse and mental
    disorders in order to treat both, related
    problems, and the whole person more effectively.
  • SAMHSA, TIP 42

Delivery of Services(samhsa, TIP 42)
  • Provide access
  • Complete a full assessment
  • Provide appropriate level of care
  • Achieve integrated treatment
  • Treatment planning and review
  • Psychopharmacotherapy
  • Provide comprehensive services
  • Supportive and Ancillary Wrap Services
  • Ensure continuity of care
  • Extended Care, Halfway Homes and other Residence

Achieving Integrated Treatment
  • Beginning
  • Addiction Only
  • Intermediate
  • COD capable
  • Advanced
  • COD Enhanced
  • Fully Integrated

Fully Integrated Treatment
  • One program that provides treatment for both
  • Mental and substance use disorders are treated by
    the same clinicians.
  • The clinicians are trained in psychopathology,
    assessment, and treatment strategies for both

Fully Integrated, cont.
  • The focus is on preventing anxiety rather than
    breaking through denial.
  • Emphasis is placed on trust, understanding, and
  • Treatment is characterized by a slow pace and a
    long-term perspective.
  • Providers offer stagewise and motivational

Fully Integrated, cont.
  • Supportive clinicians are readily available.
  • 12-Step groups are available to those who choose
    to participate and can benefit from
  • Pharmacotherapies are indicated according to
    clients' psychiatric and other medical needs

  • Purpose
  • To identify adolescents who need a more
    comprehensive assessment for substance use
  • Components
  • Questions to uncover red flags or indicators of
    serious substance-related problems among
  • Include multiple domains including substance use
    disorder severity, home life, psychiatric status,
    and school status preferably from more than one

  • CRAFFT yes no
  • Have you ever ridden in a Car driven by someone
  • yourself) who was high or had been using alcohol
    or drugs? __ __
  • 2. Do you ever use alcohol or drugs to Relax,
    feel better about
  • yourself, or fit in? __ __
  • 3. Do you ever use alcohol or drugs while you are
    by yourself
  • Alone? __ __
  • 4. Do you ever Forget things you did while using
    alcohol or
  • drugs? __ __
  • 5. Do your Family or Friends ever tell you that
    you should cut
  • down on your drinking or drug use? __ __
  • 6. Have you ever gotten into Trouble while you
    were using
  • alcohol or drugs? __ __
  • Scoring 2 or more positive items indicate the
    need for further assessment.
  • The CRAFFT is intended specifically for
    adolescents. It draws upon adult screening
    instruments, covers alcohol and other drugs, and
    calls upon situations that are suited to

Who can (and should) do a Screening?
  • Health service providers
  • Juvenile justice workers
  • Educators
  • Community organizations (schools, health care,
    judiciary, vocational rehabilitation, religious
  • Other individuals associated with adolescents at

  • The comprehensive assessment, which is based on
    the initial screening, has several purposes
  • To accurately identify those youth who need
  • To further evaluate is a substance use disorder
    exists, and to what severity
  • To learn more about the nature of the youths
    substance-using behavior

Assessment (continued)
  1. To identify other problem areas (medical,
    psychological, nutrition, social, family,
    education, delinquent behavior)
  2. Evaluate the extent to which the family can be
    involved (assessment and interventions)
  3. Identify strengths of the adolescent
  4. Develop a written report (including severity of
    the problem areas, corrective plan of action, and
    recommendations for services)

Evidence Based Assessment Tool
  • The Global Appraisal of Individual Needs (GAIN)
    is a progressive and integrated family of
    instruments for
  • initial screenings, brief interventions and
  • standardized biopsychosocial clinical assessments
    for diagnosis, placement and treatment planning
  • monitoring of changes in clinical status, service
    utilization, and costs to society
  • subgroup and program level needs assessment and
  • The GAIN has been used with both adolescents and
    adults and in outpatient, intensive outpatient,
    partial hospitalization, methadone, short-term
    residential, long-term residential, therapeutic
    communities, and correctional programs.

  • GAIN-Short Screener (GAIN-SS) a two page, brief
  • The GAIN-Quick (GAIN-Q) - a general assessment
    (11-14 pages) used to identify various life
    problems among adolescents and adults in the
    general population. It is designed for use by
    personnel in diverse settings (e.g. Employee
    Assistance Programs, Student Assistance Programs,
    health clinics, juvenile justice, criminal
    justice, etc.)
  • GAIN-Initial (GAIN-I) - a full bio-psycho-social
    that integrates research and clinical assessment
    to do assist with diagnosis, placement,
    individualized treatment planning, program
    evaluation and meets major reporting

Effective Treatment Program Characteristics
  • Assessment and Treatment Matching
  • Comprehensive integrated treatment approach
  • Family Involvement
  • Developmentally Appropriate
  • Engagement and Retention
  • Trust
  • Length of stay
  • Qualified Staff
  • Gender and Cultural Competence
  • Continuing Care
  • Treatment Outcomes

Evidence Based Interventions
  • Motivational Enhancement Therapy (MET)
  • Family-Based
  • Behavioral Therapy
  • Cognitive-Behavioral Therapy (CBT)
  • Community Reinforcement Approach

Motivational Enhancement Therapy
  • Stand-alone brief interventions OR
  • Integrated with other modalities
  • Client-centered approach for resolving
    ambivalence and planning for change
  • Demonstrates improved treatment commitment and
    reduction of substance use and risky behaviors
  • Developmentally appropriate with adolescents

Family Based Interventions
  • Structural-Strategic Family Therapy
  • Parent Management Training (PMT)
  • Functional Family Therapy (FFT)
  • Multisystemic Therapy (MST)
  • Multidimensional Family Therapy (MDFT)
  • All based on
  • Family systems theory
  • Use of functional analysis for interventions that
    restructure interactions
  • Teaching parents behavioral principles and better
    monitoring skills to increase the adolescents
    pro-social behaviors, decrease substance use,
    improve family functioning, and hold treatment

Purposes for Family Involvement
  • Learn about child from family perspective
  • Mutual education and redefinitions
  • Define substance use in the family context
  • Establish/re-establish parental influence
  • To decrease familys resistance to treatment
  • To assess interpersonal function of drug use

Family Involvement, cont.
  • To interrupt non-useful family behaviors
  • Identify and implement change strategies
    consistent with familys interpersonal
    functioning and cultural identity
  • Provide assertion training for child and any
    high-risk siblings

Behavioral Therapy Approaches
  • Based on operant behavioral principles
  • Reward behaviors incompatible with drug use
  • Withhold rewards or apply sanctions for use or
    other negative behaviors targeted
  • Use of physical monitoring (urines, etc.) for
    close link of consequences
  • Use of individual approach and family involvement
  • Has demonstrated positive results for a number of
    problem areas

Cognitive-Behavioral Therapy
  • Based on learning theory
  • Has individual and group applicability
  • Has a number of manualized approaches
  • Uses MET
  • Uses functional analysis to target areas
  • Teaches coping strategies, problem-solving
    communication skills (practice homework)
  • Uses relapse-prevention and alternative
    activities strategies for avoiding substance use

Behavioral Treatment Studies
  • Interventions associated with reduced substance
    use and problems
  • 12-Step Treatment
  • Behavioral Therapies
  • Family Therapies
  • Engagement and maintenance is associated with
    several interventions
  • case management, stepping down residential to OP,
    assertive aftercare

Lessons from Behavioral Studies
  • Family therapies were associated with less
    initial change but more change post active
  • Effectiveness was associated with therapies that
  • were manual-guided and had developmentally
    appropriate materials
  • involved more quality assurance and clinical
  • achieved therapeutic alliance and early positive
  • successfully engaged adolescents in aftercare,
    support groups, positive peer reference groups,
    more supportive recovery environments

Lessons from Behavioral Studies
  • The effectiveness of group therapy was dependent
    on the composition of the group
  • The effectiveness of therapy was dependent on
    changes in the recovery environment and social
  • Effectiveness was not consistently associated
    with the amount of therapy over 6-12 weeks or
    type of therapy
  • As other therapies have improved, there is no
    longer the clear advantage of family therapy
    found in early literature reviews
  • Differences between conditions change over time,
    with many people fluctuating between use and

Community Reinforcement Therapy
  • Combines principles techniques derived from
    others (behavioral, CBT, MET, and family therapy)
  • Uses incentives to enhance treatment outcomes

Specific Treatment Manuals
  • Cannabis Youth Treatment (CYT) Series
  • Motivational Enhancement Therapy and Cognitive
    Behavioral Therapy 5 Sessions
  • The Motivational Enhancement Therapy and
    Cognitive Behavioral Therapy Supplement 7
    Sessions of CBT
  • Family Support Network
  • The Adolescent Community Reinforcement Approach
  • Multidimensional Family Therapy

Additional Adolescent Programs
  • The Seven Challenges
  • The Seven Challenges Program is designed for
    adolescent and young adult substance abusing or
    substance dependent individuals, to motivate a
    decision and commitment to change. It helps young
    people look at themselves, understand what it
    takes to give up a drug abusing lifestyle - and
    prepare for and attain success when they commit
    to such change.The Seven Challenges is a
    comprehensive program that is developmentally
    appropriate, research based, culturally sensitive
    and holistic.

The Seven Challenges
  • 1. We decided to open up and talk honestly about
    ourselves and about alcohol and other drugs.
  • 2. We looked at what we liked about alcohol and
    other drugs, and why we were using them.
  • 3. We looked at our use of alcohol or other drugs
    to see if it has caused harm or could cause harm.
  • 4. We looked at our responsibility and the
    responsibility of others for our problems.
  • 5. We thought about where we seemed to be headed,
    where we wanted to go, and what we wanted to
  • 6. We made thoughtful decisions about our lives
    and about our use of alcohol and other drugs.
  • 7. We followed through on our decisions about our
    lives and drug use. If we saw problems, we went
    back to earlier challenges and mastered them.

Culturally Competent Treatment Programs
  • Family (as defined by culture) seen as primary
    support system
  • Clinical decisions culturally driven
  • Dynamics within cross-cultural interactions
    discussed explicitly accepted
  • Cultural knowledge build into all practice,
    programming policy decisions
  • Providers explore youths level of

Culturally Competent Treatment Programs
  • Respect for cultural differences
  • Creative outreach services to underserved
  • Awareness of different cultural views of
    treatment/help-seeking behaviors
  • Program staff work collaboratively with community
    support system
  • Treatment approaches build on cultural strengths
    values of minorities
  • Ongoing diversity training for all staff
  • Providers are similar to youth of color served

Level of Care Determination
  • Treatment matching
  • Long-term Outpatient Treatment
  • Greater effect for more severe social, family and
    employment problems (Friedman 1993)
  • Better outcomes for adolescents with more sever
    psychiatric problems

ASAM PPC 2R - Dimensions
  • Acute Intoxication/Withdrawal
  • Biomedical Condition and Complications
  • Emotional, Behavioral or Cognitive
  • Co-morbidity
  • Dangerousness
  • Interference with addiction recovery
  • Social functioning
  • Ability for self-care
  • Course of illness
  • Readiness to Change
  • Relapse, Continued use
  • Recovery Environment

ASAM PPC 2R Levels of Care
  • Early Intervention
  • Outpatient Treatment
  • Intensive Outpatient/Partial Hospitalization
  • Residential/Inpatient
  • Low intensity
  • Medium Intensity
  • High intensity
  • Medically Managed Intensive Inpatient

Factors Affecting Treatment Placement
  • Developmental Stages
  • Ethnicity
  • Gender
  • Co-occurring Disorders
  • Pharmacotherapy
  • Family Factors
  • Social and Community Factors
  • Peer influences
  • Environmental Influences
  • School Factors

Other Services Needed
  • Determine need for multidimensional services
  • Consider
  • Adolescent and familys living conditions,
  • Other family issues/needs,
  • Other agencies already involved/needing to be
  • What supports will be necessary and must be
    coordinated in order to support treatment

Youth with Distinctive Treatment Needs
  • Youth involved in the juvenile justice system
  • Diversion programs
  • Juvenile treatment/drug courts
  • Homeless and Precariously Housed Youth
  • Homosexual, Bisexual, and Transgendered Youth
  • Youth with Co-occurring Disorders
  • Physical Health Problems
  • Mental and Emotional Health Problems
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