Organizational Integration in the Treatment of Concurrent Disorders

Working Together:
Organizational Integration in the Treatment
of Concurrent Disorders
Françoise Drouin –Soucy MSW /RSW (CMHA-Ottawa)
Craig Defries MSW/RSW (CMHA-Ottawa)
Tom Dobson SSW (ROHCG)
Human Services & Justice Coordinating Committees
Provincial Conference
November 27th , 2013
Toronto, ON
Disclosure
✦ Presenters report no financial relationships with
commercial interests.
✦ Francoise Drouin-Soucy & Craig Defries are employed by
the Canadian Mental Health Association (Ottawa
Branch)
✦ Tom Dobson is employed by The Royal Ottawa Hospital
(ROHCG)
Session Overview
1. Learning Objectives
2. CMHA Referral Guidelines
3. Concurrent Disorders (Dual Disorders) &
Integrated
Treatment
4. CMHA Ottawa CD Program & Partnership with ROH
Forensic Unit and Ottawa Salus under the TRHP Program
Learning Objectives
• Understand the core principles of the Integrated
Treatment Model,how it forms the foundation of CMHA
(Ottawa Branch) support services and approach to
concurrent disorder treatment.
• Explain how integration of community partnerships are
at the core of integrated treatment of concurrent
disorders- specifically the partnership between CMHA,
The ROH, and Ottawa Salus under the TRHP Program
• Speak specifically to the ROH CD group in context of
CMHA’s Concurrent Disorder Program
CMHA REFERRAL GUIDELINES
✦Clients must have a serious mental illness, as
defined by the Ministry of Health
✦Clients must be homeless or at imminent risk
of becoming homeless.
✦Clients with multiple and complex needs and
as a result are not able to formulate and/or
implement their own community support
plan without intensive support
Quadrant 3
High
A
D
D
I
C
T
I
O
N
Low
Quadrant 4
PSYCH. LOW /
PSYCH. HIGH
SUBSTANCE HIGH SUBSTANCE HIGH
A high level of addiction A high level of addiction
problems with a low
problems with a high level of
level of mental illness
mental illness
Quadrant 1
PSYCH. LOW
Quadrant 2
PSYCH. HIGH
SUBSTANCE LOW SUBSTANCE LOW
A low level of addiction A low level of addiction
problems with a low
problems with a high level of
level of mental illness
mental illness
Low
High
MENTAL ILLNESS
6
• Why is CMHA in
the business of
addressing
concurrent
disorders?
7
Why Concurrent Disorders?
•
Approximately 50% of persons with severe
mental illnesses will develop alcohol or other drug
use disorders at some point in their lives.
•
•
•
•
Small amounts of
substance use have
a severe impact on
mental health.
Why is Tobacco Use of Concern to a
Mental Health Agency?
•
Individuals with severe mental illness die
twenty-five years earlier than the general
population,
• Sixty percent of these deaths are due to
cardiovascular and respiratory disease
• For individuals with schizophrenia, heart
disease is now associated with twenty-five
to thirty years premature mortality
9
Impact of Substance Abuse
on Psychiatric Illness
•




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
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
The Effects are Additive……….
Relapse and re-hospitalizations
In severity of symptoms of mental illness
Family / interpersonal conflict
Financial problems
Risk of violence / aggression (perpetrator and/or victim)
Risk of homelessness / housing problems
Legal problems
Risk of severe physical health problems
Suicide risk
• All of these effects add up to Early Mortality
Socio-environmental Factors
• “Substance abuse and mental illness are
not ‘medical’ diagnoses alone, but are
also strongly influenced by socioenvironmental factors that are an
indication of deep social inequities and
poverty”
• (Drake et al., 2008)
11
Integrated Treatment:
CMHA OTTAWA
Integrated Treatment for
Dual Disorders
–Drake, R. E., Fox, L., Mueser, K.T., & Noordsy, D.L. (2003) Integrated Treatment for
Dual Disorders: A Guide to Effective Practice.
.
✦Substance Abuse and Severe Mental Illness
✦Integrated Treatment
✦Assessments
✦Individual Approaches
✦Group Interventions
✦Working with Families
✦Appendices
–NewYork: The Guilford Press
Why Integrated Treatment?
• Among those with co-occurring disorders:
•
•
•
•
The commonest cause of psychiatric relapse is
resumption of alcohol or drug USE, not necessarily
abuse
The commonest cause of relapse to alcohol or
drug use is untreated psychiatric disorders, especially
depression and anxiety
Co–occurring Disorders: Overview COSIG teleconference, 10/7/04 Bert Pepper, MD, downloaded from
http://coce.samhsa.gov/cod_resources/PDF/Co-OccurringDisordersOverview10-04.pdf
Components of Integrated Treatment
•
•
•
•
•
•
Integration of services
Comprehensiveness
Assertiveness
Harm Reduction Approach
Long term perspective
Motivational based treatment
• Availability of multiple bio-psycho-social interventions
• In all interventions, both mental illness and addictions are
taken into consideration and considered primary
“I’m short in ingredients.
What’s a good substitute
for filet mignon?”
16
Definition of Motivation Interviewing
•
A set of therapeutic strategies designed to help clients
understand the impact of substance abuse on their lives in their
own terms. (Mueser)
•
We define motivational interviewing as a client centred,
directive method for enhancing intrinsic motivation to change
by exploring and resolving ambivalence. (Miller & Rollnick)
17
CMHA Concurrent Disorder Program
Stage-Wise Group Treatment
Detection- Strategies
• CAST A WIDE NET
• BE OVERINCLUSIVE
• MAINTAIN A HIGH INDEX OF WELCOMING AND
EXPECTATION
19
Typical Dimensions of
Assessment in Substance Use
Disorder
• …….what types of experiences are being
measured/assessed?
•
•
•
•
Patterns of Use
Consequences of Use
Subjective Distress
Dependence Syndrome
Stages of Change
Prochaska and DiClemente (1992)
1.
2.
3.
4.
5.
Pre-Contemplation
Contemplation
Preparation
Action
Maintenance
Levels of Treatment within the CD Program
Matched to Stages of Change
• Stage of Change = Treatment Group
• Pre-contemplation
Engagement
• Contemplation/
Persuasion
Preparation
• Action
Active Treatment
• Maintenance
Relapse Prevention
• Termination
Peer Support
Clients in Concurrent Disorder
Treatment Groups: September 2013
• Total of 358 clients participate in 28 weekly group sessions (5+
art therapy)
• All groups are open-ended, many are population specific. (e.g.
Smoking Cessation Group, DD/CD Group, Young Adults, Older
Adults, DBT-S, etc.)
• The groups are held on site and in the community at various
partner agencies
Community Partners
• Community Partnerships are an
extension of integrated
treatment
• 28 groups ranging in age, gender,
stages of change , specific areas
(art therapy, trauma)
• Groups co-facilitated in
partnership with 6 community
partner agencies
• Rideauwood
• ROHCG
• Addiction & Mental Health
Services (Sandy Hill CHC)
• Maison Fraternité
• Ottawa Inner City Health
• The Men’s Project
ROHCG CD Group
•
•
•
•
•
Overview of group: Meets weekly, Co-ed; Average 6-8
in the group
Different stages of change
As facilitators we meet clients where they’re at. They
also meet each other where they’re at.
Core Values: Non-judgmental; Positive; Validation of
all; MI [“MI attacks the problem not the person”]
Allowing for more freedom of expression
Key Elements of Engagement Groups
• An accepting environment where clients are free to discuss their
experiences with alcohol, drugs & serious mental illness without
fear of judgment, confrontation, or social censure
• Providing a safe environment to discuss positive aspects of
substance use, often sets the stage to discuss negative
consequences of use……ultimately the goal being to develop and
nurture that interest in working on substance abuse issues
• To meet clients where they are at by addressing their concerns
and not imposing goals on them
• Instillation of strengths and hope essential
Themes often discussed in Engagement
Groups
•
•
•
•
•
•
•
Crisis
Goals
Strengths
Needs
Stages of Change
Exploration of SUD &SMI
Triggers
•
•
•
•
•
•
Coping Skills
Identifying Feelings
Safety
Boundaries
Communication Skills
Values
31
Client Feedback of CD Groups
•
•
•
•
•
•
•
•
Provides support
Sense of humour
Safe environment
Socialize without drugs
Acceptance
Positive input
Enjoyable
Reduces shame
•
Share emotions
•
Improve creativity
•
Relaxing
•
Companionship
•
Trying new things
•
Caring
•
Decreases isolation
•
Makes me happier
•
Feeling human
ROHCG Group Client Feedback
•Diminishes anxiety
•Builds confidence
•Feel supported, cared about
•Ability is recognized
•Feel can express self more openly
Ottawa TRHP Program
•
The Transitional Rehabilitation Housing Program is a
partnership involving Ottawa Salus, Canadian Mental Health
Association (CMHA) and the Royal Ottawa Health Care
Group (ROHCG)
•
The TRHP provides psychosocial rehabilitation
opportunities for 10 adults (4 Grove Ave residents; 6 clients
living in the community) who live with severe and persistent
mental illness to undertake their recovery process
TRHP – Fundamentals
Shared experience and communication
Trust
Flexibility
Improved client outcomes
Principles of Recovery
Person involvement- each person participates actively in
all aspects of their recovery plan
•Self-determination/choice-each person determines
their own unique recovery plan
•Growth Potential- everyone has the potential to change
and to continually improve
•Hope- each person has the hope and belief that they will
recover
•The need of a supportive environment to thrive-
each person is helped by the presence of others, who
believe in them.
Principles of Providing
Choice in Housing
• Individuals choose their own living situation (informed and meaningful
choice)
• Individuals live in regular, stable housing; not in “programs”
• Regular landlord/tenant relationship; no substance use or treatment
compliance clauses
• Individuals have access to services and supports that enable them to
succeed in the living situation
• These supports are:
• Flexible
• Portable
• Available when the person wants them
Rehabilitation-Recovery Intervention
Phase
Services from the ROHCG
•Expertise of the nurse (bridge
between TRHP and ROHCG,
monitoring, etc…)
•On call psychiatrist available after
hours for consultation to Salus
Transitional Housing
•Support and monitoring
Services from CMHA
•Transitional Case Manager
•Community Support and Rehabilitation
Plan
•Assessment and strengthening of client
support network
•Concurrent Disorder Groups
• Assistance /Coordation of securing
long term housing
Services from Ottawa Salus
•Connecting phase with Key worker, the Grove
team and program participants
•Developing readiness (psychosocial
rehabilitation supports - group & individual)
•Teaching apartment
•Development of a recovery plan
•Individualised Risk Management Plan (if
applicable)
•Early Intervention Plan (if applicable)
•Symptoms Management Interventions
Transitional Rehabilitation Housing
Program Ottawa
Housing Model at CMHA: Features
• Direct tenant leasing, not agency leasing
• Housing Coordinator = CMHA Landlord role (particularly for
condos)
• Community Support Workers and Outreach Workers =
Support role
• Primarily private landlords partnering for units
• Rent supplements allow clients to access higher quality units
Organizational Integration
Salus
Grove
• Transitional
Housing
Long term
Housing,
Intensive
Case Mgmt;
CD Program
• Client at the centre
ROH
Forensics
Inpatient /
Outpatient
• Integrated
Supports
• Medical
Support
Benefits of
Organizational Integration and CD Groups
• Group at ROHCG an engagement group. Purpose is to put ongoing
supports in place before discharge.
• Partnership makes transition to the community seamless; many
supports already in place.
• Clients spend overnights at Salus Grove; begin CD groups at CMHA
before discharge; continuity, double support
• Transition from Salus Grove to independent apartment with ongoing
supports from ROHCG, CMHA, Ottawa Salus
Questions ?