SAMHSA TIP 42 Treatment of Co-Occurring Disorders Part 3


This episode was pre-recorded as part of
a live continuing education webinar. On demand CEUs are still available for this
presentation through ALLCEUs. Register at ALLCEUs.com/CounselorToolbox. Alrighty everybody welcome to today’s
presentation on treatment of persons with co-occurring disorders based on
Samsa tip 42 and this is part three. The first recording was part one and two
because those were short. Today is part three well a recording of that and then
later today at 1:00 p.m. CST 2 p.m. EST I will be doing part 4 so we’re slowly
working through tip 42 which is kind of a monster of a treatment improvement
protocol for those of you who are not familiar with tips you can download tip
42 from Samsa go to Samsa or store Thompson gov and search for tip 42 and
you can download that if you want to read the whole thing which is you know
it’s several hundred pages but anyhow today in this particular presentation
we’re going to identify guiding principles and treatment core components
and the delivery of services and how to improve substance abuse treatment
systems and programs now part four we’re going to go in depth into screening and
assessment so we’re not really going to talk about that a lot in this hour so
today we’re still hitting those meta concepts so for each component that are
identified as guiding principles I want you to think about how you already do or
could apply this or do this in your program so you want to employ a recovery
perspective that means we want to help people build on what they have to
achieve their goals it’s less about eliminating a problem and more about
enhancing quality of life we want to adopt a multi problem viewpoint instead
of just seeing someone as presenting with alcohol addiction or depression we
want to see them as a whole person so we can look at the multiple different
problems that might be contributing to their current symptoms and it can be
mental health substance addiction like behavioral addictions medical issues can
also be psychosocial issues there are a lot of things that can contribute to
mood and behavioral symptoms we want to develop a phased approach to treatment
so people aren’t going into residential and then being discharged to once a week
after care that’s too stark of a step down we need to have that phased step
where I used to work we were lucky enough to have multiple levels of
treatment in our facility so when somebody stepped down from residential
they stepped down to intensive outpatient they did intensive outpatient
four hours a day five days a week for a month if they were still clean having no
problems then we reduced it to three hours a day three days a week for a
month and if they were still doing great then we discharged them to aftercare but
it was a step down because they went from that sanctuary if you will of
residential where all they had to do was focus on what was right in front of them
to dealing with recovery and supposed to cute withdrawal issues and life however
it was being thrown at them so a phased approach to treatment helps people
solidify solidify their treatment goals likewise in a phased approach if
somebody is in IOP and they’re struggling to maintain their sobriety or
they’re struggling with their mental health issues and they need more
intensive treatment a phased approach will allow them to phase up while
they’re symptomatic and then phase back down again as soon
as you know they’ve gotten the tools or whatever they need to be more stabilized
we need to address specific real-life problems early in treatment you know you
can talk about meta concepts and you can talk about self esteem and you know all
this other stuff which is great but when people come into treatment they’re
motivated they are sick and tired of being sick and tired whether it’s from
addiction or mental health or physical issues whatever they are there because
they are ready to feel better so we need to figure out okay what was different
when you felt better before and how can we help you start feeling better now or
what are the top three things that you really want to focus on changing right
now those are the real life issues so for a lot of people who come into
substance abuse treatment yes they’ve got to focus on their substance use but
one of their real life problems might be the fact that their spouse is getting
ready to leave them because of their addiction so they want to focus on
relationship issues or they might be getting ready to lose custody of their
kids so we want to focus on maybe parenting issues or any legal issues
related to that we want to help them identify some of those real life
problems that are sort of supporting the unhealth unhealthy thoughts and
behaviors and help them start addressing those so we take away that undercurrent
of negativity we want to plan for clients cognitive and functional
impairments when they’re in early recovery there are going to be cognitive
and functional impairments if they have been using for any length of time most
likely while the fog lifts and that’s what we generally refer to it as but
it’s also important to remember that for most substances out there there is a
post acute withdrawal syndrome that will intermittently sort of rear its ugly
head for up to a year so the person may be doing fine be asymptomatic and then
how a really bad few days really bad weekend
really bad week where they’re feeling cravings where they’re feeling lethargic
where they’re feeling you know not good again with benzodiazepines for example
and marijuana that’s another one the first 30 days the post acute withdrawal
syndromes seem to be a lot worse than after that but we do want to recognize
that clients for a variety of reasons not just for due to substance
intoxication or exhaustion but for a variety of reasons clients in recovery
may go through periods where they have difficulty concentrating remembering
focusing we may need to slow things down a little bit for them because they’re
kind of foggy headed for some reason and if they’ve got co-occurring issues if
their depression or their anxiety has spun up if you will then it’s going to
make it more difficult for them to focus and treatment likewise if they’re using
it’s they’re gonna have difficulty focusing and treatment so we do need to
focus on those things when someone starts a new medication a new
psychotropic medication it may make it difficult for them to focus in treatment
even if it’s an SSRI you know some people the first week have difficulty
focusing the first week after a dose is adjusted if it’s an atypical
antipsychotic or a mood stabilizer it may hit them really hard and they may
feel really groggy for a little bit until they get their dose worked out so
it’s important to be aware that they’re going to wax and wane and their ability
to participate and we need to use support systems to maintain and extend
treatment effectiveness including support systems in the community you
know any sort of wraparound services that we have there including significant
others family self-help groups religious organizations anyone who’s out there
that can help support this person in meeting their biopsychosocial needs so
what do we have for housing for transportation for legal services for
employment services yada yada there are more core components that
we’re going to talk about but we really want to look at programs that have
access for people so how can people get into your program you know that’s a
pretty basic issue if there’s a six-week waiting list that is not accessed when
where I used to work in order to enhance access we had a walk-in clinic two days
a week where people could come in and get their initial assessment so they
didn’t have to wait weeks and weeks to get an assessment we did a
strengths-based assessment and tried to give them some tools and things to work
on even when they left the assessment but then we also had intervention level
groups a SAM level 0.5 I mean it’s not treatment but it was something to help
them out because they were motivated and they were struggling when they came in
so we want to you know strike while the iron’s hot so to speak so we had I think
it was three times a week we had an hourly group or an hour-long group that
people could come to was it what they needed no most of them needed
residential or something much more intense but it did give them somewhere
that they could come and get some tips and tools start working on some things
and it gave us the ability to lay eyes on them to make sure that they were safe
and it gave us the ability to keep track of them so when a bed opened in detox or
in residential we knew how to access them and they didn’t just kind of fall
off the radar so access is important you also want to have access to culturally
sensitive programs you know not everybody is going to want to go into
the same type of program not everybody’s going to be comfortable with the same
types of counselor some you know for example some people may want a male
counselor and some people may only feel comfortable with a female counselor
yada-yada so you do want to be sensitive to culture to gender to disability and
just temporal access can they get in you want to make sure that you provide a
full assessment not just a substance abuse assessment in co-occurring
disorder we need to assess the substance use
issues we also need to assess the mental health issues and any other ancillary
issues that might be contributing to the problem you need to have appropriate
levels of care and if you don’t in your agency you know that’s okay but you need
to know where those levels of care are so if you provide if you’re an
independent practitioner you provide outpatient treatment maybe you have
groups every night but not nothing like intensive outpatient that’s fine that’s
cool but you need to be able to refer up to a program that does have intensive
outpatient partial hospitalization or residential or detox as needed so even
if you don’t have it in your organization you need to be able to make
sure that you’re connected with other facilities that offer appropriate levels
of care treatment needs to be integrated you don’t want somebody coming in and
seeing their substance abuse therapist and then going somewhere else and seeing
their mental health therapist and those two therapists don’t even know what each
other are doing we need to have at the very least medical mental health and
substance abuse all on the same page about what’s going on what the treatment
plans are where we’re moving with this even if you don’t treat the mental
health and another substance and another clinician does that’s okay but you need
to be aware of what’s going on in those treatment sessions so for example if
they start working on intense trauma issues there you know that the person is
going to be at greater risk for relapse and you can maybe tailor what you’re
doing in substance abuse treatment to help them prepare for that comprehensive
services need to be available again not necessarily through just your agency you
can make referrals you could have consultations that’s cool but we need to
be able to make sure those connections are seamless and not just say well why
don’t you call information and referral and see what’s out there that doesn’t
work and there has to be continuity of care we want to make sure the clients
are being handed over nicely to the next and the next person gets the chart and
they can actually review the chart and there are notes in the chart you know
all that stuff that you would assume happens that often doesn’t happen even
in the agency that I used to work for we would refer to another program and the
chart may not ever get over to that building unless the clinician walked it
over so obviously this was before electronic medical records but you get
my point so access occurs in four main ways
there’s routine access for individuals seeking services who are not in crisis
and that’s what I was talking about with the walk-in clinic and then putting them
in the intervention level groups those people are not in crisis but we’re able
to keep eyes on them to make sure that they don’t decompensate then there’s
crisis access for individuals requiring immediate services either because of
their level of intoxication they need to get into detox now or because of their
mental health status they need to get into crisis stabilization now or they
need something in between you know there are generally a few other permutations
so you’ve routine access crisis access then you have outreach in which agencies
target individuals who are in great needs such as people who are homeless or
we had an entire outreach program for older adults because they didn’t
typically reach out to seek treatment and access that is involuntary so you
have people who don’t normally access services that might consider it if they
kind of knew about it or would think about it and then you have access for
the people who don’t really care about services because they’re not voluntary
and sometimes well a lot of times you will be working with those clients so
it’s important to be aware of where your clients come from and how they funnel
through the system so if a client comes in and is for an assessment is deemed to
be in crisis and they’re referred over to the crisis stabilization unit then
where do they go from there you need to be able to trace the client from
entrance to discharge and make sure that they have seamless handoffs between
all of the different departments assessment well generally starts with a
screening not all places do screenings sometimes somebody walks in off you know
off the street they say I’m struggling here I need treatment okay you know
we’re going to kind of do screening and assessment all at once then other times
like when there’s a visit from the child services caseworker or law enforcement
contact or probation officer or something those people can do screenings
and if they determine that the person might be developing an issue then they
can refer for an assessment so anyway screening detects the possible presence
of a co-occurring disorder in the setting where the client is first seen
and you know not doesn’t know not necessarily even for treatment it can be
done in by a pastor by a Pio even by a judge you know there are a lot of people
who can do a brief screening and go yep you know I asked you these five
questions you answered seems like you need to be referred for an assessment
Butterbean an assessment evaluates background factors including family
trauma history marital status health education work history mental health
issues substance use issues related medical and psychosocial problems like
living circumstances and employment and other things that are critical to
address in treatment planning you’re not going to address all these at
once but you’re going to develop a laundry list if you will of issues that
may need to be addressed and then you’re going to work with the client to
prioritize and determine which ones to address first during an assessment a
diagnosis is made of the type and severity of substance use and mental
health mental health issues and a lot of times we also refer out for a physical
at that point to rule out any physiological issues like HIV hepatitis
hypothyroid cirrhosis of the liver anything like that which may be a
complicating factor then we match during the assessment the client to services
although often this must be done before a full assessment is completed and
diagnosis is clarified because assessment is not a one-time thing it’s
an ongoing process clients aren’t going to meet you and tell you every deep dark
secret they’ve ever had in the first hour
it just ain’t going to happen so assessment is ongoing as the person’s
condition unfolds we do want to pay attention to what’s going on but during
this initial assessment we’re getting an idea of what the main presenting issues
or symptoms are their motivation to change with regard to one or more of
those symptoms and moving on we want to appraise existing social and community
support systems you know if they’re not in treatment you know in residential for
example what do they have in the community that can support their
recovery the other you know six days and 23 hours of the week and continuous
evaluation is important re-evaluation over time needs to be done as symptoms
change and more information becomes available a lot of times I’ll work with
clients for a month or so in outpatient or a week or so in residential before
they start really telling me about a trauma history that’s okay or before
they start telling me about some shame issue that they have that’s okay but at
that point you know I may need to you know adjust the treatment plan a little
bit in order to focus on the new presenting issue so there are multiple
appropriate levels of care a basic program has the capacity to provide
treatment for one disorder you know you treat substances or you treat mental
health but you screen for the other disorder and you can access necessary
consultations so you may be an alcohol treatment program okay but if somebody
comes in and they’ve also got PTSD you screen for it you say yeah this person
might have PTSD you can access consultation with someone who can do an
assessment and either get them enrolled in a co-occurring program or you know
serve as an additional clinical resource program with an intermediate level of
capacity focuses primarily on one disorder without substantial
modification to its usual treatment but explicitly addresses some specific needs
of the other disorder so you primarily treat addiction you’re an addiction
treatment program however you recognize that depression and anxiety often
co-occur and grief and some of those things so you may provide some coping
skills training some information on cognitive behavioral you know yadda
yadda you’re not specifically treating the mental health issue as a separate
entity but you are providing some information to help the person in
substance recovery also deal with their mental health issue a program with
advanced level of capacity provides integrated substance use treatment and
mental health services for clients with co-occurring disorders so this is when
you know you’ve got clinicians on board in your program either substance abuse
and mental health clinicians or people who are dually trained and certified who
can work with clients you’re not having to refer out to other programs or other
agencies and you’re able to treat and you do treat both of them concurrently
when you’re treating when you’re talking about relapse prevention for example
you’re not just talking about substances you’re talking about relapse prevention
in terms of substance use as well as relapse prevention in terms of the
mental health disorder because if you relapse with either one it’s going to
affect the other one a program that is fully integrated combines substance use
and mental health interventions to treat disorders but also treats related
problems and the whole person more effectively so you really have
integrated medical here you have social services employment and educational
consultations vocational rehabilitation you know the whole gamut of things for a
fully integrated program that recognizes that people are multi-dimensional and we
need to make sure that each one of those dimensions is optimally function
functional for them to have an optimal quality of life integrated treatment can
occur on different levels and through different
mechanisms for example one clinician can deliver a variety of needed services so
when I worked in a clinic I provided mental health as well as
substance services as well as case management you know I kind of wore a
bunch of different hats you can also have two or more clinicians working
together to provide needed services so you know maybe you have a clinician who
specializes in trauma and that’s not your thing you know you provide the
services that you’re trained in and that clinician will handle the trauma piece
but you work together a clinician may consult with other specialties and then
integrate that consultation into the care provided I used to do this
occasionally when we’d have a client come in who had schizophrenia that is
not my strength so I would consult with our attending physician and say okay you
know what’s the best approach to work with this person you know he was a
psychiatrist what’s the best approach to work with this person and help them
achieve treatment goals and you know is there anything I’m missing so we were
working together I was working with an expert on that particular disorder
we can also coordinator variety of efforts in an individualized treatment
plan that integrates needed services which is a fancy way of saying we’re the
single point of contact and we do a lot of case management because the person
needs vocational rehabilitation they need physical therapy they need medical
issues they need financial consultations they need legal services and there’s a
bunch of moving pieces and so that person serves as the single point of
contact for all those other agencies and we can coordinate a single treatment
plan through that person and finally integrated treatment can involve
multiple agencies which join together to create a program that serves a specific
population when we created the no wrong door program for co-occurring disorders
we worked with the criminal justice system the potential clients would be
released from jail three months before their sentence was up so they were on
extended limits of confinement so they weren’t released released but they were
not in jail they were at our bility so we were working with them we
had to do you know Collins for bed count every day and all that stuff we were
working with vocational rehabilitation to help these people develop job skills
write a resume and get bonded so they could get employment we were providing
the mental health and substance abuse counseling as well as psychiatric
services and we were working with shanz in order to and the Health Department in
order to make sure that people were getting their basic physical health
needs met so when they graduated the program they had had all their basic bio
psychosocial needs met but our agency wasn’t doing all of it we were doing
what we specialized in and we basically contracted with other agencies to do
what they specialized in in integrated treatment the focus is on preventing
anxiety and helping people feel empowered rather than breaking through
denial the emphasis is placed on trust understanding and learning and treatment
is characterized by a slow pace and a long-term perspective you’re not gonna
get from pre contemplation to maintenance in 30 days you are going to
you know help the person in the first 30 days maybe just get through the fog and
develop some basic relapse prevention tools and then you know the next 30 days
work on something else research has indicated that even for things like
cocaine and alcohol a treatment program less than 90 days is really relatively
ineffective and you can go look at the research for from National Institute of
drug abuse and Samsa defined find that information so we don’t want to tell
somebody 28 days and you’re you’re cured you know they’re not and and you can
argue about whether they’re ever cured but you know 28 days is basically just
enough for that fog to lift and you’re still and maybe get through the brunt of
post-acute withdrawal you’re still having to relearn or learn a bunch of
you know coping skills interpersonal skills whatever you know you need in
order to stay clean happy and sober providers offers
stage-wise and motivational counseling and you need to review tip 35 and the
stages of stages of change that were posited by Prochaska and DiClemente
really important to know those like the back ear hand but we need to be able to
make sure that the stage wise treatment you know we keep people moving forward
when it gets tough clients are not going to go from pre contemplation to
contemplation to preparation to action to maintenance and off it’s just not how
it happens you know they will go from contemplation to preparation to action
and then when they’re in treatment they may start getting frustrated it may hurt
too much they may feel frustrated their cravings may be too bad you know
whatever so their motivation may wane back to
contemplation or preparation so they’re not really even interested in working
anymore they’re thinking you know what maybe my problem wasn’t so bad I think I
can probably handle it on my own so we need to provide motivational counseling
to help them recognize what they need in order to stay clean and sober self-help
groups are available to those who choose to participate and can benefit from
participation people who are actively psychotic people who with who have
significant cognitive deficits may not be able to benefit from participation
people who you know choose to participate in self-help groups may not
embrace the 12 steps they may prefer smart recovery or some of the other
options that are out there and that’s okay
but we need to provide a range of options that are available for people
who choose to participate in those and neuroleptics and other pharmacotherapies
are indicated according to the clients psychiatric and other medical needs so
we’re not saying this is a drug-free program you can’t be on any medicines
we’re saying we’re gonna take each person individually and figure out what
the psychiatrist thinks is the best course of action comprehensive services
are provided to address mood issues cognitive and attentional issues any
psychotic issues personality disorders and eating disorders we also address
substance use and behavioral and compulsive behavioral things like
gambling and internet gaming addiction housing issues medical and dental issues
employment and education referrals and all of these things so the person can
when they get out of treatment be financially independent keep a roof over
their head stay safe it may not be you know they
may not be living at the Ritz but if they are in a place where they are safe
and comfortable and can get good rest and able to feel empowered and self
sufficient it’s going to go a long way towards their recovery we need to
provide continuity of care by making sure there’s consistency between primary
treatment what we’re doing in therapy and ancillary services so if you refer
somebody to voc rehab for example and voc rehab counselor says okay let’s get
you enrolled in school starting in two weeks you can start you can go back to
school and start working for your a a well that’s wonderful but the person is
in residential for another two months so that’s not going to work so we need to
make sure that the primary treatment provider communicates with ancillary
service providers and everybody’s on the same page and the same timeline there
needs to be seamlessness as client clients move across levels of care so if
they go from residential to IOP again when they show up for IOP the clinician
needs to be expecting them not go who are you
that doesn’t go over well trust me so we need to make sure that paperwork is
transferred the transfer process goes smoothly ideally there’s actually a
phone call or some sort of an email letting the person letting the receiving
clinician know that the client is coming so there’s a nice warm handoff and then
the referring clinician has to follow up so you want to make sure that those
transitions whether it’s to more intense or less intense levels of care go
smoothly and we want to coordinate present and past treatment episodes
don’t make the person reinvent the wheel every time they come in if they’ve been
at your agency four times already pull out the daggum chart and look at it
and you can figure out what they’ve done you can get a good idea about what
worked or at least what was tried and then you can start talking about it
talking to them about it from there you know the stuff like where they were born
that hasn’t changed you know so the stuff from the first assessment is still
really pretty germane so go through their chart ahead of time get some of
the stuff that just wouldn’t have changed like their their date of birth
and you know that kind of stuff try to fill that out early if you can so you’re
not asking them the same questions again a lot of times clients will actually not
back for a repeat episode if they know they’re going to have to go through that
arduous assessment process again and like start all over again from square
one at least let them start from square
three so when you’re thinking about your agency’s capacity remember I said think
about how you can do these things in your agency you want to think about the
profile of your current clients with co-occurring disorders and any potential
changes that are anticipated for example if you typically are seeing people with
opioid use disorders okay that’s what you’re typically seeing in your area
right now but the tides change I know where I came from it was opioids for
quite a while and now it’s switched over to methamphetamine so be prepared in
changes of drugs of abuse be prepared in changes of client profiles for example
the agency I used to work out we got a contract for example to work with the VA
so we opened an entire program just for veterans well that changed the makeup of
our our clients with co-occurring disorders when we opened the methadone
clinic and we had people who are on medication assisted therapy that changed
the profile of the clients we were working with so we needed you need to be
aware of who your agency serves and then you know who they might be serving in
the future you need to identify services needed by clients you know not everybody
needs transportation if you live in a metropolitan area that has great bus
service that may not be as much of an issue as it is for us out here in rural
Tennessee identify and assess resources available to meet client needs so what
services are immediately available in the program you know what do you offer
at your facility what services could be added to the program you know sometimes
it’s not hard to add a one hour a day group for outpatient or aftercare that
people can come to so they still can come five days a week but it’s only for
an hour there are a lot of different options that you can look at what
services are available from the community that would enhance care
and that can include HIV counseling vocational rehabilitation you know it’s
a whole range of services you need to know what your clients want and need and
find out who’s already providing it there is no sense having your agency
start a program that provides X service if somebody in the community is already
doing it and is willing to partner with you and how well our outside agencies
meeting clients needs you know we do have to consider that if there’s a great
program for vocational rehabilitation but clients can’t get into it or they
won’t work with substance abuse clients until the substance abuse client has six
months of clean time that’s not meeting our client’s needs so
we may need to add either advocate for them with that agency or look at a
different Avenue you need to assess resource gaps to identify any resources
that are in needed to enhance treatment for persons with co-occurring disorders
for example medication access we ended up opening a pharmacy at the facility
that I worked at because clients were having difficulty getting on patient
assistant programs so the pharmacists at our facility would help them get on the
patient assistance programs so they could get their meds for free which was
helpful what can your agency do to enhance its capacity to serve these
clients so looking around and sometimes it’s just developing memorandums of
understanding with other agencies and improving coordination other times it’s
making simple changes you know you don’t necessarily need to start from scratch
with something look at small changes you can make and only make one or two
changes at a time see how it does if you make a change and it doesn’t seem like
it’s you know helping at all you know you may want to back off and
back off and try something different assess your capacity to address resource
gaps a small practice or a small agency is not going to be able to do the same
things that an agency that has an eight or eighty million dollar budget is going
to be able to do so what do you have the capacity to do with in your building you
if you want to have groups that’s great but do you have a group room if you
don’t that’s a problem and then develop a plan to enhance the capacity to treat
clients by increasing the skills of existing staff for example you know
maybe getting a staff person certified in EMDR or getting somebody if you’re a
mental health clinic getting somebody certified in addictions counseling can
additional expertise be accessed through consulting agreements sometimes you just
need to have a Memorandum of Understanding look for additional
programs or services that you can offer and look for sources of funding to
support efforts to enhance capacity salsa has grants that they put out every
single year and every single year we would write grants so it’s competitive
but those grants are significant and can really an help help you enhance capacity
if you’re able to get one so Workforce Development is important and the first
thing we want to develop is people’s attitudes before we even work with
skills so people need to appreciate the complexity of co-occurring disorders
depression plus substance abuse is not one plus one equals two it’s one plus
one equals five so it’s important to understand how the two interact how the
substance use affects the neurotransmitters how the depression
affects the substance use and how all of that affects interpersonal relationships
cognitive abilities occupational functioning all that stuff people need
to be open to new information and aware of their personal reactions and feelings
towards people with co-occurring disorders if you’re not comfortable
working with someone who is schizophrenic you know it’s important to
get a handle on that and be become comfortable you know develop your
knowledge so you understand what’s going on and how to work with those clients if
you’re not comfortable working with a client or maybe you come from a family
where there’s a lot of alcoholism and you have negative reactions to people
who are parents who are also alcoholics you need to handle that in supervision
and deal with your transference issues you need to recognize the limits of your
own personal knowledge and expertise so if you’re not trained to work with
something you know be able to stand up and say I’m not trained to handle that
or that’s not my expertise so somebody else can step in or you can receive the
training you need recognize the value of client input into treatment goals not
only do they know what works for them and what doesn’t work for them but if
they have input into their goals they’re gonna be more motivated and they’re
gonna see any progress they make as more the result of their work instead of you
doing something to them so it’s very empowering to them to be involved in
treatment we need to be patient persevere and have therapeutic optimism
and believe they can get better we need to be able to employ diverse theories
concepts models and methods so you know you’re gonna have your primary theory of
mental health and substance abuse but you also need to be open to other
theories like theories from Family Therapy that talk about family
positioning or whatever or family dynamics you need to have flexibility
and approach because no two clients are going to require the same approach be
culturally competent and you can look at Samsa tip 59 I believe for cultural
competence believe that all individuals have strengths and are capable of growth
and recognize the rights of clients with co-occurring disorders including the
right and need to understand assessment results and the treatment plan don’t do
the treatment plan for them do the treatment plan with them when you do the
assessment you know help them understand why you’re asking the questions you’re
asking and how you arrived at the conclusions that you are arrived at in
terms of competencies you need to be able to perform a basic screening to
determine whether a co-occurring disorder might exist and be able to
refer for a formal assessment if necessary you need to be able to conduct
a preliminary screening of whether clients pose an immediate danger to self
or others and coordinate treatment accordingly you need to be able to
engage the client in a way to enhance and facilitate future interaction you
need to be able to de-escalate a client who’s agitated anxious or in a
vulnerable state and manage crises involving clients with co-occurring
disorders it is not uncommon to have a client who is in a mental health crisis
who is depressed who is moderately suicidal who is also severely
intoxicated so you need to know how to manage that kind of issue you need to be
able to refer a client to the appropriate mental health or substance
abuse treatment facility and follow up to ensure continuity of care so don’t
just send them to crisis stabilization or detox and go good luck I’ll see if
you come back you want to follow up the next day to make sure that they got
there and everything’s going well goes a long way to enhancing engagement and
helping the client feel like they’re important which gets them involved in
treatment and you need to coordinate care with mental health counselors
serving the same clients to ensure that the interaction of the clients disorders
is well understood and treatment plans are coordinated intermediate
competencies include being able to integrate diagnosis and needs assessment
and also create an integrated treatment plan that addresses all of their bio
psychosocial issues you need to be able to engage motivate and educate clients
and be familiar with treatment methods including relapse prevention case
management mental health pharmacotherapy psycho education as well as family
interventions and education advanced competencies and I struggle with calling
these advanced I think you know if you’re working with clients you probably
need these two you need to be able to comprehend the effects of function of
the disorders on people’s level of functioning and degree of disability so
you know when their mental health issues are when they are symptomatic that will
impact their level of functioning maybe in substance abuse treatment and at work
and in their relationships so you need to know how that impacts everything you
need to know how a flare-up of their mental health impacts their
lacks potential you need to know how their substance use impacts their mental
health diagnosis you need to recognize classes of psychotropic medications
their actions medical risks side effects and possible interactions for example
opiates increase and LSD increase the level of serotonin if the person
increases serotonin too much they can precipitate a serotonin syndrome which
is a life-threatening condition remember that all relapse is an opportunity for
additional learning for all so it’s important to involve the person family
members and other supports and service providers in establishing monitoring and
refining the current treatment plan even after a relapse relapse means we missed
something and we’ve got more to learn not it’s time to discharge yeah it
drives me crazy when I see people discharged for relapse because that
tells me that you know something went hiccup II in treatment and we need to
support quality improvement efforts including but not limited to
satisfaction surveys accurate reporting and use of act outcome data to determine
what we’re doing that’s working and what we’re doing that’s either having no
effect or is working against us in terms of treatment planning and documentation
we need to review the principles and processes that support thorough and
accurate assessment and diagnosis including strengths based interviewing
skills and cultural diversity issues cultural diversity is a huge thing you
need to be aware of is this client independent or interdependent culturally
is this client meeting or believing that their family should be an integral part
of their treatment how does this client and their family view this disorder or
disorders and what types of treatment does this client and their family and/or
their family believe are the appropriate courses of action for this disorder you
know not everybody is gonna say you know run-of-the-mill residential treatment or
outpatient you know some people want to go to spiritual guides first or
use culturally based practices you need to examine each step in the treatment
service planning and rationale with the client and describe the importance of
the person with the co-occurring disorder having active involvement and
real choice in their treatment planning process you need to be able to help them
understand why it’s not okay for you to just write their treatment plan for them
you know and I tell them from the beginning you’ve lived in your skin for
40 years I’ve known you for 40 minutes so you know what works for you and you
know what things are going to help you the most
in starting the momentum towards getting better so instead of you know just me
spitting in the wind and trying to figure out what might work why don’t you
tell me what you think the best course of action is and then we’ll go from
there you need to know a means of writing brief and useful progress notes
that support movement toward positive outcomes and use those progress notes
with the client as a piece of the ongoing treatment process at the end of
every treatment session I sleep the last 10 15 minutes depending on the client
and we identify the goals that they achieved over the past week the
treatment plan issues that they addressed what their goals are for the
next week and any referrals that are necessary as well as any you know other
ancillary stuff that was important but we review everything to kind of
summarize the treatment session and I write that down in the progress note and
then I give them a copy that helps them solidify in their mind what we
accomplished so they’re seeing the progress they’re seeing their steps and
they know what they need to do next in terms of Workforce Development it’s
important to ensure that people have adequate supervision that includes
shadowing and cross-training so they know how to do different things
regular peer supervision and it can be a monthly brown-bag it can be a weekly
staff meeting whatever it is where peers can review each other’s case notes
you know charts and talk over certain cases and case conferences are
always important programs and directors program directors and supervisors can
assist clinicians in avoiding burnout by encouraging them to work within a team
structure rather than isolation clients can be draining and exhausting when if
you’re that you know connected and empathic and everything it’s it’s
draining for anybody and if you’re in a residential facility where clients can
drop by you know all day long it can be draining so you need to figure out how
to work as a team structure so everybody can get the stuff they need to get done
done as well as provide high-quality treatment to clients building
opportunities to discuss feelings and issues with other staff who handle
similar cases develop and use a healthy support network both inside work and
outside of work you know there has to be a time where you can just leave work at
work and go be a person not a clinician but just a person help clinicians manet
maintain a caseload that’s a manageable size and you know sometimes agency
requirements push caseloads up a little bit one way you can help maintain a
manageable size is to reduce turnover so if you’ve got ten clinicians you know
each one is seeing eight clients if two of them suddenly quit their clients have
to be shifted to everybody else and everybody else’s caseloads go way up so
reducing turnover can help reduce burnout it incorporate time to rest and
relax encourage staff to actually take their breaks you know at lunchtime don’t
sit at the computer and work on their notes while they’re scarfing down their
lunch encourage them I had one actually two employees over the years who refused
to use any of their vacation time and at the end of the year every year I’m like
you got to use it or lose it because you can only carry over 200 hours and they
would be grudgingly used some of their time but they would end up giving back
leave time to the agency because they just wouldn’t take time out
and separate personal and professional time like I said you have to have some
time where you’re just a human in order to reduce turnover as hiring managers we
can hire staff members who have familiarity with both substance abuse
and mental health issues maybe not licensed in both but they’re
familiar and have positive regard for clients with either disorder we need to
hire staff members who are critically minded and can think independently so
they’re not having to be micromanaged but they’re also willing to ask
questions listen remain open to new ideas work cooperatively with the team
and sometimes just be creative and problem-solving because you have to
think on the fly provide staff with a framework of realistic expectations for
the progress of clients what are they supposed to accomplish while they’re in
your program so we’re not expecting too much you know I used to expect every
person who went into residential would come out in maintenance and my
supervisor pointed out to me one day you know you’ve got clinic
you’ve got clients who are coming in here at different stages of readiness
for change they’re not going to move from pre contemplation to maintenance in
28 days it just ain’t gonna happen if you can move them one step you know
in terms of their motivation and their readiness for change that’s what you
need to do ensure supervisory staff are supportive and knowledgeable supervisors
you know I’ve been one for many many years you don’t know everything and it’s
okay to say I don’t know I can find out if they ask you if clinicians ask you
about something and you’re not familiar with it you can say I don’t know but you
know see if you can find a conference or a training on it and I’ll send you to it
you know there are a variety of ways to accomplish that but we do need to be
supportive of people clinicians enhancing their knowledge and abilities
to work with these clients which goes along with providing support and
opportunities for further education and training bring training in online
resources that are available brown bags I would have my clinicians once a month
each person would teach a a concept or something that they learned
about with relation to co-occurring disorders treatment and it was like a
ten minute presentation but it helped all of us stay keep our nose a little
bit in those journals and provide structured opportunities for staff
feedback in the areas of program design and implementation some of the best
ideas for programming comes from line staff those clinicians that are working
with cut with clients day in and day out and they’re seeing this need that isn’t
being met or they’re seeing how we could enhance treatment by adding this program
so pay attention to what line staff has to say because they’re probably going on
on some really good you know practical feedback in order to reduce turnover
provide a desirable work environment through adequate compensation stop
laughing you know we get into this because it’s a calling not because we’re
we think we’re gonna get rich so you know what we know we’re not going to be
making 60 70 80 thousand dollars a year but we want to make sure that people do
have adequate compensation for their level of training provide salary
incentives for co-occurring disorders expertise so every additional
certification or in intensive training certificate that they get they can get a
salary incentive provide opportunities for training and career advancement so
people who want to become supervisors can so people who want to become program
managers can it does a lot to enhance stay power if you will and reduce
turnover if people believe that they actually can move up in the organization
and they’re not stuck at you know line staff or wherever they’re at involve
staff in quality improvement and clinical research activities so they
feel like they have a voice and make efforts to adjust workloads sometimes
workloads are gonna need to be adjusted maybe your clinician who’s you know one
a great clinician but her mom is suddenly going through chemotherapy and
she’s you know needing a little bit of extra time off to take
to and from the hospital to get her chemo treatments and take care of her
you know that clinician may not be at a hundred percent right then even that
even if she’s there forty hours a week so how can you adjust workloads to help
her out so she can get her work done maybe have people cover her groups so
she spoke focusing more on doing the individual sessions and keeping her
paperwork up so there are a lot of different ways you can wax and wane to
make sure that people are getting their needs met and there’s a work/life
balance so there are a variety of competencies and attitudes unique to
treating clients with co-occurring disorders many avenues exist to
integrate care and all agencies should strive for integrated care since
co-occurring disorders are the expectation not the exception preventing
burnout and turnover are essential for several reasons one it enhances program
capacity if you maintain ten therapists then you can maintain a higher census
than if you periodically drop down to six or eight therapists it’s expensive
to recruit hire and train every new employee and clients tend to lose faith
in the facility if there’s a high level of turnover and they get frustrated if
they can’t see their therapists that they saw the last time when they come
back so there’s an impact on client outcomes and there you know willingness
to continue to seek treatment at your agency there are five more videos in
this series and they’ll be all beyond the playlist tip 42 co-occurring
disorders on the YouTube channel at all CEUs dot-com / YouTube once they’re
recorded and I’m in in the process this is episode three or section three I’m going
to be doing for later today and then there are nine segments all together to
earn CEUs for this presentation you can go to all CEUs comm slash podcast CEUs
where you’ll find a direct link to the class associated with this presentation
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