Introduction to Co-existing Mental Health

& Substance Use Problems (CEP)

Fraser Todd and Michelle Fowler
2013
Workshop Introduction
Workshop Series Overview
MHERC
o CDHB
o Matua Raki/Te Pou
Te Ariari o te Oranga
7 Workshops
Workshop1a: Introduction to CEP for frontline staff (x3)
Workshop1a:1b. Introduction to CEP for managers
Workshop 2: Recovery and well-being
Workshop 3: Engagement & Motivation
Workshop 4:. Assessment
Workshop 5: Management I
Workshop 6: Management II
Workshop 7: Integrated Care
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Workshop Agenda
PART A
Introductions
Workshop Overview
Learning About CEP
The Spirit of Te Ariari o te Oranga
Learning about CEP
The Spirit of Te Ariari Frameworks
The Nature, Extent and Impact of CEP

PART B:
Te Ariari O Te Oranga and The 7 Key Principles
Wrap up, feedback and finish
Please note: Self-directed learning modules on the content of this
workshop will be available on fraserscepblog.com Part A is available now, Part B
will be posted in the next few weeks.
The hyperlinks to resources are active in PowerPoint slide show format
Three Dimensions of CEP Practice
Spirit Principles - Techniques:
Spirit
Principles
Techniques
1. Cultural Considerations
2. Recovery & Well-being
3. Engagement
4. Motivation
5. Assessment
6. Management
7. Integrated Care
Person-focused care
Well-being orientated care Integrated care
Walk the Talk
CEP and the Workshop Series
Spirit
Principles
Techniques
CEP
Specific
Generic
Intro
Advanced
MHERC WORKSHOPS
The MHERC Workshop Series:
Thinking About CEP
Thinking About CEP
Simple-Complicated-Complex:
Learning About CEP:
Thinking About CEP
The Spirit of Te Ariari O Te Oranga
Underpinning Te Ariari is a philosophy representing a set of principles & values:
person-focused
wellbeing orientated
integrated care
Walk the talk
Exercise 1: Personal Values
Complete the Values Paper Card Sort Questionnaire
In pairs or threes, share your three most important values
One person leads a discussion with the other around one of the top three values
1. What is it about this value that is important to you?
2. To what extent do you feel you are or are not able to live up to this value?
3. Are there ways you would like to be living up to this value more
than you are at the moment
4. How do you express this value in your work?
5. Are there ways you would like to express this value more in your work?
Part A: Overview of CEP
CEP in NZ
History:
Barriers:
1. Belief: simply a matter of clinicians
getting better at their work.
2. Deep-seated negative attitudes
between MH and AOD
3. Work with MH problems or AOD
problems; the other was not their business.
Double Trouble Groups
1998 The Assessment and Management of Co-existing Substance Use &
Mental Health Disorders (Todd, Robertson & Selman)
CEP in NZ
Recent Developments:
2010
Te Ariari o te Oranga (clinical)
Integrated Solutions (service level)
Current:
MOH guidance led by Director of Mental Health
Workforce development programmes collaborating CEP Focus
All DHBs - action plans to enhance CEP capability
monitored by MOH
Enhancing of Service Capability
Developing Capability:
Enhancing of Service Capability
System-wide Development Model:
1. Across-service
generic training
2. Service-based
training
3. Collaborative
Learning
Background Information:
The Nature, Extent and Impact of CEP
Definitions:
Background Information
Clinical Definition:
The co-occurrence of mental health and substance use problems in
one person at the same time
Synonyms:
Double Trouble, Dual Diagnosis, MICA, Comorbidity, Co-existing Disorders
Co-occurring Disorders
*Co-existing Problems (NZ)
Background Information
The Nature of CEP:
Heterogeneous
Ranges from simple to multi-dimensional & complicated
Poor outcomes
Exposes weaknesses in health system
Generic
Specific
Background Information
The Nature of CEP:
Background Information
The Impact of CEP:
CEP is associated with:
Poorer compliance
More relapses
More readmissions
Poorer outcomes
Treatment resistance
Increased rates of suicide
& violence
More of unemployment
AnxleLy 12 monLh prevalence
1oLal popn 14.8
Suu popn 40.0 x 2.7
Mood
1oLal popn 7.9
Suu popn 29.0 x 3.7
Suu
1oLal popn 3.3
AnxleLy popn 9.4 x 2.7
Mood popn 12.9 x 3.7
Te Rau Hinengaro: The New Zealand Mental Health Survey (2007)
Psychiatric Disorder % who suffer SUD
Depressive 30
Bipolar 50
Schizophrenia 50
Antisocial PD 80
Anxiety 30
Phobic 25
Background Information
General Epidemiology SUDS in people with MH Problems:
N=105, From Adamson, Todd et al Aust NZ J Psychiatry 2006;40:164-170
Disorder Current Lifetime Onset (SD)
Any Mood 53% 73% 19 (10)
MDE 34% 44% 20 (11)
Any Anxiety 65% 77% 13(10)
PTSD 31% 45% 19(11)
Social Phobia 31% 37% 12 (7)
Any Axis 1 74% 90% 13 (9)
ASPD 27% 41% 9 (4)*
* Childhood conduct disorder
Background Information
NZ Epidemiology:
1980s 1990s
2000s
DSM
Community treatment
Population Studies (ECA)
Increasing awareness in MH
- prevalence
- poor MH outcome
Engagement-persuasion Model (Osher and Kofoed 1989)
Background Information
A Brief History of CEP 1980s:
1980s 1990s
2000s
double trouble groups
Increasing evidence of high prevalence and poor outcome
Drake, Mueser, Carey
Integrated treatment models, MI, Assertive Community Treatment
Minkoff - Service integration models
Background Information
A Brief History of CEP - 1990s:
x
1980s 1990s
2000s
universal screening and assessment
Increasing development of integrated treatment programmes in US
2004 UKDDx Toolkit
2005 TIP 42
Increasing attention to systems, policies
Key Research Reviews
Background Information
A Brief History of CEP 2000s:
1.
substance use mental health problems
2.
mental health problems substance use
3. common factors
Background Information
Aetiology (Causes) Traditional Views:
Aetiology (Causes):
Background Information
All three mechanisms
are usually involved.
MH may drive SUDS
Especially:
Bipolar disorder
PTSD
Social phobia
Aetiology (Causes) Common Factors:
Background Information
Some Trans-diagnostic Factors:
Genes
Attention control
Impulsivity
Negative urgency
Negative emotionality
Cog/Attention bias
Emotion regulation
Rumination
Perfectionism
Coping (approach/avoid)
Sleep
Social context
Background Information
Standard Approaches to CEP Core Components:
Core Components of CEP programmes include:
o Comprehensiveness
o Treatment integration MH & AOD treatments delivered by a single team
o Assertive Community follow-up
o Staged interventions
o Harm minimisation
o Long-term perspective
o Recovery approach
o MI + CBT
Integrated Continuous Systems of Care (Minkoff)
o Fully integrated team
o Multiple coordinated teamS
TIP42 (2005) http://www.ncbi.nlm.nih.gov/books/NBK64197/
Difficult to implement
o training but limited action - thinking v doing gap
o fidelity of implementation of EBPs e,g, MI
Effectiveness questionable
o Group counselling,
o Contingency management,
o Long-term residential treatment
Engagement remains problematic
o 30-50% with serious CEP engage
Constructs and models used
o based on chronic psychosis
o treatment integration = services
o Integration = AOD + MH
Background Information
Limitations of Current Approaches:
Part B: Te Ariari & the 7 Key Principles
Te Ariari O Te Oranga
Te Ariari o te Oranga Download
The Assessment and Management of People with
Co-existing Mental Health and Substance Use Problems 2010
Three Dimensions of CEP Practice
Spirit Principles - Techniques:
Spirit
Principles
Techniques
1. Cultural Considerations
2. Recovery & Well-being
3. Engagement
4. Motivation
5. Assessment
6. Management
7. Integrated Care
Person-focused care
Well-being orientated care Integrated care
Walk the Talk
The Spirit of Te Ariari O Te Oranga
The Spirit of Te Ariari O Te Oranga
Underpinning Te Ariari is a philosophy representing a set of principles & values:
person-focused
wellbeing orientated
integrated care
Walk the talk
The Spirit of Te Ariari: Person-focused Care
Exercise 2
In small groups;
1. Appoint someone to take notes and feedback
2. Discuss what the concept of person-focused care means
3. What strategies do or can you use I your work to
make it person-focused
Not patient/consumer/client
Treat problems always in the context of persons
values and vision of wellbeing
Empower partnership, participation, protection
Better:
engagement
motivation,
treatment compliance
service satisfaction
Person-focused Care:
The Spirit of Te Ariari
Four interventions that can assist this process
1. Measuring treatment improvement by rating overall quality of life:
(WHOQOL (100 item questionnaire) & WHOQOL-BREF)

http://www.who.int/substance_abuse/research_tools/whoqolbref/en/
and Identifying:
2. Personal values
(Values Card Sort Execise Paper Version)
3. Strengths
(Character Strengths Assessment, VIA Signature Strengths)
4. Identify Hopes, Aspirations &Wellbeing
(Best Possible Self Exercise)
Person-focused Care Tools and Strategies:
The Spirit of Te Ariari
The Spirit of Te Ariari: Well-being Orientated Care
Exercise 3: Best Possible Selves
Think about your best possible self at some point in the future say, in
5 years time.
Imagine yourself after everything has gone as well as it possibly could
You have worked hard and succeeded at accomplishing all of your life
Goals.
Think of this as the realization of your own best potential. You are realistically
Identifying the best possible way that things might turn out in your life.
Take a few moments to write down what this life would be like.
People desire a state of flourishing; a high degree of wellbeing
Well-being Orientated Care:
The Spirit of Te Ariari
They experience distress when they are languishing i.e there is a significant
gap between their desired and actual state of wellbeing.
Well-being Orientated Care Distress:
The Spirit of Te Ariari
Well-being Orientated Care Seeking Help:
The Spirit of Te Ariari
Well-being:
The Spirit of Te Ariari
Key aspects of recovery include:
Multiple unique path to recovery
Hope
Self-responsibility
Meaning as a valuable member of society
Identity distinct from that of patient or consumer
Finding a valuable niche
Being a consumer is a culture - Partnership, Participation,
Protection
The Spirit of Te Ariari
Recovery:
The Spirit of Te Ariari
Well-being:
People who have recovered from
depression have lower levels of
wellbeing than those who have never
been depressed.
+ interventions have a moderate size
effect depressive symptoms
Quality of life can be improved with
no improvement in symptoms of
disorder
The Spirit of Te Ariari
Implementing a Well-being Approach:
Key steps to implementing a well-being approach include:
Identifying the persons definition of wellbeing for them
Values congruence, strengths, hopes and aspirations (Well-being)
Enhancing functioning in positive domains
positive experiences, positive thinking, relationships
Improving functioning in deficit domains
comprehensive assessment formulation
Incorporate positive interventions into treatment planning.
The Spirit of Te Ariari
Strategies to Enhance Well-being:
www.authentichappiness.com
The Spirit of Te Ariari
Strategies to Enhance Well-being:
Exercise 4: Rachels Best Possible Self
Take a few minutes to quietly read through the case of Rachel in the manual
As you read, imagine what Rachels top three values would be and what
she would describe as her Best Possible Self in 5 years time.
Write them down.
The Spirit of Te Ariari: Integrated Care
Integrated care comes from:
Understanding what wellbeing means for the
person
Starting with the needs of the person
Considering both pathways to wellbeing and
barriers to wellbeing (deficits)
Multi-dimensional integrated formulation & plan
Effective collaboration
Systems organised to support integrated care
Integrated Care:
The Spirit of Te Ariari
Mental
Health
Corrections
AOD
Physical
Health
Education
running an efficient system
Financial
Workforce
Policies/Procedures
The Spirit of Te Ariari
Systems Integration:
Servlce
MP
hyslcal
sychosoclal
ACu
running an efficient and coherent service
Treatment Integration:
The Spirit of Te Ariari
SocleLy
CommunlLy
lamlly
erson
enhancing wellbeing of people and their and families
Integrated Care:
The Spirit of Te Ariari
Process of Integration:
The Spirit of Te Ariari
Integration Using Timelines:
The Spirit of Te Ariari
Exercise 5: Self-directed Learning - Timelines
In the days after completing this workshop, take a few moments to think
about Exercise 5 in the manual.
Walk the Talk OR Bringing these principles to life within the clinical relationship
Walking the Talk:
The Spirit of Te Ariari: Walking the Talk
Walking the Talk:
The Spirit of Te Ariari: Walking the Talk
erson-cenLred
values ersonal values Cuesuonnalre
SLrengLhs vlA slgnaLure sLrengLhs
Wellbelng orlenLaLed
vlslon of well-belng WPCCCL
8esL osslble Selves
lnLegraLed Care
Well-belng perspecuve, lormulauon,
Collaborauon
CulLure
LngagemenL
Mouvauon
lmplemenLauon lnLenuon, self-emcacy,
auLonomy, Ml
AssessmenL
Screenlng, 8rlef, Comprehenslve WPC-asslsL
Comp AssL + lormulauon
ManagemenL
8rlef l8AMLS
Comprehenslve 404 1emplaLe
The 7 Key Principles
1. Cultural Considerations
2. Well-being
3. Engagement
4. Motivation
5. Assessment
6. Management
7. Integrated Care
Te Ariari O Te Oranga
7 Key Principles
Pre-treatment
Early Treatment
Middle Treatment
Late Treatment
Autonomous Independence
Te Ariari O Te Oranga
Phases of Treatment:
1 2 3 4 5 6 7
Pre-treatment
Early Treatment
Middle Treatment
Late Treatment
Autonomous
Independence
Incorporation of 7 Key Principles
into goals and strategies during
each phase of treatment
Te Ariari O Te Oranga Framework
Principle 1: Cultural Considerations
Cultural issues are essential to consider in terms of
their relevance to values and engagement especially.
They will not be discussed in this workshop. Further
reading is available in Te Ariari O Te Oranga.
Principle 3: Engagement
Strategies to Enhance Engagement 1:
Values, vision of well-being
Cognitive mapping
MI Engagement Interview
Autonomy-supportive environment
(3-5 choices)
Treat hostility, emotional dysregn early
Clearly structured sessions
Adapt to coping style
Remove barriers
Consistency of approach
Peer Support to engage
Assertive follow-up
Adapt for cultural needs
MI
Principle 4: Motivation
Crucial Transitions; Contemplation-Preparation-Action:
Principle 5: Assessment
Stepped Care:
Step 1
Primary Care with Support
Basic Psychotherapy
Medication
+
Brief AOD Intervention
Step 2
CEP Capable MH or AOD
Teams
Step 3
Highly capable/enhanced
specialist teams
Te Ariari Approach
Focus on common
individualised
underlying factors
Combine standard
MH and AOD treatments
+ MI/CBT
+ standard approaches
Increasing Treatment Intensity
Principle 5: Assessment
Screening:
Substance Use
WHO-ASSIST
http://www.who.int/substance_abuse/activities/assist_v3_english.pdf
Mental Health:
Modified MINI Screen for Co-existing Disorders
http://www.nyc.gov/html/doh/downloads/pdf/qi/qi-mms-scoringsht.pdf
Combines MI + FRAMES:
Feedback
Responsibility
Advice
Menu of Options
Empathy
Self-efficacy
Principle 5: Assessment
Brief Assessment:
WHO-ASSIST Linked Brief Substance Use Intervention
http://whqlibdoc.who.int/publications/2010/9789241599399_eng.pdf
Multi-dimensional management plan from Aetiological Formulation
Clinical case management
Use Generic + specific strategies
Combine Evidence-based practices for each diagnosis and problem
Phases/Stages of Treatment and Stage of Change for each problem
Address Trans-diagnostic/Common Factors
Structure sessions around motivational interactions
Principle 6: Management
Principles:
1. Setting
2. Further Information Needed
3. Treatment of medical conditions
4. Psychopharmacological interventions
5. Psychological interventions
6. Whanau/family and social interventions
7. Spiritual interventions
8. Education/Work/Occupation
9. Education of tangata whaiora and significant others
10. Self-help groups
All of the above considered for each phase of treatment
Principle 6: Management
Structured Management Plan - 404 Template:
Integrate key strategies into follow-up/therapy sessions
Principle 6: Management
Structured Follow-up Session:
MI
Strengthen
Commitment Talk
Take opportunities to reflect and summarise
Change talk
Commitment talk
Wellbeing talk
Specific
Tasks
Reinforce
values
Exercise 6: Going Forward
In pairs, take a few minutes to discuss and write down for yourself
A. Three things you will do to enhance your own practice
B. Three things you will do to enhance your services CEP capability
Tools for Enhancing Practitioner & Service
Capability
Tools for Practitioner & Service Capability
System Wide Development Model:
A number of tools have been produced to help services and practitioners
self-assess their CEP capability:
1. Co-existing Problems (CEP) Resource Map
http://www.tepou.co.nz/improving-services/co-existing-problems/cep-roadmap
Part of the Te Pou website which includes a links to a large number of
local resources CEP relevant resources
2. Co-existing Problems (CEP) Service Checklist
http://www.matuaraki.org.nz/library/matuaraki/co-existing-problems-cep-service-checklist
A checklist approach to service self-assessment of CEP capability
developed by Matua Raki (National Addiction Workforce Development
Centre
3. Co-existing Problems (CEP) Tools and Resources
http://www.matuaraki.org.nz/library/matuaraki/co-existing-problems-cep-tools-and-resources-may-2011
Downloadable PDF listing and linking to a range of local and international
CEP resources and readings.
Tools for Practitioner & Service Capability
System Wide Development Model:
4. fraserscepblog.com
5. Practitioner CEP Skill Set and Capability Checklist