Introduction to CEP for Managers Workshop Workbook

Fraser Todd & Michelle Fowler 2013

This workshop is provided through the Mental Health Education Resource Centre and supported by the Canterbury District Health Board. It is one of a series of workshops designed to help practitioners and services improve their capability to work with people experiencing complicated and complex mental heath problems. The material presented in this workshop is drawn from Te Ariari o te Oranga (Todd 2010), though is updated here in several areas. Copyright is asserted by Fraser Todd over the content. It may be freely used with permission. The name Te Ariari o te Oranga means the dynamics of well-being. The name was coined by that staff ad students of Te Ngaru Learning Systems, was given to a series of bicultural training events on co-exiting and mental health and substance use problems (CEP) over the past decade, and given to the document Te Ariari o te Oranga: The Assessment and Management of Co-existing Mental Health and Substance Use Problems (Todd 2010) by Paraire Huata. As a term, it captures the practice and teaching of CEP in New Zealand where bicultural approaches are honoured.

Welcome to this Workshop

This introductory workshop provides an overview of coexisting mental health and substance use problems (CEP) and an opportunity for managers to explore ways of enhancing CEP capability within their services. . The main focus is on the philosophy of the CEP model currently being promoted nationally by Matua Raki, the National Addiction Treatment Workforce Development Programme, with the support of the other Workforce Development programmes. The essence of this approach involves the application of the values of person-focused care, wellbeing orientated treatment and integrated care in a meaningful way, bringing them to life within the relationship between the client and the clinician. This will be the main focus of the introductory workshop. This 3-hour workshop provides an Introduction to CEP, an overview and update of current approaches to working clinically with CEP based on Te Ariari O Te Oranga (Assessment and Management of People with Coexisting Mental Health and Substance Use Problems) published by the Ministry of Health in 2010, and consideration of how services may respond more effectively to CEP (based on Integrated Solutions: Service Delivery for People with Co-existing Mental Health and Addiction Problems, published by the Ministry of Health in 2010.

Learning Intentions
Upon the completion of the workshop, participants will: Understand the nature, extent and impact of CEP on people they work with clinically Use clinical frameworks to manage the complexity of CEP Be able to utilize a range of strategies to enhance service CEP capability Know how to access further resources to develop their services CEP capability.

The MHERC CEP Workshop Series

Workshop 1: 1a. Introduction to CEP for frontline staff 1b. Introduction to CEP for managers Workshop 2: Recovery and Wellbeing Workshop 3: Motivation and Engagement Workshop 4: Assessment Workshop 5: Management I Workshop 6: Management II

Workshop 7: Integrated Care

To attend workshops 2-7, it is expected that participants will have either attended module 1 OR completed a self-directed learning package based on Workshop 1. It is essential that they are conversant with the generic principles that will be the focus of Workshop 1.

Workshop Introduction and Overview

MF
Housekeeping Workshop Series Overview Workshop Agenda Resources CEP Introduction Self-directed Learning Module Te Ariari Integrated Solutions CDHB Action Plan CEP Service Checklist CEP Practitioner Skill Set Wellbeing questionnaires and activities Screening Tools VAADA Capacity Building Manual

Part A: Overview of CEP (35 minutes)

History of CEP and NZ Context Three Dimensions of CEP Practice Exercise 1: Discuss Background Information: The Nature, Extent and Impact of CEP The Spirit of Te Ariari 7 Key Principles Skill Set Exercise 1: Discuss BREAK sometime around here

Part B: Service Development

CDHB Action Plan Workforce Development Outline & Enhancing Service Capability Overview Service Capability Checklist Exercise 2: Assess your service CEP Capability How will you know that you are achieving CEP capability (targets)? Tools for Enhancing Service Capability Practical FINNISH Resources to Support this Workshop

There are a number of resources provided to support this workshop and to allow further learning. These include: The Workbook Te Ariari o te Oranga Presentation Slides Self-directed Learning (SDL) Module A; in the form of a PowerPoint module with considerable added information; this SDL was produced for my postgraduate paper PSMX404 but is directly relevant to this workshop. It updates a number of concepts from Te Ariari. FrasersCEPblog; my blog designed to support interested CEP clinicians. Tools and Exercises as appendices CD-ROM; contains the above PowerPoint material.

CEP in New Zealand

There has been an interest in CEP in New Zealand since the early 1990s. Double Trouble groups were the initial response in many places. These involved the establishment of group treatments for people with both substance use and mental health problems alongside standard substance use group treatments, mainly within Alcohol and Drug services. Early Psychosis teams were also pioneers by including CEP approaches, especially for young people with psychosis who were using cannabis. The Assessment and Management of People with Co-existing Substance Use and Mental Health Disorders (Todd, Robertson, Sellman 1998) were a set of guidelines with clinical applications to scenarios based on the models used internationally at the time. This was the basis of widespread training over the next decade had a little impact on clinical practice but which failed to generate significant change. Barriers to improving CEP practice included: o The failure of Mental Health systems to support clinical training despite systems issues being highlighted from the outset o DHBs seeing CEP as an add-on to their current services requiring extra resources rather than core business o Negative attitudes and suspicion between AOD and Mental Health services o A view that substance use was not the business of Mental Health Services and vice versa; that MH services treated, for example, depression or psychosis and not substance use problems. As a consequence, most clinical training during the mid-2000s focused on attitude change, especially towards a more person-centred approach in which clinicians were seen as working with people rather than disorders. Relationship building and collaboration between MH and AOD services was also a focus. From around 2007, new efforts were made to enhance the CEP capability of services and practitioners. A closer relationship between the service interests of the Ministry of Health and clinical practice led to the release in 2010 of Te Ariari O Te Oranga (a clinical framework) and Integrated Solutions (guidance for mangers and services), which are companions to each other. Subsequently there have been a number of significant developments: o Establishment of a Ministry of Health Advisory Group led by the Director of Mental Health to monitor and promote enhanced CEP capability in the DHBs o CEP incorporated into all relevant MOH strategic plans and documents o CEP prioritized by the workforce development programmes, led by Matua Raki o The development of a number of resources to support practitioners and services enhancing their CEP capability o Training provided to a number of DHBs o The development of local and national CEP practitioner networks.

Part A: An Overview of CEP

Three Dimensions of CEP Practice
The practice of CEP as descried in Te Ariari can be thought of as having three levels of practice of increasing specificity Spirit Principles Techniques The spirit of Te Ariari is a philosophy or set of values that underpin practice. They are not specific to CEP; rather they apply to any person seeking help for health related problems, especially where there is a degree of complexity in their problems. In short, this philosophy is about placing the whole person at the centre of care and recognizing that the outcome they desire is an enhanced quality. Principles are comprised of Seven Key Principles: 1. Cultural considerations 2. Well-being 3. Engagement 4. Motivation 5. Assessment 6. Management 7. Integrated care These principles have been chosen because they are felt to be those most needing highlighting in the current health environment. They differ slightly from those identified in 1998 Guidelines, and are likely to be different from those needing stressing in the future. Techniques include specific clinical skills that put into practice the Spirit and the 7 Key Principles. These include, for example: Strategies to assess values and character strengths Positive interventions Cognitive mapping Motivational interviewing skills Development of autonomy supportive environments Tools for screening Brief assessment and interventions Comprehensive assessment Etiological formulation Structured follow-up and intervention sessions. These will be the subjects of the more advanced workshops later in the year.

Thinking About CEP

With increasing knowledge and detail, clinicians often find it complicated dealing with the MH and AOD problems and have no cognitive room to deal with further issues. They experience cognitive overload. In other words, the number of things they must think about and manage is too great for their brains to handle. When faced with large amounts of complicated information, clinicians will often forget to do things they know well to do, and focus on the details they are most familiar with. Similarly mental health care becomes more detailed, dividing up into detailed areas of specific focus such as anxiety disorders, eating disorder, alcohol and drug problems and so on. The key to managing complicated problems is to connect the details, to integrate them into a whole. Complex things are multi-dimensional but manageable. While expert practitioners do know more detail, the key difference between them and novice practitioners is the connections they make between their pieces of knowledge. They integrate information by making connections and using frameworks. Similarly, learning about CEP is about using frameworks to integrate knowledge and skills There are a range of frameworks and structures that can organise CEP knowledge and turn if from complicated to complex. The key ones are those that provide the big picture and make up the spirit of Te Ariari.

Summary: The Spirit of Te Ariari

Person-focused care o Especially personal values, strengths and vision of well-being. Wellbeing orientated care o Using quality of life as the most important outcome and focusing equally on enhancing positive attributes and removing barriers to well-being Integrated care

Driving care from the needs of the person and fitting the system round these rather than vice versa Walking the talk o While we know the above, we are seldom able to put it into practice for a number of reasons. Walking the talk involves using specific techniques to incorporate them into our clinical work. o

Exercise 1: Personal and Professional Values

Complete the Values Paper Card Sort Questionnaire (below) In Pairs or threes, share your three most important values
One person leads a discussion with the other around one of their top three values: 1. What is 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 these values in your work? 5. Are there ways you would like to express this value more in your work?

Personal Values Card Questionnaire

(Adapted from Bill Millers Personal Values Card Sort)

Instructions: 1. Consider each of the values in the list and place a tick in the appropriate box to indicate whether that value is not important, important or very important to you. 2. Aim to have no more than 10-15 ticks in the very important box 3. Look over the values you have rated very important and rate from 1 -5 or so the most important to you, in order of importance

Value Acceptance Accuracy Achievement Adventure Attractiveness Authority Autonomy Beauty Caring Challenge Change Comfort Commitment Compassion Contribution Cooperation Courtesy

Description To be accepted as I am To be accurate in my opinions and beliefs To have important accomplishments To have new and exciting experiences To be physically attractive To be in charge of and responsible for others To be self-determined and independent To appreciate beauty around me To take care of others To take on difficult challenges To have a life full of challenge and variety To have a pleasant and comfortable life To make enduring and meaningful commitments To feel and act on concern for others TO make a lasting contribution in the world To work collaboratively with others To be considerate and polite

Not Important

Important

Very Important

Top 5 Rating

Creativity Dependability Duty Ecology Excitement Faithfulness Fame Family Fitness Flexibility Forgiveness Friendship Fun Generosity Genuineness God's will Growth Health Helpfulness Honesty Hope Humility Humour Independence Industry Inner Peace Intimacy Justice Knowledge Leisure

To have new and original ideas To be reliable and trustworthy To carry out my duty and obligations To live in harmony with the environment To have a life full of thrills and stimulation To be loyal and true in relationships To be known and recognized To have a happy, loving family To be physically fit and strong To adjust to new circumstances easily To be forgiving of others To have close, supportive friends To play and have fun To give what I have to others To act in a manner that is true to who I am To seek and obey the will of God To keep changing and growing To be physically well and healthy To be helpful to others To be honest and truthful To maintain a positive and optimistic outlook To be modest and unassuming To see the humorous side of myself & the world To be free from dependence on others To work hard and well at my life tasks To experience personal peace To share my innermost experiences with others To promote fair and equal treatment for all To learn and contribute valuable knowledge To take time to relax and

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Loved Loving Mastery Mindfulness

enjoy To be loved by those close to me To give love to others To be competent in my everyday activities To live conscious & mindful of the present moment To avoid excesses and find a middle ground To have one close, loving relationship To question & challenge authority and norms To take care of and nurture others To be open to new experiences, ideas & opinions To have a life that is well ordered and organised To have deep feelings about ideas/activities/ people To feel good To be well liked by many people To have control over others To have meaning and direction in my life To be guided by reason and logic To make and carry out responsible decisions To take risks and chances To have intense, exciting love in my life To be safe and secure To accept myself as I am To be disciplined in my own actions To feel good about myself To have a deep and honest understanding of myself To be of service to others To have and active and gratifying sex life To live life simply, with minimal needs

Moderation Monogamy Non-conformity Nurturance Openness

Order Passion

Pleasure Popularity Power Purpose Rationality Responsibility Risk Romance Safety Self-acceptance Self-control Self-esteem Self-knowledge

Service Sexuality Simplicity

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Solitude

Spirituality Stability Tolerance Tradition

To have time space where I can be apart from others To grow and mature spiritually To have a life that stays fairly consistent To accept and respect those who differ from me To follow respected patterns of the past To live a morally pure and excellent life To have plenty of money To work to promote peace in the world

Virtue Wealth World Peace

Choose one of the top 5 most important values.

Discuss What is it about this value that is important to you?

In what ways are you living up to this value in your life?

In what ways are you not living up to this value as you would like to?

How might you live up to this value more?

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Background Information: The Nature, Extent and Impact of CEP

Definitions
Coexisting substance use and mental health problems (CEP) are known by many different names; Double Trouble, Dual Diagnosis, Mental Illness with Chemical Abuse (MICA), Co -occurring Disorders, or Co-existing Problems. They all mean much the same thing. Co-existing has been the term used in New Zealand for the last decade and problems was chosen to move away from the focus on disorders while still being acceptable to MH services. The usual definition is the co-occurrence of mental health and substance use problems in the same person at the same time. Research definitions often report lifetime rates of CEP; the person has MH and AOD problems at some point in their life, not necessarily at the same time. Current CEP in research usually means that the problems were present during the last month.

The Nature of CEP

CEP is not a single thing. Rather, there are as many different subtypes as there are combinations of drugs and mental health problems. Problems related to CEP range from the simple and straightforward to the multi-dimensional and complicated. The more complicated cases of CEP are among the most difficult to treat and expose the weaknesses in the health system. As such, there are general or generic things that need to occur for all people with CEP, as well as specific things for each combination of MH and AOD problems. In almost all cases, when a MH problem is complicated by AOD problems, engagement, treatment outcome, suicide rates and psychosocial functioning are much worse.

The Impact of CEP

The presence of CEP is associated with a range of poorer outcomes including: Poorer compliance with treatment and medication More relapses More readmissions Poorer outcomes Treatment resistance Increased rates of suicide and violence Higher rates of unemployment

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Epidemiology
CEP is common. In general terms, the rate of AOD problems in people with specific mental health disorders ranges from 25-30% for most anxiety disorders and major depression, to 50% of those with bipolar disorder and schizophrenia. Rates in those with antisocial personality disorder are up to 80%. In those in treatment for AOD problems, rates of comorbid MH disorders appear to be very high. A New Zealand study of two community AOD services showed that 70% had an axis I non-AOD DSMIV diagnosis in Mood and anxiety disorders were the most common. Of note just under a third had a current diagnosis of PTSD, and 10% had a current diagnosis of bipolar disorder, with less than half of them being in current mental health treatment. Also of note are the very low rates of psychosis in those with AOD problems, and even lower rates of schizophrenia. This is very important given the past emphasis in CEP on chronic psychotic disorders they are very uncommon.

A Brief History of CEP

CEP is an artifact of the way health problems are diagnosed and health systems structured. It emerged as an issue in the 1980s due to a number of developments in treatment, not least the move of clients from hospital to the community. Increased access to alcohol and drugs undoubtedly played a part, as did the advent of DSMIII and its insistence that if criteria for more than one diagnosis was met, all diagnoses should be made. Large population studies such as the ECA and NCS studies also raised awareness of CEP and community mental health clinicians began reporting on the high prevalence CEP and the poor outcomes it was associated with. Most of the treatment models used today were developed during the early 1990s, most prominently those by Osher and Koefed, Drake, Carey and Mueser. At the heart of these models were the principles of comprehensiveness and integration. During the 2000s, the need for widespread screening leading where appropriate to assessment was promoted and several treatment guidelines were published including TIP42 and the UK Dual Diagnosis Toolkit. These guidelines summarise the major standard approaches to CEP that had been developed over the past decade and are considered best practice.

Aetiology (Causes) Traditional Views

The causes of CEP have traditionally been described as: 1. Substance use causes mental health problems 2. Mental heath problems cause substance use problems 3. Common underlying factors cause both substance use and mental health problems which are themselves not necessarily causally related. Of note common factor models seldom specify what the common factors actually are.

Aetiology (Causes) Common/Trans-diagnostic Factors

In fact, in most cases, all the above models are usually involved in either causing or maintaining problems. For some combinations, the substance use may cause the mental health problems e.g. Alcohol and depression, stimulants and psychosis. For other combinations, the mental health problems appear to be the main driver for the development of substance use problems, especially in the case of bipolar disorder, PTSD and social phobia. Common factors often underpin CEP. Factors that underpin and lead to the development and maintenance of several disorders are also called Trans-diagnostic factors.

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Different factors may be important in individuals and it is essential to identify if this occurs, given that many of the factors are treatable and that other problems are unlikely to resolve until they themselves are treated effectively. Common Trans-diagnostic factors include: Shared genes Attention control Impulsivity Negative urgency Negative emotionality Cog/Attention bias Emotion regulation Rumination Perfectionism Coping (approach/avoid) Sleep Social context

Limitations of Current Approaches

The best practice guidelines such as TIP 42 have a number of limitations. First, the gold standard integrated dual diagnosis team approach of Drake and colleagues, as well as interventions such as motivation interviewing are very hard to put into practice in clinical settings with fidelity. Pejorative attitudes between MH and AOD clinicians remain significant barriers to implementation. After the release of TIP42, a number of systematic reviews have indicated that the best practice approaches are not effective in changing both MH and AOD problems, and that while these approaches have been shown to improve psychosocial functioning, they do not appear to change symptoms. The strongest evidence is for group approaches, long-term residential treatments and contingency management. While there is some improvement in functioning with the standard CEP approaches, engagement remains highly problematic. Only 30-50% of people with severe CEP engage in treatment. The standard treatments are built around the paradigms for treating chronic illnesses such as schizophrenia, which is uncommon. They may not be applicable to other types of CEP. Most of the strategies for treating CEP involve change at the level of the service and system, such as bringing together AOD and MH treatments. At the clinical level there remains a lack of guidance for how to implement these change. Finally, integration is a key principle, but invariable deals with the integration of AOD and MH treatments. For most people with CEP, there is a lot more to integrate than just the AOD and MH problems.

The Spirit of Te Ariari

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As mentioned, the Spirit of Te Ariari is a philosophical context for care based on four values: 1. Person-focused care 2. Wellbeing orientated care 3. Integrated care 4. Walking the talk; or expressing these values in our clinical practice. There is good evidence that a person-focused approach increases engagement, motivation, treatment compliance and service satisfaction. There is a lot written about person-focused or person-centred care. While we are usually able to describe it, we frequently fail to put it into practice with the people we work with. Reasons for this include cognitive overload, lack of time and therefore a focus on the detail of our work, a lack of simple techniques to implement it and a lack of value placed on by the systems we work in. For person-focused care to be integral to our practice, we need to include it as a central part of our overall framework of care something we consciously think about as a key driver of what we do. We also need specific strategies to implement it. Some strategies include: Referring to the person as a person, preferably by their name rather than their role in our system (patient/client/consumer) Taking time to get to know the person, especially: o Personal values o Strengths (especially character strengths) o Their vision of what wellbeing is for them Empowering the person within the therapeutic relationship Several specific techniques and tools are very useful 1. WHOQOL-100 and WHOQOL-Bref Using quality of life as the key outcome measure, using it at baseline and then at crucial points during follow-up gives a measure of a persons overall quality of life, this, after all is the key thing they and we are seeking. The WHOQOL is a widely used and validated instrument developed by the World Health Organization. The full 100-quesiton version is a very good instrument. However, the Bref is a briefer instrument of 24 questions and seems preferable in clinical practice. 2. Personal Values Card Sort/Paper Questionnaire This is the first exercise you did. The Values Card Sort was developed by Bill Miller of Motivational Interviewing fame. It is a very nice exercise to do, but requires that you have a set of Values Cards on you and it takes 20-30 minutes. I have developed the paper questionnaire based on the Values Cards; it takes less time and can be given as homework tasks, thus being more practical in a busy outpatient setting and it works very well. However, if you have time, I think the Values Card Sort itself is preferable. 3. Character Strengths measures Character strengths are very useful things to be aware of. Helping a person identify their character strengths (they are not always what people initially think they are), and then putting one or two of the key ones into practice in a new way, each day, for one week has been shown to enhance subjective well-being for at least the next six months. There are a number of ways of identifying a persons core character strengths. The simplest is to ask them which, from a list (see appendix), are their top strengths. A more effective way is to use a rating scale or test such as the VIA-signature strengths test accessed free at the www.authentichappiness.com website. A person needs to register and log on, and take the test online. It takes 20-30 minutes. A paper-based version is in development brief version is in development locally and we will let you know when it is available. 4. Best Possible Selves Exercise

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This is a positive psychology intervention that aims to improve a persons optimism and hope. Undertaking this exercise has been shown to lead to measurable increases subjective well-being sustained for at least six months. It is also a very useful way to help a person identify their hopes and aspirations for their lives; i.e. what well-being means to them.

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.
. . . . . . . . . . . . . . . . .

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. .

Well-being Orientated Care

Wellbeing orientated care relates closely to the second key principle of Te Ariari, Recovery and Well-being. The second value and one that provides the key overarching framework by which to organise care is that of well-being orientated care. This framework is as follows: People desire a state of flourishing; a high degree of wellbeing. They experience distress when they are languishing i.e there is a significant gap between their desired state of wellbeing and their actual state of wellbeing. They try many strategies to improve their wellbeing before they seek help from us specialist services. The traditional role of health services plays a small part in their movement towards increased wellbeing

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This framework is obvious; we know it well when it is stated. However, we often fail to put it in to practice in our work. The importance of it is that it reminds use that there is more to wellbeing than simply treating disease or disorder, and more to it than maintaining the health gains made when we are able to treat those disorders. There are active things that can be done to enhance well-being beyond minimizing the barriers. Of note: People who have had complete recovery from major depression have a significantly lower degree of well-being compared to people who have never had major depression. Quality of life can be improved with no improvement in symptoms of disorder Effective positive interventions have an effect size for improving depression around the same as CBT for depression. In particular, forgiveness exercises have a much higher effect size. Positive interventions and CBT are not mutually exclusive. We are well placed to help people take positive steps toward enhanced wellbeing, and even if we choose not to we should see our role as a part of the bigger picture

Therefore, key steps to a well-being orientated approach include: 1. Identifying the persons vision of well-being 2. Enhancing functioning in positive domains 3. Improving functioning in deficit domains 4. Incorporating positive interventions into treatment planning. Therefore, specific evidence-based strategies and techniques to enhance well-being include: 1. Values card sort 2. Character Strengths (VIA-signature strengths above) 3. Gratitude interventions 4. Cultivate optimism (best possible selves) 5. Avoid over-thinking or rumination (mindfulness) and social comparison 6. Nurture social relationships 7. Develop strategies for coping; find meaning, social supports 8. Practice acts of kindness to self (loving kindness medication) and others 9. Learn to forgive 10. Increase flow activities

Integrated Care
Delivering person-focused wellbeing-oriented integrated care must start with the needs of the client and their family, identify detailed issues within that context, organise services flexibly to support these needs and design systems that support services to do this. Systems integration = brings systems closer together Treatment integration = combines treatments under one service Integrated care = brings all treatments together behind the need of the person Integrated care comes from: Understanding a persons vision of well-being Starting with the needs of the person Considering both pathways to wellbeing and barriers to well-being (deficits) Aetiological formulation from multi-dimensional/comprehensive assessment Effective collaboration (within and outside multidisciplinary team) Systems organised to support integrated care.

Much of what we do as clinicians and practitioners involves integration.

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There are a number of key points in the clinical process, which we can leverage to enhance integration The tools and strategies we use clinically include: 1. Taking a wellbeing perspective 2. Screening and assessment processes that integrate a range of sources of information and information across multiple domains 3. Specific processes and structures within the assessment to integrate issues such as MH and AOD problems timelines, ecograms 4. The process of forming an opinion and a multi-dimensional formulation 5. Combining of perspectives within the multi-disciplinary team 6. Collaboration with others outside the MDT It is also important to think about integration over time (longitudinally). People deal with a number of different services over time. Often, each service will take a narrow perspective of the persons problems based on what they usually deal with. As a result, problem formulation, diagnosis and treatment approaches may change frequently. This is unhelpful. Integration therefore starts with the big picture the client seeking enhanced wellbeing and our role in this, in particular removing barriers in the context of wellbeing.

Walking the Talk

As mentioned, there are numerous barriers stopping us putting these values and principles into practice. It is therefore important to have clear, simple and quick strategies we can use in our practice to help us apply them. Below is a table summarising the important values and principles we have mentioned and some useful some techniques and strategies for putting them in to practice. Person-centred Values Strengths Wellbeing Integrated Care Vision of well-being Personal Values Questionnaire VIA signature strengths WHOQOL Best Possible Selves Well-being perspective, timelines, Formulation, Collaboration Culture Engagement Motivation Assessment Management Screening, Brief, Comprehensive Brief Comprehensive Implementation intention, self-efficacy, autonomy, MI WHO-assist Comp Asst + Formulation FRAMES 404 Template

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The Te Ariari Framework & The 7 Key Principles

Te Ariari is organized around 7 key principles: 1. Cultural considerations 2. Wellbeing 3. Engagement 4. Motivation 5. Assessment 6. Management 7. Integrated Care These principles were chosen because they seem to be the ones that require enhancing in the context of our current approaches to treatment. It is likely that in a few years, different principles will need stressing. These principles are applied in each of five phases of treatment. 1. Pre-treatment 2. Early treatment 3. Middle treatment 4. Late treatment 5. Autonomous independence Thus the Te Ariari framework can be expressed as a matrix with related goals at each phase of treatment

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Within this framework each phase of treatment can be associate with key goals and specific strategies. These will be discussed in detail in the advanced workshops later this year. For further information, see Te Ariari o te Oranga. The 7 Key Principles are discussed in more depth in Te Ariari o te Oranga, will be the focus of

specific advanced workshops, and will be outlined in the Self-directed Learning Module Part B which should be available by late April 2013 from FrasersCEPblog.

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Part B: Enhancing Service Capability

The Local Context
1. 2. 3. 4. 5. CDHB Action Plan CEP Implementation Group CEP Interest Group Service Capability Enhancement Workforce Capability Enhancement

This section deals with implementing CEP responsiveness at a service level.

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PROGRESS REPORT

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December 2012
Canterbury and West Coast DHBs CEP PLAN IMPLEMENTATION

Introduction: Canterbury and West Coast support the focus on CEP capability across the mental health and addictions sector. The requirement of a CEP plan to improve care for people is welcomed in both districts with plans to share expertise more as the relationship between the two DHBs strengthens.

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Progress to Date: The West Coast DHB is working with the national workforce development organisations to upskill clinicians so there is greater CEP capability. Screening tools have been agreed on for use in mental health and AOD services respectively to ensure the other issues are adequately identified. Mental health and AOD teams close proximity in terms of location increases the opportunities for good collaboration. Work is underway within the primary mental health team to strengthen AOD expertise as to date work has focused on mental health. A review of the needs of the West Coast community in terms of mental health and AOD has commenced with stakeholders and this will incorporate a CEP focus. Canterbury has adopted an approach informed by local expertise. Once the plan (attached with updates in italics) was developed and submitted, an implementation group, with leaders from different parts of the system, was formed. This group meets fortnightly and is aligned with the SMHS Direction of Change Implementation. Achievements to date include: Development of a shared understanding of a CEP approach across clinical, community and consumer services A greater appreciation of perspectives from other parts of the MH/AOD system Identification of ways group members can influence change Discussions held with SMHS Leadership Team, Consumer Leadership Groups, Maori and Pacific Leadership Group Strengthened cross sector relationships SMHS AOD clinicians supporting mental health teams

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Self assessment tools (individual and team) reviewed and amended for local use A CEP approach being developed in a community mental health team An invitation to people interested in CEP to form a network led by people with significant expertise* Plans for a sector wide forum in first quarter of 2013*

*potential to include West Coast Next Steps: The Canterbury Implementation Group will reconvene late January to review progress and establish milestones for the coming months. Direction will be discussed with the West Coast network and opportunities for sharing expertise and resources considered. The next progress report will be submitted mid-2013.

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Canterbury DHB CEP ACTION PLAN UPDATE

Goal 1: All services become client and family, whanau centred and CEP responsive Objective Actions Measure/outcomes

Responsibility

A shared understanding for CEP is developed across the AOD and MH system.

Dec 2012 An Implementation Group has been established and meets fortnightly. This group has links with all key stakeholder groups and has presented at a variety of forums. The MHLG has oversight of the work with regular updates provided at monthly meetings.

The CEP plan is endorsed by the Planning and Funding Mental Health Leadership Group, Access Canterbury and other advisory/oversight bodies - achieved. This group meets regularly and keeps the MH Leadership Group etc informed about progress - achieved. Contracts for all MH and AOD services Clinical and include expectations regarding CEP management leaders capability and audit outcomes support this national service specs have expectations outlined and as contracts are renewed an increased focus on CEP is being included when appropriate.

Time frame 2012/1 3

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CEP capability is built into audit processes H&Dis Stds partially address this and contract audits are focused as required. Service policy is client and whanau centred and includes working definitions of CEP, integrated care and best practice protocols after significant discussion within the group, members of the Implementation Group can lead discussion in other parts of the sector about best practice based on a wellbeing approach.

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Objective Mental Health and Addiction services including advocacy and peer support services collaborate to ensure integrated treatment.

Actions The Implementation Group is made up of people who have stakeholder networks they can feed back to and influence.

The MHLG similarly has people from all stakeholder groups. The SMHS Direction of Change has a number of working groups with system wide participation. SMHS AOD Services are focused on supporting the other teams with people who have CEP A CEP best practice approach is being piloted within one of SMHS community teams. This includes reviewing competency frameworks/checklists. Peer based advocacy, and recovery support services are part of the Implementation

Measures/outcomes Documented system of care incorporates an integrated response to people with CEP incorporated in a variety of documents but needs pulled into one overarching system of care.

Responsibility P&F/Service leaders

Timeframe 2012/14

Service leaders

2012/14

SMHS AOD has a focus on CEP in their documentation and staff workforce development plans incorporate CEP enhancement achieved. All services have documented processes that describe procedures for responding to and managing people with CEP, including staff skills resources to achieve this will be available to the sector along with training and support. Access rates to peer services increase and consumer and family feedback endorses the approach

Service leaders

2012/14

Community service leaders/peer organisations

2012/14

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Group and are considered an essential part of the system.

peer services are increasing and there is work occurring to identify to desired configuration.

A CEP interest group is being established to progress shared understandings and influence the wider system. People from all Documented protocols describe parts of the system can be the pathways and linkages to be involved developed A CEP forum and ongoing training will be open to people from all parts of the system. T

Consumer and family support services are able to access clinical support for people with CEP when needed require formalising. Performance activity monitored and reviewed by oversight group need to continue monitoring. Service leaders, P&F 2012/14

Review Specialist CEP Resource.

To date people are taking up responsibility without any change to formal roles.

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Goal 2: Integrated Systems of Care systems are to acknowledge and incorporate CEP approaches Objective Services are responsible for ensuring systems acknowledge and incorporate CEP. Actions The implementation of SMHS Direction of Change is incorporating a CEP focus and workforce development plans are underway. Measures/outcomes Workforce development plans include CEP being developed. Responsibility Service leaders Timeframe 2012/14

A group of CEP focused people is under development.

There are lists of supervisors with CEP expertise available to be developed. NHI reports analysed and reported to oversight committee show increased identification of CEP yet to commence. Tangata whaiora and family/whanau feedback endorses approach to be developed. Services have identified the CEP needs of their client group and have a documented record of their current status, desired position and plan to achieve (e.g. as a quality improvement initiative) this approach is part of a pilot with a community team and will be

Services develop a strategy to meet the CEP needs of their service users.

The Implementation group includes people connected to consumer and family networks. Regular forums are being held with consumers. Tools are being developed for organisations and individuals to undertake self-assessments so that plans can be developed for improving CEP capability.

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available more widely if successful.. Service Leaders facilitate development of relationships, collaboration and dialogue at all levels across the community. People are being supported to participate in CEP focused activities across the system. The Implementation group includes leaders from across the system. Protocols exist across the system Service leaders for strengthening relationships, information sharing and responsibilities, including lead service etc. protocols documented for SMHS AOD liaison staff. Staff and client wellbeing improves mechanisms to determine to be developed as change occurs. . 2012/14

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Goal3: Workforce Development a highly skilled workforce that is CEP responsive and effective. Objective Specialist CEP expertise is retained and consideration given to recruitment of CEP FTE/team. Actions A CEP implementation group meets fortnightly. A special interest group is being developed. Indications are that there is commitment from across the system to supporting people to attend CEP focused forums. Key Performance Indicator Key people are able to commit to this work in a sustainable way yet to be determined. Responsibility Service leaders/P&F Timeframe 2012/14

The key focus area is piloting a CEP approach within a community mental health team. This is being supported by key people.

Regular CEP training is provided across the system provided as part of the community mental health team initiative and plan for more widely available training also. Training delivery is part of the CEP specialist job description yet to be developed. Number of people trained, including peer roles. Number of people providing mentoring/coaching post training Need to develop mechanisms for recording this information. Numbers of people engaged in training initiatives yet to be developed

Services support training initiatives provided nationally regionally and locally.

Matua Raki and other training providers are being engaged in discussions about what can be made available. The mental health team initiative, the implementation group and the special interest group all include

Service leaders/P&F in collaboration with workforce development organisations Service leaders

2012/14

2012/14

34

opportunities to better understand CEP concepts. Formulation training will continue to be available. Increased CEP capability demonstrated through access rates and care plans yet to be developed.

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Current CDHB CEP Capability Strategies

Enhancing CEP capability involves change on systems, services and practitioner levels. Tools are available to help services assess their current CEP capability. CEP capability is best conceptualized on a continuum as MH or AOD only (the service does not detect the presence of the other), a range of CEP Capabilities (detect through routine screening, detect and assess, detect/assess/plan management) and CEP Enhanced (are able to detect, assess, and treat most relevant cases of CEP within the one service). Most services do not need to be CEP enhanced. The best approach is for a service to identify its level of CEP capability, determine what level of capability it would like to have and plan to develop towards this. The Canterbury District Health Board has an implementation group to oversees developments on system, service and clinical levels. The capability enhancement approach is shown in the diagram below. There are three approaches, each covering similar material but adapted to the specific needs at the time: 1. Generic training for as many staff as possible across services 2. Work with specific services to help plan and implement capability enhancement 3. Learning around specific clinical situations through CADS liaison roles within mental health teams.

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Exercise 2: Below is the CEP Service Checklist produced by Matua Raki. In small groups, go over the checklist and discuss the how your service currently meets the objectives and what need to be done to meet the objectives.

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About this checklist

This is a brief tool for mental health and addiction/AOD services to use for self-assessment, reflection and planning to develop service level co-existing problems (CEP) responsiveness and capability. There is no expectation that services will provide treatment outside their core business (refer to page seven for a reference to where services fit along the continuum of CEP responsiveness) rather that they will welcome and engage with all tangata whaiora regardless of which service is accessed. Assistance will be provided to access appropriate support and treatment based on mental health and addiction/AOD screening. Working towards CEP capability means services are able to screen, assess and identify complex mental health and addiction/AOD problems. This will result in plans that formulate and reflect integrated care and collaboration with other services. The checklist will assist services to monitor their progress towards meeting the goals of the CEP plans submitted by DHBs to the Ministry of Health in 2010 and 2011. The checklist can be used to develop an action plan that identifies work to develop service level CEP responsiveness and capability (including any workforce development needs).

Using this checklist

To achieve the greatest benefit it is important to involve as many members of the team as possible in completing the checklist. Consider a range of different perspectives across the service, which includes tangata whaiora, family and whnau advisors, clinical and leadership roles. The team discussions, reflections and information sharing about a services progress towards CEP responsiveness and capability provide the principle benefit of using this checklist. It is important that the group completing the checklist understands that there are no wrong answers and that the development of a services CEP capability is most usefully regarded as a process that is to be supported by whole team reflection and planning. The checklist recognises existing practice and provides guidance in the development of a plan to support a service to further develop CEP responsiveness and capability. Six monthly reviews of the checklist are recommended. Links to supporting documentation are available at: www.matuaraki.org.nz, www.tepou.co.nz www.acts.co.nz, and www.werrycentre.org.nz,
(The checklist is adapted from the Diagnosis Capability (Croton, G).

Victorian ChecklistAgency Dual

Terminology
This checklist uses the terms: Co-existing problems to refer to co-occurring complex mental health, gambling and substance use disorders, often also referred to as dual diagnosis, co -existing disorders or comorbidity Tangata whaiora to refer to people who access mental health and addiction/AOD services, including children, youth, tamariki, rangatahi and adult service users, clients and consumers. Tangata whaiora can be used to also refer to whole family and whnau systems .

CEP Service Checklist

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Service Objectives CEP responsiveness is identified as core business Service plans, service descriptions and mission statements reflect a CEP focus and responsiveness that reflects that any door is the right door for tangata whaiora and family and whnau seeking help. (Service Delivery for People with Co-existing Mental Health and Addiction Problems-Integrated Solutions). Effective partnerships and agreed mechanisms to ensure any door is the right door to support and treatment Formal agreements are in place between and with local DHB, NGO and PHO addiction/AOD, gambling and mental health services defining pathways of care and primary responsibility for support and treatment for tangata whaiora, family and whnau. Screening All people seeking assistance from services are screened for mental health, substance use and gambling, using standardised and validated screening tools where appropriate. (Screening, Assessment and Evaluation, Choice and Partnership approach (CAPA),Problem Gambling Service - Intervention Service Practice Requirements Handbook, Assessment Mental health services carry out a thorough alcohol and other drug and gambling assessment, including where necessary information from family, whnau and other relevant agencies, when screening indicates the presence of co-existing problems. Addiction/AOD and gambling services carry out a thorough Mental State Examination when screening indicates the presence of co-existing problems. (Te Ariari o te Oranga).

How the objective is currently being met

What needs to be done to better meet the objective

Comments

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Service Objectives Use of outcomes information Outcomes information is used by individual staff and teams to inform support and treatment.(PRIMHD, outcome measures, CLIC) Integrated Treatment Either one case manager or team provide/co-ordinate treatment and support for people presenting with coexisting problems or staff of separate services work together to formulate, implement and monitor a single documented plan in consultation and in partnership with tangata whaiora, family and whnau. (Te Ariari o te Oranga, Choice and Partnership Approach(CAPA)). Follow-up Tangata whaiora with identified co-existing problems are prioritised for proactive follow-up following self or planned discharge and community agencies are actively engaged to provide ongoing support. Co-existing problem champion The service has at least one practitioner with appropriate experience, training and seniority who is the identified CEP champion. Workforce co-existing problem capability The service routinely carries out internal audits or inventories of the teams and individual staff members CEP knowledge and skills in order to inform workforce development needed to meet service objectives.

How the objective is currently being met

What needs to be done to better meet the objective

Comments

CEP Service Checklist

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Service Objectives Outcomes and service responsiveness for tangata whaiora with co-existing problems are recorded, monitored, and regularly reviewed Outcomes information about problematic substance use and gambling among tangata whaiora who use mental health services and mental health problems among tangata whaiora who use addiction/AOD and gambling services is routinely collected and systematically analysed to inform team and service development. (PRIMHD, outcome measures, CLIC). Service Delivery: Planning and Development The service routinely screens for co-existing problems with all tangata whaiora accessing services The results of screens will be reviewed periodically for wider service improvement and planning purposes as well as to assist support and treatment for tangata whaiora. The service routinely provides comprehensive assessment for tangata whaiora presenting with coexisting problems Assessment information, where relevant, will be reviewed regularly as part of support and treatment planning and for wider service improvement. The service routinely provides integrated support and treatment for tangata whaiora presenting with co-existing problems Integrated treatment and support approaches will be regularly reviewed for effectiveness and any potential for quality improvement.

How the objective is currently being met

What needs to be done to better meet the objective

Comments

How the objective is currently being met

What needs to be done to better meet the objective

Comments

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Service Objectives Tangata whaiora, family and whnau are involved in advisory and planning activities Experience or a reasonable awareness of CEP could be included in the criteria for the appointment of Consumer and Family and Whnau Advisor positions. Tangata whaiora, family and whnau are involved in the education and training of staff Tangata whaiora, family and whnau provide regular input into or lead the development, delivery and evaluation of training packages, around co-existing problems that are inclusive of a developmental life stage perspective. Service Workforce Development Objectives Ethnocultural Responsiveness Workers or teams providing services have been assessed to have essential, practitioner and or leader level Real Skills and are engaged with a relevant appropriate skills or competency framework that reflects the population needs of the service. (Lets Get Real, Real_Skills_Plus_CAMHS, Real Skills Seitapu , Takarangi_Competency_Framework) Use of ethnicity information Workers collect ethnicity data to understand and respond to the cultural diversity of tangata whaiora accessing the service. Ethnicity data is used to inform support, treatment and service planning. (Engaging Maori in outcomes information)

How the objective is currently being met

What needs to be done to better meet the objective

Comments

How the objective is currently being met

What needs to be done to better meet the objective

Comments

CEP Service Checklist

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Service Objectives Staff in mental health, addiction/AOD and gambling services are co-existing problems capable Position descriptions reflect the expectation that all staff are or will become co-existing problem capable, i.e. have the knowledge and skills necessary to identify and respond appropriately to people with co-existing problems, including referral on as needed. Advanced practitioner capability Position descriptions for all senior or advanced practitioner positions include advanced/enhanced coexisting problem skills and knowledge criteria. Advanced practitioners are able to support integrated assessment, treatment, and recovery; and contribute to ongoing service evaluation

How the objective is currently being met

What needs to be done to better meet the objective

Comments

*Outcomes information: Includes the use of information that is available through PRIMHD -Programme for the Integration of Mental Health Data KPI - Key Performance Indicator Framework CLIC - Client Information Collection Patient Management System ADOM - Alcohol and Drug Outcome Measure

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Quadrants of Care
High Severity 2. Low Psych High Substance (CADS/NGO) 3. High Psych High Substance (CEP/Youth Specialty)

Continuum of service capability to deliver integrated care

Low Severity

With thanks to Counties Manukau DHB

CEP Service Checklist

Substance Use Disorder

1. Low Psych Low Substance (Primary Health)

4. High Psych Low Substance (MHS/CAMHS)

Addiction/ AOD only

CEP capable

CEP enhanced

CEP capable

Mental Health only

Psychiatric Disorder

Psychiatri c Disorder

High Severity

From: Service Delivery for People with Co-existing Mental Health and Addiction Problems-Integrated Solutions-2010

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APPENDICES AND RESOURCES

Additional Resources See Accompanying CD
Included 1. Self-directed Learning Module Part A PDF 2. PowerPoint of slides from this presentation 3. Self-directed Learning module Intro to CEP 4. Screening instruments for AOD and MH 5. WHOQOL-Bref, WHOQOL-100 and users manual 6. Personal Values Card Sort Paper Questionnaire 7. Character Strengths 72 8. CEP Practitioner Knowledge and Skills Framework 9. VAADA Capacity Building and Change Management: A guide for Services Implementing Dual Diagnosis Processes

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CEP Workshop Manual 2013

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Some Positive Intervention Exercises

Exercise: Values Paper Card Sort Complete the Values Paper Card Sort In pairs or threes, share your three most important values One person leads a discussion with the other around one of the top 3 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 living up to this value? 3. Are there ways you would like be living up to this value more than you are at the moment?

Exercise: Character Strengths Using the VIA Signature Strengths Inventory (online) or filling out a paper version of a brief character strengths inventory, identify your 3-5 key characters strengths. Pick one of these. Use this strength in a new way each day for a week.

Exercise: Best Possible Selves Think about your best possible self; imagine yourself I the 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. Write down what this life would be like.

Exercise: Gratitude 1 Think about the many things in your life, both large and small, that you have to be grateful about. These might include particular supportive relationships, sacrifices or contributions that others have made for you, facts about your life such as your advantages and opportunities, or even gratitude for life itself and the world we live in. Identify and think about three underappreciated aspects of your life for which you can be grateful.

Exercise: Gratitude 2 Count Your Blessings Every night for the next week, right before you go to bed, write down three things (large of small) that went really well that day.

Fraser Todd 2013

Explain why they happened that way.

Exercise: Gratitude 3 - Gratitude Visit: Think of someone who has been especially kind to you, but who has never heard you express your gratitude. Write and rewrite a Gratitude Letter, describing in concrete terms what they did for you and how it affected your life. Make it soar. Visit them in person, if possible, and read it aloud.

Exercise: Gratitude 4 Think about something you have experienced in the last day or two, or something around you that you wouldnt usually notice. This might include particular meetings or classes that you attended, typical interactions with acquaintances, typical thoughts that you have had as you move trough the day, a flower or tree you pass frequently. Spend 10 minutes contemplating that experience, appreciating the beauty in it and expressing gratitude for that experience.

Exercise: Pleasure and Savoring Savoring is the process of mindfully engaging in thoughts or activities that encourage positive events to lead to positive feelings. Reminisce about the past Savor the present moment Anticipate the future

Exercise: Kindness Random Acts of Kindness Each day for a week, perform an act of kindness. The acts do not need to be for the same person and the person may or may not be aware of the act.

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