Cultural Clashes in Co-Occurring Disorders and What To Do About It

 

David Mee-Lee, M.D.www.DMLMD.com 

 

 

Philosophical Clashes- Polarized on Presenting Problem

3 D’s Deadly DiseaseDenialDetachment

3P’s Psychiatric DisordersPsychopharmacologyProcess

Philosophical Clashes- Different Theories, Treatments

1. Addiction vs Mental Health System 

3 D’s and 3 P’s - implications for medication, staff credentials, attitudes towards physicians, role of staff and team, data gathering, 12 Step programs

 

Philosophical Clashes- Different Theories, Treatments

2. Integrated vs Parallel or Sequential

Hybrid programs - staffing difficulties; numbers of patients and variability, but one-stop treatment

  Parallel programs - use of existing programs and

staff, but more difficult to case manage

Philosophical Clashes- Different Theories, Treatments

3. Care versus Confrontation

Mental health - care, support, understanding, passivity

Addiction - accountability, behavior change

Philosophical Clashes - Different Theories, Treatments

4. Abstinence-oriented versus Abstinence-mandated

Treatment as a process, not an event  Respective roles in both approaches

Philosophical Clashes- Different Theories, Treatments

5. Deinstitutionalization versus Recovery and Rehabilitation

Role of “least restrictive” setting

Role for individualized treatment with continuum of care(Ken Minkoff, 1991)

 

“Every Door is the Right Door”

People with co-occurring disorders: “individuals who have at least one mental disorder as well as an alcohol or drug use disorder. While these disorders may interact differently in any one person…at least one disorder of each type can be diagnosed independently of the other”

(In “A Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders”)

SAMHSA Report to Congress

“Co-occurring disorders may include any combination of two or more substance abuse disorders and mental disorders identified in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). There are no specific combinations of….disorders that are defined uniquely as co-occurring disorders.”

Underlying Principles

1. Firstly people of all ages with co-occurring disorders are people first, fully deserving of respect

 2. At same time, consumers, recovering persons and their

families need be involved in all aspects of their treatment and recovery

 3. People with co-occurring disorders can and do recover. Be

optimistic about prospects for achieving stability and recovery, provide long-term support needed to maintain their progress

 

Recovery in Addiction

“Recovery is the process through which severe alcohol and other drug problems (here defined as those problems meeting DSM-IV criteria for substance abuse or substance dependence) are resolved in tandem with the development of physical, emotional, ontological (spirituality, life meaning), relational and occupational health.”

(White, W. & Kurtz, E. (2005). “The Varieties of Recovery Experience”. Chicago, IL. Great Lakes Addiction Technology Transfer Center. Posted at http//:www.glattc.org) 

Recovery in Mental Health

“Recovery occurs when people with mental illness discover, or rediscover, their strengths and abilities for pursuing personal goals and develop a sense of identity that allows them to grow beyond their mental illness”

(Pat Deegan, a consumer leader and psychologist with schizophrenic disorder defines recovery from serious mental illness)

 

Underlying Principles (cont.)

4. People with co-occurring disorders deserve access to services they need to recover. To put these beliefs into practice, development of this report has been guided by following principles:

    Ensure development of system in which “any door is

the right door” to receive treatment for co-occurring disorders. This means people with co-occurring disorders can enter any appropriate agency in service system and be provided or referred to appropriate services

     

Underlying Principles (cont.)

Develop client-centered, individualized treatment plans based on accurate assessment of person's condition and degree of service coordination he or she requires. Family members must be involved in treatment, where appropriate

Ensure maximum feasible degree of integration for individuals with most serious substance abuse disorders and mental disorders

Underlying Principles (cont.)

Provide prevention and treatment services that are culturally competent, age, sexuality and gender appropriate and that reflect diversity in community

Promote expansion and enhancement of service providers’ capabilities to treat individuals of all ages who have co-occurring substance abuse disorders and mental disorders

Underlying Principles (cont.)

5. Not recommending creation of separate system of care for people with dual diagnosis. Indeed, people with co-occurring disorders must be able to receive treatment in mainstream systems of care that are well-prepared to support their recovery

 6. Formation of partnerships should be developed at all levels, from national to community and neighborhood, for developing/enhancing seamless systems of care that allow people to move freely between and among entire constellation of services

 

     

What to Do About Philosophical Clashes?

- Person-Centered Services

Assessment: (ASAM PPC-2R, 2001) 

1. Acute Intoxication and/or Withdrawal Potential2. Biomedical Conditions and Complications 3. Emotional, Behavioral or Cognitive Conditions and

Complications 4. Readiness to Change5. Relapse/Continued Use, Continued Problem Potential6. Recovery Environment

Individualized Treatment

  Patient/Participant Assessment

BIOPSYCHOSOCIAL Dimensions

Progress

Treatment Response Problems/Priorities

Proximal Outcomes e.g Build alliance working with Session Rating Scale (SRS) Multidimensional Assessment

Outcome Rating Scale (ORS)

Plan

Intensity of Service – Modalities and Levels of Service(Clinical and wrap-around services)

 

     

Biopsychosocial Treatment Treatment Matching - Modalities

Motivate - Dimension 4  

Manage – All Six Dimensions

Medication – Dimensions 1, 2, 3, 5

Meetings – Dimensions 2, 3, 4, 5, 6

Monitor - All Six Dimensions

 

Treatment Levels of Service

I Outpatient Treatment

II Intensive Outpatient and Partial Hospitalization

III Residential/Inpatient Treatment

IV Medically-Managed Intensive Inpatient Treatment

 

People and Personnel Clashes and Solutions

Collaborative, concurrent interdisciplinary team Vulnerabilities inhibiting team cohesiveness Team communication Staff-program match Stress of working with multiple vulnerabilities

People and Personnel Clashes and Solutions (cont.)

Tolerance – To listen to another’s opinion

Open-mindedness – To give up old views

Patience – To explore before jumping to diagnosis

Education – To learn more about SUD and MH

Serenity – To realize we don’t have all the answers

Policy and Program Clashes and Solutions

- Program Issues

Mission of the program, department, institution or agency

Equal emphasizes both mental health and addictions issues

Admission criteria and patient mix - what can staff/program manage

Policy and Program Clashes and Solutions

- Program Issues (cont.)

Terminology and treatment tools e.g., “disorientated”; “reformed alcoholic”

Non-cognitive, activity groups e.g., time use charts; collages

Groups – education about dual identity and feelings groups to learn to cope

Policy and Program Clashes and Solutions

- Program Issues (cont.)

Family involvement; systems work and continuing care Self/mutual help groups - preparation for AA/NA

mainstreaming; MICA and Dual Diagnosis Anonymous; Dual Recovery Anonymous

Staff composition reflects training proportionate to program’s clientele

Policy and Program Clashes and Solutions

- Payment Issues

Person- centered funding of services based on priorities in all assessment dimensions

Move from medical necessity (withdrawal, biomedical, psychiatric severity), to multidimensional severity requiring interventions in any/all six dimensions

Policy and Program Clashes and Solutions

- Payment Issues (cont.)

Fund case management to allow proactive, not reactive treatment

Turf battles between mental health and addiction services (often more neglected of the two systems due to fewer numbers of clients and/or stigma)

Data to Identify Gaps

Systems issues cannot change quickly. Each incident of inefficient or inadequate care can be a data point that promotes systems change

Finding efficient ways to gather data as it happens in daily care of clients can provide hope, direction for change

Data to Identify Gaps (cont.)

PLACEMENT SUMMARY 

Level of Care/Service Indicated

Level of Care/Service Received  

Data to Identify Gaps (cont.)

PLACEMENT SUMMARY 

Reason for Difference - Circle only one number -- 1. Level of care or Service not available; 2. Provider judgment; 3. Client preference; 4. Client is on waiting list for appropriate level/service; 5. Level of care or Service available, but no payment source; 6. Geographic inaccessibility etc.

 

     

 

David Mee-Lee, M.D. www.DMLMD.com