1. 1 CALIFORNIA MENTAL HEALTH PLANNING COUNCIL October 14, 2009 ELIZABETH OAKES, MFT CHIEF, ADULT SYSTEM OF CARE STANISLAUS COUNTY BEHAVIORAL HEALTH & RECOVERY SERVICES

2. 2 Co-Occurring Treatment Stanislaus County Behavioral Health and Recovery Services 1998 – 2009

3. 3  In 1998, Alcohol and Other Drug (AOD) services were decentralized and moved into shared space within 5 Mental Health Outpatient Regional Teams. Services were co-located by treatment continued to be parallel.

4. 4  In 2004, Stanislaus County – BHRS entered into a two-year grant through CIMH to study implementation of Integrated Dual Diagnosis Training in California. CIMH provided training in this model for two years.

5. 5 Organizational Context  How IDDT fits for BHRS : -Committed to integrated services BHRS -Integrated system isn’t integrated treatment -Established experience with co-occurring Tx -Valued EBP aspect -Interested in ‘implementation’ aspect -High mortality rate

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7. 7 Organizational Context  How IDDT fits for BHRS (continued) -High co-morbidity -High treatment failure rate -Cost of not serving for system -Highly underserved -Co-occurring conditions often used as exclusion criteria, rather than inclusion criteria

8. 8 Benefits of Integrated Recovery - Saves money - Helps staff motivation - Impacts long-time ‘stuck’ clients - Stage-based treatment - Formulation helps consumers understand how 2 conditions creates a 3 rd condition - Recovering peers from either MH or AOD can support each other - DRA sustained - Recognition with in AOD for need of specialized track

9. 9 FORMULATION

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11. 11 Integrated Dual Diagnosis Treatment (IDDT) 1. Integrated Assessment of Dual Diagnosed (DD) Clients 2. Integrated Treatment Plan 3. Multidisciplinary Team 4. Integrated Substance Abuse Specialist 5. Stage-Wise Interventions 6. Access for IDDT Clients to Comprehensive DD Services 7. Time-Unlimited Services 8. Outreach 9. Motivational Interventions 10. Substance Abuse Counseling

12. 12 Integrated Dual Diagnosis Treatment (IDDT) continued 11. Group DD Treatment 12. Family Education and Support on DD 13. Participation in Alcohol & Drug Self-Help Groups 14. Pharmacological Treatment 15. Interventions to Promote Health 16. Secondary Interventions for Substance Abuse Treatment Non-Responders 17. High Intensity Services

13. 13 STAGE-WISE INTERVENTIONS MOTIVATIONAL INTERVENTIONS STAGE-WISE INTERVENTIONS RECOVERY DIALOGUE MOTIVATIONAL INTERVENTIONS

14. 14 FOCUS ON RECOVERY

15. 15 Recovery Client Recovery Care Plan Page 1 and 2 to be completed by consumer 1. My recovery goals are: _____________________________________________________ __________________________________________________________________________ Recovery 2. The people who are important in my life believe in my Recovery (circle one) Strongly Agree Agree Disagree Strongly Disagree recovery 3. How can we assist you as partners in your recovery _____________________________ _________________________________________________________________________ 4. What keeps you from reaching your goals? ____________________________________ _________________________________________________________________________ 5. My diagnosis is: __________________________________________________________ 6. Please list the medications your receive from us and a brief reason you take them _____________________________________________________________________ _____________________________________________________________________ _________________________________________________________________________ (Staff: Please attach a copy of the medication sheet for complete list of all medications.)

16. 16 Client Recovery Care Plan continued Things about my life 7. Something you should know about me is _______________________________________ 8. Something really important to me is ___________________________________________ 9. When it comes to my culture please be sensitive about ____________________________ 10. We all have gifts in life. My gifts are: __________________________________________ 11. My best place to live_________________________ Where I live works for me Yes No 12. My best way to spend time____________________ I like how I spend my time Yes No 13. My most ideal job would be: _________________I would like employment help Yes No 14. I need help with budgeting and money Yes No 15. What gives me hope is_____________________________________________________ __________________________________________________________________________

17. 17 Client Recovery Care Plan continued My Health 16. My health goals are: _______________________________________________________ ___________________________________________________________________________ _ 17. I see my dentist on a regular basis: Yes No Don’t Have One 18. I see my Primary Care Doctor on a regular basis: Yes No Don’t Have One 19. In the future I would feel comfortable receiving all of my medication services from my Primary Care Doctor: Yes No Primary Care Doctor Name_________________________ 20. Because specialty mental health services generally are time limited, do you have any discharge / graduation concerns? Yes No Comment:____________________________ 21. Have you had a problem with alcohol or drugs in the past: Yes No 22. Currently use alcohol or drugs: Yes No If yes, do you want help to stop using them? Yes No

18. 18 Client Recovery Care Plan continued How My Mental Illness Affects Me 23. Please check any area that your mental illness interferes with: Self care and health includes taking care of yourself daily How much? None Mild Moderate Severe Things I want to do like work, school, volunteering, hobbies, job training etc. How much? None Mild Moderate Severe Relationships with family, friends, peers, co-workers, health care staff, etc. How much? None Mild Moderate Severe Progress in Recovery Goal(s) Since working on my life goals on my own or since my last Recovery Care Plan, I have had the following Improvements or Setbacks: Much Slightly No Change Some Much WorseWorseImprovement Improved Home or where I live Recovery Goals Use of Support System/Free Time Physical Health Effects of My Illness

19. 19 Client Recovery Care Plan continued recovery goal 24. What I will start doing now towards my recovery goal(s)_____________________________ 25. What I need from my treatment team now________________________________________ 26. What I need from other people in my life now_____________________________________

20. 20 Stanislaus County Behavioral Health and Recovery Services Adult System of Care Stages of Mental Health Recovery and Treatment 9/2004 Crosswalk with Milestones, Stages of Change and Stages of Treatment

21. 21 Stanislaus County Behavioral Health and Recovery Services Adult System of Care Stages of Mental Health Recovery and Treatment 9/2004 Crosswalk with Milestones, Stages of Change and Stages of Treatment - Continued -

22. 22 LEVEL OF CARE Recovery Recovery Maintenance Health Management Low Intensity Community Based Services High Intensity Community Based Services Medically Monitored Non- Residential Services Medically Monitored Residential Services Medically Managed Residential Services 123456 DIMENSIONS SURVEYED Risk of Harm Functional Status Co- Morbidity Recovery Environment Recovery Environment “Level of Stress” Recovery Environment Recovery Environment “Level of Support” Treatment Recovery History Treatment & Recovery History Recovery Status Engagement & Recovery Status Level of Care Utilization System (LOCUS)

23. 23 Team Structure

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25. 25 Stage-Wise Case Management  Case management is the central clinical intervention for the community treatment of clients with dual disorders.  Considering the range of potential treatment options, the complexity of identifying and prioritizing treatment goals, and the limited cognitive capacity of many clients with dual disorders (due to the mental illness, the effects of substances, or their combination), one clinician needs to take responsibility for ensuring that clients' needs are assessed, systematic treatment planning takes place, interventions are delivered in a coordinated fashion as intended, and treatment has its desired effects (or if not, treatment is suitably altered).  The case manager works with the client and serves this vital role, and therefore is the glue that holds together and ensures the integration of the various components of treatment for dual disorders.

26. 26 Motivational Interviewing  All interactions with DD clients are based on motivational interviewing that includes:  Expressing empathy  Developing discrepancy between goals and continued use  Avoiding argumentation  Rolling with resistance  Instilling self-efficacy and hope

27. 27 What is Motivational Interviewing? (continued)  Motivational Interviewing is not just a collection of techniques, but a way of being with a client. ----Miller and Rollnick

28. 28 BRIAN MADEAROS ARTIST

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