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MHERC o CDHB o Matua Raki / Te Pou Te Ariari o te Oranga - Introduction to Co-existing Mental Health & Substance Use Problems (CEP) Fraser Todd and Michelle Fowler 2013 workshop Introduction workshop Series Overview 7 Workshops Workshop1a: Introduction to CEP for frontline staff (x3) Workshop2: Recovery and Well-being Workshop3: Engagement and Motivation workshop4: Assessment workshop5: Management I workshop6: Management II workshop7: integrated
MHERC o CDHB o Matua Raki / Te Pou Te Ariari o te Oranga - Introduction to Co-existing Mental Health & Substance Use Problems (CEP) Fraser Todd and Michelle Fowler 2013 workshop Introduction workshop Series Overview 7 Workshops Workshop1a: Introduction to CEP for frontline staff (x3) Workshop2: Recovery and Well-being Workshop3: Engagement and Motivation workshop4: Assessment workshop5: Management I workshop6: Management II workshop7: integrated
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MHERC o CDHB o Matua Raki / Te Pou Te Ariari o te Oranga - Introduction to Co-existing Mental Health & Substance Use Problems (CEP) Fraser Todd and Michelle Fowler 2013 workshop Introduction workshop Series Overview 7 Workshops Workshop1a: Introduction to CEP for frontline staff (x3) Workshop2: Recovery and Well-being Workshop3: Engagement and Motivation workshop4: Assessment workshop5: Management I workshop6: Management II workshop7: integrated
Copyright:
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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 QR Codes: the bar code looking things for phones with camera/internet. Open QR Reader app, point phone at the barcode, it goes straight to the website. QR Reader: i-nigma free, downloadable from www.i-nigma .com 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