SAMHSA TIP 42 Treatment of Co-Occurring Disorders Part 3 | Addiction Counselor Exam Review

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com counselortoolbox Alrighty everybody. Welcome to today's presentation on treatment of persons with co occurring disorders based on SAMHSA tip 42 and this is part three. The first recording was parts one and two because those were short. Today's part three, well a rerecording of that. And then later today at 1:00pm CST 2:00pm EST, I will be doing part four. So we're slowly working through tip 42 which is kind of a monster of a treatment improvement protocol. For those of you who are not familiar with tips, you can download tip 42 from SAMHSA, go to SAMSA or store.samhsa.gov and search for tip 42 and you can download that if you want to read the whole thing, which is, you know, it's several hundred pages. But anyhow, today in this particular presentation we're going to identify guiding principles in treatment, core components in the delivery of services, and how to improve substance abuse treatment systems, systems and programs. Now part four we're going to go in depth into screening and assessment. So we're not really going to talk about that a lot in this hour. So today we're still hitting those meta concepts. So for each component that are identified as guiding principles, I want you to think about how you already do or could apply this or do this in your program. So you want to employ a recovery perspective. That means we want to help people build on what they have to achieve their goals. It's less about eliminating a problem and more about enhancing quality of life. We want to adopt a multi problem viewpoint. Instead of just seeing someone as presenting with alcohol addiction or depression, we want to see them as a whole person so we can look at the multiple different problems that might be contributing to their current symptoms. And it can be mental health, substance addiction, like behavioral addictions. Medical issues can also be psychosocial issues. There are a lot of things that can contribute to mood and behavioral symptoms. We want to develop a phased approach to treatment so people aren't going into residential and then being discharged to once a week after care. That's too stark of a step down. We need to have that phased step. Where I used to work, we were lucky enough to have multiple levels of treatment in our facility. So when somebody stepped down from residential, they stepped down to intensive outpatient. They did intensive outpatient four hours a day, five days a week For a month. If they were still clean, having no problems, then we reduced it to three hours a day, three days a week for a month. And if they were still doing great, then we discharged them to aftercare. But it was a step down because they went from that sanctuary, if you will, of residential, where all they had to do was focus on what was right in front of them and to dealing with recovery and some post acute withdrawal issues and life, however it was being thrown at them. So a phased approach to treatment helps people solidify their treatment goals. Likewise, in a phased approach, if somebody is in IOP and they're struggling to maintain their sobriety, or they're struggling with their mental health issues and they need more intensive treatment, a phased approach will allow them to phase up while they're symptomatic and then phase back down again as soon as they've gotten the tools or whatever. They need to be more stabilized. We need to address specific real life problems early in treatment. You can talk about meta concepts and you can talk about self esteem and all this other stuff, which is great. But when people come into treatment, they're motivated. They are sick and tired of being sick and tired. Whether it's from addiction or mental health or physical issues, whatever. They are there because they are ready to feel better. So we need to figure out, okay, what was different when you felt better before and how can we help you start feeling better now, or what are the top three things that you really want to focus on changing right now? Those are the real life issues. So for a lot of people who come into substance abuse treatment, yes, they've got to focus on their substance use, but one of their real life problems might be the fact that their spouse is getting ready to leave them because of their addiction. So the they want to focus on relationship issues or they might be getting ready to lose custody of their kids. So we want to focus on maybe parenting issues or any legal issues related to that. We want to help them identify some of those real life problems that are sort of supporting the unhealthy thoughts and behaviors and help them start addressing those. So we take away that undercurrent of negativity. We want to plan for clients cognitive and functional impairments when they're in early recovery. There are going to be cognitive and functional impairments if they have been using for any length of time, most likely while the fog lifts. And that's what we generally refer to it as. But it's also important to remember that for most substances out there, there is a post acute withdrawal Syndrome that will intermittently sort of rear its ugly head for up to a year. So the person may be doing fine, be asymptomatic, and then have a really bad few days, really bad weekend, really bad week where they're feeling cravings, where they're feeling lethargic, where they're feeling, you know, not good again with benzodiazepines, for example, and marijuana, that's another one. The first 30 days, the post acute withdrawal syndrome seemed to be a lot worse, worse than after that. But we do want to recognize that clients, for a variety of reasons, not just for due to substance intoxication or exhaustion, but for a variety of reasons. Clients in recovery may go through periods where they have difficulty concentrating, remembering, focusing. We may need to slow things down a little bit for them because they're kind of foggy headed for some reason. And if they've got co occurring issues, if their depression or their anxiety has spun up, if you will, then it's going to make it more difficult for them to focus in treatment. Likewise, if they're using, they're going to have difficulty focusing in treatment. So we do need to focus on those things. When someone starts a new medication, a new psychotropic medication, it may make it difficult for them to focus in treatment, even if it's an ssri. Some people the first week have difficulty focusing the first week after a dose is adjusted. If it's an atypical antipsychotic or a mood stabilizer, it may hit them really hard and they may feel really groggy for a little bit until they get their dose worked out. So it's important to be aware that they're going to wax and wane in their ability to participate. And we need to use support systems to maintain and extend treatment effectiveness, including support systems in the community, employment, you know, any sort of wraparound services that we have there, including significant others, family, self help groups, religious organizations, anyone who's out there that can help support this person in meeting their biopsychosocial needs. So what do we have for housing, for transportation, for legal services, for employment services, yada yada. There are more core components that we're going to talk about, but we really want to look at programs that have access for people. So can people get into your program? You know, that's a pretty basic issue. If there's a six week waiting list that is not accessed. Where I used to work, in order to enhance access, we had a walk in clinic two days a week where people could come in and get their initial Assessment so they didn't have to wait weeks and weeks to get an assessment. We did a strengths based assessment and tried to give them some tools and things to work on even when they left the assessment. But then we also had intervention level groups, ASAM level five. I mean, it's not treatment, but it was something to help them out because they were motivated and they were struggling when they came in. So we want to strike while the iron's hot, so to speak. So we had, I think it was three times a week we had an hourly group or an hour long group that people could come to. Was it what they needed? No, most of them needed residential or something much more intense. But it did give them somewhere that they could come and get some tips and tools, start working on some things. And it gave us the ability to lay eyes on them, to make sure that they were safe and it gave us the ability to keep track of them. So when a bed opened in detox or in residential or we knew how to access them and they didn't just kind of fall off the radar. So access is important. You also want to have access to culturally sensitive programs. You know, not everybody's going to want to go into the same type of program. Not everybody's going to be comfortable with the same types of counselors. Some, you know, for example, some people may want a male counselor and some people may only feel comfortable with a female counselor, yada yada. So you do want to be sensitive to culture, to gender, to disability, and just temporal access. Can they get in? You want to make sure that you provide a full assessment, not just a substance abuse assessment. In co occurring disorders, we need to assess the substance use issues. We also need to assess the mental health issues and any other ancillary issues that might be contributing to the problem. You need to have appropriate levels of care. And if you don't in your agency, you know that's okay. But you need to know where those levels of care are. So if you provide, if you're an independent practitioner, you provide outpatient treatment. Maybe you have groups every night, but nothing like intensive outpatient. That's fine, that's cool. But you need to be able to refer up to a program that does have intensive outpatient, partial hospitalization or residential or detox as needed. So even if you don't have it in your organization, you need to be able to make sure that you're connected with other facilities that offer appropriate levels of care. Treatment needs to be integrated. You don't want somebody coming in and seeing their substance abuse therapist and then going somewhere else and seeing their mental health therapist. And those two therapists don't even know what each other are doing. We need to have, at the very least, medical, mental health and substance abuse all on the same page about what's going on, what the treatment plans are, where we're moving with this. Even if you don't treat the mental health and another substance and another clinician does, that's okay. But you need to be aware of what's going on in those treatment sessions. So, for example, if they start working on intense trauma issues there, you know that the person is going to be at greater risk for relapse. And you can maybe tailor what you're doing in substance abuse treatment to help them prepare for that. Comprehensive services need to be available. Again, not necessarily through just your agency. You can make referrals, you can have consultations, that's cool. But we need to be able to make sure those connections are seamless and not just say, well, why don't you call information and referral and see what's out there? That doesn't work. And there has to be continuity of care. We want to make sure that clients are being handed over nicely to the next person and the next person gets the chart, and they can actually review the chart and there are notes in the chart. You know, all that stuff that you would assume happens that often doesn't happen. Even in the agency that I used to work for, we would refer to another program and the chart may not ever get over to that building unless the clinician walked it over. So obviously this was before electronic medical records, but you get my point. So access occurs in four main ways. There's routine access for individuals seeking services who are not in crisis. And that's what I was talking about with the walk in clinic and then putting them in the intervention level groups. Those people are not in crisis, but we're able to keep eyes on them to make sure that they don't decompensate. Then there's crisis access for individuals requiring immediate services, either because of their level of intoxication, they need to get into detox now, or because of their mental health status, they need to get into crisis stabilization now, or they need something in between. You know, there are generally a few other permutations. So you have routine access, crisis access. Then you have outreach, in which agencies target individuals who are in great need, such as people who are homeless. Or we had an entire outreach program for older adults because they didn't typically reach out to seek treatment and access that is involuntary. So you have people who don't normally access services that might consider it if they kind of knew about it or would think about it. And then you have access for the people who really care about services because they're not voluntary. And sometimes, well, a lot of times you will be working with those clients. So it's important to be aware of where your clients come from and how they funnel through the system. So if a client comes in and is for an assessment, is deemed to be in crisis and they're referred over to the crisis stabilization unit, then where do they go from there? You need to be able to trace the client from entrance to discharge and make sure that they have seamless handoffs between all of the different departments. Assessment, well, generally starts with a screening. Not all places do screening. Sometimes somebody walks in off the street, they say, I'm struggling here, I need treatment. Okay, we're going to kind of do screening and assessment all at once. Then other times, like when there's a visit from the child services caseworker or law enforcement contact or probation officer or something, those people can do screenings and if they determine that the person might be developing an issue, then they can refer for an assessment. So anyway, screening detects the possible presence of a co occurring disorder in the setting where the client is first seen. You know, not necessarily even for treatment. It can be done in by a pastor, by a po, even by a judge. You know, there are a lot of people who can do a brief screening and go, yep, you know, I asked you these five questions, you answered, seems like you need to be referred for an assessment. Bada bang. An assessment evaluates background factors including family trauma history, marital status, health education, work history, mental health issues, substance issues, related medical and psychosocial problems like living circumstances and employment, and other things that are critical to address in treatment planning. You're not going to address all these at once, but you're going to develop a laundry list, if you will, of issues that may need to be addressed. And then you're going to work with the client to prioritize and determine which ones to address first. During an assessment, a diagnosis is made of the type and severity of substance use and mental health issues. And a lot of times we also refer out for a physical at that point to rule out any physiological issues like hiv, hepatitis, hypothyroid, cirrhosis of the liver, anything like that, which may be a complicating factor. Then we match during the assessment the client to services. Often this must be done before a full assessment is completed and diagnosis is clarified. Because assessment is not a one time thing, it's an ongoing process. Clients aren't going to meet you and tell you every deep dark secret they've ever had in the first hour. It just ain't going to happen. So assessment is ongoing. As the person's condition unfolds, we do want to pay attention to what's going on. But during this initial assessment, we're getting an idea of what the main presenting issues or symptoms are, their motivation to change with regard to one or more of those symptoms, and moving on. We want to appraise existing social and community support systems. If they're not in treatment in residential, for example, what do they have in the community that can support their recovery? The other, you know, six days and 23 hours of the week. And continuous evaluation is important. Reevaluation over time needs to be done as symptoms change and more information becomes available. You know, a lot of times I'll work with clients for a month or so in outpatient, or a week or so in residential before they start really telling me about a trauma history, that's okay. Or before they start telling me about some shame issue that they have, that's okay. But at that point I may need to adjust the treatment plan a little bit in order to focus on the new presenting issue. There are multiple appropriate levels of care. A basic program has the capacity to provide treatment for one disorder. You treat substances or you treat mental health, but you screen for the other disorder and you can access necessary consultations. So you may be an alcohol treatment program, okay, but if somebody comes in and they've also got ptsd, you screen for it, you say, yeah, this person might have ptsd. You can access consultation with someone who can do an assessment and either get them enrolled in a co occurring program or you know, serve as an additional clinical resource. A program with an intermediate level of capacity focuses primarily on one disorder without substantial modification to its usual treatment, but explicitly addresses some specific needs of the other disorder. So you primarily treat addiction, you're an addiction treatment program. However, you recognize that depression and anxiety often co occur and grief and some of those things. So you may provide some coping skills training, some information on cognitive, behavioral, you know, yada yada. You're not specifically treating the mental health issue as a separate entity, but you are providing some information to help the person in substance recovery also deal with their mental health issue. A program with advanced level of capacity provides integrated substance use, treatment and mental health services for clients with co occurring disorders. So this is when you Know, you've got clinicians on board in your program, either substance abuse and mental health clinicians or people who are duly trained and certified who can work with clients. You're not having to refer out to other programs or other agencies, and you're able to treat, and you do treat both of them concurrently. When you're treating, when you're talking about relapse prevention, for example, you're not just talking about substances. You're talking about relapse prevention in terms of substance use as well as relapse prevention in terms of the mental health disorder. Because if you relapse with either one, it's going to affect the other one. A program that is fully integrated combines substance use and mental health interventions to treat disorders, but also treats related problems and the whole person more effectively. So you really have integrated medical here. You have social services, employment and educational consultations, vocational rehabilitation, you know, the whole gamut of things. For a fully integrated program that recognizes that people are multidimensional and we need to make sure that each one of those dimensions is optimally function functional for them to have an optimal quality of life. Integrated treatment can occur on different levels and through different mechanisms. But for example, one clinician can deliver a variety of needed services. So when I worked in a clinic, I provided mental health as well as substance services as well as case management. I kind of wore a bunch of different hats. You can also have two or more clinicians working together to provide needed services. So maybe you have a clinician who specializes in trauma, and that's not your thing. You provide the services that you're trained in, and that clinician will handle the trauma piece. But you work together. A clinician may consult with other specialties and then integrate that consultation into the care provided. I used to do this occasionally when we would have a client come in who had schizophrenia. That is not my strength. So I would consult with our attending physician and say, okay, you know, what's the best approach to work with this person? He was a psychiatrist. What's the best approach to work with this person and help them achieve treatment goals? And, you know, is there anything I'm missing? So we were working together. I was working with an expert on that particular disorder. We can also coordinate a variety of efforts in an individualized treatment plan that integrates needed services, which is a fancy way of saying we're the single point of contact and we do a lot of case management because the person needs vocational rehabilitation. They need physical therapy, they need medical issues, they need financial consultations, they need. They need legal services and there's a bunch of moving pieces. And so that person serves as the single point of contact for all those other agencies. And we can coordinate a single treatment plan through that person. And finally, integrated treatment can involve multiple agencies which join together to create a program that serves a specific population. When we created the no Wrong door program for co occurring disorders, we worked with the criminal justice system. The potential clients would be released from jail three months before their sentence was up. So they were on extended limits of confinement. So they weren't released released, but they were not in jail. They were at our facility. So we were working with them. We had to do, you know, call ins for bed count every day and all that stuff. We were working with vocational rehabilitation to help these people develop job skills, write a resume and get bonded so they could get employment. We were providing the mental health and substance abuse counseling as well as psychiatric services. And we were working with shands in order to and the health department in order to make sure that people were getting their basic physical health needs met. So when they graduated the program, they had had all their basic biopsychosocial needs met. But our agency wasn't doing all of it. We were doing what we specialized in and we basically contracted with other agencies to do what they specialized in. In integrated treatment. The focus is on preventing anxiety and helping people feel empowered rather than breaking through denial. The emphasis is placed on trust, understanding and learning. And treatment is characterized by a slow pace and a long term perspective. You're not going to get from pre contemplation to maintenance in 30 days. You are going to help the person in the first 30 days, maybe just get through the fog and develop some basic relapse prevention tools and then the next 30 days work on something else. Research has indicated that even for things like cocaine and alcohol treatment program, less than 90 days is really relatively ineffective. And you can go look at the research from National Institute of Drug Abuse and SAMHSA to find that information. So we don't want to tell somebody 28 days and you're cured. They're not. And you can argue about whether they're ever cured. But 28 days is basically just enough for that fog to lift and you're still and maybe get through the brunt of post acute withdrawal. You're still having to relearn or learn a bunch of, you know, coping skills, interpersonal skills, whatever you know you need in order to stay clean, happy and sober. Providers offer stage wise and motivational counseling and you need to review tip 35 and the stages of stages of change that were posited by Prochaska and Diclemente. Really important to know those like the back of your hand. But we need to be able to make sure that this stage wise treatment, you know, we keep people moving forward. When it gets tough, clients are not going to go from pre contemplation to contemplation to preparation to action, to maintenance and off. It's just not how it happens. You know, they will go from contemplation to preparation to action. And then when they're in treatment, they may start getting frustrated, it may hurt too much, they may feel frustrated, their cravings may be too bad, you know, whatever. So their motivation may wane back to contemplation or preparation. So they're not really even interested in working anymore. They're thinking, you know what, maybe my problem wasn't so bad. I think I can probably handle it on my own. So we need to provide motivational counseling to help them recognize what they need in order to stay clean and sober. Self help groups are available to those who choose to participate and can benefit from participation. People who are actively psychotic, people who have significant cognitive deficits may not be able to benefit from participation. People who, you know, choose to participate in self help groups may not embrace the 12 steps. They may prefer smart recovery or some of the other options that are out there. And that's okay. But we need to provide a range of options that are available for people who choose to participate in those. And neuroleptics and other pharmacotherapies are indicated according to the client's psychiatric and other medical needs. So we're not saying this is a drug free program, you can't be on any medicines. We're saying we're going to take each person individually and figure out what the psychiatrist thinks is the best course of action. Comprehensive services are provided to address mood issues, cognitive and attentional issues, antipsychotic issues, personality disorders and eating disorders. We also address substance use and behavioral and compulsive behavioral things like gambling and Internet gaming addiction, housing issues, medical and dental issues, employment and education referrals, all of these things. So the person can, when they get out of treatment, be financially independent, keep a roof over their head, stay safe. It may not be, you know, they may not be living at the Ritz, but if they are in a place where they are safe and comfortable and can get good restaurants and able to feel empowered and self sufficient, it's going to go a long way towards their recovery. We need to provide Continuity of care by making sure there's consistency between primary treatment, what we're doing in therapy, and ancillary services. So if you refer somebody to voc rehab, for example, and the voc rehab counselor says, okay, let's get you enrolled in school, starting in two weeks, you can go back to school and start working for your aa. Well, that's wonderful, but the person is in residential for another two months, so that's not going to work. So we need to make sure that the primary treatment provider communicates with ancillary service providers and everybody's on the same page and the same timeline. There needs to be seamlessness as clients move across levels of care. So if they go from residential to iop again, when they show up for iop, the clinician needs to be expecting them, not go, who are you? That doesn't go over well, trust me. So we need to make sure that paperwork is transferred, the transfer process goes smoothly. Ideally, there's actually a phone call or some sort of an email letting the person, letting the receiving clinician know that the client is coming. So there's a nice warm handoff, and then the referring clinician has to follow up. So you want to make sure that those transitions, whether it's to more intense or less intense levels of care, go smoothly. And we want to coordinate present and past treatment episodes. Don't make the person reinvent the wheel every time they come in. If they've been at your agency four times already, pull out the daggom chart and look at it and you can figure out what they've done. You can get a good idea about what worked or at least what was tried. And then you can start talking about it, talking to them about it from there. You know, the stuff like where they were born, that hasn't changed, you know, so the stuff from the first assessment is still really pretty germane. So go through their chart ahead of time, get some of the stuff that just wouldn't have changed, like their date of birth and, you know, that kind of stuff. Try to fill that out early if you can, so you're not asking them the same questions again. A lot of times clients will actually not come back for a repeat episode if they know they're going to have to go through that arduous assessment process again and, like, start all over again from square one. At least let them start from square three. So when you're thinking about your agency's capacity, remember I said think about how you can do these things in your agency. You want to think about the Profile of your current clients with co occurring disorders and any potential changes that are anticipated. For example, if you typically are seeing people with opioid use disorders, okay, that's what you're typically seeing in your area right now. But the tides change. I know where I came from, it was opioids for quite a while and now it's switched over to methamphetamine. So be prepared in changes of drugs of abuse. Be prepared in changes of client profiles. For example, the agency I used to work at, we got a contract, for example to work with the va. So we opened an entire program just for veterans. Well, that changed the makeup of our clients with co occurring disorders. When we opened the methadone clinic and we had people who were on medication assisted therapy, that changed the profile of the clients we were working with. So you need to be aware of who your agency serves and then you know who they might be serving in the future. You need to identify services needed by clients. You know, not everybody needs transportation. If you live in a metropolitan area that has great bus service, that may not be as much of an issue as it is for us out here in rural Tennessee. Identify and assess resources available to meet client needs. So what services are immediately available in the program? You know, what do you offer at your facility? What services could be added to the program? You know, sometimes it's not hard to add a one hour a day group for outpatient or aftercare that people can come to. So they still can come five days a week, but it's only for an hour. There are a lot of different options that you can look at. What services are available from the community that would enhance care and that can include HIV counseling, vocational rehabilitation, you know, a whole range of services. You need to know what your clients want and need and find out who's already providing it. There is no sense having your agency start a program that provides X service. Somebody in the community is already doing it and is willing to partner with you. And how well are outside agencies meeting clients needs? You know, we do have to consider that if there's a great program for vocational rehabilitation, but clients can't get into it or they won't work with substance abuse clients until the substance abuse client has six months of clean time, that's not meeting our clients needs. So we may need to add either advocate for them with that agency or look at a different avenue. You need to assess resource gaps to identify any resources that are needed to enhance treatment for persons with co occurring disorders. For example, medication access. We ended up opening a pharmacy at the facility that I worked at because clients were having difficulty getting on patient assistant programs. So the pharmacist, our facility would help them get on the patient assistance programs so they could get their meds for free, which was helpful. What can your agency do to enhance its capacity to serve these clients? So looking around and sometimes it's just developing memorandums of understanding with other agencies and improving coordination. Other times it's making simple changes. You know, you don't necessarily need to start from scratch with something. Look at small changes you can make and only make one or two changes at a time. See how it does. If you make a change and it doesn't seem like it's, you know, helping at all, you know, you may want to back off and back off and try something different. Assess your capacity to address resource gaps. A small practice or a small agency is not going to be able to do the same things that an agency that has an 8 or $80 million budget is going to be able to do. So what do you have the capacity to do with in your building? If you want to have groups, that's great, but do you have a group room? If you don't, that's a problem. And then develop a plan to enhance the capacity to treat clients by increasing the skills of existing staff. For example, maybe getting a staff person certified in EMDR or getting somebody, if you're a mental health clinic, getting somebody certified in addictions counseling. Can additional expertise be accessed through consulting agreements? Sometimes you just need to have a memorandum of understanding. Look for additional programs or services that you can offer and look for sources of funding to support efforts to enhance capacity. SAMHSA has grants that they put out every single year. And every single year we would write grants. So it's competitive, but those grants are significant and can really help you enhance capacity if you're able to get one. So workforce development is important and the first thing we want to develop is people's attitudes before we even work with skills. So people need to appreciate the complexity of co occurring disorders. Depression plus substance abuse is not one plus one equals two, it's one plus one equals five. So it's important to understand how the two interact, how the substance use affects the neurotransmitters, how the depression affects the substance use, and how all of that affects interpersonal relationships, cognitive abilities, occupational functioning, all that stuff. People need to be open to new information and aware of their personal reactions and feelings towards people with co occurring disorders. If you're not comfortable working with someone who is schizophrenic you know, it's important to get a handle on that and become comfortable, you know, develop your knowledge so you understand what's going on and how to work with those clients. If you're not comfortable working with a client, or maybe you come from a family where there's a lot of alcoholism and you have negative reactions to people who are parents who are also alcoholics, you need to handle that in supervision and deal with your transference issues. You need to recognize the limits of your own personal knowledge and expertise. So if you're not trained to work with something, you know, be able to stand up and say I'm not trained to handle that or that's not my expertise, so somebody else can step in or you can receive the training you need. Recognize the value of client input into treatment goals. Not only do they know what works for them and what doesn't work for them, but if they have input into their goals, they're going to be more motivated and they're going to see any progress they make as more the result of their work instead of you doing something to them. So it's very empowering to them to be involved in treatment. We need to be patient, persevere and have therapeutic optimism and believe they can get better. We need to be able to employ diverse theories, concepts, models and methods. So you know you're going to have your primary theory of mental health and substance abuse, but you also need to be open to other theories like theories from family therapy that talk about family positioning or whatever or family dynamics. You need to have flexibility and approach because no two clients are going to require the same approach. Be culturally competent and you can look at SAMHSA tip 59. I believe for cultural competence. Believe that all individuals have strengths and are capable of growth and recognize the rights of clients with co occurring disorders, including the right and need to understand assessment results and the treatment plan. Don't do the treatment plan for them, do the treatment plan with them. When you do the assessment, you know, help them understand why you're asking, the questions you're asking and how you arrived at the conclusions that you are arrived at in terms of competencies. You need to be able to perform a basic screening to determine whether a co occurring disorder might exist and be able to refer for a formal assessment if necessary. You need to be able to conduct a preliminary screening of whether clients pose an immediate danger to self or others and coordinate treatment accordingly. You need to be able to engage the client in a way to enhance and facilitate feedback future interaction. You need to be able to de escalate a client who's agitated, anxious or in a vulnerable state and manage crises involving clients with co occurring disorders. It is not uncommon to have a client who is in a mental health crisis, who is depressed, who is moderately suicidal, who is also severely intoxicated. So you need to know how to manage that kind of issue. You need to be able to refer a client to the appropriate mental health or substance abuse treatment facility and follow up to ensure continuity of care. So don't just send them to crisis stabilization or detox and go, good luck, I'll see you if you come back. You want to follow up the next day to make sure that they got there and everything's going well goes a long way to enhancing engagement and helping the client feel like they're important, which gets them involved in treatment. And you need to coordinate care with mental health counselors serving the same clients to ensure that the interaction of the client's disorders is well understood and treatment plans are coordinated. Intermediate competencies include being able to integrate diagnosis and needs assessment and also create an integrated treatment plan that addresses all of their biopsychosocial issues. You need to be able to engage, motivate and educate clients and be familiar with treatment methods including relapse prevention, case management, mental health, pharmacotherapy, psychoeducation, as well as family interventions and education. Advanced competencies and I struggle with calling these advanced. I think you know if you're working with clients, you probably need these too. You need to be able to comprehend the effects of the disorders on people's level of functioning and degree of disability. So you know when their mental health issues are, when they're symptomatic that will impact their level of functioning, maybe in substance abuse treatment and at work and in their relationships. So you need to know how that impacts everything. You need to know how a flare up of their mental health impacts their relapse potential. You need to know how their substance use impacts their mental health diagnosis. You need to recognize classes of psychotropic medications, their actions, medical risks, side effects and possible interactions. For example, opiates increase and LSD increase the level of serotonin. If the person increases serotonin too much, they can precipitate a serotonin syndrome which is a life threatening condition. Remember that all relapse is an opportunity for additional learning for all. So it's important to involve the person, family members and other supports and service providers in establishing, monitoring and refining the current treatment plan. Even after a relapse. Relapse means we missed something and we've got more to learn. Not it's time to discharge. It drives me crazy when I see people discharged for relapse because that tells me that, you know, something went hiccupy in treatment. And we need to support quality improvement efforts including but not limited to satisfaction surveys, accurate reporting and use of outcome data to determine what we're doing that's working and what we're doing that's either having no effect or is working against us. In terms of treatment planning and documentation, we need to review the principles and processes that support thorough and accurate assessment and diagnosis, including strengths based interviewing skills and cultural diversity issues. Cultural diversity is a huge thing you need to be aware of. Is this client independent or interdependent? Culturally, is this client needing or believing that their family should be an integral part of their treatment? How does this client and their family view this disorder or disorders and what types of treatment does this client and their family and or their family believe are the appropriate courses of action for this disorder? Not everybody is going to say run of the mill residential treatment or outpatient. Some people want to go to spiritual guides first or use culturally based practices. You need to examine each step in the treatment service planning and rationale with the client and describe the importance of the person with the co occurring disorder having active involvement and real choice in their treatment planning process. You need to be able to help them understand why it's not okay for you to just write their treatment plan for them. I tell them from the beginning, you've lived in your skin for 40 years, I've known you for 40 minutes, you know what works for you and you know what things are going to help you the most in starting the momentum towards getting better. So instead of, you know, just me spitting in the wind and trying to figure out what might work, why don't you tell me what you think the best course of action is and then we'll go from there. You need to know a means of writing brief and useful progress notes that support movement toward positive outcomes and use those progress notes with the client as a piece of the ongoing treatment process. At the end of every treatment session, I leave the last 10, 15 minutes depending on the client, and we identify the goals that they achieved over the past week, the treatment plan issues that they addressed, what their goals are for the next week, and any referrals that are necessary, as well as any, you know, other ancillary stuff that was important. But we review everything to kind of summarize the treatment session and I write that down in the progress note, and then I give them a copy that helps them solidify in their mind what we accomplished. So they're seeing the progress, they're seeing their steps, and they know what they need to do next. In terms of workforce development, it's important to ensure that people have adequate supervision. That includes shadowing and cross training so they know how to do different things. Regular peer supervision, and it can be a monthly brown bag. It can be a weekly staff meeting, whatever it is, where peers can review each other's case notes, you know, charts, and talk over certain cases. Case conferences are always important. Program directors and supervisors can assist clinicians in avoiding burnout by encouraging them to work within a team structure rather than isolation. Clients can be draining and exhausting when, if you're that, you know, connected and empathic and everything, it's. It's draining for anybody. And if you're in a residential facility where clients can drop by, you know, all day long, it can be draining. So you need to figure out how to work as a team structure so everybody can get the stuff they need to get done done, as well as provide high quality treatment to clients. Build in opportunities to discuss feelings and issues with other staff who handle similar cases. Develop and use a healthy support network both inside work and outside of work. You know, there has to be a time where you can just leave work at work and go be a person. Not a clinician, but just a person. Help clinicians maintain a caseload that's a manageable size. And, you know, sometimes agency requirements push caseloads up a little bit. One way you can help maintain a manageable size is to reduce turnover. So if you've got 10 clinicians, you know, each one is seeing eight clients. If two of them suddenly quit, their clients have to be shifted to everybody else, and everybody else's caseloads go way up. So reducing turnover can help reduce burnout, incorporate time to rest and relax. Encourage staff to actually take their breaks, you know, at lunchtime. Don't sit at the computer and work on their notes while they're scarfing down their lunch. Encourage them. I had one, actually two employees over the years who refused to use any of their vacation time. And at the end of the year, every year, I'm like, you got to use it or lose it, because you can only carry over 200 hours. And they would begrudgingly use some of their time, but they would end up giving back leave time to the agency because they just wouldn't take time out and separate personal and professional time like I said, you have to have some time where you're just a human in order to reduce turnover. As hiring managers, we can hire staff members who have familiarity with both substance abuse and mental health issues. Maybe not licensed in both, but they're familiar and have positive regard for clients with either disorder. We need to hire staff members who are critically minded and can think independently so they're not having to be micromanaged. But they're also willing to ask questions, listen, remain open to new ideas, work cooperatively with the team, and sometimes just be creative and problem solving because you have to think on the fly. Provide staff with a framework of realistic expectations for the progress of clients. What are they supposed to accomplish while they're in your program? So we're not expecting too much. You know, I used to expect every person who went into residential would come out in maintenance. And my supervisor pointed out to me one day, you know, you've got clinic, you've got clients who are coming in here at different stages of readiness for change. They're not going to move from pre contemplation to maintenance in 28 days. It just ain't going to happen. If you can move them one step, you know, in terms of their motivation and their readiness for change, that's what you need to do. Ensure supervisory staff are supportive and knowledgeable supervisors. You know, I've been one for many, many years. You don't know everything and it's okay to say I don't know. I can find out if they ask you. If clinicians ask you about something and you're not familiar with it, you can say I don't know. But you know, see if you can find a conference or a training on it and I'll send you to it. You know, there are a variety of ways to accomplish that, but we do need to be supportive of people, clinicians enhancing their knowledge and abilities to work with these clients. Which goes along with providing support and opportunities for further education and training. Bring training in online resources that are available brown bags. I would have my clinicians once a month, each person would teach a concept or something that they learned about with relation to co occurring disorders treatment. And it was like a 10 minute presentation, but it helped all of us stay, keep our nose a little bit in those journals and provide structured opportunities for staff feedback in the areas of program design and implementation. Some of the best ideas for programming comes from line staff, those clinicians that are working with clients day in and day out. And they're seeing this need that isn't being met or they're seeing how we could enhance treatment by adding this program. So pay attention to what linestaff has to say because they're probably going on some really good, you know, practical feedback in order to reduce turnover. Provide a desirable work environment through adequate compensation. Stop laughing. You know, we get into this because it's a calling, not because we think we're going to get rich. So you know, we know we're not going to be making 60, 70, $80,000 a year, but we want to make sure that people do have adequate compensation for their level of training. Provide salary incentives for co occurring disorders expertise, so every additional certification or intensive training certificate that they get, they can get a salary incentive. Provide opportunities for training and career advancement so people who want to become supervisors can. So people who want to become program managers can. It does a lot to enhance stay power, if you will, and reduce turnover. If people believe that they actually can move up in the organization and they're not stuck at line staff or wherever they're at. Involve staff in quality improvement and clinical research activities so they feel like they have a voice. And make efforts to adjust workloads. Sometimes workloads are going to need to be adjusted. Maybe your clinician, who's a great clinician, but her mom is suddenly going through chemotherapy and she's needing a little bit of extra time off to take her to and from the hospital to get her chemo treatments and take care of her. That clinician may not be at 100% right then, even if she's there 40 hours a week. So how can you adjust workloads to help her out so she can get her work done? Maybe have people cover her groups so she's focusing more on doing the individual sessions and keeping her paperwork up. So there are a lot of different ways you can wax and wane to make sure that people are getting their needs met. And there's a work life balance. So there are a variety of competencies and attitudes unique to treating clients with co occurring disorders. Many avenues exist to integrate care and all agencies should strive for integrated care since co occurring disorders are the expectation, not the exception. Preventing burnout and turnover are essential for several reasons. One, it enhances program capacity. If you maintain 10 therapists, then you can maintain a higher census than if you periodically drop down to six or eight therapists. It's expensive to recruit, hire and train every new employee. And clients tend to lose faith in the facility if there's a high level of turnover and they get frustrated if they can't see their therapist that they saw the last time when they come back. So there's an impact on client outcomes and their willingness to continue to seek treatment at your agency. There are five more videos in this series and they'll be all be on the playlist. Tip 4:42 CO occurring disorders on the YouTube channel@allceus.com YouTube Once they're recorded and I'm in the process, this is episode three or section three. I'm going to be doing four later today and then there are nine segments altogether. To earn CEUS for this presentation, you can go to allce.compodcasts where you'll find a direct link to the class associated with this presentation. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. If you want to attend and participate in our live webinars with Dr. Snipes, you can subscribe atoolbox. This episode has been brought to you in part by allce.com, providing 24. 7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. 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