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How can CEIC help us increase the co-occurring capability of our programs?
My agency wants technical assistance from CEIC.
Treatment – Program services for co-occurring disorders should integrate motivational interventions, education about the symptoms, course, and treatments for both mental health and substance use disorders, and information about the interactive nature of co-occurring conditions. If psychopharmacologic and addiction pharmacotherapy interventions are not provided on-site, the program should establish a process to ensure access to such interventions through a seamless and integrated collaboration with a complementary entity. Peer supports for persons with co-occurring disorders should be available on-site or through collaboration (e.g., assertive linkage to 12-step groups that welcome individuals with co-occurring disorders, alumni groups, Dual Disorders Anonymous, Double Trouble in Recovery). Treatment should encourage the participation of family members and/or others who support the person's recovery. Interventions, which incorporate a focus on co-occurring disorders, could include family psycho-education, multi-family peer support groups, or family therapy.
Continuity of Care – Co-occurring disorders should be considered during the discharge planning process. Upon discharge, willing individuals should be connected with recovery support services, including (but not limited to) clinical recovery check-ups and a referral to telephone peer-recovery support.
Treatment
Program services integrate education about symptoms, motivation, and treatments for mental health and substance use disorders, as well as information about the interactive nature of the co-occurring conditions.
“Dual Disorder Capable” (DDC) programs offer information about psychiatric conditions and substance use disorders, mainly through general lectures (psycho-education), but occasionally via group therapy or community meetings, as well as during family and individual sessions. These services can include efforts to increase clients’ readiness to change, to improve clients’ ability to verbalize their diagnosis, to understand the interaction of the two disorders, to express the risks of failing to follow through with treatment, and to comprehend the role of the family (including inheritability issues) in both the psychiatric and substance use disorders. DDC programs will offer didactic sessions on co-occurring disorders and, for those who are taking prescribed medication, sessions could be incorporated to discuss the differences between recreational drugs and prescribed medications, and to explore the role of medication in self-help recovery traditions.
If psychopharmacologic or addiction pharmacotherapy interventions are not provided on-site, the program establishes a seamless and integrated collaboration with an appropriate entity that ensures clients will have access to such interventions.
In general, “Addiction only” (AOS) programs will not have any patients taking prescribed medications, and will likely have informal, undocumented policies concerning which medications are appropriate. AOS and “Mental Health only” (MHOS) programs moving toward “Dual Diagnosis Capable” (DDC) will need to develop clearer medication policies and protocols, and will likely increase the range of medications deemed appropriate. Medications are to be kept in a secure, locked storage area, and to be self-administered but observed. Medications can be brought in by a patient, renewed by prescribers, or newly prescribed during treatment. Necessary adjustments to medications can be made according to formal, documented protocols. DDC programs document the use of medications and the patient’s compliance with prescribed regimens, which is then evident in the patient’s medical record.
Peer supports for people with co-occurring disorders are available on-site or through collaboration (assertive linkage to 12 step groups that are welcoming to people with co-occurring disorders, alumni groups).
“Addiction only” and “Mental Health only” programs do not routinely stress attendance at peer support recovery groups on-site or in the community for individuals with co-occurring disorders. “Dual Disorder Capable” programs will typically assign staff members to individuals with co-occurring disorders to encourage attendance at self help meetings known to be accepting of co-occurring disorders. Often the staffs of “Dual Disorder Capable” programs will include those who are in personal recovery, and who attempt to “match” patients with temporary sponsors according to common aspects of psychiatric diagnoses. These efforts are normally clinician-driven and not arising from a protocol feature intended to facilitate assignments to peers who would be more likely to identify with one another by virtue of their common experience of co-occurring disorders.
CEIC Experience in New York State – Treatment plans typically address the co-occurring disorder[s] but tend to regard the co-occurring disorder[s] as secondary, though a systematic secondary focus remains variable. The interactive course of both disorders is generally not well addressed in treatment plans. Emergency procedures for management of clinical crises are often verbally communicated as in-house guidelines and are infrequently codified. Stage-wise treatment is normally not assessed or explicit in the treatment plan. Many substance abuse treatment agencies have on-site capability to provide medication for the mental disorder[s], while some refer to a collaborating service provider. Mental health agencies do not normally prescribe medications for the treatment of substance use disorders. Specialized interventions with co-occurring disorders content often depend on the judgment and capability of an individual clinician and generally do not indicate the routine use of evidence-based practices. CEIC has observed that, although the treatment of co-occurring disorders is apparent in many clinics, significant use of the State’s recommended evidence-based treatments is not evident.
Most New York State outpatient programs are engaged in advancing to “Dual Diagnosis Capable” (DDC) status. CEIC has been able to promote the addition of dual recovery groups and psycho-educational groups, and to provide assistance in enhancing the mental health or substance abuse content of the interventions already in place. Educational material on co-occurring disorders is usually generic in form and content, and conveyed individually; when conveyed to a group, co-occurring information is informally integrated. Clinicians incorporate family education and support variably. Specialized interventions to facilitate the use of peer support groups, when available, are usually held off-site and variably recommended. Peer recovery supports for patients with co-occurring disorders are not commonly available. CEIC is now conducting Building Recovery Workshops for the collaborative cohorts (formed subsequent to the Building Capability Forums) to strengthen this feature of programming.
Continuity of Care
Co-occurring disorders are considered when planning for treatment after discharge. On discharge, willing individuals are connected with recovery support services, including (but not limited to) clinical recovery check-ups and a referral to obtain telephone peer-recovery support.
Since “Addiction only” and “Mental Health only” programs typically do not list the co-existing disorder or problem on the treatment plan, the discharge planning process often fails to consider both conditions. To achieve “Dual Disorder Capable” status, a program must construct a more deliberate post-discharge plan that takes into account the influence that each of the co-occurring disorders exerts on the other. “Dual Disorder Capable” programs will conceptualize one disorder as primary, but will underscore the importance of treatment for the other disorder (pharmacological and psychosocial), and will develop discharge plans accordingly. Collaborative relationships are particularly important, since successful linkage is predicated on close relationships and clear protocols shared across providers. The discharge process, in considering both disorders, retains a format that is primarily clinician-driven (versus protocol-driven).
CEIC Experience in New York State – Disorders that co-occur are usually addressed as secondary in the planning process for off-site referral. Most clinicians assure that the appropriate referral is made and follow-up to the extent possible. Connections to peer recovery supports in the community depend on availability. Medication is normally made available until a connection can be made with another provider off-site.
OMH / OASAS COD documents (all; letter & Assessment guide only)
The Commissioners’ letter and Guidance documents for Co-occurring Disorders sent to the Directors of all NYS OMH- and OASAS-licensed clinics
OMH OASAS Commissioners’ letter of June 20, 2008 regarding evidence-based practices
CEIC Clinical Pathways Resource Guide (all; Assessment & Treatment Planning section only)
The entire CEIC Clinical Pathways Resource Guide
The Evidence-based Practices section of the CEIC Clinical Pathways Resource Guide
CEIC listing of EBPs (list & table format)
List and a table showing the OMH and OASAS recommended Evidence-based Practices
General /
Technical Assistance
Michael Chaple, Ph.D.
Project Coordinator
(212) 845-4539
chaple@ndri.org
OMH-OASAS COD Package
Commissioners’ letter to Clinic Directors & NYS Guidelines for COD
OMH/OASAS Commissioners’ Letter
June 20, 2008
CEIC Clinical Pathways Resource Guide
This document is intended to provide basic guidance for counselors working with people with co-occurring conditions (July 1, 2009 v4).
CEIC Clinical Pathways Resource Guide –
Evidence-based Practices (EBP) section