Designing, Implementing, and Managing Treatment Services for Individuals with Co-Occurring Mental Health and Substance Use Disorders

Blueprints for Action

Edward L. Hendrickson

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317825883
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Your blueprint to develop and manage effective co-occurring treatment programs! Sequential or parallel treatments for co-occurring disorders are much less effective than a quality co-occurring treatment program. Most mental health and substance abuse professionals know how to provide an effective program for individuals with a substance use or mental health disorder, but few are aware of the issues involved in providing services for those with dual diagnosis. Designing, Implementing, and Managing Treatment Services for Individuals with Co-Occurring Mental Health and Substance Use Disorders: Blueprints for Action gives you with the tools you need to develop an effective program specific to co-occurring treatment as well as to implement and manage the program's services. Author Edward Hendrickson shares his knowledge from over two decades of developing and implementing co-occurring treatment services. Designing, Implementing, and Managing Treatment Services for Individuals with Co-Occurring Mental Health and Substance Use Disorders: Blueprints for Action is thorough, insightful, and informative, covering all facets of plan and execution, helping you form strategies to address a co-occurring treatment program's unique issues. The book examines the historical basis of the current dual treatment system to provide the philosophical tenets the program must follow and the essential qualities for an effective treatment program. It explores the issues in creating a new program or expanding an existing one, as well as the mechanics of day-to-day management. Helpful appendices, tables, and case examples illustrate the discussion. Designing, Implementing, and Managing Treatment Services for Individuals with Co-Occurring Mental Health and Substance Use Disorders: Blueprints for Action discusses:

• developing the necessary infrastructure for integrated treatment programs
  
• the eight essential qualities for an effective treatment program
  
• choosing a target population
  
• identifying specific services to implement
  
• implementation of services in an existing treatment setting
  
• implementation of services in a non-mental health or substance abuse setting
  
• hiring and training staff
  
• clinical supervision and human resource development
  
• program management issues
  
• multilevel and multi-organization systems
  
• steps to ensure program survival
  

Designing, Implementing, and Managing Treatment Services for Individuals with Co-Occurring Mental Health and Substance Use Disorders: Blueprints for Action is more than an instructional text for students; it is an essential resource for any substance abuse and mental health professional considering implementing a co-occurring treatment program.

Section III:
Making It Work—The Day-to-Day Management of Treatment Services for Co-Occurring Disorders

Once treatment services for individuals with co-occurring disorders have been established, the spotlight turns to the day-to-day basis of making them work. The first three chapters of this section focus on the human resources issues faced by these treatment services. Chapter 6 outlines the critical issues involved in hiring and training direct service staff. Chapter 7 examines what is involved in effective clinical supervision of these services, and Chapter 8 discusses the tasks involved in effective program management. Chapter 9 focuses on the manner in which these services operate within a larger multilevel/multi-organizational system, and Chapter 10 describes activities that programs must successfully accomplish if they are to prosper and endure. The purpose of this section is to examine these day-to-day activities that ensure treatment effectiveness and program survival.

Chapter 6

Hiring and Training Clinical Staff

The quality of treatment services for individuals with co-occurring disorders is directly related to the quality of the staff providing these services. Staff hired to provide these services must have or obtain the necessary attitudes, knowledge, and skills needed to provide high-quality services to this population. This chapter reviews the essential knowledge and skill bases that staff must have; describes the types of staff attitudes and temperaments that are most effective with this population; makes recommendations concerning how the application, interviewing, and hiring process can be most effectively used to identify applicants with these qualities; and because most staff will not initially have all the necessary skills, knowledge, and attitudes, presents methods of developing, implementing, and evaluating training programs to increase staff competencies.

ESSENTIAL KNOWLEDGE AND SKILLS

In most instances, staff of new co-occurring treatment services will not have all the essential skills, knowledge, and attitudes in their therapeutic repertoire. They often bring either a set of substance abuse or mental health treatment competencies. Table 6.1 outlines the additional knowledge and skills that mental health and substance abuse trained therapists need to add to their therapeutic toolbox to be effective with this population.

Staff members with mental health training and experience backgrounds normally need to learn about the different types of drugs that their clients are using and what short- and long-term effects the drugs may have on their clients. They need to learn how to monitor urine screens or administer breath tests in a manner that does not interfere with the therapeutic relationship. In addition, they must come to understand the power and the nature of addiction and not be surprised or offended when clients say they want to abstain but then surrender to cravings and compulsions. Staff members with substance abuse training and experience, on the other hand, need to learn how to identify the various mental disorders that cluster frequently with substance use, and gain an appreciation of how these disorders affect a person’s social skills and ability to function independently in the community.

TABLE 6.1. Additional Knowledge and Skill Needs

Mental Health Therapists	Substance Abuse Therapists
Nature and effects of psychoactive drugs and the importance of drug testing	Nature and effects of mental disorders
Nature of addiction	Importance of functioning level
Importance of abstinence	Importance of medication
Importance of self-help involvement	Long-term view of self-help involvement
Working with court-referred clients	Engaging self-referred clients
Being more concrete, directive, and confrontive	Being less directive, more flexible, and confronting more gently
Use of self-disclosure	Maintaining clear boundaries

The therapists with substance abuse backgrounds who are normally used to having court-ordered clients must learn how to engage self-referred clients, or individuals with whom the court has little leverage. Therapists with mental health backgrounds must learn to work with clients whose only perceived problem is getting the court system off their backs. Thus substance abuse therapists must learn to be less directive, more flexible, and gentler during confrontations in an effort to engage and keep clients who are not court ordered. Mental health therapists, meanwhile, must learn to be more concrete and directive in setting treatment contracts. They need to learn to use psychoeducation and confrontational feedback techniques to motivate some clients to address their substance use. Such techniques also may help these clients in controlling some of their psychiatric symptoms.

The therapists with substance abuse backgrounds also need to be familiar with the different types of medications used to treat these disorders and be able to identify their side effects. They also must learn how to promote medication compliance and deal with any negative values or attitudes that clients, members of their families, self-help groups, or other substance abuse professionals may have concerning the use of medications. The therapists with the mental health background will need to gain an understanding of the importance of abstinence from alcohol and other drugs for individuals with mental disorders. They will need to learn about the purpose, culture, and traditions of twelve-step self-help groups such as Alcoholics Anonymous and Narcotics Anonymous, and become comfortable promoting clients’ participation in these groups. The therapists with substance abuse backgrounds must learn that for some individuals, such as those who have social phobias or paranoid thoughts, attendance at these meetings may need to be a long-term goal instead of one required early in treatment. Therapists will first need to help clients manage their fears about attending such meetings, and teach them what is appropriate to talk about, depending on the type of meeting they are attending. Some meetings may be open to discussion of psychiatric symptoms and others may not. With so many different types of self-help recovery groups now available for both substance use and mental health disorders, both types of therapists need to understand the principles of each in order to help clients select the type of group that is most effective for them.

The therapists with substance abuse backgrounds who are normally used to having court-ordered clients must learn how to engage self-referred clients, or individuals with whom the court has little leverage. Therapists with mental health backgrounds must learn to work with clients whose only perceived problem is getting the court system off their backs. Thus substance abuse therapists must learn to be less directive, more flexible, and gentler during confrontations in an effort to engage and keep clients who are not court ordered. Mental health therapists, meanwhile, must learn to be more concrete and directive in setting treatment contracts. They need to learn to use psychoeducation and confrontational feedback techniques to motivate some clients to address their substance use. Such techniques also may help these clients in controlling some of their psychiatric symptoms.

The therapist whose professional mental health training may have taught him or her never to self-disclose must learn that some clients need self-disclosure to help them differentiate normal feelings and behaviors from those generated by their mental health or substance use disorders. For example, a client who had just ended a significant relationship was experiencing a significant increase in depressive symptoms and attributed this to her medication no longer working. The mental health therapist can assure the client by telling her that’s exactly how she or her friends felt when ending such a relationship; such feelings are normal and will pass with time. The therapist with the substance abuse training background, on the other hand, must learn that maintaining clear boundaries is essential when interacting with some clients. Substance abuse therapists, especially if they themselves are recovering, are used to sharing with clients the history of dependency, and may in fact encounter clients when attending self-help meetings. However, for clients with certain psychotic, anxiety, and personality disorders, too much self-disclosure or even a simple touch of a shoulder can trigger confusion concerning what is intended or really meant. Thus substance abuse therapists must learn to be much more withholding with certain clients than they have been in the past.

Finally, both mental health and substance abuse therapists must learn that words they use in their everyday work may have very different meanings for professionals in another field. For example, when a therapist with training in mental health uses the term “defense mechanisms,” she means a psychological process that protects individuals from pain and thus helps them function effectively in the community. The therapist with training in substance abuse, of course, sees defense mechanisms as a negative process that prevents clients from recognizing and acknowledging that they have a substance use disorder. When a therapist with a substance abuse background uses the term “enabling,” he is referring to a behavior that protects individuals from the consequences of their substance use and thus contributes to continued use. The therapist with a mental health background may see enabling as a positive process that is often used in behavioral training or case management services to promote effective community functioning, such as helping a client learn how to ride the bus or go to a job interview. Similarly, a therapist with a mental health background normally uses the term “residential” to refer to a facility that provides housing and support for individuals but to a substance abuse therapist, the term refers to a form of intensive substance abuse treatment. Both therapists need to learn the multiple definitions for many commonly used psychological terms in order to communicate effectively with each other and avoid misunderstandings.

ESSENTIAL TEMPERAMENTS AND PHILOSOPHY

In addition to having certain knowledge and skills, therapists working with individuals with co-occurring disorders must also possess characteristics of flexibility, optimism, creativity, respectfulness, and cooperativeness if they are to be effective with this population. Staff with these temperaments can treat each client individually, promote optimism about treatment outcome, develop creative treatment interventions, be respectful of the difficulties some clients have making changes, and have the ability to work closely with other professionals serving their clients. The TAUT-SOAR Model (Hendrickson and Schmal, 1993) can be a useful philosophical model for staff working with individuals with co-occurring disorders (see Figure 6.1). This model is based on the premise that the more difficult the clinical issues, the more growth opportunities there are for the therapist.

TAUT stands for Thoughts of incompetence; Apprehension; Unclear what and how to treat; and Treatment avoidance. These are thoughts, feelings, and behaviors that therapists may experience or demonstrate when encountering problems that they believe they are unequipped to treat effectively. For example, the substance abuse therapist might have these reactions to a young adult male client who presents with a history of alcohol and cocaine dependence but also reports hearing voices occasionally and believes that the FBI is following him with helicopters and has bugged his home and car. The mental health therapist might react with TAUT in treating a young female with a history of bipolar disorder who reports drinking excessively and smoking marijuana on a daily basis. When therapists’ anxious thoughts and feelings combine with their confusion concerning a treatment approach, the temptation is to avoid treating the client. They may either refer the client to another agency based on the excuse that the client has a principlal diagnosis that they are not mandated to treat, or make treatment demands that a client cannot achieve. The first method, if successful, simply results in either the mental health therapist treating the substance abuse therapist’s client or the substance abuse therapist treating the mental health therapist’s client, leaving both therapists still feeling capable only of treating part of the client’s problem. The second method, such as the mental health therapist requiring her client to stop all alcohol and drug use before offering medication or other services, or the substance abuse therapist requiring his very paranoid client to attend ninety Alcoholics Anonymous meetings in ninety days, inevitably leads to clients dropping out of treatment. The therapist has achieved his or her goal not to treat the individual, but the client remains untreated.

FIGURE 6.1. TAUT-SOAR Model

To engage and maintain such clients in treatment, both the substance abuse and the mental health therapist must approach treatment from a different perspective. The second part of our model, SOAR, stands for Seeks growth, Opportunity viewpoint, “And” instead of “or”, and Reasonable expectations. This approach allows therapists to view their clients with less anxiety, more optimism, and more flexibility. Treating these clients becomes an opportunity for the therapists to expand their knowledge about mental disorders and treatment techniques. The client often presents with a history of many treatment failures, so the therapist can feel free to try various techniques with hopes of finding one that works. Each client becomes a research project with an opportunity for that client to obtain something he or she had not yet achieved—a treatment success. Furthermore, therapists never have to forget what they already know; however, they now have the opportunity to expand that knowledge and integrate the new and old knowledge into a broader paradigm, which ultimately makes them more effective.

Finally, once a therapist decides to treat an individual with co-occurring disorders, he or she can establish more reasonable expectations. For example, the mental health therapist can help a client attend an alcohol and drug education class as a first step in addressing the substance abuse disorders; the substance abuse therapist may introduce the concept of schizophrenia to the client, and slowly move him or her toward a medication evaluation while probing to understand how the psychiatric symptoms impact the client’s substance use. Approaching treatment from a SOAR viewpoint increases the chances that the client will remain in treatment and helps therapists gain confidence in their ability to promote change in clients who have complex problems.

THE APPLICATION, INTERVIEWING, AND HIRING DECISION PROCESS

The front door for any program’s acquisition of human resources is the application, interviewing, and hiring decision process. Since hiring decisions are always based on limited amounts of information, it is important that the application and interviewing components of this process yield as much information as possible about potential employees. This section describes key pieces of information that should be obtained on the application form for co-occurring disorders clinical positions; makes recommendations concerning how interviews can be conducted to maximize information about applicants’ knowledge and experience concerning co-occurring disorders treatment; and discusses how the decision-making process can be most effective.

Most agencies have standardized application forms that fulfill all the essential and mandated data elements that must be collected regarding future employees. This type of information ranges from name and address to the applicant’s specialized licenses or certifications. Program managers who hire individuals to provide co-occurring disorders clinical services must ensure that their application form includes the following four important pieces of background information: (1) experience providing co-occurring treatment services; (2) type of co-occurring treatment population worked with and the work setting; (3) specific treatment functions performed with the clients; and (4) specific education and training the applicant has had concerning co-occurring treatment. These questions can be woven either into other similar questions on the application form or attached as a supplement to it.

Applicants can realistically accomplish the following during an interview:

• highlight their co-occurring disorders education, training, and treatment backgrounds;

• demonstrate their knowledge about the treatment of such disorders;

• show their ability to diagnose and develop treatment plans for this population; and

• present a limited picture of how they interact with others.

Depending on the size of the program and the size of the applicant pool, interviews may be structured as an interaction between the applicant and a single interviewer; an interaction between the applicant and an interview panel; or an interaction between several applicants and an individual or interview panel (group interview). Group interviews are usually used to reduce the applicant pool to a more manageable size. Interviews are usually conducted face to face, but many are now being conducted by phone or via the Internet.

In order for interviews to obtain the clearest picture of candidates, the questions must be specific enough to ensure that vague answers will not suffice. Appendix B provides sample interview questions that can be used to allow applicants to expand on the information they provided on the application form concerning their education, training, and experience with co-occurring disorders. Appendix B also provides sample interview questions that address the applicant’s knowledge of the nature of co-occurring disorders and the best treatment practices for this population, as well as providing a client scenario and sample questions that allow applicants to demonstrate their ability to make initial diagnostic assessments and treatment plans. Because these questions take some time to think about, they should be either given to the applicant ahead of time or be answered as a written exercise following the formal portion of the interview. Including such questions in the interview will provide the broadest picture possible of the applicants.

Once all the intervie...