Beyond the Triad Integrating and Individualizing the Treatment Experience
Steve Lansing, LICSW, PhD Clinical Director/CEO
EmPower CTC
Ann M. Lansing, MPH, RN, BSN, CARN
Medical Director/President
EmPower CTC
Presentation for
2017 MARRCH Annual Conference
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Who We Are – Basic
Assumptions
Background Ann
Background Steve
Agency functions – EmPower CTC
F.I.S.H.E.S.
Whole person focus
Balance
Integrated
Combine (one thing) with another so that they
become a whole Synonyms: Combine, Merge, Unite, Fuse, Blend
To bring (people or groups with particular
characteristics or needs) into equal participation in
or membership of a social group or institution
To form, coordinate or blend into a functioning or
unified whole
To produce a whole of a larger unit as parts do
To give or cause to give equal opportunity and
consideration to.
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IMR versus Enhanced IMR
IMR was developed with focus on mental
heath care.
E-IMR was developed to provide
integrated treatment for co-occurring
mental health and substance
populations.
It is an advancement that combines two
evidence based practices Both are promoting mental health and substance use providers to
identify the existence of the co-occurring disorders and to address
both.
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Guiding Principles of IMR - 1
Disorders are treated in a stage wise fashion
with different services for different stages
Motivational intervention are used at all stages
especially in persuasion stage.
CBT is used to treat clients in the active
treatment and relapse prevention stages
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Guiding Principles of IMR - 2
Uses Stress Vulnerability Model
Practical facts about mental illness
Effective medication utilization
Symptom management
Stress & problem management skills
Relapse reduction
Alcohol and drug use
Getting needs met in the mental health
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Guiding Principles of IMR - 3
Multiple formats for services are used
including individual, group, self help, and
family.
Medication services are integrated and
coordinated with psychological/MH services
Providers need to understand the
terminology of both disorders.
Providers need to understand the short and
long term consequences of all areas.
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Core Values of IMR
Hope is key
Person centered – they are the expert of their
experience
Personal choice
Providers are collaborators
Providers demonstrate respect for those with
psychiatric symptoms
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E-IMR Principles
Integration of mental health and substance use
language
Access to comprehensive assessment of both
substance use and mental health concerns
Comprehensive variety of services offered to clients
An collaborative approach to care/service delivery
Using a harm reduction approach to care
Motivation based and stage wise interventions
Long term perspective of care
Providing multiple psychotherapeutic modalities.
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Stages of Change vs Treatment
Stages of Change is a person’s internal
motivation or what they believe
Stages of Treatment is a measure of change
behaviors – a more objective measure
May be in different stages of change with mental
health and substance use disorders and
awareness of this will help direct treatment goals
and objectives.
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Stages of Treatment
Engagement
Persuasion
Active Treatment
Relapse Prevention
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Stages of Change vs Treatment
[handout]
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Stage of Change Stage of Treatment
Pre-contemplation Pre-engagement Sees no need for help
Meets the criteria for SUD
No contact with counselor
Engagement
Meets criteria for a SUD
Irregular contact with counselor
Contemplation Early persuasion Regular contact with counselor
OR
Has reduced use for less than two weeks
Preparation Late Persuasion Regular counselor contact
Evidence of reduced use last two to four weeks
Meets criteria for a SUD
Action Early active treatment Engaged in treatment
Reduced use for more than a month
Meets criteria for a SUD
Late active treatment Engaged in treatment
Does not meet criteria for a SUD for past 1 to 5 months
Maintenance
Relapse Prevention Does not meet criteria for SUD for past 6 to 12 months
Remission More than a year of not meeting criteria for SUD
Stage-wise Treatment of SUD
Pre-engagement
Sees no need for help
Meets criteria for a SUD
No contact with counselor
Engagement
Meets criteria for a SUD
Irregular contact with counselor
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Precontemplaton
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Contemplation
Early Persuasion
Regular contact with counselor
OR
Has reduced use for less than two weeks
Stage-wise Treatment of SUD
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Stage-wise Treatment of SUD
Preparation
Late Persuasion
Regular counselor contact
Evidence of reduced use last two to four weeks
Meets criteria for a SUD
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Stage-wise Treatment of SUD
Action
Early Active Treatment
Engaged in Treatment
Reduced use for more than a month
Meets criteria for a SUD
Late Active Treatment
Engaged in treatment
Does not meet criteria for a SUD for past 1 to 5 months
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Stage-wise Treatment of SUD
Maintenance
Relapse Prevention
Does not meet criteria for a SUD for past 6 to 12 months
Remission
More than a year of not meeting criteria for SUD
Stage-wise Behavioral Objectives and Strategies
Build therapeutic relationship WIIFM (them) Offer useful outreach and practical assistance to meet immediate needs Use good listening skills Develop a crisis plan Establish peer support or healthy supports Further assessment and collateral information Don’t confront about substance use issue at this stage
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Engagement (Pre-contemplation)
Active listening Look for gaps Ask exploratory questions about experiences, goals and educate about substance use and mental health issues. Explore if substance use has had any impact on moving toward or away from their goals Identify triggers for use Manage triggers, cope with them, and avoid triggers using replacement strategies such as sober friends or activities
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Persuasion (Contemplation)
Stage-wise Behavioral Objectives and Strategies
Understand the relationships between use and symptoms and symptoms and use Teach assertiveness skills Teach social skills Teach stress management skills Manage stress /triggers that lead to us
(Identification, learning, practicing and using skills)
Manage cravings and urges (thoughts about use)
Learn refusal skills Use CBT tools
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Early/Late Action (Action)
Stage-wise Behavioral Objectives and Strategies
Address grief and loss issues Identify further triggers such as feelings or social situations Develop healthy lifestyle behaviors and social activities Participate in self-help groups Develop a relapse prevention plan Conduct further assessment Use CBT tools
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Relapse Prevention (Maintenance)
Stage-wise Behavioral Objectives and Strategies
Motivational Interviewing:
More than a good principle, it takes skill to implement
Express empathy – Build rapport Develop discrepancy – Elicit pros and cons Roll with resistance – Respect autonomy Instill self-efficacy – They are capable of change
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Motivational Strategies – O.A.R.S.
Open ended questions - 4 open ended to 1 close ended -
No more than 3 questions in a row
Affirmation of decisions – Client should do at least 50% of the talking
Reflective listening Summary reflections
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Traditional Treatment Person Centered Treatment
Self-determination comes after individuals have successfully used treatment. to achieve clinical stability.
Self-determination and community inclusion are viewed as fundamental civil rights of all people
Compliance with practitioner’s instructions and recommendations is valued.
Active participation and empowerment is vital.
Only professionals have access to information.
All parties have access to the same information and information is shared readily between them.
Disabilities, deficits, dysfunction and problems drive treatment. Focus is on illness.
Interests, abilities, and personal choices define supports. Focus is on promoting health.
Lower expectations of patient. High expectations of person.
Clinical stability is valued Quality of life is valued
Traditional vs Person Centered Treatment
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Traditional Treatment Person Centered Treatment
Linear progress and movement through an established continuum of services is expected
Person chooses from a flexible array of supports and/or creates news supports options with the team
Primary emphasis is on professional services.
Diverse supports (professional services, non-traditional, natural supports.
Facility-based settings and professional supporters.
Integrated settings and natural supporters are also valued.
Avoidance of risk: protection of person and community.
Responsible risk-taking and growth.
Traditional vs Person Centered Treatment
An Example: IMR Tools
Question: Table Talk
What challenges does this bring in
practical application in your CD treatment
programs?
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SAMHSA Recovery Definition
A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.
Four Major Dimensions That Support a Life in Recovery: 1. Health
a. Disease management
b. Making informed health choices that support
physical and emotional wellbeing
2. Home a. A stable and safe place to live
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3. Purpose a.Meaningful daily activities
b.Independence, income and resources to
participate in society
4.Community a.Relationships and social networks for
support, friendship, love and hope.
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SAMHSA Recovery Definition
Questions:
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