The People with Co-occurring Disorders - Math Problem Example

Co-Occurring Disorders [Name Of Student] [Name Of Institution] CO-OCCURRING DISORERS ABSTRACT The basic aim of this paper is to examine the people with COD (CO-occurring disorders). To identify the need for a change, propose a strategy for change and then further evaluate the effectiveness of that change. A series of four focus groups were conducted with 35 clients with a co-occurring diagnosis of mental illness and substance abuse to obtain their perspectives on treatment. Four content areas emerged. System barriers, such as poor therapeutic environment, difficulties navigating complex systems, and poor integration of services were most frequently mentioned. Factors facilitating recovery included consumer strengths, a positive therapeutic environment, and helpful recovery tools. Consumer challenges refer to obstacles in the client's life including the long-term chronic nature of their illness, self-medication of psychiatric symptoms, and limited personal resources and options. Specific treatment needs, such as treatment from "similar others," one-on-one counseling, and time management were identified. The results demonstrate that a client-centered approach is preferred. Limited system resources continue to be a barrier. Improved coordination of services and cross-training on co-occurring diagnosis are needed. Consumers recognize the long-term nature of their problems and have strengths for dealing with them. IDENTIFYING THE NEED FOR CHANGE Individuals who suffer from severe mental illnesses such as bipolar disorder or schizophrenia are at much greater risk for co-occurring substance use disorders. However, treating persons with co-occurring disorders (COD) is challenging. Persons with COD are more prone to relapse, are less compliant with medications and treatment, are impaired by social and economic stressors (e.g., homelessness), experience more negative outcomes (e.g., incarceration, HIV, hepatitis C), and often do not respond well to accepted treatments for single diagnoses (see Drake et al., 2001; Dumaine, 2003; Mueser et al., 2003; Torrey et al., 2002). Consequently, they consume a greater proportion of time, money, and resources than other populations, yet with worse outcomes. This in turn leads to increased stress on those treating them, resulting in higher levels of burnout in treatment staff (Dumaine, 2003). Because of these difficulties, there has been a consistent call for integrating the treatment of mental health and substance abuse disorders, in which both are treated simultaneously in programs specifically tailored to each client's needs (Brooks & Penn, 2003; Ford, Hillard, Giesler, Lassen, & Thomas, 1989; Inderlin & Belisle, 1991; Minkoff, 1991; Ridgely, 1991; Ziedonis & Fisher, 1994). A high prevalence of 12-month co-occurring addictive and mental disorders can also be found in other service sectors. Indeed, only a minority of these patients are treated in specialty addictive treatment clinics (in the NCS sample, 0% of those in treatment with co-occurring substance abuse, 28% of those with co-occurring AD, and 23% of those with co-occurring DD). One in four patients in specialty mental health treatment with an affective disorder and one in five of those in treatment with an anxiety disorder also have a co-occurring addictive disorder. One possible reason for the fact that no patients with co-occurring mental disorder and substance abuse were found in specialty addictive treatment clinics is that their substance use problems were minor in relation to their mental disorders, in which case they presumably selected themselves into sectors of treatment other than specialty addiction treatment. It is also possible, though, that patients of this type are refused treatment by some specialty addiction clinics and referred elsewhere for treatment of their mental disorder. Despite recommendations for enhancing COD treatment programs, a gap between research, policy, and practice continues to exist. Consumer input offers a unique opportunity to generate firsthand knowledge about the challenges and successes of current COD treatment programs. For example, detailed accounts of individual experiences have appeared in both popular (e.g., Jamison, 1995) and professional literature (e.g., Bassman, 2000; Frese, 2000; Schiff, 2004). Some of these former consumers are now mental health professionals, and their criticisms of the oppressive nature of previous treatment models have helped to pave the way for the development of client-centered approaches. PROPOSED PROGRAM CHANGE The name of the program that I propose is known as ACT-NOW Plus, which is an outpatient day treatment program that provides a multidimensional, multi-method (i.e., cognitive methods, 12-Step, auricular acupuncture) continuum of care that allows clients to move easily between different levels of intensity and choose from an array of services as needed. In addition to the groups and services offered as part of the ACT NOW Plus day treatment program, ancillary services are coordinated by the ACT NOW Plus treatment team. The conventional COD treatment program was in an agency that had recently merged with another community agency. In addition to consolidating treatment services between the two agencies, the agency also needed to develop an integrated COD treatment program as mandated by the state. So, while the goal was to eventually provide integrated services for persons with co-occurring disorders, at the time the focus groups were conducted services were still somewhat fragmented, with the case manager as the focal point for service coordination. Services provided at the conventional (TAU- treatment as usual) site consisted of a weekly co-occurring disorders group and other groups, case management, medication management, a methadone clinic, some individual therapy, in-home daily living skills instructions, and crisis, hospital and residential services as needed. The TAU treatment was not as integrated, i.e., most of the treatment was not provided by the same staff members or team. With the exception of the co-occurring disorders group, the integration of treating both substance and mental health issues in the various program components was limited. All TAU study participants were recruited from the co-occurring disorders group. While both programs were located in large community behavioral health centers providing both substance abuse and mental health treatment services, the ACT NOW Plus program only treated persons with COD, while some of the services TAU participants received could include singly diagnosed substance abusers or were originally designed for singly diagnosed individuals. CLINICAL IMPLICATIONS These results have a number of implications for treatment. Perhaps the most obvious is that special assessment and treatment procedures are needed for patients who present with co-occurring addictive and mental disorders, a variety of which are discussed in other papers in this special section. In addition, clinicians should routinely consider the possibility of a co-occurring disorder among patients presenting for treatment of either a mental or an addictive disorder. Among patients with only one type of disorder, furthermore, clinicians should be aware that these patients are at increased risk of the subsequent oc-currence of later disorders of another type, making them prime candidates for preventive interventions. PROCEDURE Three of the focus groups were facilitated by the first author and a substance abuse counselor from the intervention agency; however, he was not one of the ACT NOW Plus counselors and had no current or prior treatment contact with any of the study participants. A third research staff person served as note taker. The fourth author facilitated the fourth focus group. Participants were asked four main questions regarding their past and current treatment: (a) experience of living with substance abuse and mental health issues, (b) positive treatment experiences, (c) negative treatment experiences, and (d) possible strategies for enhancing treatment services. On average the focus groups lasted 1 1/2 hours. In general, participants commented freely and interacted well with each other, generating much spontaneous discussion. As is possible in any focus group, one or two participants were not as interactive. In those cases, the facilitator would solicit input from the participant to ensure that all participants had a chance to comment on each of the key questions SYSTEM BARRIERS TO RECOVERY Participants expressed a total of 335 passages relating to system barriers to recovery. The most frequently mentioned system barrier to recovery was a poor therapeutic environment, identified in 118 responses. Poor therapeutic environment was characterized by ineffective treatment strategies that hinder recovery, including a lack of acceptance of relapse and the harm reduction approach to treatment. Most often mentioned, though, was the desire for client-centered services. A lack of individualized treatment and lack of understanding of the client typified non-client-centered treatment. For example, one participant described it this way: "If they walked in my shoes they could probably get a better insight of what's me and what is good for me.” Finally, the high prevalence of 12-month mental-substance co-occurrence has important implications for the design of managed care plans. There is currently an artificial separation between mental health and addictive treatment funding schemes at the federal level. There is also considerable interest on the part of several state Medicaid programs in managed care plans that separately carve out mental health and substance abuse management and treatment. Such schemes require individuals who have co-occurring addictive and mental disorders to be classified as having either a primary mental illness or a primary addictive disorder and discourage treatment for disorders. The second prominent theme under barriers to recovery was system navigation issues, highlighted in 95 passages. Respondents noted that insurance and financial limitations make it difficult to receive adequate services. The recognition of the limited system resources was described by one participant: "I still feel like I need more guidance, more help, and I can't ask that of these people because they are giving me all they can already within the system." Moreover, due to insufficient treatment capabilities and bureaucratic procedural delays, many direct and ancillary services are difficult to access in a timely manner. Another barrier mentioned is the lack of coordination of services across agencies, which decreased the likelihood that clients would have all of their needs addressed in treatment that are not considered primary. The findings reported in the present paper suggest strongly that this kind of separation of services is not in the best interests of the patient. Clients also reported diminished trust with their case managers due to high turnover rates. Relatively long treatment is required for successful recovery among dually-diagnosed patients as evidenced in a study of 10-year remission rates (Xie, McHugo, Fox, & Drake, 2005); over two thirds had relapsed by nine years. Thus, given the long term treatment needs of this population, revolving case managers are unlikely to establish the much needed rapport with these patients. Medication issues were highlighted in 38 passages. Some participants expressed positive sentiments regarding their medication regimens and the sense of accomplishment when the correct mediation and dose is identified. Legal involvement interfering with clients' lives surfaced in 23 passages. Decriminalization of substances was supported by a number of participants, and most agreed that the legal system should not be responsible for treating substance use disorders. FACTORS FACILITATING RECOVERY The factor most frequently mentioned by participants was their own strengths, represented in 149 responses. Maintaining a positive outlook also was highlighted as a factor facilitating recovery, including expressions of gratitude and hope: Therapeutic environment factors that facilitated treatment recovery were highlighted in 85 responses. As would be expected, feeling supported was the most frequently mentioned characteristic of the environment that facilitated recovery. Twenty-four of the responses centered on the strong bonds that clients formed with other group members: "I like this program because there ain't much of nothing you can say that is going to surprise somebody. Everybody here has a mental issue or they're addicted to a drug of some sort or alcohol." An additional 20 passages focused on the supportiveness of the staff, including affirming the client's condition in a constructive rather than a demeaning manner. In addition to consumer strengths and the therapeutic environment, participants also highlighted in 39 passages specific recovery tools that assisted them in their recovery. Most frequently mentioned were specific coping skills, such as setting goals, seeking support, anger management, and cognitive strategies. Anger management was helpful for one participant: "I like the anger management that we go to. It really helped me to be able to stop and think before I do something." Participants also stated that participation in acu-detox therapy--a popular treatment involving acupuncture that results in relaxation and reduced cravings--was a useful strategy. Finally, a group of clients focused on their spirituality as an important tool in the recovery process. DISCUSSION Persons with multiple disorders often have very complex histories and needs. However, behavioral health and medical systems have traditionally compartmentalized co-occurring issues, resulting in fragmented treatment and decreased effectiveness. The purpose of the present study was to provide a comprehensive view of this experience, as opposed to focusing on one element of recovery or treatment. In addition to corroborating the results from previous studies, the present findings integrate many of these concepts together into a more comprehensive picture of treatment experiences from the perspective of clients with CODs. Client responses were categorized into four broad themes: system barriers to recovery, consumer challenges, consumer needs, and factors facilitating recovery. Similar to previous reports of client feedback, a poor therapeutic environment was the most frequently mentioned system barrier to recovery (Maisto et al., 1999; Glass & Arnkoff, 2000). In addition, a poor therapeutic environment was mentioned more frequently in the less integrated treatment program (TAU). This finding suggests that as substance use and mental health treatment integration occurs, these types of experiences decrease. The next most frequent system barrier mentioned--system navigation issues--has also been reported in previous research evaluating treatment systems (Todd, Sellman, & Robertson, 2002). Although integration of substance abuse and mental health treatment remained a barrier, it was mentioned less frequently. This suggests that progress has been made following persistent recommendations for treatment integration (e.g., Drake et al., 2001). Integrated treatment can include linkages and coordination between programs, extensive referral networks, information and support networks, and cross-training between mental health and substance abuse treatment providers (Doughty & Hunt, 2000; Grella, 1996; Holland, 1998). In addition to cross-training between mental health and substance abuse providers, education and training programs need to provide cross-training as well (Carey, Bradizza, Stasiewicz, & Maisto, 2001; Drake et al., 2001; Klee, 1991). Medication issues also remained a barrier to recovery for some clients, although they were not as prominent as in other studies (e.g., Glass & Arnkoff, 2000). A number of strategies have been offered in the literature to overcome many of the implementation barriers, both in terms of system navigation and therapeutic environment. For example, Todd, Sellman, and Robertson (2002) organized their recommendations around five key principles of treatment: safety, stabilization, comprehensive assessment and treatment planning, clinical case management, and treatment integration. Drake et al. (2001) discuss a number of system-level strategies for enhancing COD treatment, including developing a consensus around a strategy for integrated services and implementing changes in regulations and reimbursement rates. Utilizing fidelity measures is another recommended strategy for successful implementation, as modifications can be made to the program based on the process findings (Penn & Brooks, in review). Torrey and colleagues (2002) stress the importance of involving all stakeholders, including policy makers, program staff, families, and consumers. This is particularly true because different stakeholders have been found to have divergent perspectives on some aspects of psychiatric services (Piat et al., 2004). More recently, we offered a series of more specific recommendations based on a process evaluation of a COD treatment program including: (a) manifest a client-centered approach; (b) make the program flexible in attendance and abstinence requirements; (c) provide a wide variety of activities, groups, and supportive services; (d) include and teach healthy recreation; (e) work with the problems persons with COD may have with 12-Step and other self-help groups; and (f) provide a variety of support and training options for counselors (Penn & Brooks, in review). Similarly, recommendations for client-centered services, such as a positive therapeutic alliance, a nonjudgmental, empathic therapist (Ziedonis, 2004), consumer input into programming structure (Mayes & Handley, 2005), and individualized treatment (Minkoff & Cline, 2004) would address some of the poor therapeutic environment issues. Although the most persistent themes concerned the ongoing difficulty with obtaining services in an underfunded, overworked system, the second most frequent theme was factors that facilitated the clients' recovery process. Moreover, the single most frequent category of response among the respondents was consumer strengths. These results are consistent with consumer advocates' calls for client empowerment (e.g., Bassman, 2000; Schiff 2004) and the principle of client-centered treatment--build on strengths. Furthermore, this pattern of responses indicates that, although the system still needs much improvement, clients have been able to develop skills to facilitate their recovery process as well as identify therapeutic factors they need in order to manage their disorders. Just as therapeutic environment was a prominent barrier to recovery for some; it was an important factor facilitating recovery as well. Together, negative and positive statements regarding therapeutic environment accounted for over 25% of consumers' statements, again attesting to the fundamental role it plays for this population (Maisto et al., 1999; Glass & Arnkoff, 2000). CONCLUSION Consumer challenges and needs were the final two themes raised during client focus groups. In terms of challenges, the long-term nature of recovery was most frequently mentioned, followed by hopelessness about the future. The pattern of multiple treatment attempts highlights the chronic nature of the dual-diagnosis condition as well as the gradual improvement that has been identified--by both researchers and practitioners--as standard for this population (e.g., Cuffel & Chase, 1994; Drake et al., 2001). Considering the well-established course of CODs (RachBeisel, Scott, & Dixon, 1999), these clients' responses are understandable and an accurate reflection on the overwhelming challenges they face in their lives and underscore the need for long-term treatment. Additional challenges highlighted by clients, such as self-medication of psychiatric symptoms and limited personal resources, reveal further the intense difficulties this population must overcome in recovering from their illnesses. Given these challenges and the sometimes chaotic nature of their lives, it is not surprising that the two most frequently mentioned consumer needs were structure (in life and in treatment) and to be around others who have faced similar challenges. Medical issues are common and were mentioned as an additional challenge. Although there is recognition of the prevalence of medical disorders in this population among researchers (Drake et al., 2001; Gallagher, Brooks, & Penn, in press), the misleading term dual diagnosis continues to be widely used. Given the clarity with which COD populations can articulate their strengths and challenges, co-occurring disorders seems a more representative label with which to refer to their condition. REFERENCES Alverson, H., Alverson, M., & Drake, R. E. 2000 An ethnographic study of the longitudinal course of substance abuse among people with severe mental illness. Community Mental Health Journal, 36, 557-569. Bassman, R. 2000 Agents, not objects: Our fights to be. Journal of Clinical Psychology, 56, 1395-1411. Bellenger, D. N., Bernhardt, K. L, & Goldstucker, J. L. 1976 Qualitative research in marketing. American Marketing Association Monograph Series, 3, 7-28. Brooks, A. J., & Penn, P. 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APPENDIX TABLE 1 NUMBER OF PASSAGES BY CONTENT AREA AND THEME Legend for Chart: A - Primary content area / theme B - Number of passages (N=35) C - % Within ACT NOW Plus (N=11) D - % Within TAU (N=16) A B C D System barriers to recovery 335 32.5 39.4 Poor therapeutic environment 118 6.3 21.5 System navigation issues 95 11.8 5.5 Treatment integration 39 5.5 3.6 Medication issues 38 5.5 6.2 Legal system involvement 23 0 2.0 Stigma of substance abuse 12 0.4 0.3 Limitations of 12-Step 10 3.0 0.3 Factors facilitating recovery 266 45.6 33.9 Consumer strengths 149 17.3 11.4 Therapeutic environment 85 16.9 18.6 Recovery tools 39 11.4 3.9 Consumer challenges 121 6.8 24.1 Long-term recovery process 32 3.8 4.6 Limited options/hopeless 28 0 7.5 Self-medication of symptoms 16 0 2.9 Pre-contemplation stage 16 0 2.9 Limited personal resources 14 0.4 2.9 Boredom 10 1.3 1.6 Denial of mental illness 5 1.3 0.7 Avoid consequences of use 3 0 1.0 Consumer needs 65 15.2 2.6 Need for structure 18 3.4 1.0 Need for similar others 16 4.6 0.3 Triply-diagnosed (medical) 12 0.4 0.7 Sensitive interpersonal issues 11 4.6 0 Pacing in recovery 5 2.1 0 Desire normal life 3 0 0.7 Read More