TIP 42 (and Beyond)

1
TIP 42 (and Beyond) Substance Treatment for
Persons with Co-Occurring Disorders

• Stanley Sacks, Ph.D., Center for the Integration
  of Research Practice National Development
  Research Institutes, Inc.

European Federation of Therapeutic Communities
Conference Ljubljana, Slovenia ? June 2007
2
SAMHSAs Definition of Co-Occurring Disorders

• The term refers to co-occurring substance use
  (abuse or dependence) and mental disorders.
  Clients said to have co-occurring disorders have
  one or more mental disorders as well as one or
  more disorders relating to the use of alcohol
  and/or other drugs.

Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders, TIP 42
(2005a)
3
Co-Occurring Mental and Substance Use Disorders
Adapted from Osher, F.C. (1996)
4
COD Treatment Outcomes

• COD clients have poorer outcomes, such as higher
  rates of HIV infection, relapse,
  rehospitalization, depression and suicide risk.
• COD clients have better outcomes with treatment
  designed for their special needs.

Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders, TIP 42
(2005a)
5
COD Advances Timeline
1979
1981
1989
1993
Mid 1990s
Early 1990s
Woody Blaine Substance Abuse Depression
PepperChronic Young Adult
Minkoff Integrated Treatment
Ries TIP 9
Kessler National Comorbidity Survey
Drake ACT
2000-2003
2002-Pres.
Mid 1990s
1996-7
1999
Late 1998
Evidenced-Based Practices for SMI
Sacks De Leon MTC
DATOS Studies
NASADADNASMPHD Four Quadrants
Research on Strategies Models
TIP 42Report to CongressCo-Occurring Center
for ExcellenceState InitiativesToolkits
6
Prevalence of Co-Occurring Disorders
7
The Four Quadrants
Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders, TIP 42
(2005a)
8
The Clinical Planning Process
9
Screening Definition

• Screening is a formal process of testing to
  determine whether or not a person has a disorder
  that warrants further attention at the time of
  testing and, within this context, to determine
  whether or not a co-occurring substance use or
  mental disorder may be present (Center for
  Substance Abuse Treatment CSAT, 2005a 2005b).
  
• The screening process for co-occurring disorders
  seeks to answer a yes or no question Does
  the client with a substance use or mental
  disorder show signs of a possible mental or
  substance use disorder?
• The screening process does not necessarily
  identify the type or the severity of the
  disorder, but determines only whether or not the
  person has a disorder and indicates when
  additional assessment is needed.

Source CSAT 2005a, b
10
Features of Screening Instruments

• High sensitivity
• Brief
• Low cost and no cost
• Minimal staff training required
• Consumer friendly

Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders, TIP 42
(2005a)
11
Measures of Precision Defined

• Sensitivity the probability that the screening
  test is positive given that the person has the
  disorder. This is also know as the true positive
  rate. A large sensitivity means that a negative
  test can rule out the disorder.
• Specificity the probability that the screening
  test is negative given that the person does not
  have the disorder. This is also known as true
  negative rate . A large specificity means that a
  positive test can rule in the disorder.
• Overall Accuracy is the combination of
  sensitivity and specificity the probability
  that the screening test is positive given that
  the person has the disorder combined with the
  probability that the screening test is negative
  given that the person does not have the disorder.

12
Validation Results Any Mental Disorder
Instrument Sensitivity Specificity Overall Accuracy
CODSI-MD
Score of 3 or higher 78.8 47.7 72.6
MHSF
Score of 3 or higher 84.9 45.5 77.1
M.I.N.I.
Score of 5 or higher 67.6 52.3 64.6
GSS
Score of 2 or higher 83.8 36.4 74.4
13
Counselor Role in Screening

• In substance abuse or mental health treatment
  settings, every counselor or clinician who
  conducts intake should be able to screen for the
  most common COD and know how to implement the
  protocol for obtaining COD assessment information
  and recommendations.

Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders, TIP 42
(2005a)
14
List of Screening Instruments
Mental Disorder Screening Instruments The Mental Health Screening Form-III (MHSF)-III Mini-International Neuropsychiatric Interview (M.I.N.I.) M.I.N.I. Screen Modified National Center for Health Statistics - 10 Questions (K10) Referral Decision Scale (RDS)
Substance Use Disorder Screening Instruments CAGE Questionnaire Adapted to Include Drugs (CAGE-AID) Dartmouth Assessment of Lifestyle (DALI) DALI Screen Modified (NYS) Drug Abuse Screening Test (DAST) Short Alcohol Dependence Data Questionnaire (SADD) Simple Screening Instrument for Substance Abuse (SSI-SA) TCU-Drug Screen II (TCUDS)
Substance Use and Mental Disorder Screening Instrument Alcohol Dependence Scale (ADS) Global Appraisal of Individual Needs (GAIN) GAIN - Quick (GAIN-Q)
15
COCE Recommendations for a Selection Process

1. Screening Instruments in the Matrix review are
   all acceptable.
2. Decide if you want a screening instrument for
   substance use disorder, a screening instrument
   for mental disorders or both.
3. If the latter, either use a combination of SA and
   MH screening instruments (for example, MINI
   Screen Modified/DALI) or use the GAIN.
4. COCE recognizes that the use of other instruments
   may be desirable in a particular circumstance and
   that there are other viable options available.
5. Consider customizing your instrument with
   additional items selected from the comprehensive
   list of instruments.
6. Involve stakeholders and users in the instruments
   selection process.
7. Begin parallel development of coordinated
   assessment instruments, placement determination,
   treatment planning and treatment resources.

16
Assessment Definition

• Gathers information and engages in a process with
  the client that enables the provider to establish
  (or rule out) the presence or absence of a
  co-occurring disorder.
• Determines the clients readiness for change,
  identifies client strengths or problem areas that
  may affect the processes of treatment and
  recovery, and engages the client in the
  development of an appropriate treatment
  relationship.

Source CSAT 2005b.
17
Basic Assessment Consists of

• Background
• Substance use
• Psychiatric problems
• Integrated assessment

Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders, TIP 42
(2005a)
18
List of Selected Assessment Instruments
Substance Abuse Addiction Severity Index (ASI) Global Appraisal of Individual Needs (GAIN) Individual Assessment Profile (IAP)
Mental Health Beck Depression InventoryII (BDIII) Beck Hopelessness Scale (BHS) Brief Psychiatric Rating Scale (BPRS) Brief Symptom Inventory (BSI) General Behavioral Inventory (GBI) Referral Decision Scale (RDS)
Trauma Informed Post-traumatic Stress Symptom Scale Self Report (PSS-SR) Trauma History Questionnaire (THQ)
19
List of Selected Assessment Instruments Continued
General Health Medical Outcomes Study Short Form (SF-36)
Diagnostic Diagnostic Interview Schedule (DIS-IV) Structured Clinical Interview for DSM-IV Disorders (SCID)
Motivation and Readiness to Change Circumstances, Motivation, and Readiness Scales (CMR Scales) Readiness to Change Questionnaire Stages of Change, Readiness and Treatment Eagerness Scale (SOCRATES) University of Rhode Island Change Assessment (URICA) Recovery Attitude and Treatment Evaluator (RAATE)
Level of Care Level of Care Utilization System (LOCUS)
20
Additional Considerations

• Assessment should be a clinical driven process-
  involves clinician making connection with the
  client.
• Consider the client in a context (i.e. setting)
  and fit assessment process to the setting.
• Take into account the system of care the person
  is in think of systems available so you can do
  treatment planning.

21

Advice to the Counselor Dos and Donts of
Assessment for COD

• Do keep in mind that assessment is about getting
  to know a person with complex and individual
  needs. Do not rely on tools alone for a
  comprehensive assessment.
• Do always make every effort to contact all
  involved parties.
• Dont allow preconceptions about addiction to
  interfere with learning about what the client
  really needs.
• Do become familiar with the diagnostic criteria
  for common mental disorders, including
  personality disorders, and with the names and
  indications of common psychiatric medications.
• Dont assume that there is one correct treatment
  approach or program for any type of COD.
• Do become familiar with the specific role that
  your program or setting plays in delivering
  services related to COD in the wider context of
  the system of care.
• Dont be afraid to admit when you dont know,
  either to the client or yourself.
• Most important, do remember that empathy and hope
  are the most valuable components of your work
  with a client.

Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders, TIP 42
(2005a)
22
Treatment PlanningDefinition

• Develops a comprehensive set of staged,
  integrated program placements and treatment
  interventions for each disorder that is adjusted
  as needed to take into account issues related to
  the other disorder.
• The plan is matched to the individual needs,
  readiness, preferences, and personal goals of the
  client.

Source CSAT 2005b
23
What is an Evidence-Based Practice?

• In the area of COD treatment, EBP is defined by
  COCE primarily as the use of current and best
  research evidence in making clinical and
  programmatic decisions about services to
  clients). The research considerations involved
  in determining what constitutes an evidence-based
  practice include not only the robustness of the
  study findings but also the type of design
  employed and the methodological rigor of the
  procedures.
• A broader definition of EBP also includes taking
  into account clinician expertise and patient
  values, as indicated by the Institute of Medicine
  (2000) and more recently by the American
  Psychological Association (2005).

Center for Substance Abuse Treatment. (2005c)
24
Pyramid of Evidence Based Practices in COD Type
of Design
Center for Substance Abuse Treatment. (2005c)
25
Quality of the Research

• Sample Representativeness
• Psychometric Features of Interview Instruments
• Appropriateness of Analytic Techniques
• Robustness of the Findings
• Threats to Validity

26
Readiness for Dissemination

• Curriculum
• Training
• Technical Assistance
• Supervision
• Quality Assurance of Fidelity

27
Table of Consensus- and Evidence-Based Practices
for COD
Consensus-Based Principles for COD Services Consensus-Based COD Program Components Evidence-Based Practices from Substance Abuse Treatment Evidence-Based Practices from Mental Health1 Evidence-Based Practices for COD For Substance Abuse and Other Outcomes (mostly those with severe mental disorders)2
Employ a recovery perspective Screening, assessment, and referral Motivational enhancement Medical management approaches in psychiatry Group Counseling
Adopt a multi-problem viewpoint Psychiatric and mental health consultation Cognitive-behavioral therapy Family Psychoeducational Contingency Management
Develop a phased approach to treatment Intensive case management Relapse prevention Supported employment Long-Term Residential (including Modified TCs)
Address specific real-life problems early in treatment Prescribing on-site psychiatrist Illness management and recovery skills For Other Outcomes (but not substance abuse)
Plan for the clients cognitive and functional impairments Medication and medication monitoring Assertive Community Treatment Case Management (including both Assertive Community Treatment and Intensive Case Management)
Use support systems to maintain and extend treatment effectiveness Psychoeducational classes Integrated Dual Disorder Treatment Legal Interventions
Expect co-occurring disorders and reflect that assumption in screening, assessment, and treatment planning Double recovery groups
Consider both substance use and mental disorders as equally important
Individualize treatment plans to accommodate specific needs and personal goals of clients

1 The last two in this column are specific to
those with co-occurring disorders. 2 Based on
Drake, R., ONeal, E.L., Wallach, M.A. A
systematic review of research on interventions
for people with co-occurring severe mental and
substance use disorders. Journal of Substance
Abuse Treatment, (in press).
28
Modified TCKey Modifications

• to structure
• more flexible activities
• shorter meetings activities
• more staff guidance
• more staff
• responsibility as role models

• to process
• fewer sanctions
• engagement emphasis
• individually paced progress in program
• flexible criteria for moving to next stage
• live-out re-entry (aftercare) essential

• to elements
• accent on orientation instruction
• individualized task assignments
• engagement emphasis throughout
• activities proceed at a slower pace
• counseling to assist use of community

Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders TIP, 2005a
29
Summary

• The Modified TC is
• more flexible
• less intense
• more individualized
• The quintessential elements remain
• peer self-help
• community-as-method

Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders TIP, 2005a
30
Outcomes baseline vs 2-year follow-up
Modified TC2
TAU
De Leon, G., Sacks, S., et al. 2000.
31
Benefit Cost Analysis

• incremental benefit of modified TC
• 273,115

cost per client of modified TC treatment 20,36
1
total net benefit per client (273,115 - 20,361)
252,114
6
Benefit cost ratio 252,114/20,361 (131
data winsorized 61)6 benefit for every 1 of
cost
Source French, M., McCollister, K., Sacks, S.
et al 2002.
32
reincarceration rates
MICA Offender 12 Month Outcomes
33
MH
TC after-care
16
5
TC only
Total n 139 n64 n32
n43
Sacks, S., Sacks, J., et al. 2004
33
Substance AbuseIllegal Drug Use (Plt.05)
86
79
44
25
34
MTC for Co-Occurring Disorders A Meta-Analysis
of Three Studies (Four Comparisons)
Summary of meta-analysis combined study
comparisons random effects analysis
(differential treatment effects MTC vs.
Comparison)
  Domain Effect Size Odds Ratio 95 CI p Q (p) I2 I2  
Substance abuse Substance abuse 0.650 (0.428 0.986) .043 4.998 (0.172) 4.998 (0.172) 39.977 39.977
Mental health Mental health 0.679 (0.478 0.966) .031 2.026 (0.567) 2.026 (0.567) 0.000 0.000
Crime Crime 0.662 (0.454 0.966) .032 2.573 (0.462) 2.573 (0.462) 0.000 0.000
HIV-risk behavior HIV-risk behavior 1.007 (0.659 1.539) .974 3.068 (0.381) 3.068 (0.381) 2.225 2.225
Employment Employment 0.404 (0.251 0.651) .000 6.351 (0.096) 6.351 (0.096) 52.761 52.761
Housing Housing 0.634 (0.420 0.958) .030 0.370 (0.946) 0.370 (0.946) 0.000 0.000
plt0.05 plt0.01 plt0.001 An odds ratio
less than one indicates a greater improvement for
clients in the MTC group than in the comparison
group.
Source Sacks, Banks, McKendrick et al 2007
35
Advice to Counselors Administrators
Recommended Treatment and Services From the MTC
Model

• Treat the whole person.
• Provide a highly structured daily regimen.
• Use peers to help one another.
• Rely on a network or community for both support
  and healing.
• Regard all interactions as opportunities for
  change.
• Foster positive growth and development.
• Promote change in behavior, attitudes, values,
  and lifestyle.
• Teach, honor, and respect cultural values,
  beliefs, and differences.

Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders TIP 42, 2005a
36
Services Integration and Other Forms of
Integration
Center for Substance Abuse Treatment, (2005d)
37
Levels of Program Capacity in COD
Adapted from CSAT, 2005a, Substance Abuse
Treatment for Persons With Co-Occurring
Disorders, TIP 42
38
Principles That Guide Provider Activity For
People With COD

• Co-occurring disorders must be expected and
  treatment approaches should incorporate this
  assumption in all screening, assessment and
  treatment planning.
• Within the treatment context, both co-occurring
  disorders are considered of equal importance1.
• Empathy, respect, and the belief in the
  individuals capacity for change are fundamental
  provider attitudes.
• Treatment should be individualized to accommodate
  the specific needs and personal goals of unique
  individuals in different stages of change.

1Adapted from original
Center for Substance Abuse Treatment. 2005e
39
Building Blocks for Constructing a Co-Occurring
Treatment System
Infrastructure
Clinical Capacity
Evaluation and Monitoring
Information Sharing
Certification and Licensure
Evidence and Consensus- Based Practices
Workforce Development and Training
Financing Mechanisms
Systems Change
Screening, Assessment, Treatment Planning
Definitions, Terminology, Classification
Services Integration
40
Conclusion

• Much has been accomplished in the field of COD in
  the last 10 years, and the knowledge acquired is
  ready for broader dissemination and application.
• The importance of the transfer and application of
  knowledge and technology has likewise become
  better understood.
• New government initiatives (for example, COSIG,
  COCE, and MHT) are underway that improve services
  by promoting innovative technology transfer
  strategies using material that reflect the recent
  advances in the field.

Source Center for Substance Abuse Treatment.
2005a
41
References

• Center for Substance Abuse Treatment. 2005a.
  Substance Abuse Treatment for Persons With
  Co-Occurring Disorders. Treatment Improvement
  Protocol (TIP) Series, Number 42. DHHS Pub. No.
  (SMA) 05-39920. Rockville, MD Substance Abuse
  and Mental Health Services Administration.
• Center for Substance Abuse Treatment (CSAT).
  (2005b) Screening, Assessment, and Treatment
  Planning. Co-Occurring Center for Excellence
  (COCE) Overview Paper No. 2. DHHS Publication No.
  (SMA) XX-XXXX. Rockville, MD Substance Abuse and
  Mental Health Services Administration (SAMHSA),
  and Center for Mental Health Services (CMHS).
  Retrieved online 09/08/06 at http//coce.samhsa.go
  v/cod_resources/index_right_2.aspx?obj77.Center
  for Substance Abuse Treatment. 2005d. Services
  Integration. COCE Overview Paper. Rockville, MD
  Substance Abuse and Mental Health Services
  Administration.
• Center for Substance Abuse Treatment. 2005c. The
  Use of Evidence- and Consensus-Based Practices in
  Treating Persons With Co-Occurring Disorders.
  COCE Overview Paper No. 4. Rockville, MD
  Substance Abuse and Mental Health Services
  Administration.
• Center for Substance Abuse Treatment. 2005d.
  Services Integration. COCE Overview Paper.
  Rockville, MD Substance Abuse and Mental Health
  Services Administration.
• Center for Substance Abuse Treatment. 2005e.
  Overarching Principles in the Planning,
  Implementation, and Delivery of Service for
  Persons with Co-Occurring Disorders. COCE
  Overview Paper. Rockville, MD Substance Abuse
  and Mental Health Services Administration.
• De Leon, G., Sacks, S., Staines, G.,
  McKendrick, K. 2000. Modified therapeutic
  community for homeless MICAs Treatment Outcomes.
  American Journal of Drug and Alcohol Abuse,
  26(3), 461-480.
• Drake, R., O'Neal, E.L., Wallach, M.A. (2007)
  A Systematic Review of Research on Interventions
  for People with Co-occurring Severe Mental and
  Substance Use Disorders. Journal of Substance
  Abuse Treatment, special issue, accepted for
  publication.
• French, M.T, McCollister, K.E., Sacks, S.,
  McKendrick K. De Leon, G. 2002. Benefit-cost
  analysis of a modified TC for mentally ill
  chemical abusers. Evaluation and Program
  Planning, 25(2), 137-148.

CSAT/SAMHSA COCE OVERVIEW PAPERS CAN BE
DOWNLOADED AT http//coce.samhsa.gov/
42
References

• Grant, B.F., Stinson, F.S., Dawson, D.A., Chou,
  S.P., Dufour, M.C., Comptom, W., Pickering, R.P.
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  substance use disorders and independent mood and
  anxiety disorders. Archives of General
  Psychiatry, 61, 807816, 2004.
• Kessler, R.C., McGonagle, K., Zhao, S., Nelson,
  C.D., Hughes, M., Eshleman, S., Wittchen, H., and
  Kendler, K. Lifetime and 12-month prevalence of
  DSM-IIIR psychiatric disorders in the United
  States Results from the National Comorbidity
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• Mueser, K.T., Torrey, W.C., Lynde, D., Singer,
  P., Drake, R.E. 2003. Implementing
  evidence-based practices for people with severe
  mental illness. Behavior Modification, 27(3),
  387-411.
• Sacks, S., Sacks. J.Y., De Leon, G., Bernhardt,
  A.I. Staines. G.L. 1997. Modified therapeutic
  community for mentally Ill chemical abusers
  Background influences Program description
  Preliminary findings. Substance Use and Misuse,
  32(9), 1217-1259.
• Sacks, S., Sacks, J.Y., McKendrick, K., Banks,
  S., Stommel, J. 2004. Modified TC for MICA
  Offenders Crime Outcomes. Behavioral Sciences
  The Law, 22, 477-501.
• Sacks, S., Banks, S., McKendrick, K., Sacks, J.,
  Cleland, C. 2007. Modified Therapeutic
  Community for Co-Occurring Disorders A
  Research Synthesis Using Meta Analysis. Submitted
  to the American Journal on Addictions.
• Substance Abuse and Mental Health Services
  Administration. 2002.Report to Congress on the
  Prevention and Treatment of Co-occurring
  Substance Abuse Disorders and Mental Disorders.
  Rockville, MD Substance Abuse and Mental Health
  Services Administration.
• Substance Abuse Mental Health Administration.
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  Rockville, MD Office of Applied Studies.

43
Contact informationStanley Sacks,
Ph.D.Director, Center for the Integration of
Research PracticeNational Development
Research Institutes, Inc.71 W 23rd Street, 8th
FloorNew York, NY 10010tel [phone] ? fax
212.845.4650http//www.ndri.org ?
stansacks_at_mac.com
European Federation of Therapeutic Communities
Conference Ljubljana, Slovenia ? June 2007