Towards integrated dual disorder treatment in the Netherlands. Symposium S3-61, Friday, 7 October 2011

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1 Towards integrated dual disorder treatment in the Netherlands. Symposium S3-61, Friday, 7 October 2011

2 Who are we? LEDD 4 Mental health care institutions and Trimbos Institute Goal: central base of knowledge and experience Activities Website: downloads, information, literature Bi-annual conferences 'Meet-the-expert' Platform meetings Advice Training Supervision Implementation projects Products

3 Implementing integrated treatment in The Netherlands, the Dutch experience. Anneke van Wamel

4 Treatment models Sequential Parallel

5 Consequences One disorder remains untreated Were to begin and when to stop? Limited or no communication Separate treatments, different views Client responsible for integration Thresholds for both treatment systems Result: client slips through the net and receives no help, no one takes responsibility

6 IDDT Principles Integrated treatment one multidisciplinary team of dually trained professionals based and working from one location integrated treatment of both disorders treatment matches motivational stage of change of client

7 Family Psycho education Motivational Interviewing Stage-Wise Interventions Pharmacological Treatment IDDT Outreach Alcohol & Drug Self- Help Groups Group DD Treatment

8 Stages: a means to an end Stage of change Precontemplation Contemplation Preparation Action Consolidation Stage of treatment Engagement Pursuasion/motivating Pursuasion/motivating Active treatment Relapse prevention

9 Implementing IDDT pilot study High fidelity implementation of IDDT in 5 out patient mental health teams Deciding whether integrated treatment can be implemented in the Netherlands

10 Implementing IDDT Breakthrought project Dual disorders -7 breakthrough teams/ 6 institutions - Using screening instruments - preventing underdiagnosis - Uniform care allotment, regardless of where people enter care -Using available DD guidelines and toolkit IDDT

11 Implementing IDDT 2009 LEDD Current projects

12 Other dual disorder services -Clinical and outpatient facilities - Forensic/DD teams - ACT/DD teams - Youth/adolescents DD teams

13 Integrated treatment for patients with personality disorders and addiction A. Dijkhuizen

14 Integrated treatment for patients with personality disorders and addiction relationship personality disorders <> SUD Integrated Dual Disorder Treatment stagewise implementing IDDT fidelity scale results research results CCM

15 Relationship SUD <> PD Experience greater benefit from the pharmacologically induced effects of psychoactive drug use Are more likely to engage in substance use at an earlier age and polydrug use with greater frequency Are more likely to develop substance dependance Are more vulnerable to having a compulsive and rigid substance use pattern Are more vulnerable to relapse Have more difficulty working cooperatively and collaboratively with service providers (Ekleberry, 2009)

16 Therapy / treatment SUD <> PD Clinical settings Therapeutic communities (hierarchical, CBT) Ambulatory settings Dual Focused Schema Therapy (Ball & Young, 1998) Dialectische Behavioral Therapy-Substance (Linehan,1999) IDDT

>>> Why IDDT <<< The difficult to treat patient (Clinical casemanagement) severe personality disorders [extreme traits] [GAF < 50] substance use disorders (80%) no working alliance no

17 >>> Why IDDT <<< The difficult to treat patient (Clinical casemanagement) severe personality disorders [extreme traits] [GAF < 50] substance use disorders (80%) no working alliance no or a slight motivation extreme demand, acting out, crisis, countertransference chronic clients, incapable, negative consequences > experienced necessity for an adequate model of treatment

18 Integrated Dual Disorder Treatment A simultaneously and coordinated offered treatment of both psychiatric disorders and substance use disorders by one therapist or team trained and skilled in both forms of treatment, through which the patient sees himself addressed in a consistent way with the same philosophy and attitude. (Mueser, Noordy, Drake, Fox, 2003)

19 Implementing Integrated Treatment System society addiction institute insurrance companies Board of Directors change Organisation Board of Directors programleaders managers individual workers Clinical practice managers individual workers patients (

20 Where do you place your institute? Your team? / you in your professional behavioral change? precontempletion relapse contempletion maintenance preparation action Adapted from Prochaska & DiClemente (1982), Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research, and Practice, 19:

21 Stagewise implementing integrated treatment Fase Change precontemplation contemplation preparation action maintenance Implementation not aware / not interested consensus motivation implementation maintenance System change Organisation Clinical practice (

22 Implementing IDDT contempletion 1. Conduct a needs assessment 2. Develop awareness of available options 3. Identify current practices and rationales 4. Examine your mission, values, goals and vision 5. Check it out 6. Engage technical assistance 7. Assess pros and cons 8. Develop informed consent and consensus 9. Explore concerns

23 Implementing IDDT action 1. Conduct a baseline fidelity review 2. Develop a baseline fidelity action plan 3. Develop stage-wise interventions 4. Acquire and integrate training 5. Engage in clinical consultation 6. Provide stage-wise interventions 7. Develop and monitor outcomes 8. Continue to educate and train stakeholders 9. Address barriers 10.Address unintended consequences

24 Why measuring fidelity? 5 4 Starting point < implementing Efforts and results becoming noticeable Results are decisive for objectives; offer handles for plan of action Comparison: internal and external Model fidelity is equal to good implementation meting 1 meting 2 meting 3

25 4,5 Clinical casemanagement measurements 4,0 3,5 3,0 2,5 2,0 Fidelity GOI 1,5 1,0 0,5 0,0 T1/12-04 T2/12-05 T3/12-06 T4/01-11

26 Plan of action Trimbos-instituut

27 Research : SCL-90 Fear Agoraphobia Depression Physical problems Insufficiency of thinking and acting Distrust and interpersonal sensitivity Hostility Sleeping problems Total score psychoneurosis (R. Stals, 2010)

28 Research : VKP General criteria PD Paranoid PD Schizoid PD Schizotypal PD Antisocial PD Borderline PD Histrionic PD Narcissistic PD Avoidant PD Dependant PD Obsessive compulsive PD (R. Stals, 2010)

29 Research conclusions Significant changes in problems experienced Patients learned to cope Change in SUD limited to case report > ROM (R. Stals, 2010)

31 Group treatment for dual disorder patients Martje van Giffen

32 Basic principles derived from the IDDT model stagewise treatment groups

33 Attitude patient centered garantee of safety and trust emphasis on peer conversation and feedback basic principles Motivational Interviewing basic principles Solution Focused Therapy empowerment and rehabilitation

34 Stagewise dual disorder groups

35 Precontemplation Goal: building confidence and raising doubts low threshold building confidence seduction basic information about mental illnesses and psycho-active substances open groups playful (games, exchange, quizzes, internet) contingency management

36 Resolving ambivalence

37 Contemplation Goal: awareness of risks of substance abuse and decision making open groups, on a voluntary base outreach and seduction safety and privacy psycho-education: interaction psychiatric symptoms and psycho-active substances exchange, recognition and feedback among peers support

38 Active treatment Goal: lifestyle change closed groups selfcontrol and relapse prevention support from peers and important others CBT principles rehabilitation relapse offers opportunity to learn!

39 Usable methods An upward spiral Workbook for greater selfcontrol over drug use

40 Relapsepreventiongroups Goal: recovery and rehabilitation closed or open groups based on twelve step program exchange with and support from peers and important others Dual Recovery Anonymous

41 Evidence one of the effective IDDT components (Drake) grouptreatment as effective as individual treatment (2001, Jaap van der Stel) essential elements: motivation, selfcontrol, relapseprevention and CBT principles important: patient centered, structured and directive (2001, Jaap van der Stel)

42 According to patients satisfied growing awareness of risks growing motivation to reduce or stop growing selfesteem appreciate exchange and support appreciate motivational spirit

43 Housing for dual disorder patients in the Netherlands Christien Muusse

44 Current situation Housing options for DD patients in the Netherlands: independent living: ambulantory care & housing support residential facilities: -part of mental health agency /independent organization -(permanent) shelter for homeless

45 Residential programs & DD Residential facilities for DD are important: Vulnerability to housing instability and homelessness. Housing instability makes engagement in treatment & recovery more difficult. Offer safe & protective living.

46 3 problem domains I. Availability: many DD clients live in a facility not suitable for DD II. Challenges concerning safety & controlling substance abuse III. Problems with proper/fitting support

47 some experiments with specialized facilities stage-wise facilities: tailored to meet the needs of clients at different stages of treatment Mueser at al 2003

48 good practice: wet housing hostel project in Utrecht permanent shelter for long-term drug users strict agreements on & monitoring of nuisance in neighborhood services provides by dual perspective: -reducing nuisance & -improving quality of life

49 good practice: damp housing specialized residential program Bavo europoort: facilities differentiate in restrictions on use. (soft drugs) special attention for dual disorders: open attitude towards substance use, persuasion groups, involvement of family, & training of staff in dealing with DD. linked to ACT-team that offers treatment

50 good practice: dry housing WTC Mentrum: substance-free living & training center. Offers: a combination of rehabilitation, supported living, training in living skills and relapse prevention. Personal support and alignment with ambulant case manager. Focus is on retaining suitable housing & rehabilitation

51 current problems: I:Availability: many DD clients live in a facility not suitable for DD II problems concerning safety & controlling substance abuse III. problems in support Elements of IDDT useful in offering supported living to DD clients: continuity of care open attitude towards substance use. stage-wise approach: facilities tailored to meet the needs of clients in different stages of treatment,

52 Plans for the future? LEDD receives growing amount of questions concerning supported living. Plans: Analysis of good practices and it s working elements (financed by ministry of health 2012.) Composing a toolkit with guidelines. Offering a platform to share experiences.

53 Barcelona 2011 Bas van der Hoorn

54 The (Dutch) rapid changing environment...needs IDDT (?) Bas van der Hoorn

55 IDDT, everybody benefits(?) Europe today The changing environment Why implement IDDT now?

57 Changing environment More severely ill DD population: involuntary treatment housing problems more aggression new, more potent drugs on market Social values regarding treatment, addicts and general safety Reduce criminal behavior by treatment Expected shortage high professionals And. Overall cut down in expences!

58 Financing health Differences in financing healthcare: Stimulating market forces and strategic planning Rewarding productivity Diagnostic treatment combinations (Fixed prices, combinations!) Still lots of governmental control

59 Financing (psych) health To gain control over expending costs: Health care production limit 3 sponsors (Health Assurance comp., Justice, local gov.) Leading to: More burocracy Inflexibility More risks for health institutions Institutions favor low risk & high benefit care! Merging companies to gain power

60 Mental health challenges Gain favourable market position by: Minimizing costs Less inpatient, more outpatient care Raising productivity (expanding, merging) Raise efficiency Innovations on specialities, or Synergetic cooperation forcing excellent mental health care model of IDDT

61 IDDT as vehicle to.. Nat. Center of excellence on DD treatment Increase professional integrity Increase efficiency Decrease hospitalisation, favouring (cheaper) outpatient care Increased hospitality in mental health care Higher satisfaction among both patients as professionals Stimulate bottom up implementation Transparent health care

62 Discussion Sonja van Rooijen: Anneke van Wamel: Albert Dijkhuizen: Martje van Giffen: Christien Muusse: Bas van der Hoorn:

Implementing integrated treatment for dual disorders in The Netherlands: lessons learned. Anneke van Wamel

Implementing integrated treatment for dual disorders in The Netherlands: lessons learned Anneke van Wamel Who are we? LEDD 4 Mental health care institutions and Trimbos Institute Goal: central base of