Supervising to the Treatment of Co-occurring Disorderss. Tianna D. Nelson, PhD, LMFT October 10, 2017

Transcription

1 Supervising to the Treatment of Co-occurring Disorderss Tianna D. Nelson, PhD, LMFT October 10, 2017

2 Most people do not listen with the intent to understand. Most people listen with the intent to reply. Stephen R. Covey

3 HOPE

4 What is Clinical Supervision for Co-occurring Issues? SAMSHA/CSAT Treatment Improvement Protocols defines supervision as a disciplined, tutorial process where principles are transformed into practical skills, with four overlapping foci: administrative, evaluative, clinical, and supportive (Powell & Brodsky, 2004, p. 11). Supervision is a social influence process that occurs over time, in which the supervisor participates with supervisees to ensure quality of care. Effective supervisors observe, mentor, coach, evaluate, inspire, and create an atmosphere that promotes self-motivation, learning, and professional development. They build teams, create cohesion, resolve conflict, and shape agency culture, while attending to ethical and diversity issues in all aspects of the process. Such supervision is key to both quality improvement and the successful implementation of consensus- and evidence-based practices (CSAT,2007,p. 3).

5 What is Clinical Supervision for Co-occurring Issues? Clinical supervision is an interactional process between supervisor and supervisee that promotes the development of responsibility, skill, knowledge, attitudes, and ethical standards in the practice of clinical work - Melanie Stern, LCSW Clinical supervision is an interactional, parallel, collaborative, and learning process between supervisor and supervisee that promotes quality assurance that (1) each and every individual client is receiving the best care possible; and,(2) the development of both supervisee and supervisor of responsibility, clinically evidence-based and promising, culturally sensitive practices, knowledge, attitudes, and legal and ethical standards are regarded in clinical work and the advancement of the profession Tianna Nelson, PhD, LMFT

6 What is Clinical Supervision for Co-occurring Issues? What does clinical supervision mean to you as a supervisor? What does clinical supervision mean to your colleagues/supervisees? What layers of clinical supervision exist for your agency, e.g. county contracts What are the expectations for clinical supervision from your supervisees, yourself, your agency, the profession? Helping clinicians understand why they do what they do, how they do what they do, reflective process, and understanding their own theory of change vs. their clients theories of change vs. clinical supervisor s and agency s theory of change

7 What is Clinical Supervision for Co-occurring Issues?

8 Concept of Co-occurring Models of Integration Clinical supervision for co-occurring issues requires a foundational understanding of the theoretical models one has for integrated health care. For some practitioners, the model may mean a psycho-social format, while for others, this model may include a bio-psycho-social understanding. It is important to understand not only your personal perspective of the concept of integrated care, but also, your supervisee s perspective, your agency s perspective, and the greater health care system in which you operate.

9 Concept of Co-occurring Models of Integration Physical Health Substance Use Mental Health

10 Concept of Co-occurring Models of Integration Physical Health Substance Use Mental Health

11 Concept of Co-occurring Models of Integration Mental Health Physical Health Mental Health Substance Use

12 Concept of Co-occurring Models of Integration It is important to understand that similar to knowledge, Mental models Health of integration are not static they evolve If one s theory of change is that the self is ever-evolving, there are multiple layers of parallel processes of which to be aware: the client s process, the client/clinician relationship, the clinician/clinical supervisor relationship, clinical supervisor/clinical supervisor relationship, and the relationship to agency and system all of these have impact on one another either supporting development or posing barriers in coordination of care.

13 Concept of Co-occurring Models of Integration Mental Health

14 Concept of Co-occurring Models of Integration Mental Health Minkoff s Complexity Challenge: As health care providers, we can either accept the challenge and welcome every opportunity for every client need, or we subject ourselves to a lower quality of care for our clients. To be a cooccurring provider is to welcome every individual that walks to our front door and help him/her navigate a very complicated health-care system e.g. 22-year-old single Laotian mother of 3 children, victim of domestic violence, methamphetamine/marijuana abuse, who has been charged with welfare fraud, with a previous history of suicide attempt and chronic depression.

15 Concept of Co-occurring Models of Integration Mental Health Minkoff s Complexity Challenge: As a clinical supervisor, how do you apply this challenge to your practice model? (reflection) As a clinical supervisor, how do you encourage and promote your supervisee to apply this challenge to his/her practice model? (reflective practice) How do both of you apply this challenge (belief system) to your system of care?

16 Concept of Co-occurring Models of Integration Mental Health In addition to understanding from which model of co-occurring care your agency is operating, it is equally important to understand your theoretical model for clinical supervision: Developmental strengths, opportunities, areas for growth Orientation-specific family, CBT, adolescent-devt., etc Discrimination teacher, counselor, consultant Understanding your personal learning style as well as the unique learning style of your supervisees enhances the clinical supervision relationship.

17 Concept of Co-occurring Models of Integration Mental Health Clinical supervision should: 1) Be safe 2) Ethical 3) Collaborative 4) Sensitive to learning styles 5) Transformative 6) Adhere to clinical standards of care and practice guidelines 7) Culturally competent 8) Be within the scope of the supervisor s practice

18 Concept of Co-occurring Models of Integration Mental Health A note about cultural competency: Often, culture and/or diversity do not come up in supervision, either due to the lack of knowledge of supervisor or supervisee. Multi-cultural competence includes knowledge of clients culture and status, actual experiences with these clients, and the ability to devise innovative strategies vis-à-vis the unique client s needs (Ponterotto and Casas, 1987, p. 433) Multi-cultural competence also includes integrated awareness of one s own multi-diverse background (Falender and Shafranske, 2010, p.122).

19 Concept of Co-occurring Models of Integration Mental Health Clinical supervision of co-occurring issues should: Be all of the above and additionally address the the dance of co-occurring issues with equal sensitivity throughout the treatment episode from welcoming the client and client s family/support members to intake, assessment, treatment, discharge, and aftercare.

20 Concept of Co-occurring Models of Integration Mental Health BREAK

21 The Dance of Co-occurring Issues The Report of the Center for Mental Health Services Managed Mental Health Care Initiative: Clinical Standards and Workforce Competencies Project Co-Occurring Mental and Substance Disorders Panel: Created a standards of care, practice guidelines, workforce competencies, and training curricula the panel consisted of experts in the field of co-occurring care and was chaired by Minkoff. The panel designed a set of core elements in the standard of care of individuals struggling with co-morbidity who enter a managed care system.

22 The Dance of Co-occurring Issues 1. They must create a system of care that welcomes cooccurring diagnosis consumers and families at every Mental Health level. 2. There must be a system of access that can accommodate people with co-occurring disorders no matter where or how they present. 3. Managed care entities must implement program integration throughout the system of care. 4. Managed care entities need to create system structures which promote the initiation and maintenance of continuity of clinical responsibility regardless of point of entry (competent clinicians and/or integrated programs).

23 The Dance of Co-occurring Issues 5. Treatment must be individualized to accommodate the Mental Health specific needs of different subtypes of co-occurring individuals it is necessary that co-occurring services are the responsibility of the entire system of care, and that gaps in services for specific consumers are identified and addressed (e.g. adolescent residential substance use treatment and special education needs of certain youth) 6. Create formal quality management structures (clinical supervision and quality improvement) which include consumers and their families in the design and oversight of an integrated continuous and comprehensive delivery system.

24 The Dance of Co-occurring Issues Mental Health The panel encouraged establishing a set of standards for the system as a whole with this in mind, the mission statements of each entity in the system of care should welcome co-occurring individuals and their families/support systems this does not equate provision of the actual services needed at each entity, rather the intention of the standards is to provide hope and optimism that at some place in the system, the individual s treatment needs are capable of being met, and, the system as a whole will take responsibility for helping co-occurring individuals and their families/support navigate that system of care and determine the recipe for their individual care.

25 The Dance of Co-occurring Issues Mental It is Health our responsibility as clinical supervisors (and program managers) to ensure that all clinical operations are also directed to the accomplishment of that same mission. (Standards of Care, Practice Guidelines, p. 17) Then we must ask, what are our biases in treatment? How might these biases impact our responsibility?

26 The Dance of Co-occurring Issues What is the dance of co-occurring issues? Co-occurring disorders are treated as dual primary disorders, in Mental which Health each disorder receives specific and appropriately intensive treatment simultaneously. (p.34) Therefore, clinical supervision is a reflection of these primary disorders, deserving equal/equitable attention in guiding clinicians to determine just exactly what the dance entails a) how does an individual s substance use pattern impact the individual s mental health disorder? b) how does an individual s mental health symptomology impact the individual s pattern of substance use?

27 The Dance of Co-occurring Issues What is the dance of co-occurring issues? To complicate matters, what cultural sensitivities are there for the Mental individual s Healthpattern of substance use? Likewise, what cultural sensitivities are there for the individual s experience of mental health symptoms? Where does the individual s motivation for change lie? With mental health symptomology relief? Pattern of substance use relief? Both? What is the individual s awareness and/or perception of their cooccurring issues? How does the individual view the dance, if at all? Multiple layers of complexity that must ALL be welcomed with empathy, non-judgment, hope, adaptability, and integration.

28 The Dance of Co-occurring Issues What is the dance of co-occurring issues? According to the panel of experts who created the aforementioned Mental guidelines: Health People with serious mental illness and substance dependence will require more substance use treatment to attain sobriety than people with comparable substance dependence and no mental illness. (p. 34) Clinical supervisors are responsible in a parallel way to treatment providing clinicians of individuals with co-occurring issues to adapt, be flexible, creative, and provide hope as individuals receiving care relapse, traverse varying stages of change, progress in some areas while digressing in others, always keeping in mind the learning style of the client, the learning style of the treating clinician, and any barriers to learning.

29 The Dance of Co-occurring Issues What is the dance of co-occurring issues? Mental What Health is the tempo of the dance? Is the dance new (hip hop) or has it been around for years (waltz)? Is the dance flagrant or subtle? What is the intensity of the dance? How is the dancer surviving because of the dance? Who else is participating in the dance with the dancer? Is the dancer willing to try a different dance?

30 The Dance of Co-occurring Issues Effective clinical supervision requires more than a basic understanding of clinical supervision models, clinical styles, and Mental an understanding Health of evidence-based and promising practices in the field. Effective clinical supervision requires an understanding of: a) your personal scope of practice b) the supervisee s scope of practice c) multiple modalities of treatment d) cultural influences on treatment e) process and outcomes of treatment f) methods for measuring outcomes g) self-evaluative measures for personal growth

31 Mental Health The Dance of Co-occurring Issues

32 The Dance of Co-occurring Issues A note about learning styles: Mental Health Effective clinical supervision is also being aware of not only your supervisee s learning style, but also, your personal learning style. Without understanding these learning styles, the collaborative ability to create knowledge becomes limited and may even inhibit the growth and development of the supervisee, as well as, that of the supervisor.

33 The Dance of Co-occurring Issues As clinical supervisors to co-occurring issues, Mental Health we must reflect on our ability to both weave the web of our understanding of cooccurring issues, as well as, guide our supervisees processes to weave their webs of understanding. Example: the hostile client discussion between supervisees and the supervisors response to this discussion.

34 Mental Health The Dance of Co-occurring Issues

35 The Dance of Co-occurring Issues The client s narrative begins with the walk through the door. The uniqueness and complexity of their narrative brings deep Mental culture Health and diversity, and it is an honor for us to experience it. Imagine, then, in group supervision, how many voices are at the forum of discussion: not one voice free from influence If each supervisee has 5 clients, and there are 5 supervisees and one clinical supervisor, there are a minimum of 26 voices of which to be aware The number of voices, we know, is much greater, as we all bring years of client voices to the table a rich tapestry marked with many opportunities for learning, change, development, and celebration.

36 The Dance of Co-occurring Issues It is important to thread this narrative from engagement to intake to assessment to treatment to cessation of the Mental treatment Healthepisode and aftercare. The language of the dance of co-occurring issues does not end with a comprehensive integrated assessment. The language must continue in all phases of the client s relationship with their clinical team, one of whom is the clinical supervisor. It is our responsibility as the clinical supervisor to ask supervisees how they will measure the progress of their clients and offer feedback based on the information that our supervisees give us about their clients learning styles. It is also our responsibility as clinical supervisors to ensure that we are providing the clinical supervision appropriate to our supervisee s scope of practice.

37 The Dance of Co-occurring Issues Example: Integrated ASAM Mental Dim 1: Health management of withdrawal symptoms hospitalization for substance-induced psychosis Dim 2: medication for seizures Dim 3: history of depression dx, psychosis unspecified Dim 4: willing to work on MH - action harm reduction for substance use contemplative Dim 5: uses when with significant other uses to escape negative emotions Dim 6: no peer support network no current MH provider

38 The Dance of Co-occurring Issues Example: Integrated ASAM Mental Dim 1: Health detox? Who will provide? can symptoms be managed without hospitalization? Dim 2: consent for PCP? Dim 3: willing to take medication? Who will be provider? Dim 4: re-referral, new referral MH resources? supervisee is registered alcohol and drug counselor Dim 5: supervisee capable of addressing supports supervisee to work with LMFT? psychmd? LCSW? Dim 6: supervisee capable of addressing pattern of use supervisee capable of referral - collaborates

39 The Dance of Co-occurring Issues Example: Integrated ASAM Mental Helping Health your supervisee determine the appropriate levels of care for treatment services for ALL needs means understanding the varying levels of care for both Mental Health and Substance Use Treatment Services. Examples: 1) daily meth user with depression history 2) individual with Bipolar, rapid cycling, sporadic mj 3) cocaine runs, mj daily, no prior SUTS, MH? IOT SUTS = IOP MH? NO

40 The Dance of Co-occurring Issues Example: Integrated ASAM Mental In this Health example the clinical supervisor role may act as administrator, consultant, or counselor the added piece is that the clinical supervisor may also provide reflection and oversight of the coordinator of care for the co-occurring issues depending upon the agency s adopted level of integration. a) can all services be received within the agency? b) can all services be provided by one clinician? c) how will the quality of care be insured if spread across multiple agencies? How will the clinical supervision piece be operationalized? These are sample questions of the reflection necessary in clinical supervision of co-occurring issues.

41 Mental Health The Dance of Co-occurring Issues

42 The Dance of Co-occurring Issues l LUNCH

43 INTERVENTION brain exercise

44 Parallel Process/Developmental Model of Clinical Supervision for Co-Occurring Issues Concept of Developmental Model of Clinical Supervision: developmental implies perhaps stages, growth, evolving, and change when applied to the clinical supervision/collaboration process, there is an inherent expectation of individualized learning processes, growth processes, and opportunities for change for supervisees Parallel to this process, is the development also of the clinical supervisor. That is to say that parallel process does not only align with the therapeutic process between therapist/counselor and client, and supervisee and clinical supervisor, but also, the parallel process is emulated in the development of both the supervisee and clinical supervisor.

45 Parallel Process/Developmental Model of Clinical Supervision for Co-Occurring Issues Concept of Developmental Model of Clinical Supervision: Development focuses on strengths, growth areas, and opportunities for change, noting the process throughout supervision. Phase 1 inception of process, learning styles, learning orientations, learning skills, much interaction between supervisee and supervisor, contracts, protocols, the nuts and bolts. Phase 2 trial and error, developing clinical style/ego, promoting challenges, understanding theory applied to praxis

46 Parallel Process/Developmental Model of Clinical Supervision for Co-Occurring Issues Concept of Developmental Model of Clinical Supervision: Phase 3 Supervisee becoming more independent, having a sense of clinical style and orientation, able to step back from clients, more effective boundary setting, having a clinical voice. Phase 4 - Clinical supervision does not halt here understand your agency s clinical standards for ongoing clinical consultation and supervision into higher areas of development

47 Parallel Process/Developmental Model of Clinical Supervision for Co-Occurring Issues Concept of Developmental Model of Clinical Supervision - Regular feedback in verbal and/or written form: 1) Keeping a journal, sharing material 2) Pre and post assessments 3) Reviewing the clinical contract 4) Evaluating areas of strengths, opportunities for change, and areas of life roles, e.g. mother, student, counselor

48 Parallel Process/Developmental Model of Clinical Supervision for Co-Occurring Issues Concept of Developmental Model of Clinical Supervision - Regular feedback in verbal and/or written form: 1) therapist/client relationship 2) therapist/clinical team relationships 3) supervisee/supervisor relationship 4) Supervisee/agency relationship

49 Parallel Process/Developmental Model of Clinical Supervision for Co-Occurring Issues Concept of Developmental Model of Clinical Supervision - Regular feedback in verbal and/or written form: 1) Encourage reflective practice e.g., what do you feel your attitudes are toward diversity and cultural incorporation? What do you feel your strengths are providing honest feedback? How do you feel your ability is to align appropriate resources for the client/clinician? 2) Encourage research e.g., let s see what you can find on reactive attachment disorder; from who are you going to learn about culture, a class or an individual s story?

50 Parallel Process/Developmental Model of Clinical Supervision for Co-Occurring Issues Concept of Developmental Model of Clinical Supervision - Regular feedback in verbal and/or written form: 3) Encourage client feedback do not wait for the treatment plan, check in regularly, how was this for you today? 4) Encourage colleague feedback e.g., what would your peers say about your ability to be empathic? Know the difference between awareness and competence? 5) Model the evaluation process for your clinicians e.g., do you recognize your privilege? If not, how will you model for them to recognize theirs?

51 Parallel Process/Developmental Model of Clinical Supervision for Co-Occurring Issues Concept of Developmental Model of Clinical Supervision - Regular feedback in verbal and/or written form: 6) Ask supervisees their preferred method of evaluation - focuses on learning style and help de-stigmatize the evaluation process as a process of development not judgment 7) Keep clinical supervision records and offer to review them as a way of measuring progress and change CHANGE SHOULD BE ENCOURAGED NOT FEARED!

52 Parallel Process/Developmental Model of Clinical Supervision for Co-Occurring Issues YOU ARE PERFECT AS YOU ARE BUT WHY SHOULD THAT PREVENT YOU FROM STRIVING TO BE BETTER

53 Special Issues for Clinical Supervision for Co- Occurring Issues: 42CFR and Minors Providing co-occurring care for agencies receiving state reimbursement means understanding both of the state regulations for each issue Title 9 and Title 22. It also means understanding the clinical standards, laws and ethics of each domain area, as well as the security and safety of protected health information (HIPAA). Any agency/individual providing any form of recovery service or substance treatment program that receives any federal monies is subject to the privacy restrictions of 42 CFR a higher standard that HIPAA!

54 Special Issues for Clinical Supervision for Co- Occurring Issues: 42CFR and Minors When in doubt err on the side of caution legal advice if contracted with county, seek contract monitor approval and possible county council Issues concerning minors and the privilege of record holding become complicated in co-occurring care Always align with the highest standard for protection of privacy

55 Thank you