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Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

Recovery Oriented Systems of Care

Sean Bear, BA, CADC

National American Indian/Alaskan Native ATTC

Funded by: • The National American Indian and Alaska Native Addiction Technology Transfer Center is supported by a grant from SAMHSA/CSAT.

• The content of this publication does not necessarily reflect the views or policies of SAMHSA or HHS.

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Overview of the Presentation• Introduction to the National American Indian and Alaska Native Addiction Technology Transfer Center

• Project/Program Design• Community buy-in• Assessing Needs of the Community• Alternative methods of engagement• ROSC • Best Practices

Learning ObjectivesBy the end of the workshop participants will be able to: 1) List two challenges that can impede the process of ROSC

when working in Native Communities2) List two effective approaches to complete a CBPR-based

needs assessment, intervention, an evaluation for the use of ROSC with Native Communities

3) List two methods of integrating/utilizing ROSC with Native Communities.

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ATTC Network 2012 – 2017

National Focus Areas 2012-2017

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Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

National American Indian and Alaska Native ATTC

2012 to 2017

Our Mission

Serve as the national subject expert and key resource on adoption of culturally

legitimate and relevant addiction treatment/recovery services to support professionals working with AI/AN clients with substance use and other behavioral

health disorders and the AI/AN behavioral health workforce.

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Target Population

• Behavioral health workforce providing treatment for American Indian and Alaska Native clients– Recovery support specialists

• Trainers• Educators• Clinical supervisors• Future leaders in behavioral health organizations

Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

ROSC with Native Communities

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Program Philosophy• A Holistic recovery model of care, influenced by current science

surrounding addiction treatment

• Whole Person care deflects the stigma associated with substance use and mental health issues, and allows for a broader understanding of behavior and beliefs

• Promote and facilitate health and overall wellness through the provision of medically-monitored treatment, evidence-based clinical approaches, and in respect to the community beliefs and practices through recognizing and responding to social determinants of health and well-being

Program Overview• Design a safe environment that assist clients in reducing physical,

cognitive, social, and environmental barriers to improved overall health

• Collaborate with other programs, providers, and local traditional, spiritual, or medicine peoples to fill specialized service needs within a continuum of care that seeks to promote positive change, integrate service delivery, and facilitate client referrals to needed services

• Partner with a local organizations or programs to provide long term programs for men, women, women with children, and youth with

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Holistic Healing Environment• Holistic health care environment should reflect the value placed on client care

• Work with local artists, potters, craftsman, quilters, traditional attire making, pow-wow outfit making peoples

• Recognize research that indicates a healing environment can: reduce client stress, reduce the need for medications, and provide for the improved psychological well being of clients and staff

Needs AssessmentAssessing client needs and developing program goals and objectives involves the collection of various data and input from both clients and staff:

◦ Formal assessment of client health domains and addiction severity, as well as review of aggregate data gathered by DAANES (Drug and Alcohol Normative Evaluation System)

◦ Incorporate input from clients through the use of questionnaires (before, during, and after), groups, client suggestion box, and surveys (i.e.,. satisfaction)

◦ Use of clinical staff meetings and staff suggestion box to illicit ideas and strategies pertaining to systems improvement, client-centered care and workforce development

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Tribal Cultural and Spiritual Assessment

• Cultural Assessments– Songs– Dances– Dress

• Ethnic Identity• Ethnic Self-esteem• Special Knowledge and Skills

– Stories and legends– Art work– Quill work– Beading

Program Development • Develop programming specific to the population served • Programming may include:

– Daily client orientation groups

– Nurse-led health education groups

– Facilitation of Stages of Change, motivational enhancement, psycho-educational and interactive groups

– Activities groups

– Community-led self-help groups

– Peer support through volunteer “Peer Advocates”

– Sweat Lodges, Talking Circles, Walk, Exercise

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Program Design• Provide clients with skills development, information, structure, and the

opportunity to engage in the change process

• Program content, intensity and design based on length of stay as well as the physical, developmental, emotional, cognitive, and social characteristics of clients

• Utilize current science in the Behavioral and Public Health fields, but also traditional, spiritual, and medicine practices and beliefs to serve as a guide to program design, with the vision of providing “Holistic Health care”

Relationship Issues and Context

• Age• Ethnicity• Recovery Status• Religion• Sexual Orientation• Disability• Gender• Race• Education

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Evaluation Programs and services should be monitored and evaluated to determine their effectiveness in reducing the recurrence and amount of substance use among those served. Outcome

Evaluation involves the on-going collection of input from clients and staff to develop and refine specific program goals and objectives

Outcome data (such as that collected from DAANES reports) assist in measuring trends and the long term impact of interventions

A combination of process and outcome evaluation methods can be used to measure program effectiveness

Integration• Coordinate client care with chemical dependency assessment teams, case managers, and mental health service teams (Urgent Care & Crisis Stabilization), all co-located at one location if possible

• Pursue options to better integrate behavioral health services with primary health care that are respectful and utilize Native practices, values, and beliefs

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• Current science in behavioral health indicates that an ecological model of care is a promising practice and a driving force behind the Affordable Care Act

• Pursue a “Health Home” model that attends to the diverse influences on client health

• Detoxification services should not operate in a vacuum, separate from other health care in order to assist in reducing stigma

Integration (cont.)

• An Ecological Model of care can be operationalized within the framework of a “Health Home”

• Health Homes attend to whole person care, with the proper “dosage” of service delivery, with a longitudinal approach

• Health Homes strive to meet the physical, psychological, environmental, social and spiritual needs of clients

• Detoxification services should be fully integrated with other medical and social services

Health Homes

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• Many agrees with current science that has established addiction as a chronic disease of the brain

• As with other chronic diseases, addiction has a physical genesis that often leads to a maladaptive pattern of behavior with physical, emotional and psychological consequences

• The disease creates the behavior, not the other way around

Chronic Disease

• Treatment of addiction requires behavior change, similar to the treatment of other diseases

• Current theories surrounding behavior change assist in recognizing obstacles to achieving and maintaining better health

Chronic Disease(Cont.)

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SummaryBe diligent in evolving to better meet client needs through evaluation, program development, use of evidence-based practices, improved service integration, and the use of Best Practices, such as Experienced based practices that have been utilized with local Native tribes

Prevention• Strengthen relapse prevention skills• Rebuild positive support networks

–Old habits must be broken and remade• Sustain one’s connection to traditional practices

–Make this a daily practice• Rebuild trust with loved ones

–For client and their loved ones• Seek employment, education, or trade

–Stay busy, don’t stagnate• Attend to one’s overall health care/needs

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Positive Prevention and Intervention Strategies for Reservation Settings

• Youth prevention activities• Juvenile Detention Centers• School and after-school programs• Summer programs• Increasing number of cultural programs:• Learning the language, wacipi dancing, learning songs for various

occasions, equine therapy, canoe program, ropes program etc.• Increasing number of spiritual ceremonies being attended by

various age groups• Other

RECOVERY ORIENTED SYSTEM OF CARE (ROSC):“IT TAKES A VILLAGE”

Chronic disease and continuum of care

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From Intake to continuum of care and sustained recovery

• Detox : acute care• Addiction is not an acute illness, but oftentimes a chronic illness

– Acute treatment + Aftercare= Improvement– Acute treatment with no aftercare= poor outcome– Continuing care= Improvement– No Continuing care = Poorer outcomes

• Thinking beyond treatment: It tales a village– Recovery takes place in a community– Community involvement

• Toward integrated care– Mental health, physical health, emotional and spiritual health

Important other factors for recovery

• The longer people stay in treatment the likely it is that the person will recover

• Other factors– Natural recovery

– Lack of dose effect• More expensive treatments were not generally more effective

– Evidence based approaches

– Experienced based approaches

– Culturally informed approaches

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Other issues in treatment and prevention of substance use disorders

• Expert model:– Treatment delivered to correct a deficiency

– Sometimes overlooking the protective factors

• Important to not overlook strengths– in the person

– In the family

– In the community

• Treatment works

Recovery oriented system of care• Treatment agencies are considered one of many resources for the client

• No one source is more important than another• Various support systems need to work together very closely with the client

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V

ROSC support person-centered and self-directed approaches to care that build on the personal responsibility, strengths, and resilience of individuals, families and communities to achieve health,

wellness, and recovery from mental disorders.

IndividualFamily

Community

Recovery

Wellness Health

ROSC offer a comprehensive menu of services and supports that can be combined and readily adjusted to meet the individual’s needs and chosen pathways to recovery.

IndividualFamily

Community

Family/Child Care

Housing/Transportation

Financial

Legal Case Mgt

VSO & Peer Support

Physical Health Care

PTSD &Mental Health

Alcohol/Drug Services

VocationalEducation

Spiritual HIV Services

Services & Supports

Recovery

Wellness Health

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ROSC encompass and coordinates the operations of multiple systems…

IndividualFamily

Community

Family/Child Care

Housing/Transportation

Financial

Legal Case Mgt

VSO & Peer Support

Health Care

PTSD & Mental Health

Alcohol/Drug Treatment

Vocational

Educational

Spiritual

Addiction Services System 

Mental HealthSystem

Primary Care System

Child  Welfareand FamilyServices

Housing System

Social Services

Health Insurance

DoD & Veterans Affairs

Indian HealthServices

Criminal JusticeSystem

Vocational Services

HIV ServicesFaith Community

HealthWellness

Services & Supports

Systems of Care

Recovery

It takes a village

• Recovery-oriented care

• Continuum of care

• Recovery schools• Community engagement

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Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

An Integrated Behavioral Health Healing and Recovery Model with

Native American Populations

Best Practices in Counseling Native Americans

•Build Relationships with local Native communities• Incorporate attention to spirituality into counseling•Reduce administrative obstacle to receiving care• Inform clients of confidentiality rights•Coordinate community resources with prioritized clients needs in a manner consistent with the client’s diagnoses

• Thomason, Timothy (2011). ‘‘Best Practices in Counseling Native Americans’’, Journal of Indigenous Research. Vol. 1, issue 1, Article 3.

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An Integrated Behavioral Health Healing and Recovery Model with Native American

Populations

Red Road

Cultural Spiritual

AA

Acupuncture

Alternative Healing

Art Therapy

Behavioral

Cognitive

Emotional

Meditation

Motivational Interviewing

Other

Relative(Client)

Navajo Way

Western EasternOther

Culture Informed Best Practices

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The Red Road Approach

The innate cultural/spiritual resources of an indigenous (Native American) person are a focus of this treatment approach. Cultural and spiritual information are a normal part of the treatment regimen. When and where appropriate, spiritual ceremonies are included in treatment and aftercare plans.

Teaching

• Spiritual Road that we all travel (Individualized) throughLife in order to Learn what we have come to Learn

• Brain-Heart Connections Male-Female –Androgynous

• Longest and Hardest path one will ever take

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• Evidence-Informed Culture-Based Intervention in American Indian and Alaska Native Communities

Evidence-Based Practice in Tribal Communities

• Lessons on Evidence-Based Practice in Tribal Communities:

–Utilizing Tribal leadership and community input into theadaptation of intervention–Cultural sensitivity and competence of staff–Building programs on cultural strengths and customs of community

• Walker, R. D., Bigelow, D. A. (2015). ‘‘Evidence-Informed, Culture-Based Intervention and Best Practices In American Indian and Alaska Native Communities’’.

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Culture Informed Best Practices

• This approach respects and accommodates•Culture-based knowledge, skills, ceremonies, valuesstories etc.•Ways of knowing•Practices, social services in AI/AN communities•Facilitates the derivation of new and improved culture-based intervention

• Walker, R. D., Bigelow, D. A. (2015). ‘‘Evidence-Informed, Culture-Based Intervention and Best Practices In American Indian and Alaska Native Communities’’.