Welcoming and Culturally Appropriate Engagement for ......Welcoming and Culturally Appropriate Engagement for Individuals ... Disorders. Ken Minkoff, M.D. Senior System Consultant,

Welcoming and

Culturally Appropriate

Engagement for Individuals

with Co-occurring Mental

Health and Substance Use

Disorders

Ken Minkoff, M.D.

Senior System Consultant,Zia Partners, Inc.

Clinical Assistant Professor of Psychiatry,

Harvard Medical School

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Chris Gordon, M.D.

Medical Director and Senior Vice President for

Clinical Services, Advocates, Inc.

Associate Professor of Psychiatry, Harvard

Medical School

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Jackie Pettis, M.S.N., R.N.

Advisor and Trainer, Recovery to Practice

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1. Describe specific techniques and strategies for welcoming, engaging, and inspiring individuals with co-occurring disorders in psychopharmacologic practice, as well as in other treatment settings.

2. Describe strategies to successfully engage individuals with co-occurring disorders where differences in culture, values, beliefs, and experiences exist between the individual and the provider.

Learning Objectives

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The Complexity Challenge

• Individuals with complex multiple issues have the poorest outcomes in multiple domains.

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The Complexity Challenge

• In order for our system to inspire people and families with serious challenges and multiple issues, every person, including those with the greatest challenges, is inspired when they meet us with hope for achieving a happy, hopeful, productive, and meaningful life.

• ALL services are designed to welcome, engage, and provide integrated services to individuals and families with multiple complex issues (comprehensive, continuous integrated system of care).

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Is This Your Vision?

If so, how do you get there?

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How do we get there clinically?

In recovery-oriented integrated systems of

care, research-based principles of

successful intervention can be applied to

any population in any program by any

person delivering care.

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Principle #1

• Welcome people with complexity as priority customers.

• Remove access barriers that make it hard to be welcomed.

• See all the complex issues: integrated screening and documentation.

Complexity is an expectation.

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Talking with Nick: A Recovery-oriented

Approach

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• We hope that he feels he’s come to the right place.

• We “get” him – that is, we understand him as he understands himself.

Principle #2

• Hopeful goals for a happy life.

• Work with all your issues step by step over time to achieve success.

• Build on strengths used during periods of success.

Service partnerships are empathic, hopeful, integrated, and strength-based.

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We all know that

Good outcomes, especially for people facing complex challenges, are more likely if the person has a good, solid, durable relationship with his or her provider.

Good relationships are much more likely if we get off on the right foot; the process of engagement goes well.

Welcoming Engagement

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• We need to take time to welcome, meet, and get to know the person, not just the problems. Of course, time is in terribly short supply!

• We need to lead with the person’s strengths; meet the person with an open mind and open heart.

• A tone of friendliness, warmth, and neighborliness can go a long way.

Engagement: helping each person feel safe and hopeful

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When looking over the history, pay as much attention to strengths, accomplishments, and other good qualities as to problems and diagnoses.

• Success in achieving citizenship; bilingual• A devoted father• A person of religious faith

Beware referral information that points in a particular direction or particular treatment path.

• How does Mr. M. view his depression?• How does Mr. M. view his drinking?

See Strengths and Accomplishments

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Look for the adaptive, coping aspects of how the person has tried to deal with the challenges up to now.

• A good work ethic; he prioritized working over his own care.

Include a person’s culture and other aspects of the person’s identity. The faith system, gender and sexual identification, or country of origin, for example, can be rich sources of support and care.

Recognize Coping and Cultural Context

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Attend to the power asymmetry; make space for collaboration.

Offer to share what you know, or think you know, in a strength-based, non-pathologizing way.

• Would it be helpful if I share with you what was sent from the hospital so if anything is wrong, you can correct it?

• I see you came to the U.S. at 18, and are now a citizen—a great accomplishment!

• I see you have kids and have been working hard to provide for them and see them.

• I hear that it has been very hard recently – your marriage ended and it’s been hard to find work. I gather that this has been very difficult, depressing, and led to drinking?

Make Room For Mutuality

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Take time to find out what’s worked and what hasn’t and why.

• From your point of view, over the past couple of years of dealing with the drinking and the depression, what has been helpful, and what has not?

What is the person’s perspective on what would be best now?

• Do you have thoughts about what would be most helpful now?

• You had a bad experience with antidepressants in the past: was it so bad that you’d never want to try them again, or is your mind open? Can we explore some options for dealing with depression?

• What do you think about the drinking? Can we explore some options for managing this?

• What are your hopes for the next couple of months? The next year? What are your long-term dreams?

What Is the Person’s Perspective?

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Choices that draw on and work with natural supports.

• Peer specialists

• Brazilian-American or Catholic Church affiliated AA

Choices that provide safety and relief, and a clear path toward recovery.

• A mutually crafted wellness and crisis plan

Choices that promote a sense of a mutually crafted plan that moves toward the person’s own goals.

It Helps to Have Good Resources

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“The integrated pattern of human behavior that includes language, thoughts, communications,

actions, customs, beliefs, values, and institutions of a racial, ethnic, religious or social group.”

Health and Human Services Administration,

Office of Minority Health

Culture

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• Culture is personal and an important aspect of patient care to understand and is an essential component of person-centered care and shared decision making. A person can identify with more than one culture.

• Personal and cultural beliefs influence Nick M.’s perception of his illness and the healing process. Understanding how a person explains his or her illness and the origin of beliefs help engage a person in treatment and allows the clinician to speak in terms the person understands.

Cultural Competency

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• In addition to the clinician’s personal culture and background, the medical field has its own cultural beliefs and world views that may contrast to Nick M.’s cultural beliefs and values.

• Important for clinicians to examine their cultural beliefs and values to understand and address how they influence treatment.

• Although Nick M. speaks English well, he is under a lot of stress, including treatment. Problems are likely to arise because of translation of words and the cultural context that may have different meanings.

Cultural Differences Are Common

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Approach

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Nick M. feels lonely, even though he lists his church community as an important source of support. With his

consent, the ex-wife may be an important source of history, cultural beliefs, and information about community

resources.


Approach

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Nick M. is a first generation immigrant whose parents and siblings live in Brazil. There may be unmet cultural expectations and family obligations causing additional stress contributing to his heavy drinking and depression.


Approach

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Nick has many strengths (English speaking, educated, naturalized citizen, housing, support from his faith community, relationship with his children, and desire to work, etc.). Important to communicate hope on the initial and subsequent visits.


Approach

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Cultural identity is individualized and personal. Important to ask Nick M. about his cultural beliefs, values, and experiences. He is the best person to provide the information. Helps to avoid stereotyping based on a monolithic view of a group of people.


Approach

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From Nick M.’s perspective, what is going well in his life?What is he doing that helps things go well? What is not going as well as he would like? Are there things he would like to work on in treatment? If so, what support does he need? Are there specific customs or beliefs that he feels are important?


Approach

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What (if anything) did he find helpful in the past? What are his expectations of treatment? Clinician shares his or her expectations and come to an agreement on where to begin.


Approach

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Explore more deeply his relationships with his church members as a place of support. Are there recovery support groups such as Celebrate Recovery, 12-step fellowships, etc.? With his permission reach out to supporters.

Treatment goals are developed together and address the issues that Nick M. identifies as most important and include needed supports.

The most important contributor to success is the degree to which you establish a relationship.

No matter how much or how little time you have in the encounter, you need to purposefully plan time to establish that relationship.

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Stage-based Interventions,

Including Peer Supports,

for Individuals with

Co-occurring Mental Health

and Substance Use Disorders

Ken Minkoff, M.D.




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Melody Riefer, M.S.W.

Senior Program Manager Advocates for Human

Potential

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1. Detail the application of “stages of change” and stage-based interventions in recovery-oriented treatment –including psychopharmacology – for people with co-occurring mental and substance use disorders.

2. Describe the value of peer supporters in working with persons in various stages of change.

Learning Objectives

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1. Co-occurring disorders are an expectation, NOT an exception.

• Welcoming, access, and integrated screening

2. Empathic, hopeful, integrated, strength-based partnership is the essence of success.

• Integrated longitudinal strength-based assessment (ILSA)

• Integrated, strength-based, community-based learning for each issue in small steps over time

Principles of Recovery-oriented Treatment

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3. Four Quadrant Model to distinguish• Abuse from dependence• Serious mental health disorders from other mental health

conditions • Transient disorders from painful feelings

4. When substance disorder and psychiatric disorder co-exist, each disorder is primary.

• Integrated primary disorder-specific treatment

6 Principles of Recovery-oriented Treatment(b)

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6 Principles of Recovery-oriented Treatment(c)

5. Parallel process of recovery for each condition

• Integrated stage-matched interventions

6. Adequately supported, adequately rewarded, skill-based learning for each condition

• Skill teaching with rounds of applause for small steps of progress, balancing care and contingencies for each condition

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• Recovery/resiliency/self-determination of the person with one or more conditions.

• Progress involves:

– Addressing each condition over time

– Moving through stages of change for each condition

• Integrated services involve stage-matched interventions for each condition

Principle #5

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Parallel process of progress for multiple conditions


Approach

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When someone asks you or you think about what stage of change is a person in, the correct answer is: for which issue or condition?

Even though people have many issues, it is not uncommon that people are in different stages of change for each issue.

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STAGES OF CHANGEIssue-specific, not person-specific.

• Pre-contemplation: You may think this is an issue, but I don’t—and even if I do, I don’t want to deal with it, so don’t bug me.

• Contemplation: I’m willing to think with you and consider if I want to change, but have no interest in changing, at least not now.

• Preparation: I’m ready to start changing but I haven’t started, and I need some help to know how to begin.

• Early Action: I’ve begun to make some changes, and need some help to continue, but I’m not committed to maintenance or to following all your recommendations.

• Late Action: I’m working toward maintenance, but I haven’t gotten there, and I need some help to get there.

• Maintenance: I’m stable and trying to stay that way as life continues to throw challenges in my path.

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Stages of Change: Pre-contemplation

Issue-specific, not person-specific.

Pre-contemplation You may think this is an issue, but I don’t—and even if I do, I don’t want to deal with it, so don’t bug me.

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Stages of Change: ContemplationIssue-specific, not person-specific.

Contemplation: I’m willing to think with you and consider if I want to change, but have no interest in changing, at least not now.

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Stages of Change: PreparationIssue-specific, not person-specific.

Preparation: I’m ready to start changing but I haven’t started, and I need some help to know how to begin.

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Stages of Change: Early Action

Issue-specific, not person-specific.

Early Action:

I’ve begun to make some changes, and need some help to continue, but I’m not committed to maintenance or to following all your recommendations.

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Stages of Change: Late ActionIssue-specific, not person-specific.

Late Action:

I’m working toward maintenance, but I haven’t gotten there, and I need some help to get there.

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Stages of Change: MaintenanceIssue-specific, not person-specific.

Maintenance:

I’m stable and trying to stay that way as life continues to throw challenges in my path.


Approach

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The art of doing this is to identify things that are most important to him, which are probably not going to be either mental illness or alcohol use disorder. They will be things that have to do with his actual life, like getting a job or being a parent.

Even though people have many issues, it is not uncommon that people are in different stages of change for each issue.

Four Dimensions of Recovery

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Core Principles of Recovery/Resiliency• Emerges from hope

• Is person-driven

• Occurs via many pathways

• Is holistic

• Is supported by peers and allies

• Is supported through relationship and social networks

• Culturally-based and influenced

• Addresses trauma

• Involves individual, family, and community strengths and responsibility

• Based on respect

http://www.samhsa.gov/recovery

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http://www.samhsa.gov/recovery

• Strengths-based services benefit from having the authentic voice of the peer perspective integrated at all levels of care.

• Seeing that recovery is real is the most effective way of helping convey the that reality.

• Having the insights achieved through the lived experience aids both the person being served and team members who may have not experienced recovery first hand.

Peer Support and Lived Experience

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• Peer support is often naturally occurring.

• The value of peer support has been recognized and studied, leading to the formalization of peer specialists and/or recovery coaches in many levels of services.

• Paid peer workers receive training and operate from a code of ethics similar to other disciplines.

• The skill set is unique as it draws from the lived experience of recovery as the expertise.

Peer Supporters/Recovery Coaches

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A prescriber goes through a number of years of learning and education to become experts in medication, experts in dosing, evaluation, and assessment.

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Peer supporters and recovery coaches go through years of experiencing illness, displacement, the cost of having a diagnosis. They work through those experiences with various supporters and make changes in their life.

They can then offer their recovery lessons as a gift to others.

Recovery and Support Strategies

with Individuals with

Co-occurring Mental Health and

Substance Use Disorders

Ken Minkoff, M.D.




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Wayne Centrone, M.D.

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Senior Health Advisor, Center for Social

InnovationExecutive Director of

Health Bridges International

Melody Riefer, M.S.W.

Senior Program Manager Advocates for Human

Potential

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1. Demonstrate how to develop a recovery support plan including natural support networks.

2. Identify three potential interventions to support a sample client’s recovery that can be used in psychopharmacologic practice settings.

Learning Objectives

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• Recovery of the person with one or more conditions.

• Progress involves:

– Addressing each condition over time– Moving through stages of change for each condition

• Integrated services involve stage-matched interventions for each condition.

Parallel Process of Hopeful Progress for Multiple Conditions

Principle #5

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Issue-specific, not person-specific

Late Action: I’m working toward maintenance, but I haven’t gotten there, and I need some help to get there.

Maintenance: I’m stable and trying to stay that way as life continues to throw challenges in my path.

Stages of Change

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Approach

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The process of developing a recovery support plan involves not only adding in content and knowledge recommendations, education, and support

It also involves helping people develop the skills they need to do what is going to be helpful. We call this skill-based learning.

• Small steps of practical learning

• Self Management skills

Principle #6 (b)

Adequately supported, adequately rewarded, skill-based learning for each condition.

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What are the things I do when I'm by myself to help myself with

getting through tough times.

Use trength-based assessment: identify next-step skills that the person can and will learn to make progress for each issue, based on what they already know and where they are struggling now.

• Rounds of applause for each small step of progress– The assessment also identifies measurable stage-matched

objectives (“baby steps”) for each issue and how to provide a “round of applause” for each step of progress.

Principle #6 (c)


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Approach

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Use strength-based assessment to identify next-step skills that the person can and will learn to make progress for each issue, based on what they already know and where they are struggling now.

• Asking-for-help skills

Principle #6 (b)


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Who are you going to call?Who are you going to ask?


Approach

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• Use a strengths-based assessment to identify measurable stage-matched objectives (“baby steps”) for each issue.

• Provide a “round of applause” for each step of progress.

Recovery is about working with people. There is a deeply personal process of adding values, skills, and roles. There is a way of living a satisfying, hopeful, and contributing life even when limitations are caused by illness or diagnosis.

• Immigrant experience (immigrated to U.S. when he was 18 years old to further his education).

• Father (he loves his children).

• Church community (describes his primary support as the members of his Church).

• Interest in work (stopped going to appointments because he was looking for work).

• Previous management with psychotropic medication (stopped them because he did not like the side effects).

• Follow through on referral (Well, here I am – where do we go from here?”).

Supporting Nick M. Strengths, Opportunities, and Supports

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HOUSING . . . ANOTHER VITAL

SIGN

• The literature suggests that treatment for people experiencing homelessness and substance use issues requires comprehensive, highly integrated, and client-centered services, as well as stable housing.

• Service flexibility and a focus on individual needs was associated with stable housing tenure.

Data

Karus, D., Serge, L., & Goldberg, M. (2005). Homelessness, housing, and harm reduction: Stable housing

for homeless people with substance use issues. Canadian Mortgage and Housing Corporation.

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How do we call forward the recovery of

opportunity?

RECOVERY

“has no wrong door”William White

• The recovery continuum: it’s a process and not an event (Davidson, 2010)

• “No wrong door” (White, 2000)

• Drawing from the literature (Jacobson, 2001)

• Training at all levels and layers (Laird-Frick, 2010)

• Inviting collaboration – shared decision making (Schauer, 2007)

• Goal directed planning (Wagner, 2001)

• Be explicit and assure written plans (Palmer, 2013)

• Assure the “warm hand off” (Horevitz, 2015)

Recovery Support and Strategies

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ORGANIZING PRINCIPLE

• Peer Support as part of care team

• Peer Support moving beyond the walls

• Making room for informal peer support

Peer Support Workers

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• A move toward including peer support within the medication clinic environment.

• Example of successful integration: CommonGround (for more information see: www.patdeegan.com)

– Peers assist people preparing to participate in the medication consultation.

– Peers provide support post-appointment with vetted educational and decision support materials.

• Peer workers can help create an enhanced medication appointment!

Peer Support as Part of Care Team

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http://www.patdeegan.com/

“Prescribe” activities with others.

• Combating isolation and loneliness supports wellness and resiliency.

Inquire about natural strengths and supports.

• Family members, friends, hobby groups?

• Be mindful of cultural relevance and preferences.

• Ask a question that goes beyond medicine.

• Ask who in the individual’s life can help with a specific obstacle or opportunity.

Making Room for Informal Peer Support

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• Recovery must be rooted in the person’s community, not limited to moments when attending treatment/services.

• Peer support is a natural connection between formal services and life in the community.

• Helping people to see how to live a 24/7 recovery plan is best achieved via modeling.

Peer Support Moving Beyond the Walls

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Visit the RTP website at:http://www.samhsa.gov/

recovery-to-practice

JOIN RECOVERY

TO PRACTICE!

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http://www.samhsa.gov/recovery-to-practice

Documents

Welcoming and Culturally Appropriate Engagement for ......Welcoming and Culturally Appropriate Engagement for Individuals ... Disorders. Ken Minkoff, M.D. Senior System Consultant,