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Hrf 2013 ppt keynote

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    Hrf 2013 ppt   keynote Hrf 2013 ppt keynote Presentation Transcript

    • HARM REDUCTION &CONCURRENT DISORDERS POSSIBILITIES FOR CHANGE Stephanie Baker, MSW, RSW Guelph Wellington Drug Strategy Harm Reduction Forum March 20th, 2013
    • OVERVIEW• Importance & Relevance• Barriers & Gaps• Harm Reduction & CD• CD Philosophy/Treatment• Recommendations
    • IMPORTANCE & RELEVANCE PREVALENCE AND OUTCOMES
    • CONCURRENT DISORDERS Substance Concurrent Mental Use Disorders Health Disorders Disorders
    • LIFE TIME PREVALENCE OF SUBSTANCE USE DISORDER FOR EACH MENTAL HEALTH DISORDER• Major Depression 27%• Any Anxiety Disorder 24%• BPD 23%• Schizophrenia 47%• Bipolar Disorder 56%• PTSD 30-75%• Eating Disorder 23-55% (Skinner, 2005)
    • CONCURRENT DISORDERS ARE IMPORTANT BECAUSE…• Poorer treatment outcomes than if person has either a MH disorder or a SA disorder alone• Concurrent disorders affect many areas of a person’s life• Individuals with concurrent disorders are in almost every treatment setting – they are the “expectation, NOT the exception”
    • RISKS ASSOCIATED WITH CD• Suicide• Relapse• Violence• Prostitution• Victimization• Re-hospitalization• Financial problems• Loss of family/friends• Treatment non-compliance• Poor response to medication• Housing instability/homelessness• Medical problems (e.g. HIV, Hepatitis, STD, etc.)• Criminal involvement/legal problems/incarceration
    • RELATIONSHIP BETWEEN SA & MH COMMON ELEMENTS• Both SA and MH can be chronic and recurring, requiring immediate interventions and ongoing support• SA and MH problems may be triggered by the same factors• MH problems may influence the development of SA problems and SA problems may influence the development of MH problems• Outcome of treatment for MH disorders is negatively affected by SA and vice versa
    • BARRIERS & GAPSCHALLENGES TO IMPLEMENTING BEST PRACTICE
    • TREATMENT BARRIERS1.Structural Barriers: make it difficult for people withconcurrent disorders to access appropriate treatment2.Personal Barriers: characteristics of the person thatprevents her/him from initiating or continuing withtreatment for a concurrent disorder issue (Mueser et al., 2003)
    • SYSTEMIC GAPS• Present system of care in Canada is fragmented and compartmentalized • People accessing either system are often struggling with both issues• Individuals are frequently treated for only one of their co-occurring disorders• Few CD research studies considered harm reduction effects, most emphasize abstinence-related outcomes• Most CD programs studied have been unsuccessful in bringing about substance use reductions• Important need for research to assess the effects of harm-reduction programming on health improvements for individuals living with CD   (CCSA, 2009; O’Campo et al., 2009 )
    • OUTCOMES OF BARRIERS/GAPS• Dissonance in philosophical perspectives regarding the “primary problem”• Lack of coordination amongst service providers• Inappropriate service provision• Increased feelings of stigma• Poorer treatment outcomes
    • HARM REDUCTION & CD HR IS INTEGRAL TO SUPPORTING INDIVIDUALS & FAMILIES LIVING WITH CD
    • WHAT IS HARM REDUCTION? •A philosophical approach applied in practice•Often understood broadly - can encompass manyvariations of policies and programs •Intention is to support people in reducing negativeconsequences of use by moderating intake/switching toless harmful modes of use (e.g. methadone or needleexchange programs)•A health-centered approach - implicitly and explicitlyacknowledges the social determinants of health
    • FOCUS OF HARM REDUCTION• A non-judgmental response• Offers a direct point of contact• Focuses on achievable improvements that can reduce adverse health and safety consequences• Emphasizes measurable health, social, and economic outcomes as well as cost effectiveness of interventions • A best practice treatment recommendation, particularly for people with severe and persistent MI
    • PRINCIPLES OF HARM REDUCTION •Pragmatic•Respectful•Prioritizes goals•Maximizes intervention options (James, 2007)
    • PHILOSOPHY OF HARM REDUCTION• Respects people and their abilities• Recognizes the ‘Stages of Change• Removes barriers to accessing programs and services (James, 2007)
    • HARM REDUCTION MODEL (RNAO, 2009)
    • CHALLENGES WITH HARM REDUCTION1) Community resistance 2) The need to work with highly marginalized groups3) Ensuring appropriate knowledge and training4) Adequate resources to initiate and maintain initiatives  (James, 2007)
    • CD TREATMENTCD PHILOSOPHY IS HARM REDUCTION
    • QUADRANT MODELHighSeverity Specialized INTEGRATED Addiction Primary Care Specialized Mental HealthLow HighSeverity Severity (Skinner, 2005)
    • CD TREATMENT PHILOSOPHY• Integrated treatment approach• Promotes flexibility of goal choice• Importance of working as a team• Works with the person where s/he is at• Offers individualized treatment planning
    • CD TREATMENT PHILOSOPHY• No “wrong door”• Motivational enhancement• Goal of continued engagement• Involves concerned significant others• Minimization of treatment-related stress• Offers flexible hours, duration, and location
    • STAGES OF CHANGE/MOTIVATIONAL TREATMENTStage of Change Characteristics Stage of Tasks and Outcome Treatment Motivational StrategiesPre- ~ Not thinking about Pre- ~ Outreach to ~ Person has noContemplation change engagement establish contact with contact with mental ~ Feeling of no the person health or substance control ~ Listen reflectively use worker ~ Denial: does not ~ Affirm believe it applies to self ~ Believes consequences are not serious ~ Give practical help ~ Person has Engagement for person’s assigned worker but immediate concerns no regular contact ~ Model open, honest communication ~ Express empathy (Connors et al., 2001; Mueser et al., 2003)
    • STAGES OF CHANGE/MOTIVATIONAL TREATMENTStage of Change Characteristics Stage of Tasks and Outcome Treatment Motivational StrategiesContemplation ~ Weighing benefits Early Planning/ ~ Align with person’s ~ Person has and costs of struggle (MH & SU) regular contact but behaviour Persuasion no reduction in ~ Explore person’s ~ Proposed change substance use goals ~ Support person’s desire to changePreparation ~ Experimenting Late Planning/ ~ Explore person’s ~ Person discusses with small changes concerns (MH & SU) substance use in Persuasion regular contact, and ~ Develop discrepancies shows reduction in between the person’s use for at least 30 goals and current days behaviour ~ Identify options to help the person decide on a course of action ~ Plan social supports (Connors et al., 2001; Mueser et al., 2003)
    • STAGES OF CHANGE/MOTIVATIONAL TREATMENTStage of Change Characteristics Stage of Tasks and Outcome Treatment Motivational StrategiesAction ~ Taking a definitive Early Active ~ Start action plan ~ Person is action to change Treatment ~ Elicit change talk engaged in ~ Reward progress treatment with the ~ Use slips as learning goal of abstinence opportunities or reduction, ~ Involve social supports though s/he may ~ Develop specific action still be using steps to work on target substances behaviours ~ Encourage self-efficacy Late Active ~ Continue to elicit change ~ Person is talk engaged, and has Treatment ~ Review/reinforce actions achieved clear that are producing behaviour goals for changing change his/her substance ~ Review and identify new use for less than goals as person continues six months with change ~ Emphasize health alternatives ~ Identify examples of self- efficacy ~ Nurture and sustain (Connors et al., 2001; Mueser et al., 2003)
    • STAGES OF CHANGE/MOTIVATIONAL TREATMENTStage of Change Characteristics Stage of Tasks and Outcome Treatment Motivational StrategiesMaintenance ~ Maintaining new Relapse ~ Keep focus on the ~ Person is behaviour over time Prevention person’s goals engaged and has ~ Reinforce link between achieved clear change behaviour and goals for changing accomplishment of his or her person’s goals substance use for at least six months ~ Identify continuing high- risk situations (occasional lapses may occur) ~ Develop relapse prevention plans ~ Reinforce self-efficacyRelapse ~ Experiencing ~ Focus on the ~ Person discusses normal part of successful part of the substance use in process of change plan regular contact, ~ Usually feels ~ Promote problem- and shows demoralized solving reduction in use for ~ Encourage/assist the at least 30 days person to re-engage their efforts in the change process (Connors et al., 2001; Mueser et al., 2003)
    • RECOMMENDATIONSCONSIDERATIONS FOR IMPROVED SUPPORT
    • WHY RESEARCH FOR HARM REDUCTION & CD IS IMPORTANT• People with CD have been excluded from mainstream psychiatric/addiction research and scientific trials  • Results in CD not being well understood• Care provided may be inappropriate• Interdisciplinary research is needed to contribute to a comprehensive understanding (CCSA, 2009)
    • SUCCESSFUL PROGRAMS• Client choice• Positive interpersonal relationships• Proactive multidisciplinary teams• Housing provision• Instrumental supports• Flexible program policies (O’Campo et al., 2009)
    • RECOMMENDATIONS1) Integration of harm reduction mental health service2) Varied service components3) Staff qualities4) Education and information5) Community development (Altenberg et al., 2003)
    • REFERENCESAltenberg, J., Balian, R., Lunansky, L., Magee, W., & Welsh, S. (2003). Falling through the cracks: An evaluation of theneed for integrated mental health services and harm reduction services, Toronto, ON: Wellesley Central HealthCorporation. Becker, M., Fortin, S., Nepinak, D., Noel, L., & Stopkewich, L. (Directors). (2012). Here at Home [Interactive Website].Toronto, ON: National Film Board of Canada.Canadian Centre on Substance abuse. (2009). Substance abuse in Canada: concurrent disorders. Ottawa, ON:Canadian Centre on Substance Abuse.Connors, G., J., Donovan, D., M., & DiClemente, C., C. (2001). Substance abuse treatment and the stages of change:Selecting and planning interventions. New York, NY: The Guilford Press. James, D. (2007). Harm Reduction: Policy Background Paper. Alberta Alcohol and Drug Abuse Commission. Alberta, CA:Alberta Health Services.Mueser, K., Noordsy, D., Drake, R., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice.New York, NY: The Guildford Press.O’Campo, P., Kirst, M., Schaefer-McDaniel, N., Firestone, M., Scott, A., & McShane, K. (2009). Community- based servicesfor homeless adults experiencing concurrent mental health and substance use disorders: A realist approach tosynthesizing evidence, Journal of Urban Health, 86(6), 965-989. Registered Nurses’ Association of Ontario. (2009) Supporting Clients on Methadone Maintenance Treatment. Toronto,Ontario. Registered Nurses’ Association of Ontario.Skinner, W. J. (2005). Treating concurrent disorders: A guide for counselors. Toronto, ON: Centre for Addiction and Mental
    • Stephanie Baker, MSW, RSWEmail: stephbaker1@gmail.com