Responding to Mental Health Issues Within Drug &

Responding to Mental Health Issues Within Drug &

Responding to Mental Health Issues Within Drug & Alcohol Treatment Clinicians Training Package These training resources were funded by Drug Strategy Branch, Australian Government Department of Health and Ageing through the National Comorbidity Initiative Exercise 1: Who Here Do You Think

Loves The Simpsons? Can change a flat tyre? Exceeds the speed limit? Snores? Is kind to dogs? Would tell you that you have bad breath? Is trustworthy? Exercise 2: How Are You Thinking-Feeling-Doing? What are your THOUGHTS about working with clients with comorbidity? What are your FEELINGS about this

training? Notice how you BEHAVE when I say we have 2 days to get this on board? A Snapshot: Training Modules Module 1 Introduction to comorbidity PsyCheck Mental Health Screen Context Development Implementatio

n Scoring Module 2 Module 3 CBT Pre session preparation Theory of CBT

Principles & application CBT in practice Module 4 Implementati on of Brief MH Intervention Assessment Psychoeducation Case

Formulation Introduce CBT model Treatment planning Self monitoring Identify thoughts Manage thoughts Relapse planning Termination Module 1

Module 1 Introduction to Comorbidity & PsyCheck Mental Health Screen To provide a context for the PsyCheck Screening Tool To understand the development and psychometric properties of PsyCheck To gain skills in implementation, scoring and interpretation of PsyCheck Module 1 Aims of Module 1

Introduction to Comorbidity Development of PsyCheck Psychometric properties of the PsyCheck Screening Tool Negotiating the Users Guide Administering the PsyCheck Screening Tool Mental Health Screen Suicide/Self-Harm Risk Assessment Self Reporting Questionnaire Tool Interpreting the PsyCheck Screening Module 1

Overview of Components of Module 1 Up to a third of mental health clients have an AOD problem May be referred in to AOD services Up to 80% of AOD clients also have a cooccurring mental health problem Many more may have subclinical symptoms Rule rather than the exception in treatment settings Module 1

Introduction to Comorbidity Module 1 Introduction to Comorbidity Those that have comorbid AOD and mental health problems have Poorer prognosis Higher risk of harm Greater likelihood of relapse to both disorders

Greater use of health services 1. Secondary Psychopathology Model 2. Secondary Substance Use Model 3. Bidirectional Model Module 1 Models of Comorbidity 4. Common Factor Model 5. No Relationship Model

Module 1 Models of Comorbidity Comorbidity is the norm In both mental health and alcohol and drug services BUT Client group is very different in each service Module 1

Comorbidity in Practice In Mental Health Services Mostly psychotic disorders with range of alcohol and other drug issues In Alcohol and Drug Services Mostly high prevalence disorders: anxiety and depression Often not able to refer to Mental Health Services Often have subclinical symptoms: often go undetected Module

1 Comorbidity in Practice Sequential Treat one problem first Parallel Simultaneous treatment in different service provider Integrated Integrated treatment by same service provider Best empirical support Client and clinician preference

Module 1 Treatment for Comorbidity Many AOD clinicians report training is Concentrated on acute low prevalence disorders Focused on relationship building with Mental Health Services Module 1 Comorbidity Training

Module 1 PsyCheck Developed to Address Gaps Designed for AOD clinicians with little or no experience in mental health interventions But can still be used by experienced clinicians Focused on the disorders most commonly encountered in AOD Services Anxiety, depression, some somatic symptoms Offers a screening tool and articulated

intervention Offers options for training and support through clinical supervision Screening and intervention for anxiety and depression among AOD clients Brief screening 4 session intervention Youth modifications Extension material Accompanying resources PsyCheck Screening Tool PsyCheck Screening Tool Users Guide PsyCheck Clinical Treatment Guidelines

Module 1 PsyCheck Overview Comprehensive capacity building 4 module workshop Clinical supervision Part of a whole organisation approach to improving comorbidity services for our clients Managers resources (Implementation Guidelines) Clinical supervisors resources (Training and Clinical Supervision Guidelines)

Module 1 PsyCheck Overview Module 1 PsyCheck Screening Tool PsyCheck Screening Tool scientifically validated A general mental health screen, including history of treatment A suicide/self harm risk assessment

The Self Reporting Questionnaire (SRQ) World Health Organization instrument Assesses current symptoms of anxiety, depression and somatic disorders Evidence based: drawn from empirically supported treatment Intervention is designed to be integrated into routine AOD practice CBT principles used in both AOD and mental health Best practice in both sectors Easily integrated Easily manualised Focus on scientist-practitioner approach

Hypothesis testing Reflective practice Module 1 PsyCheck Intervention 120 newly engaged AOD clients PsyCheck Screening Tool compared to General Health Questionnaire (GHQ) Both compared to a diagnostic instrument (CIDI) Results SRQ superior to GHQ in predicting anxiety and depressive disorder

Cut-off identified that indicates presence of disorder General mental health screen good indicator of psychosis Module 1 Psychometric Properties About the PsyCheck Screening Tool Statistical properties Decision tree Administration and scoring General mental health screen

Suicide risk/self harm assessment Self Reporting Questionnaire PsyCheck Screening Tool Sample contingency plan Module 1 Negotiating the PsyCheck Users Guide Designed for routine screening (all clients) Administer the whole SRQ Other parts only if information not already

collected Suicidality monitored over time Suicide assessment a framework not a checklist Clinical judgement is required Assess risk of harm to others in same way Module 1 Administering the Screening Tool Work in groups of 3 Select a celebrity square One person plays the celebrity

2 clinicians assist each other in administering the PsyCheck Screening Tool Group Discussion Module 1 Exercise 3: Celebrity Squares Module 1 Interpreting the PsyCheck Screening Tool Intervention or further assessment is

required if The client reaches 5 or more on the SRQ The client is at risk of suicide/self-harm The client has a mental health history Consider Readiness to change Current symptoms Module 1 SRQ Interpretation Total Score

Interpretation Action No symptoms present. Re-screen using the PsyCheck after 4 weeks 1-4 Some symptoms of depression, anxiety and/ or somatic complaints indicated.

Offer Session 1 Re-screen after 4 weeks Provide self-help material 5 or above Considerable symptoms of depression, anxiety and/or somatic complaints indicated Offer Sessions 1-4 Re-screen after 4 If no improvement after rescreening, consider referral

0 Module 1 Decision Tree Module 1 Exercise 4: Celebrity Squares What Next? Work in the same groups of 3 From the information youve collected refer to the Decision Tree and determine what the next steps would be for your celebrity client

Think about Past mental health questions Suicide assessment, and SRQ score (and the types of answers endorsed) Group Discussion Im never going to get this I may as well give up now

Im useless Module 1 Whats on Your Mind Is It This? Module 1 Or This ? Im getting

some of this If I hang in it will fall into place I feel confident I will get it Module 1 Or Maybe This ?

This is too easy What if I get bored Ill think about how I can use it in my practice Module 2 Cognitive Behaviour Therapy To understand the theory of CBT To understand the principles of

application underpinning the PsyCheck intervention To understand of the practice of CBT Module 2 Aims: Module 2 Introduction to CBT Theoretical underpinnings CBT Model Evidenced based practice CBT in practice Standard sessions

Self-monitoring Module 2 Overview: Module 2 Module 2 Exercise 5: What Works for You? Working individually complete the worksheet, identifying which models you have an affinity with Then circle the main model you work with

Now find someone else in the room that uses a DIFFERENT model to the one you typically work with and discuss with your partner Why you use this model/strategies you do? How you know its working ? Group discussion Module 2 Planned Approach There is emerging evidence that a single theory planned approach is more effective than an ad hoc one

Most effective to have a single framework or philosophy about treatment and incorporate a range of techniques and strategies that fit with your philosophy Cognitive Behavioural Approach Module 2 Evidenced Based Practice Best evidence for CBT compared to other types of therapies Most high level research (RCTs) and the most positive research

Effective for a wide range of mental health problems including AOD, anxiety and depression BUT Whatever framework you use, you can create your own evidence through measuring individual outcomes CBT emphasises this Module 2 What is CBT? Umbrella term for a range of therapies with a cognitive and/or behavioural focus Therapy examples

Cognitive Therapy (Aaron Beck) Relapse Prevention (G. Alan Marlatt) Coping Skills Therapy (Peter Monti) Mindfulness Therapy (Mark Williams) Schema Therapy (Jeff Young) Dialectical Behaviour Therapy (Marsha Linehan) Strategy examples

Problem Solving Goal Setting Cue Exposure Therapy Thought stopping Urge surfing Activity scheduling Solution-Focused Therapy An understanding of the past and cause of problem not necessary for resolution of the problem Change occurs as a result of a focus on the future without the problem

Narrative Therapy Focus is on meaning, narrative and power Talking about the influence of problems enables talk about their defeat via the new stories Module 2 In Comparison Gestalt Therapy Focus is on the present rather than past or future Central aim is awareness-raising and creating

conditions to de-construct dysfunctional fixed or habitual patterns of interaction Change occurs through understanding and acceptance of what is Psychodynamic Therapy Focus is on initial underlying causes Understanding and having insight into the problem leads to change Therapeutic relationship is the key to change Module 2 In Comparison

Self-help oriented Clinician provides tools and framework for change Clients responsibility to create and maintain change Skills oriented Attention to therapeutic process vital but not sufficient in itself for change to occur Structured but not inflexible Clinical judgement necessary Module 2

What is CBT? CBT is based on an ever-evolving formulation of the client in cognitive terms requires a sound therapeutic alliance emphasises collaboration and active participation is goal oriented and problem focused initially emphasises the present Module 2 CBT Principles

CBT is educative, aims to teach the client to be their own therapist, and emphasises relapse prevention is time limited sessions are structured teaches clients to identify, evaluate and respond to their dysfunctional thoughts and beliefs uses a variety of techniques to change thinking, mood and behaviour Module 2

CBT Principles Module 2 Exercise 6: Mix n Match From the cards you have been given, keep the ones that represent the way you work (in the majority) and trade unwanted cards for wanted cards with other participants Either Line up on the cognitive/behavioural continuum to show whether you work more in a cognitive or behavioral approach, or Place your cards on the grid (cognitive/behavioural

vs skills/process) Group discussion Why did you put your card or yourself where you did? Did the cards fall in a pattern? Module 2 The CBT Model Early Experience Core beliefs Trigger

Unhelpful thoughts Behaviour Feelings Module 2 Bruce: Eating Disorder Absent father, poor role models Smell of restricted food

Im unlovable and need food to make me happy Eating makes me feel better Over-eating, relapse Craving Module 2 Bruce: Simplified CBT Model

Module 2 Bruce: ABC Model In pairs take it in turns to use the CBT model worksheet, choose a simple target problem for example, eating chocolate, public speaking, learning a new skill Use a recent real example or a made up one Complete the CBT model sheet with thoughts feelings and behaviours. Module 2

Exercise 7: The Cognitive Model I: Review and feedback from last session II: Information and practice of session topic III: Summary and feedback from this session Module 2 Typical Session Format Module 2

CBT in Practice I: Review and Feedback Check-in past week, mood/drug use, homework Whats been happening this week? Hows your [mood] been this week? How did you go with your homework? Bridge from previous session Remember last week we talked about [x] did you have any more thoughts about it? Were you able to get any practice of [skill] Information about skill last week we talked about [identifying

thoughts] this week I thought wed talk about how to manage those thoughts Remember the cognitive modelthe way I like to think about it is Practice of skill in session lets try to do this together [use whiteboard] Module 2 CBT in Practice II: Info & Practice Summary and feedback so what we talked about today was

how does that fit with you? Set homework tasks its really important to practice these things between sessions so they become second nature what do you think you could do that would help you remember what we did? Module 2 CBT in Practice III: Summary & Feedback A. Watch video demonstration of basic elements of a session

Discussion about the elements as a group B. Practice the elements in pairs Feedback to each other good aspects and an area for improvement Module 2 Exercise 8: CBT Demonstration I Interventions are applied from the least to most intensive Each step is incremental based on the client's response to the previous one A stepped care approach can add

flexibility to treatment and improve outcomes CBT (and PsyCheck) facilitates the stepped care approach Module 2 Stepped Care Approach Module 2 The Therapeutic Relationship Therapeutic alliance vital Basis of ALL therapy

Requires good counselling skills Necessary but not sufficient condition for change Collaboration and active participation by client and clinician essential Requires good active and empathetic listening skills CBT builds therapeutic alliance through collaboration and encouraging client involvement in their own therapy Clinical judgement is required, even though the therapy is manualised Use PsyCheck as guidelines follow steps only as closely as you need to Use flexibly with extension material to tailor

to clients needs Consider clients needs Consider existing clinical practices and pathways Module 2 Clinical Judgement PsyCheck designed to be integrated into routine AOD treatment Techniques are deliberately similar to those in AOD treatment Emphasise to the client the link between

AOD use and mental health problems Consider ways in which you can integrate into what you already do Module 2 Integrated Treatment Module 2 Exercise 9: Therapeutic Process In small groups (3-4) discuss how therapeutic processes can be used in CBT

What makes a good therapeutic alliance - list as many elements as you can? What could happen if you dont have a good therapeutic alliance? Think about the client, the practitioner and the therapy relationship Group discussion What have we learned so far..? Module 2 Lets Take a Breather

What brief practice at home would assist you to consolidate the knowledge you gained in this module? eg. Use the CBT model on your self eg. Further reading about CBT eg. Practice explain the CBT model to a client/colleague Next session you will be asked to share your experience of self practice if you are willing, (but not of the actual target problem itself if you used yourself as a client) Module 2

Homework Module 3 Pre-Session Preparation: Assessment, Formulation and Treatment Planning What did we do last time? What is your feedback about what we covered? Homework feedback Challenges in completing the homework? What was the effect of self-practice? Next step?

Module 3 Before We Start Work in groups of 3, you have just interviewed your celebrity. Write a few lines using the following criteria as if you were writing for a trash magazine

Their current problem Their presenting mood/feelings Thoughts Behaviour Whats driving the behaviour Consequences of behaviour Present to the large group Module 3 Exercise 10: The Young and The Restless

Trigger Module 3 Example: Jen X Jen X 38, an actor made a rare appearance in public today after Behaviourhusband Y, a singer was admitted to the famous Betty Ford clinic. X hasnt been seen for weeks. Sources close to the actor say she has been increasingly Feelings worried about the singers behaviour. Shes looking really drawn and a bit

Presenting issue depressed says a close friend. She says she cant bear to go out of the house Thoughts and its really starting to get to her. It is thought that Xs two adopted children of are being cared for byConsequences family. behaviour To understand how to screen for mental health issues and prepare feedback To understand how to undertake a cognitive behavioural assessment To understand how to collect sufficient

information to develop a cognitive behavioural formulation Module 3 Aims: Module 3 Negotiating the PsyCheck Intervention & Clinical Treatment Guidelines Undertake screening and preparing feedback Undertake a cognitive behavioural assessment Prepare a preliminary case formulation

Module 3 Overview: Module 3 Designed for a range of experience and background Manualised for new clinicians Use flexibly for experienced clinicians Use with Introduction to PsyCheck package PsyCheck Screening Tool and Users Guide Module 3

Negotiating the PsyCheck Clinical Treatment Guidelines Three sections Principles of intervention Practice Guidelines Extension material Worksheets Modifications for young people Module 3 Negotiating the PsyCheck Clinical

Treatment Guidelines Pre-session preparation: Reflection Prepare feedback from the PsyCheck Screening Tool Cognitive behavioural assessment Cognitive behavioural formulation Treatment planning PsyCheck intervention Session

Session Session Session 1: 2: 3: 4: Introduction Identifying unhelpful thoughts Managing unhelpful thoughts Relapse prevention Module 3

Practice Guidelines PsyCheck screening Snapshot of potential need Feedback Results of PsyCheck Screening Tool Any other information gathered Module 3 Screening in Context Module

3 Cognitive Behavioural Assessment Also known as functional assessment Occurs during an assessment session and continues through therapy Functional vs structural/diagnostic analysis Drivers vs descriptors of behaviour/problem

Presenting issues Pattern (onset and course) Predisposing factors Precipitating factors Perpetuating factors Protective factors Prognosis Other factors Module 3

Cognitive Behavioural Assessment: 7Ps Bruce Discussion Identify elements of the functional assessment for Bruce Module 3 Exercise 11: Something Fishy Case formulation is Theory driven

An interpretation - more than a case summary or summary of presenting problems A working hypothesis to be reviewed Dynamic - as new information comes to hand, your formulation is reviewed, added to, changed The case formulation puts the 7Ps into a context Always present it to your client and ask for their response Module 3 CBT Case Formulation

Clarifying hypotheses and questions Understanding the overall picture Prioritising issues and problems Planning treatment strategies Predicting responses to interventions Identifying barriers to progress Module 3

The Purpose of Case Formulation Screening Cognitive Behavioural Assessment Case formulation Treatment Plan AOD Assessment

Module 3 Assessment, Formulation and Treatment Planning Identify the components of formulation as a group In small groups, use the information from the earlier exercise, Something Fishy Write a formal formulation from this information Use the formal formulation to translate this into language suitable for a client

Group discussion Module 3 Exercise 12: Fishy Formulation Module 3 Exercise 13: Gummy Shark Return to your small groups, use the previous case formulation and develop the treatment plan for Bruce including: Immediate strategies Longer term strategies

Referral options One person in your group to role play Bruce and share presenting the formulation and treatment plan to him Think about the stage of change, insight and the way you present it to him. Notice how he responds. Lets go back over what weve done so far Module 3 Checking in Again

Module 4 Implementation of Brief Mental Health Intervention Write down your immediate response to the following Standing in a long line at the supermarket A heavily tattooed woman

Someone throwing a cigarette out of a car Running late The beach Case formulation Module 4 Exercise 14: First Response Understand cognitive behavioural practice to undertake the PsyCheck Intervention Module 4

Aims: Module 4 Negotiating the step-by-step guide to the 4-session PsyCheck Intervention Session 1: Psychoeducation Session 2: Identifying unhelpful thoughts Session 3: Managing unhelpful thoughts Session 4: Relapse prevention Module 4 Overview: Module 4 Module

4 A Snapshot: Practice Guidelines Pre PsyCheck Preparation Session 1 Psychoeducatio n Present case formulation to client Provide info on symptoms Explain CBT Homework

Session 2 Identifying unhelpful thoughts Links between thoughts & feelings Identifying unhelpful thoughts Homework Session 3

Session 4 Managing unhelpful thoughts Relapse prevention Challengin g unhelpful thoughts Homewor k

Identifying triggers Identify early warning signs Breaking the rule effect Termination Rescreening Module 4 Session 1 Presenting the Case Formulation and Beginning Psychoeducation and Self Monitoring

Psychoeducation can be about: Current symptoms Whats going on for the client (formulation) CBT model Module 4 Session 1: Psychoeducation 1. Present case formulation to the client Get feedback and modify as appropriate 2. Provide information about current symptoms Use worksheets 1, 2 and 3

3. Explain CBT model to the client Alternatively, use simplified version (extension material) Work through an hypothetical or personal example depending on readiness to change Module 4 Session 1: Psychoeducation Link the formulation and treatment Explain in detail how they are linked using personal examples

Develop a treatment plan with the client Identify areas for intervention and priorities based on the formulation Emphasise revisiting both formulation and treatment plan regularly Finalise and record treatment plan Give client a copy Module 4 Session 1: Treatment Planning Use Worksheet 4: Self monitoring Explain the role of self monitoring

A temporary tool until it becomes automatic Explain the process of self monitoring Work through example with client Give client a copy to take home Module 4 Session 1: Introduce SelfMonitoring Large group discussion What assists clients to understand self monitoring? What can clinicians do to get in the way of effective self monitoring?

How do you know if you are being effective or obstructive? Module 4 Exercise 15: Self Monitoring Summarise content and ask for feedback from the client Emphasise the importance of take home tasks Set homework Self Monitoring Identify any difficulties with content Identify easiest method Immediate recording, once a day etc

Emphasise importance Prepare for next step Outline next session topic Organise next appointment or discharge Module 4 Session 1: Session Summary Simplified explanation of the CBT model Alternative explanation of CBT model: ABCs

Module 4 Session 1: Extension Material Work in groups of 3 One person plays the client, one the practitioner and one the observer Use the celebritys PsyCheck Screen and other information you have gathered to inform this session Together develop a formulation for your celebrity and the practitioner then explains it to the client; integrate any other psychoeducation material that the client would benefit from

Group discussion Module 4 Exercise 16: Please Explain Module 4 Session 2 Identifying Unhelpful Thoughts Module 4

Whats That Noise? Must be a cat OH NO! Theres someone out there Use the Unhelpful Thoughts Worksheet What are your thoughts?

Are you a black and white thinker? Do you jump to negative conclusions? Do you catastrophise? Are you a personaliser? Are you a should/ought person? How do you manage these unhelpful thoughts Group discussion Module 4

Exercise 17: Spot the Unhelpful Thought Client didnt understand the task More explanation AND practice Task was too difficult Simplify Task was too time-consuming Do in stages or in parts Do on some days Readiness to change Motivational approach

Module 4 Homework Non-Completion Module 4 Session 2: Information Reiterate the CBT model Explain negative bias/interpretation Use monitoring to identify areas of (mis)interpretation of events Make personal link between thoughts and feelings and behaviours

Identify unhelpful thoughts Use self monitoring sheets as examples The aim is to raise awareness about when unhelpful thoughts occur Focus is on catching thoughts as they occur rather than allowing them to create negative mood Label unhelpful thoughts Use Worksheet 5 Module 4 Session 2: Practice

Module 4 Session 2: Extension Material Behavioural activation Very important especially for depression when people often withdraw and lose interest in usual activities Focus both on pleasant activities and usual daily activities (showering, washing up) Guidelines for better sleep Especially important for those with anxiety and depression who often have difficulty sleeping

Relaxation Helpful for anxiety and depression Watch the video of Richard and Lynn discussing the thinking-feeling-doing cycle In small groups, one person plays the celebrity while the others explain the thinking-feeling-doing cycle using the celebritys information that you have gathered previously and to identify some of their unhelpful thinking Group discussion Module 4

Exercise 18: CBT Demonstration II Module 4 Session 3 Managing Unhelpful Thoughts How to challenge unhelpful thoughts Go through Worksheet 6 with examples Two main strategies for challenging thoughts: Is this a misinterpretation? Is there another way to think about this?

If not, is it helpful to think this way? Even if it is true perhaps it doesnt help me if I think this way Module 4 Session 3: Information Practice challenge unhelpful thoughts Use monitoring sheets completed for homework Assist client to practice the process from monitoring sheet Use Worksheet 6 as a reference

Module 4 Session 3: Practice Communication skills Assertive communication skills are important for those who are anxious in social situations and for those who are depressed and have withdrawn from public Module 4 Session 3: Extension Material

Module 4 Exercise 19: Celebrity Challenge Work in groups of 3 One person plays the client, one the practitioner and one the observer Use the celebritys previous CBT model to assist Help the celebrity identify and challenge one of their unhelpful thoughts Use Worksheet 4 & 7 to assist you Group discussion

Module 4 Session 4 Preventing Relapse Discuss triggers and early warning signs Use Worksheet 8 to explain the breaking the rule effect Use Worksheet 9 to emphasise looking after yourself Module 4

Session 4: Information Develop a relapse prevention plan Explore ways the client can regulate thoughts and feelings Emphasise the need for additional skills and supports Remind the client to self-reward Encourage the client to take care of themself Module 4 Session 4: Practice Summarise content of sessions 1-4 and

ask for feedback from the client Reinforce gains and effort Re-emphasise the importance of continued practice Reminder about tasks to continue with If continuing AOD treatment check homework in subsequent sessions Prepare for next step Manage concerns using a motivational approach Consider and discuss referral options Boosters/continued intervention Module 4

Session 4: Termination Problem solving Seemingly irrelevant decisions Module 4 Session 4: Extension Material Work in groups of 3 One person plays the celebrity client, one the practitioner and one the observer swap roles from last exercise Summarise for the client and develop a

relapse prevention plan Group discussion Module 4 Exercise 20: Celebrity Survivor Module 4 Rescreening Rescreening has benefits for both the clients and clinician:

Monitoring client progress with the client can assist to build the clients self efficacy as they see themselves improving Clinicians can monitor and reflect on their own practice using objective data Clinicians can reorient therapy if no improvement and reflect on potential gaps in treatment Optimal supervision: A single consistent supervisor to build a relationship Weekly or fortnightly supervision preferable Individual supervision as a minimum Group and/or peer supervision as an adjunct

Module 4 Support: Clinical Supervision What aspects of the training do you feel comfortable with? What areas will you need to work on? What will you do differently in your practice In the next few weeks? In the next year? Module 4

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