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Principles of Care Associated with Positive Clinical OutcomesRR($Fred C. Osher, M.D. January 22, 2004%%ZMWhat is the Problem?(` People with mental illness are significantly over-represented in the criminal justice system 2aZ^?6)US Prisons and Jails Population 1980-1999**(\NtSix- Month Prevalence of Severe Mental Disorder Among the General Population and Jail Detainees (Teplin et al.)"uef A8XPrevalence of current substance abuse among jail detainees with serious mental disordersYYThe need for a response(8Prevalence rates in the criminal justice system are high Courts, jails, consumers, families, providers are frustrated by systemic barriers Traditional methods have limited effect on public safety and public health outcomes Costs of ineffective handling are enormous Creative interventions are being demonstrated  98}iThe Challenge  (What can criminal justice do differently? What can the MH/SA treatment system do differently? How can they work together differently?jPrinciples of Care(Integrated treatment Individualized treatment planning Close monitoring Longitudinal perspective Stable living situation Cultural competency and consumer centeredness Evidence based practice Optimism and Recovery03s#k1. Integrated Treatment(TTraditional models of treatment for complex disorders result in poor outcomes No treatment  exclusion high utilization of E.R., jails, hospitals Sequential treatment Parallel treatment -- burden of integration on individual Integrated treatment of clinical care associated with better outcomes Nznzn+OGznN+O  G    lIntegrated Treatment (cont.)(SIntegrated treatment refers broadly to any mechanism by which treatment interventions are combined within the context of a primary treatment or service setting. Integrated treatment is a means of coordinating behavioral health interventions to treat the whole person more effectively. How do we integrate clinical care and court efforts? 8T z75p$2. Individualized Treatment Planning%%(Treatment planning is derived from a comprehensive assessment. Accurate assessment is difficult to do: Inadequate screening poor clinician assessment skills lack of standardized instruments inaccuracy of self-report Appreciate the Heterogeneity ?n(0nnq 0n0nn?(q  [ Individualized Treatment Planning Critical Domains that Affect Court Participation8\)$1Severity of mental illness Severity of substance use disorder Severity of criminal charges and criminal history Motivation for recovery and Stages of Change Ancillary program resources $ZZ^ Individualized Treatment Planning Critical Domains that Affect Client Participation>_$!2Housing Medication Integrated treatment for co-occurring dx Medical Care Income Supports and Benefits Food and Clothing Transportation Civil Legal Services9ar-2. Individualized Treatment Planning - Steps..(@Evaluate pressing needs. Determine motivation to address substance use/mental health/criminal problems. Select target behaviors for change. Determine interventions to achieve desired goals. Identify the providers to implement plan. Choose measures to evaluate the intervention. Select follow-up times to review the plan."A0 " i-Av3. Close Monitoring(Intensive supervision needed until stable Sometimes coercive, always persuasive representative payees mandatory abstinence/medication compliance QqnZqnZZZ+ZZqnZQDw4. Longitudinal Perspective(9Mental illnesses and substance use disorders are chronic, relapsing conditions Treatment occurs continuously over years Progress measured over time Recovery is a process not a destination The court plays an important part in clinical conditions that precede the arrest and will endure after the court program.OvZvZovZvZzvZAz5. Stable Living Situation(Not having a home makes assessment difficult and protracted Range of safe, affordable housing options are necessary Separate assessment and treatment from housing Flexibility and tolerance required to retain people in housingHuziPPoziP{H6. Cultural Competency and Consumer CenterednessII("Seek to understand - don t assume a shared set of values or impose one s own. Respect cultural differences. Value the consumer s point of view.v|Different Perspectives on Outcomes Utility for Mild Symptoms plus Side Effects Versus Moderate Symptoms and No Side Effects (Lenert et al., 2000)2# Y Use Evidence-Based Practices(k Interventions for which there is consistent scientific evidence showing that they improve client outcomes.lk##Pyramid of Evidence-Based Practices$$( 7 Evidence Based Practice for Substance Use Disorders88$What s Popular General Counseling Lectures/Films Confrontation Relaxation Milieu Therapy Group psychotherapy"m^ What s Evidence Based Social Skills Training MET CRA CBT Relapse Prevention Modified Therapeutic Communities"mW4Evidence Based Practice for Serious Mental Illnesses55(Medications Illness Self Management Supported Employment Family Psychoeducation Assertive Community Treatment Integrated Treatment for Co-Occurring Disorders ,n2The Absence of EBPs in Behavioral Health Settings33(&        Surgeon General s Report Institute of Medicine Report New Freedom Commission Report >VvnvnX X  Mental Health Courts as EBP(    Limited Empirical Data Tremendous Variance in Court Process/Personnel Connecting to What ? What is the Courts Role in Accessing Quality Care? What if Community Care is not EBP? t]vnVvnvn]V   } 8. Optimism (/Critical ingredient for recovery Hope as an antidote to despair Must have courage to connect with the reality of despair Share belief that because the problems are severe, the person deserves help Create a vision of what a hopeful outcome might be Peer supervision and training to bolster staff optimismX@ _ 8 o_@8gW Conclusions 7Need to continue to build the science base Need to appreciate larger societal issues and advocate for: Affordable housing Health care as a right for all Access to evidence based practice Need to address stigma and discrimination Need to develop meaningful partnerships between criminal justice and mental healthHgZTZ}ZgT}/8 ` 33PP` 3333` ___MMM` 13` 333fpKNāvI` j@v۩ῑ΂H` Q_{>?" dd@,?n<d@ `7 `2@`7``2 n?" dd@   @@``PR    @ ` ` p>> "  t (  t t <Ĥ" F 0  t TǤd" F 0  t <ˤ"U_ F 0  t TΤd">& F 0  t NҤ"P F 0  t <֤"p F 0  t C x,٤?d?"bUv F 0   t 6ؤ "U  T Click to edit Master title style! !$  t 0@ޤ "   RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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You can see by looking at the red line that people who received integrated treatment were much more likely to recover from the substance use disorder than people who received parallel treatment, which is shown by the yellow line. After receiving treatment for 4 years, only about 20% of those in parallel treatment had recovered, whereas almost 60% of those in integrated treatment had recovered.   H ( 0.k ? ̙33  0 F > P ` (  `d ` c $lXK   2  ` 3 rj]j]l M(   xThis slide is based upon  What works? A methodological Analysis of the Alcohol Treatment Outcome Literature It is written by William Miller et al. The article was published as a chapter in Handbook of Alcohol Treatment Approaches, edited by Miller and Reid Hester. If you need to obtain a copy of this article contact Chet Bell at 386 947-1480 or cbell@stewartmarchman.org. It is important to read this article to present this slide authoratively. Essentially this meta-analysis of treatment outcomes from nearly 300 studies suggests that the techniques most typically provided in treatment show evidence of being the least effective. The slide has the effect of demonstrating that substance abuse treatment is more of a science than an art. The slide also sets the stage for discussion of the interventions listed in the  what s working column. 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