Te Ariari o te Oranga

Te Ariari o te OrangaTe Ariari o te Oranga

ABACUS Counselling, Training and Supervision ABACUS Counselling, Training and Supervision LtdLtd

Workshop 26 January 2010Workshop 26 January 2010

• Te Ariari o te OrangaTe Ariari o te Oranga

• Coexisting ProblemsCoexisting Problems

• ScreeningScreening

• Principles of case managementPrinciples of case management

• ReviewReview


Ariari o te Oranga – Dynamics of Ariari o te Oranga – Dynamics of HealthHealth, was a term coined by tutors , was a term coined by tutors and students of Te Ngaru Learning and students of Te Ngaru Learning Systems in 1996.Systems in 1996.


Imagine you are dancing on a Imagine you are dancing on a moonbeam to your favourite songmoonbeam to your favourite song

Towards well-being (2000). Towards well-being (2000).

Te Ariari o te Oranga: Te Ariari o te Oranga: The The Assessment and Management of Assessment and Management of People with Co-existing Mental Health People with Co-existing Mental Health and Substance use Problems and Substance use Problems

Todd F.C. (2010). National Addiction Centre, Todd F.C. (2010). National Addiction Centre,

Department of Psychological Medicine, Department of Psychological Medicine,

University of Otago. ChristchurchUniversity of Otago. Christchurch

Co-existing Conditions/ Disorders?Co-existing Conditions/ Disorders?

Relationships of Co-existing Relationships of Co-existing ConditionsConditions

• A primary mental health disorder A primary mental health disorder precipitates or leads to substance precipitates or leads to substance misusemisuse

• Use of substances makes the Use of substances makes the mental health problems worse or mental health problems worse or alters their coursealters their course

Relationships of Co-existing Relationships of Co-existing ConditionsConditions

Substance misuse and/or withdrawal Substance misuse and/or withdrawal leads to psychiatric symptoms or leads to psychiatric symptoms or disorder. disorder.

Problems develop faster; symptoms Problems develop faster; symptoms more intense and severe; less more intense and severe; less responsive to treatment; relapse responsive to treatment; relapse more likelymore likely

Co-existing Problems (CEP)Co-existing Problems (CEP)

The word “problems” is preferred The word “problems” is preferred over “disorders” or “conditions” in over “disorders” or “conditions” in recognition that problem recognition that problem gambling and mental healthgambling and mental health (including substance use) (including substance use) symptoms may occur at levels symptoms may occur at levels that do not meet criteria for that do not meet criteria for disorders in their own right. disorders in their own right.

PrevalencePrevalence

Substance use disorder in the past 12 Substance use disorder in the past 12 months:months:

• 29% also suffered a mood disorder 29% also suffered a mood disorder • 40% suffered an anxiety disorder 40% suffered an anxiety disorder

Mood disorder in the past 12 months:Mood disorder in the past 12 months:• 12.9% also had a substance use disorder12.9% also had a substance use disorder

(Te Rau Hinengaro) (Te Rau Hinengaro)

Mental Health disorders commonMental Health disorders common

0

10

20

30

40

50

60

70

80

% o

f p

rob

lem

ga

mb

lers Depression

Anxietydisorder

Drugdisorder

Alcoholdisorder

Manicdisorder

• AOD problems AOD problems may occur in may occur in 75% of PGs75% of PGs

• Anxiety in over Anxiety in over 40% of PGs40% of PGs

• Depression Depression usually 60%+ usually 60%+ in other in other researchresearch

Petry et al 2005

Problem Gambling and Co-existing Problem Gambling and Co-existing MH ProblemsMH Problems

• Likely to meet criteria for other mental Likely to meet criteria for other mental disorders disorders

• Almost all PG have another lifetime MH Almost all PG have another lifetime MH disorder disorder (Kessler et al 2008)(Kessler et al 2008)

• Co-existing mental health and addiction Co-existing mental health and addiction problems are associated with suicidal problems are associated with suicidal behaviour and increases in service usebehaviour and increases in service use

ALAC/MH Commission report, 2008

CoexistingCoexisting

• 3.7 times likely to be a current smoker 3.7 times likely to be a current smoker

• 5.2 times likely to be hazardous 5.2 times likely to be hazardous drinkingdrinking

• High rates of depression and anxiety High rates of depression and anxiety

(Focus on Gambling)(Focus on Gambling)

““Problem gambling may Problem gambling may exacerbate other exacerbate other dependencies, and they in dependencies, and they in turn may exacerbate problem turn may exacerbate problem gambling”gambling”

ALAC/MHALAC/MH Commission Report Commission Report (2008)(2008)

People with AOD and gambling People with AOD and gambling problems have greater mental problems have greater mental health problems than the general health problems than the general community, most commonly community, most commonly depression and anxietydepression and anxiety

Co-existing issues to addressCo-existing issues to address

““Counselling for problem gambling will Counselling for problem gambling will need to also deal with these co-need to also deal with these co-morbidities and treatment for other morbidities and treatment for other dependencies may need to take into dependencies may need to take into account secondary gambling problems account secondary gambling problems that may not be transparent”that may not be transparent”

Australian Productivity Commission (1999)Australian Productivity Commission (1999)

ALAC/MHALAC/MH Commission Report Commission Report (2008)(2008)

Māori - higher mental health and Māori - higher mental health and substance-use disorders than the substance-use disorders than the general population; also applies to general population; also applies to problem gamblingproblem gambling

Addiction and Co-existing Addiction and Co-existing ProblemsProblems

• Co-existing mental health and Co-existing mental health and addiction problems are associated addiction problems are associated with suicidal behaviour and increases with suicidal behaviour and increases in service usein service use

ALAC/MHALAC/MH Commission report, 2008Commission report, 2008

So What?So What?

Co-existing ProblemsCo-existing Problems

• Poor treatment Poor treatment

• Poor treatment outcomePoor treatment outcome

• High service useHigh service use

Issues of Stigma in TreatmentIssues of Stigma in Treatment

• Addiction is often linked in people’s Addiction is often linked in people’s minds with criminality minds with criminality

• There is often a tacit belief that There is often a tacit belief that “addicts” invite and deserve “addicts” invite and deserve discrimination. discrimination.

• Little recognition by society that Little recognition by society that addiction is a chronic health condition addiction is a chronic health condition for which there are proven, successful for which there are proven, successful interventionsinterventions


SummarySummary

•Coexisting problems are the Coexisting problems are the rulerule

• Substance Use, anxiety and moodSubstance Use, anxiety and mood

• Presentation higher in treatment Presentation higher in treatment populationspopulations

““Working with people with co-existing Working with people with co-existing mental health and addiction mental health and addiction problems is one of the biggest problems is one of the biggest challenges facing frontline mental challenges facing frontline mental health and addiction services in New health and addiction services in New Zealand and overseas. The co-Zealand and overseas. The co-occurrence of these problems adds occurrence of these problems adds complexity to assessment, case complexity to assessment, case planning, treatment and recovery”planning, treatment and recovery”


ScreeningScreening

Benefits of ScreeningBenefits of Screening

• Reliability and ValidityReliability and Validity

• Common LanguageCommon Language

• ‘‘Window’ of opportunityWindow’ of opportunity

• Provides some directionProvides some direction

Todays ScreensTodays Screens

• AUDIT – CAUDIT – C

• Kessler (10)Kessler (10)

• SDSSDS

• RiskRisk

AUDIT - C AUDIT - C

Standard DrinksStandard Drinks

The Standard Drinks measure is a The Standard Drinks measure is a simple way to work out how simple way to work out how much alcohol you are drinking. much alcohol you are drinking. It measures the amount of pure It measures the amount of pure alcohol in a drink. One standard alcohol in a drink. One standard drink equals 10 grams of pure drink equals 10 grams of pure alcohol.alcohol.

AOD as self- medication?AOD as self- medication?

• Temporary symptom reduction: arousal Temporary symptom reduction: arousal soothed; avoidance maintained; soothed; avoidance maintained; intrusive thoughts/memories controlled; intrusive thoughts/memories controlled; fear calmedfear calmed

• Lift sadness; increase energy/motivationLift sadness; increase energy/motivation• Reduce preoccupation with delusions Reduce preoccupation with delusions

and intrusiveness of hallucinations – PG?and intrusiveness of hallucinations – PG?• Lack of alternative coping strategies- Lack of alternative coping strategies-

avoidanceavoidance• Psychophysical state made controllablePsychophysical state made controllable

Substances: Substances: Severity of Dependence Scale Severity of Dependence Scale

Self-medication? Self-medication? (Cont’d)(Cont’d)

• Stimulants give high arousal and sensitise Stimulants give high arousal and sensitise to stressto stress

• Depressants reduce energy, motivation and Depressants reduce energy, motivation and cognitive clarity cognitive clarity

• AOD users place themselves in dangerous AOD users place themselves in dangerous or risky situations:or risky situations:

• Disinhibition, reduced impulse control, Disinhibition, reduced impulse control, deterioration of judgementdeterioration of judgement

• High-risk situations associated with ‘drugs’High-risk situations associated with ‘drugs’• PG affects health, job, finance, supports – PG affects health, job, finance, supports –

PG isolatedPG isolated

Kessler (10)Kessler (10)

What happens to MH in PGs?What happens to MH in PGs?

Does part-addressing AOD/MH mean:Does part-addressing AOD/MH mean:

• If we focus almost solely on the gambling If we focus almost solely on the gambling and are successful in reducing harm from and are successful in reducing harm from gambling, do most (74.3%) clients with gambling, do most (74.3%) clients with pre-existing disorders retain these now pre-existing disorders retain these now minus the gambling (and risk relapse from minus the gambling (and risk relapse from these?), orthese?), or

• Do we assume addressing the gambling Do we assume addressing the gambling somehow also successfully addresses the somehow also successfully addresses the client’s pre-existing AOD/MH disorders?client’s pre-existing AOD/MH disorders?

Cultural IssuesCultural Issues

• In some cultures, depression is In some cultures, depression is expressed in somatic terms, rather expressed in somatic terms, rather than sadness or guiltthan sadness or guilt

• Examples: “nerves”, headaches; Examples: “nerves”, headaches; weakness, tiredness or imbalance weakness, tiredness or imbalance (Asian); problems of the heart (Asian); problems of the heart (Middle East).(Middle East).

Cultural IssuesCultural Issues

• For some, may be irritability rather For some, may be irritability rather than sadness or withdrawalthan sadness or withdrawal

• Differentiate between culturally Differentiate between culturally distinctive experiences and distinctive experiences and hallucinations or delusions (which hallucinations or delusions (which may be psychotic part of the may be psychotic part of the depression)depression)

• Don’t dismiss possible symptoms as Don’t dismiss possible symptoms as always culturalalways cultural

Suicidality ScreenSuicidality Screen

Within the last 12 months, have you had Within the last 12 months, have you had thoughts of self-harm or suicide?thoughts of self-harm or suicide?

1.1. No thoughts in the past 12 monthsNo thoughts in the past 12 months2.2. Just thoughtsJust thoughts3.3. Not only thoughts, I have also had a plan.Not only thoughts, I have also had a plan.4.4. I have tried to harm myself in the past 12 I have tried to harm myself in the past 12

monthsmonths

Risk AssessmentRisk Assessment

Identifying Risk is important but Identifying Risk is important but don’t let it stop you from finding don’t let it stop you from finding the positive and building on the positive and building on strengthsstrengths

Case ManagementCase Management

So what should we treat?So what should we treat?

• Many disorders very complexMany disorders very complex• They are in addition to social needsThey are in addition to social needs• But governmental approach is ‘make But governmental approach is ‘make

every door the right door’every door the right door’• So could identify (screen) and referSo could identify (screen) and refer• Or identify and further briefly intervene Or identify and further briefly intervene

(in addition to referral) (in addition to referral) • Or have specialists on-site (brought in Or have specialists on-site (brought in

or base PG practitioners where these or base PG practitioners where these available)available)

QuadrantQuadrant

PGPG

High PG Low MHHigh PG Low MH

PG + MHPG + MH

Shared CareShared Care

High PG High MHHigh PG High MH

PG or MHPG or MH

EitherEither

Low PG Low MHLow PG Low MH

MHMH

High MH Low PGHigh MH Low PG

Could this quadrant model work Could this quadrant model work for your clients who have Co-for your clients who have Co-Existing Mental health or AOD Existing Mental health or AOD problems?problems?

5 Key Principles 5 Key Principles (1998)(1998)

• Safety Safety • StabilisationStabilisation• Comprehensive assessment and Comprehensive assessment and treatment planningtreatment planning•Clinical case managementClinical case management• Treatment integrationTreatment integration

Integration Integration

How do we integrate our models?How do we integrate our models?Cultural Safety and Cultural Cultural Safety and Cultural Competence?Competence?What principles underpin our practiceWhat principles underpin our practice

RANGI MATRIXState ofState of Action ofAction of AffectsAffects CreatesCreates UseUse RequiresRequires Focus onFocus on

PIRANGIPIRANGI KAPOKAPOReflective GestureReflective Gesture

Te NgakauTe Ngakau A transitoryA transitorydesiredesire

ManaakiManaaki

WAIRANGIWAIRANGI PIOPIOPIOPIOProgressive Progressive grabbing stance. grabbing stance. Feeling of being Feeling of being overcome. overcome. Drowning Drowning sensationsensation

Te Te ManawaManawa

A hunger to A hunger to satisfysatisfy

Whanau-Whanau-ngatangangatanga

ArohaAroha Kete Kete AronuiAronui(Esoteric)(Esoteric)

HAURANGIHAURANGI HURORIHURORIStaggering but a Staggering but a semblance of semblance of control. Imbalance control. Imbalance in pukuin puku

Te PukuTe Puku An urge An urge that needs that needs attending attending toto

Whanau-Whanau-ngatangangatanga

AwhiAwhi

PORANGIPORANGI KEKAKEKASpasmodic Spasmodic attempts to be attempts to be free. Feeling of free. Feeling of being trapped in being trapped in darknessdarkness

Te RoroTe Roro A panic to A panic to be freebe free

WhakapapaWhakapapa TautokoTautoko Kete Kete TuauriTuauri(Tangata)(Tangata)

WHETURANGWHETURANGII

TOITUTOITUFrozen immobility.Frozen immobility.Catatonia. Catatonia. NumbnessNumbness

Te MauriTe Mauri WhakaohoWhakaoho Kete Kete TuateaTuatea(Spiritual)(Spiritual)

WHAKAOTINGA: Completion of the journey, new beginning. The covenantof maintaining the relationship beyondphysical sight . Unlocking the Mauri

WHAKAORANGA: Respecting of life. Honouring of living. Subscription to theneed for healthier relationships.

WHAKARATARATA: Expression of openness and trust in developing relationships. The hiatus setting.Transition to a new place.

WHAKATANGITANGI: Letting thewellness spring flow. Inner mamae. Memories. Emotional commitment to common relationship.

WHAKAPUAKI: Focusing on the reason for our being there. Determining everyone’s relationship tothe issue.

MIHIMIHI: Honouring the people andthe land. Establishing personal andsocial relationships. Trust

KARAKIA: Unlocking Wairua. Acknowledging presence of Atua andHigher power than us.Acknowledge divine relationship.

POWHIRI POUTAMA

Use of Whare Tapa Wha to Use of Whare Tapa Wha to Measure OutcomesMeasure Outcomes

DimensionsDimensions WairuaWairua HinengaroHinengaro TinanaTinana WhānauWhānau

Dimension 1Dimension 1 Dignity and Dignity and RespectRespect

MotivationMotivation Mobility/ Mobility/ PainPain

CommunicationCommunication

Dimension 2Dimension 2 Cultural Cultural identityidentity

Cognition / Cognition / BehaviourBehaviour

Opportunity Opportunity for for enhanced enhanced healthhealth

Relationships/ Relationships/ respect / trustrespect / trust

Dimension 3Dimension 3 Personal Personal contentmentcontentment

Management of Management of emotions, emotions, thinkingthinking

Mind and Mind and Body linksBody links

Mutuality / Mutuality / acceptanceacceptance

Dimension 4Dimension 4 Spirituality Spirituality (non-physical (non-physical experience)experience)

UnderstandingUnderstanding Physical Physical health health statusstatus

Social Social participationparticipation

Treatment IntegrationTreatment Integration

• Aims to reduce gaps and barriers Aims to reduce gaps and barriers between servicesbetween services

• Integrates various treatments into a Integrates various treatments into a single treatment stream or packagesingle treatment stream or package

• Adapts the various treatments to be Adapts the various treatments to be consistent and not conflict with each consistent and not conflict with each otherother

• Need seamless, consistent, Need seamless, consistent, “accessible” approach to clients’ “accessible” approach to clients’ pathology, deficits and problems pathology, deficits and problems (including criminal offending issues)(including criminal offending issues)

7 key Principles7 key Principles

• Cultural needs and values considered Cultural needs and values considered throughout the treatment process.throughout the treatment process.• Well-being is the key outcome rather Well-being is the key outcome rather than than the absence of dysfunction.the absence of dysfunction.• Increase and maintain engagement Increase and maintain engagement with with the clinical case manager, the the clinical case manager, the management plan and the service.management plan and the service.• Enhance motivation including use of Enhance motivation including use of CEP-CEP- adapted MI techniquesadapted MI techniques

7 key Principles 7 key Principles (cont)(cont)

• Assessment - Screen all and if +ve Assessment - Screen all and if +ve undertake a comprehensive assessment.undertake a comprehensive assessment.• Use clinical case management to Use clinical case management to deliver deliver and coordinate multiple and coordinate multiple interventions.interventions.• Integrated Care driven by the Integrated Care driven by the integrated integrated formulation in a single formulation in a single setting and setting and ensuring close linkages.ensuring close linkages.

MI PrinciplesMI Principles

• Some coexisting problems can Some coexisting problems can be addressed without referral to be addressed without referral to MH or AOD services MH or AOD services

• Others will require referral for Others will require referral for best outcomes for the PG clientbest outcomes for the PG client

Guiding Principles Guiding Principles TIP 42, 2005TIP 42, 2005

• Develop a phased approach to Develop a phased approach to treatment – ME as front end treatment – ME as front end (engagement/persuasion), active (engagement/persuasion), active treatment/follow-up and relapse treatment/follow-up and relapse prevention, together with a “stages prevention, together with a “stages of change” approachof change” approach

Guiding Principles Guiding Principles (cont.)(cont.) TIP 42, TIP 42, 20052005

•Address specific real-life Address specific real-life problems early in treatmentproblems early in treatment

•Use support systems to Use support systems to maintain and extend maintain and extend treatment effectivenesstreatment effectiveness

Brainstorming ExerciseBrainstorming Exercise

• List four (4) AOD/MH services in List four (4) AOD/MH services in your area that you could either your area that you could either refer PGs to, or services you could refer PGs to, or services you could work with if your PG clients have work with if your PG clients have MH conditionsMH conditions

• How could you ensure this process How could you ensure this process could work for these clients?could work for these clients?

DISCUSSDISCUSS

Summary ISummary I

• Coexisting Problems are commonCoexisting Problems are common

• Coexisting problems can Coexisting problems can complicatecomplicate

• Screens provide useful information Screens provide useful information

• Screens can help create Screens can help create dissonancedissonance

• Build on strengthsBuild on strengths

Summary IISummary II

• Single co-ordinating pointSingle co-ordinating point

• Use compatible treatment Use compatible treatment models/conceptsmodels/concepts

• Harm minimisation approachHarm minimisation approach

• Close liaison between all partiesClose liaison between all parties

• Deliver all treatments from one settingDeliver all treatments from one setting

• Close liaison between therapists, Close liaison between therapists, treatment agencies and whtreatment agencies and whāānau/familynau/family

Mauri OraMauri Ora

Te Ariari o te Oranga

Health & Medicine

Transcript of Te Ariari o te Oranga