ASAM 3 3 Decoded The Nuts and Bolts

ASAM 3. 3 Decoded: The Nuts and Bolts of Clinically Managed, Population Specific, High Intensity Residential Services Mardell Gavriel, Psy. D. Vice President of Mental Health Services Health. Right 360

ASAM Level 3. 3 Modified Services for Clients with Cognitive Impairments • Provides structured recovery environments in combination with high-Intensity clinical services provided in a way to meet the functional impairments of clients with cognitive impairments in order to achieve recovery from substance use or co-occurring disorders • The cognitive impairments may be temporary or permanent and can be the result of substance use, traumatic brain injury, aging, developmental disabilities, chronic brain syndrome or other conditions such as FASD • Treatment at this level of care is characterized by a slower pace, more repetition, and concrete VS abstract information • Because the cognitive impairments can severely limit emotional coping and interpersonal functioning, the work is often habilitative rather than rehabilitative

Examples of Level 3. 3 Programs • Therapeutic Rehabilitation Facility • Traumatic Brain Injury Program • Appropriately licensed community-based treatment setting that is freestanding or a specialty track of services in an appropriately licensed and certified community-based facility that also houses other ASAM levels residential care

Screening for Cognitive Impairments • Clinician observation • Client/family self report • Treatment/services history • Previous psychological testing evaluations • Use of brief screening tools Life History Form Mini Mental Status Exam (MMSE) Addenbrook III Montreal Cognitive Assessment

ASAM 3. 3: Required Support Systems • Telephone or in-person consultation with a physician, physician assistant or in states where they are regarded as physician extenders, a nurse practitioner • Emergency services available 24/7 • Direct affiliation or accessible referral to other levels of care and other supportive services such as literacy training, supported employment, and adult education • Either through consultation or referral, medical, psychiatric, laboratory and toxicology services appropriate to the patient’s severity of need

ASAM 3. 3: Staff Requirements • Physicians, physician extenders and appropriately credentialed mental health staff • Allied health professional staff such as counselor aides or group living workers, on site 24 hours a day or as required by licensing regulations • One or m ore clinicians with competence in the treatment of substance use disorders are available on-site or by telephone 24 hours a day • Clinical staff knowledgeable about the biological and psychological dimensions of substance use and mental disorders and their treatment including the signs and symptoms of psychiatric decompensation. • Staff who have training in behavior management techniques

ASAM 3. 3: Therapies • Daily clinical services organized to help the client to structure and organize tasks of daily living, manage recovery, assume personal responsibility, follow a schedule, etc. • Family support services are provided • Clinical services arrayed to achieve and maintain stability of addiction symptoms and help utilizing recovery skills. These can include relapse prevention, building a recovery support network, and maintaining positive social relationships • Random drug screening • Range of cognitive, behavioral and otherapies delivered in individual and group settings, medication management, educational groups, and recreational activities at the client’s level of comprehension

ASAM 3. 3: Therapies (cont. ) • Counseling and support to help the client engage in meaningful daily activity (work, school, family) • Medication adherence monitoring • Daily scheduled addiction and mental health treatment appropriate for the individual needs of the client. If required, nursing services, family therapy, occupational and recreational therapies, at, music or movement therapies, physical therapy and vocational rehabilitation therapies • Clinical and didactic motivational interventions matching the patient’s stage of change

Dimensional Admissions Criteria for Level 3. 3 • 1: • 2: • 3: • 4: • 5: • 6: No withdrawal risk Stable health conditions/client can self-administer meds Client can participate and benefit from the program/requires residential structure to stabilize a psychiatric condition, maintain activities of daily living/maintain sobriety/manage threat to self or others due to intoxication/manage continuous dysfunctional behaviors/or is not likely to maintain mental stability in their home environment Either due to substance use or cognitive limitations, client has little insight for the need for treatment or the connection between addiction and their life problems Client is in imminent danger of continued use, intensifying use, or continues to use substances after treatment in a lesser level of care Client is unlikely to achieve sobriety in current living situation/Client is at risk for victimization in their current environment/ or client requires 24/7 staff monitoring for safety

Stephanie is a 34 -year-old, single. Caucasian, mother of two who was court mandated to residential substance use disorder treatment. She has significant involvement in the criminal justice system that began in adolescence and continued through adulthood. Her charges are largely drug and alcohol related, however they also include shoplifting and vandalism. Her primary drug of choice is alcohol, but more recently she has also been using Methamphetamine. Her two children, ages 5 and 7 have been placed by CPS in a kinship arrangement with Stephanie’s older sister. She has monitored visitations with her children, but they have been erratic due to Stephanie’s periodic bouts of homelessness and jail incarcerations. Stephanie was adopted at age 7 ½ months, and according to her mother who accompanied her to her intake appointment, she experienced developmental delays and behavior problems including frequent, angry outbursts from a young age. “She has a hard time focusing and sustaining attention on anything, ” her mother said. “She was diagnosed with learning disabilities in grade school, but we were told that her IQ was normal. ” She is always so impulsive and she doesn’t learn from her mistakes, she said. Stephanie’s mother also described difficulties with planning and problem solving and stated that her daughter was placed in a special classroom for children with emotional and behavioral problems by the 7 th grade. Stephanie dropped out of high school in her sophomore year. As part of her intake process, Stephanie completed a brief cognitive screen that suggests that she has a moderate level of impairment in the areas of attention and memory. Her further assessments indicate that she has an 8 th grade reading level and her preferred learning style is strongly Kinesthetic.

Poll In your opinion, what would be the most immediate treatment priority for Stephanie as she enters residential treatment? a. Develop memory cues to assist in learning recovery skills b. Learn strategies to manage anger c. Gain parenting skills

Cognitive Impairments • Memory Problems • Information processing speed • Perception problems • Planning deficits • Speech problems • Problem solving deficits • Judgement • Task shifting Problems with awareness Organizational deficits Decision making deficits Social skills Problems linking behaviors and consequences • Problems regulating behavior • Learning problems • Initiating and monitoring actions • • •

Causes of Cognitive Impairments • • • Schizophrenia and other mental health conditions Substance abuse Traumatic brain injury Progressive neurological disorders (Parkinson's, Alzheimer's) Developmental disabilities Intellectual disabilities Trauma Aging FASD

Cognitive Impairment Compromises Treatment Outcomes • Contributes to already high drop out rates • Clients with cognitive impairments more likely to drop out prematurely • The higher the severity of the impairments, the higher the risk of premature drop out • Undiagnosed FASD may be a factor in the high percentages of drop outs

What is Fetal Alcohol Spectrum Disorder (FASD)? FASD is an umbrella term describing the range of effects that can occur in an individual with prenatal alcohol exposure (PAE) – Fetal Alcohol Syndrome (FAS) – Partial FAS (PFAS) – Alcohol Related Birth Defects (ARBD) – Alcohol Related Neurodevelopmental Disorder (ARND) – Neurobehavioral Disorder associated with PAE (ND-PAE) provisional in the DSM-V

The Effects of FASD Effects may include – Executive function deficits – Attention deficits/Learning disabilities – Social cognition – Impulsivity/judgement problems – Secondary emotional/mental health disorders Effects are a result of damage to the developing fetus and they are permanent.

Prevalence of Prenatal Alcohol Exposure • There is no known safe amount of exposure to a developing fetus • National surveys show that 1 in 2 women of childbearing age drink alcohol and 18% of women in that age group binge drink • 1 in 10 pregnant women report alcohol use and 1 in 33 report binge drinking in the past 30 days • Due to problems with diagnosis, a low estimate of US prevalence is between 2 – 5%

FASD and Substance Use • 35% of individuals with FASD over the age of 12 have alcohol or drug problems • Among adults with PAE 53% of males and 70% of females experience SUD problems. This is more than 5 times that of the general population

Considerations for SUD Treatment Providers • FASD may be found at a higher rate among our clients than the general population • Because such a low number of affected patients demonstrate the physical characteristics and can confirm maternal drinking during pregnancy, the problem often goes diagnosed • A failure to address the needs of those affected by FASD or other diagnosed or unrecognized cognitive impairments creates a significant treatment barrier and establishes the conditions for premature drop-out and treatment failure

Health. RIGHT 360 is a family of integrated health programs that provides compassionate primary and behavioral health care and treatment to over 40, 000 individuals a year through more than 90 distinct and culturally competent programs in 9 California counties.

Two HR 360 Initiatives to Adapt SUD Treatment for clients with cognitive impairments • Research project to screen for possible PAE at intake for residential SUD services • Clinical re-design of residential and outpatient services to improve accessibility of treatment for clients with mild – moderate cognitive impairment

PAE Research Project Screening Tool The Life History Screen Grant et al. developed a screening tool, the Life History Screen, for treatment programs. It assesses 9 domains (including three “key” domains) that are often impacted in clients with PAE: 1. Childhood Hx 2. Maternal Alcohol Use 3. Day to Day Behaviors 4. Education 5. Criminal Hx, 6. Substance Use 7. Employment and Income 8. Living Situation 9. Mental Health

Results of the Study to Screen for PAE • HR 360 staff collected 180 PAE screens between 1/12/16 and 3/21/16 • Average of respondents was 41. 4 years at admissions • 55% of respondents were male; 41% female; and 4% transgender • 23% of respondents would be considered eligible for treatment modifications based on the initial screen • No statistical difference was found in discharge status or length of stay in number of days • People with FASD have poorer life outcomes and face greater challenges in independent living: Treatment effect unlikely to hold without preparation while in treatment and post episode acute treatment support

HR 360 Clinical Redesign • We made an assumption that because we serve a “Safety Net” population heavily impacted by chronic substance use, mental health problems, criminal justice histories, homelessness, and trauma that cognitive impairments would likely be more prevalent among our clients than the general population • We also assumed that treatment accessibility might be an important contributing factor to premature drop-out rates • While not dismissing the need to better screen clients and identify their specific impairments and strengths, we decided that we could make general changes to program content and design that would improve services for those with cognitive challenges and “wouldn’t hurt anyone else

Changed our Policy on Cell Phones • Cell phones had always been banned in our residential facilities • Our staff were turning into the “cell phone police” • When caught with cell phones, many clients opted to “walk away” from treatment rather than surrender them • Changed our policy to permit them if clients give us their phone numbers and we created as set of rules regarding their use • We established a protocol to see if we could reverse some premature departures by contacting clients on their phone and encouraging a return to treatment • We believed an added benefit was that the program could encourage the client to use their phones to better orient themselves to treatment and be where they were supposed to be

Additional Assessments • Assess reading ability: San Diego Reading Assessment • Assess preferred learning style: Georgia Learning Style Inventory • Assess for trauma/PTSD: PTSD Checklist • Ask the client and family members if available about personal strengths and any strategies they have developed for effective learning. Tap their expertise • Ensure gained information is available to the treatment team

Stephanie had a difficult time initially adjusting to the program. She had frequent conflicts with other clients and despite extra cues and reminders, she was rarely where she was supposed to be. Staff grew concerned about the frequency and intensity of her angry outbursts and they became an initial target of intervention because staff feared she risked being asked to leave treatment for threatening behavior. During groups and individual sessions, Stephanie was taught applied mindfulness skills in an effort to have her observe and notice thoughts, feelings, and behaviors that signaled the beginning of one of her outbursts. Particular focus was placed on the body sensations that warned her she was becoming angry and frustrated. It was hoped that if Stephanie could develop an early warning system, that she would have more agency over the problem. Additionally, Stephanie was taught and encouraged to practice a simple grounding exercise focused on her breath.

Program Modifications for the ASAM 3. 3 Level of Care • To the degree possible, maintain an organized physical environment and a routine and predictable schedule • Utilize signage for rooms and names on offices • Lower the stimulation level in the physical environment (Quiet the PA system and general noise level to the degree possible • Provide multiple and frequent cues and reminders as to where clients should be and what they should be doing • Provide pocket calendars and watches or coach the use of cell phones to provide information to the client about the schedule

Assist Clients to Manage Arousal Levels • Very high or very low emotional arousal can narrow cognitive abilities for individuals who demonstrate no cognitive impairment • For clients who already face cognitive challenges, this narrowing can further interfere with new learning, judgement, decision-making and other executive functions • Teach clients about arousal, emotional triggers, and trauma when they are regulated • Teach and coach the use of simple grounding techniques so they can be accessed at critical times

The Normal Window of Emotional Tolerance Hyper-arousal: highly charged, fight, overwhelm, anxiety, panic, racing thoughts, anger _________________________________________________________ Hypo-arousal: body/brain shut-down, numbing, feeling spacey, not present, dissociation

Manualized Curricula: Challenges and Strategies Challenges Most manualized approaches require a 7 th grade reading level Strategies Assess client’s reading level at admissions Many CBT manualized approaches require a lot of reading, writing, and homework Utilize alternative curricula that emphasizes learning through role play i. e. : Skills Streaming (ART) and Overcoming Addictions Pair up clients as learning partners

Manualized Curricula: Challenges and Strategies Challenges (cont. ) The pace of learning may be too fast for clients with cognitive impairments There may be too much material to cover in a reasonable timeframe Strategies (cont. ) Slow it down and “rechunk” the material in a more useful way Meet twice a week with one lesson being new learning and the second review and homework assistance Review the material and select the most useful skills & aspects and teach them as a “sampler” approach

Support Learning and Skills Acquisition Slow the pace of learning and build in more repetition Shorten groups to match reduced attention spans Institute more breaks (stretches) and interactive activities Utilize diary cards and other reminders to provide cues, track urges, and track the use of skills to manage challenges • Employ simplified behavioral analysis strategies(modified thinking reports, chain analysis, etc. ) to increase awareness of the consequences of behavior and how choices affect outcome • Ask clients to summarize what they have learned in their own words • •

Teach Mindfulness Skills and Integrate them into Program Activities • Teach and Utilize applied mindfulness skills that help clients be in the present moment with acceptance • Mindfulness helps clients direct their attention and focus • For clients with impulsivity due to cognitive impairments, mindfulness provides an opportunity to create a pause between thought and behavior • Research supports that mindfulness can improve attention, memory, and executive functioning in individuals with cognitive impairments

Work to Reduce Stigma • Manage “same and different” issues • Specialized VS mainstreamed caseloads • Educate the entire client population about cognitive impairments • Be thoughtful about naming groups

Poll With multiple levels of residential care in the same setting, what is most beneficial for clients with cognitive impairments: a. Group together specialized case loads & address stigma. b. Mainstream clients throughout caseloads & train all staff.

Stephanie The day after one of Stephanie’s loud angry exchange with another client, once she was more regulated, her therapist engaged her in a behavioral analysis of the incident. The therapist wanted to help Stephanie connect actions to consequences. Instead of mapping the analysis on paper as is customary, therapist modified the intervention to be more experiential, given the client’s preferred learning style. She brought Stephanie into a room where she had placed foam tiles on the floor in a path that led to two separate destinations. At intervals along the path, she had large poster paper stuck to the walls. . . The paper had headings with the following labels: Body Sensations, Thoughts, Emotions, and Actions. Therapist asked Stephanie to walk the path to the first destination labeled “Angry outburst” and prompted her to share information about the headings along the way. When done, therapist prompted Stephanie to walk the path to the destination labeled “Managed Emotion. ” She then helped Stephanie explore skills and alternate behaviors that could lead her to the solution focused destination. The take away message that Stephanie gained from the exercise was to utilize the grounding skill (counting her breath) she had learned when she experienced the first signal of anger and frustration which she identified as her face feeling hot. Her therapist later provided her with a rubber bracelet with the word “Breathe” on it.

Staff Training Issues • Individuals with cognitive impairments can appear to flaunt program rules and norms , • These clients often don’t follow instructions or directives because they don’t understand them or have challenges with initiating behaviors • Often, there are limitations regarding sustaining goal directed activates • Connecting behaviors and consequences is often another challenge • All of these factors can entrench problem behaviors and frustrate staff, particularly if they have not received training in these matters

The importance of case management and care coordination activities • When serving a population clients with cognitive impairments, it is important to recognize their need for more than recovery skills • If the client is not currently linked to needed services, referral with active follow-up and warm hand-off strategies should be employed • ROIs should be obtained from other providers, family members, and additional care givers • As much as possible, formal and informal care coordination with other involved providers and family members should be take place. A specific example of how this can be helpful is to have the client and/or SUD staff share information about the client’s relapse triggers with family members and other involved providers. The family may gain from training about recognizing the signs of relapse and relapse prevention skills

Treatment Modifications

Treatment Suggestions from SAMHSA • Allow the client time to stabilize to the new setting. • Help the client adjust to a structured program and develop trust in the staff. • Share the rules early and often. • Take a holistic approach - not just the substance abuse or mental health issues. • Provide opportunities to role-play skills. • • Assume the presence of co-occurring issues. Arrange aftercare, and encourage family/caregivers to participate

Some additional Tips • Allow clients ample time to complete tasks • Employ the use of memory aids (calendars, schedules, watches that beep, sticky notes) to provide redundant cues • Break down multi-step instructions to smaller bites of information • Provide short breaks to prevent cognitive fatigue or frustration • Present information in both verbal and visual ways • Encourage clients to repeat back information in their own words

From SAMHSA: What Not to Do The Impact of Prenatal Alcohol Exposure on Addiction Treatment. (2013) Grant, Therese M. Ph. D; Brown, Natalie Novick Ph. D; Dubovsky, Dan MSW; Sparrow, Joanne MA; Ries, Richard MD. Journal of Addiction Medicine

Stephanie’s residential treatment episode is coming to an end and her primary counselor, and therapist have had several meetings with the client and her mother in order to prepare Stephanie for stepping down to the intensive outpatient level of care. It had always been part of Stephanie’s discharge plan that she would live with her mother while continuing to attend OP treatment. In preparation of the transition, Stephanie has already received a warm hand-off and participated in sessions with both her new primary counselor and individual therapist. With the help of her current counselor and therapist, Stephanie has shared with her mother what she has learned regarding her specific triggers for both relapse and anger and they have reviewed together the grounding skills and other strategies that she has acquired to manage these. This was done in an effort to assist the client’s mother in becoming an effective recovery coach. Mother and daughter have also taken part in a facilitated conversation about how Stephanie can best communicate how she is doing with her mother and how her mother can respectfully approach Stephanie with concerns. They came to an agreement that they would check in with each other every morning using a Green, Yellow, Red set of code words. Stephanie would indicate she was feeling green when she felt less risk for using substances and losing her temper, yellow to indicate growing risk, and red when she felt at imminent risk. In a similar way, Stephanie’s mother would use the same set of code words if she observed Stephanie exhibiting behaviors that either supported or threatened her recovery.

Webinar Handouts • • • The Life History Form Revised The Montreal Cognitive Assessment The Mini Mental Status Exam The Addenbrooks III The PTSD Checklist The San Diego Reading Assessment The Georgia Learning Skills Inventory ASAM Residential Level of Care Questionnaire 1735 Mission Street San Francisco California 94103 415. 762. 3700 www. health. RIGHT 360. org

Kintsukuroi: The Japanese Art of repairing broken pottery with gold; restoring the object to its original purpose and making it stronger, more beautiful, and more valuable for having been broken

Questions/Discussion 1735 Mission Street San Francisco California 94103 415. 762. 3700 www. health. RIGHT 360. org