Engage and Support
For individuals who have developed a mental health need or substance use disorder that requires engagement in treatment services, this continuum of behavioral health care includes essential elements of effective, outpatient care. It is critical that behavioral health services consider active strategies to engage their clients so that they participate in and return for care.
In a report focused on mental health care engagement, the National Alliance on Mental Illness wrote, “The failure to effectively engage a person early can cause the person to turn away from mental health services and supports. Lack of effective engagement can have serious consequences when a condition gets worse: hospitalization, incarceration, homelessness, and early death. The failure to get timely, effective help often also harms relationships and traumatizes families. Watching a loved one spiral downward leaves those left on the sidelines feeling helpless, powerless and terrified.”[i]
Consider that less than half of people who enter substance use disorder treatment complete it, even as research has shown that engagement in treatment improves treatment outcomes. At the provider level, tackling obstacles to treatment engagement must be a priority. This includes wait times, ease of use, efficacy of treatment used, cost of treatment, outreach, and provider knowledge, attitude, and care coordination capacity.[ii]
Treatment plans developed at the start of care should be individualized, culturally congruent, and client centered. To be client centered, the plan should be driven by the goals of the individual (and his or her family members, when appropriate) to address their health care, education, housing, recovery, or wellness services, and social and community supports needs and preferences. More than ever, the health care industry is recognizing the importance of providing “whole person” and integrated care to address the biopsychosocial aspects of an individual’s health. Individuals should receive biopsychosocial assessments and treatment plans that identify and address the multitude of factors that impact overall health.
Treatment plans done in isolation cannot successfully help clients reach their goals. Since treatment plans specify which community resources will be employed to assist clients with their needs and goals, the full continuum of outpatient behavioral health options described in this document must be locally available to draw upon. Case managers — described next — are critical in this respect.
The importance of case management cannot be understated. At a minimum, case managers serve as a single point of contact to assist individuals and their families in accessing needed services. They help develop and monitor the client’s treatment plan, and they coordinate with the services and other treatment plans that may be underway in other systems (e.g., primary care, school, child welfare, criminal justice).
When clients’ needs change, case managers provide encouragement, consistency, and service coordination. Case managers are often the one “constant” in the care experience as individuals navigate different services and systems, and as individuals’ needs and goals change over time. They help ensure more intensive treatment is avoided whenever possible.
For children and youth with serious emotional or behavioral health conditions enrolled in Medi-Cal, Intensive Care Coordination services are available to help facilitate collaboration and coordination among mental health and other child-serving systems (e.g., mental health, child welfare, juvenile justice, education).[iii]
A dynamic and intensive model of case management called the Full Service Partnership (FSP) provides an augmented set of supports to clients. Expanded in California after passage of the Mental Health Services Act (Proposition 63) in 2004, an FSP provides individuals with a serious mental illness a “whatever it takes” approach to keeping clients healthy and living in the community. With low staff-to-client ratios, FSP case managers are available to clients on a 24/7 basis and can accommodate clients with complex conditions being treated by multiple systems. FSP case managers also have access to flexible funding to support critical aspects of their clients’ lives that prevent hospitalization or homelessness, such as rental subsidies and employment support.
Under any case management model, case managers must be able to access the broad array of community- based services articulated in this document to effectively advocate for their clients. For instance, if a client in recovery needs help dealing with a substance use disorder relapse, case managers draw upon their knowledge of available local services that can meet the client’s need. When individuals transition from a temporary residential treatment episode, case managers help ensure a safe home is available for their return and arrange for any ongoing support a client may need to stay well. Case managers are the glue that holds a comprehensive treatment system together.
COUNSELING AND EDUCATION
Therapy and counseling can help people living with a behavioral health condition manage symptoms and improve their ability to cope. It can help individuals and their families to acquire greater personal, interpersonal and community functioning, and can help them make changes to challenging feelings, thought processes, attitudes, or behaviors. Provided in an individual, family, or group setting, counseling can be provided by licensed or certified therapists or counselors, as well as by peers.
Individualized counseling not only focuses on coping with a mental health condition or reducing drug or alcohol use, but also addresses life areas that may be affected (employment, legal problems, family, and social relationships). In group counseling, the support of peers and the social reinforcement of others modeling how they overcome challenges can be uniquely effective.
Client and family education about behavioral health conditions and how to successfully manage them can
also be helpful and empowering. Well-designed “psychoeducational programs” for individuals and families
facing mental illness have been shown to reduce relapse and hospital readmission rates, improve involvement in and adherence to treatment, and produce positive outcomes for caregivers, including improved morale, better knowledge of mental illness, enhanced feelings of empowerment, and reduced worry and displeasure about their loved ones.[iv]
Since an individual’s substance use disorder can affect the entire family, family members benefit from getting educated about addiction and recovery, including how to effectively assist their loved ones through the recovery process. Particularly when provided by people with lived experience or family members, education about behavioral health conditions can be mutually beneficial; it can reduce the sense of being on one’s own and diminish feelings of guilt and shame.
MEDICATION, IF NEEDED AND DESIRED
Psychiatric medications (also called “psychotropic” medications) affect chemicals in the brain that regulate emotions and thought patterns. These medications are typically more effective when combined with therapy, rather than taken in isolation of other supports. The most common psychiatric medications are antidepressants, anti-anxiety, stimulants, antipsychotics, and mood stabilizers. For some individuals, psychiatric medication might only be taken on a short-term basis (a few months). For others, taking medication can be a long-term or lifelong strategy for maintaining their mental health. As with other prescribed medications, some psychiatric medications cause unpleasant side effects that must be considered when part of a treatment plan.
Medication Assisted Treatment (MAT)
The term “MAT” means utilizing U.S. Food and Drug Administration (FDA)-approved medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders. According to SAMHSA, medications commonly used include methadone, buprenorphine, and naltrexone, which reduce or prevent cravings and withdrawal symptoms, and reduce the risk of overdose.[v] MAT is primarily used for the treatment of addiction to opioids (heroin and prescription pain relievers that contain opiates). Additionally, acamprosate may be used to reduce cravings for individuals with alcohol use disorder, and disulfiram deters drinking because combining it with alcohol causes physical illness. Naltrexone is also used for alcohol use disorder since it blocks the euphoric effects and feelings of intoxication. Bolstered by SAMHSA grant funding, California recently initiated a variety of MAT expansion projects and made additional MAT services available to Medi-Cal enrollees in counties participating in Drug Medi-Cal Organized Delivery System pilot projects.[vi]
[i] National Alliance on Mental Illness, “Engagement: A New Standard for Mental Health Care,” https://www.nami.org/Support-Education/ Publications-Reports/Public-Policy-Reports/Engagement-A-New-Standard-for-Mental-Health-Care/NAMI_Engagement_Web
[ii] O’Brien, P. et al, “Best Practices and Barriers to Engaging People with Substance Use Disorders in Treatment,” Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, 2019, https://aspe.hhs.gov/report/best-practices-and-barriers-engag- ing-people-substance-use-disorders-treatment
[iii] California Department of Health Care Services, “Specialty Mental Health Services for Children and Youth,” 2019, https://www.dhcs. ca.gov/services/MH/Pages/Specialty_Mental_Health_Services.aspx
[iv] Sherman, M., “The Support and Family Education (SAFE) program: mental health facts for families,” Psychiatric Services, (2003) 54(1)
[v] U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), “Medication-Assisted Treatment (MAT),” https://www.samhsa.gov/medication-assisted-treatment
[vi] California Bridge Program, https://cabridge.org/solution/our-work/; DHCS, DMC-ODS, https://www.dhcs.ca.gov/provgovpart/Pages/ Drug-Medi-Cal-Organized-Delivery-System.aspx