Introduction to Co-existing Mental Health
and
Substance Use Problems (CEP)
Part A: Overview of CEP
Fraser Todd
February 2013
This self-directed learning module has been produced by Fraser Todd for FrasersCEPblog and is used on the postgraduate
paper PSMX 404 Assessment of Addiction and Coexisting Disorders. It may not be altered or used in any other form
without the permission of Fraser Todd.
Copyright and Terms of Use:
This SDL has been developed by Fraser Todd (University of Otago Christchurch, Matua Raki, Canterbury District
Health Board) as an introduction to CEP and in particular to the models approaches I use.
The module is best viewed in Microsoft Powerpoint as it contains links which not work in the PDF version.
However, the content will be the same.
If you are viewing it as a Powerpoint presentation, is best viewed as a slide show presentation. The font will be
very small if viewed in slide sorter view. The content of this module, as with Te Ariari O Te Oranga, remains the
intellectual property of Fraser Todd. Copyright is asserted over it. The ideas and content may be used freely for the
purposes of education and clinical practice as long as the sources is cited in the usual way.
Overview of this SDL
Overview of this SDL
Introductory Comments:
This self-directed learning module on CEP is designed to provide and introduction and overview of my current
approach and teaching on CEP as it stands in February 2013 (thinking is evolving rapidly in this area!).
It draws on the content of Te Ariari O Te Oranga (Todd 2010) but updates it in crucial places to incorporate the
development in thinking about some of the key points as they evolve through clinical practice and teaching and
implementation. In places it is quite different to Te Ariari, in particular:
• An increased emphasis on the context of practice, especially on brining the principles of person-centred
care, wellbeing and recovery orientated practice and integrated care to the forefront and trying to make them
live in practice, rather than just on the page.
• An emphasis on practical application, especially the use of clinical strategies to implement the thinking.
Where possible, brief strategies that can quickly be incorporated into a busy clinical workload are favoured.
• Developments in thinking on motivation
While you may feel you have a solid grounding in CEP, it is essential that you go through this introduction.
It is especially important to note the sections on thinking about CEP and the Spirit of Te Ariari. These sections
provide an essential ‘big picture’ context for CEP which is often missing from other models. The ‘big picture’
context is, I think, a key ingredient for working effectively with people with any complex
health problem and especially with CEP. The sections on assessment and management have not been elaborated
in this SDL. They are the core content of PSMX404 and will be taught in more depth during the course.
Finally, this SDL should be read in the context of Te Ariari O Te Oranga. In parts, the SDL is a summary and more
detail can be found in Te Ariari O Te Oranga. However, as mentioned, there have been developments in thinking
since Te Ariari was released three years ago and these are covered in more detail in the SDL – where thinking
differs between the two, consider the SDL an update.
Overview of this SDL
Use of This Material:
The layout of this SDL includes pictures and diagrams. These represent the powerpoint slides used
In the powerpoint presentation of this material in workshops. Information presented pictorial has been shown to
significantly improve the understanding of written word or verbal content. They also enhance this SDL.
One way this SDL can be used is to help you know the verbal content that accompanies each slide. This is useful
if you are asked to undertake training in CEP and wish to use the powerpoint slide presentation
that I have developed for my workshops in 2013.
The powerpoint presentation will be made available to those who have completed PSMX404 or other training on
the workshops and you may use it freely if you wish as long as it is cited appropriately (i.e I am acknowledged as
the creator of the work).
Overview of this SDL
Table of Contents:
Part A: Overview of CEP
1. Overview of this SDL module
2. CEP in NZ
3. The Spirit of Te Ariari O Te Oranga
2.1 Person-centred Care
2.2 Recovery and wellbeing-orientated care
2.3 Integrated care
2.4 Walking the Talk
4. Thinking about CEP
5. Background information
5.1 Definitions
5.2 The Nature of CEP
5.3 The History of CEP
5.4 Current approaches
5.5 The problem with current approaches
5.5 Stepped Care
Part B: Update of Te Ariari O Te Oranga
6. Te Ariari O Te Oranga and the 7 Key Principles
6.1 Cultural Considerations
6.2 Recovery and Wellbeing
6.3 Motivation
6.4 Engagement
6.5 Assessment
6.6 Management
6.7 Integrated Care
CEP in NZ
CEP in NZ
New Zealand has had an interest in CEP for at least the past
decade. The first set of guidelines, The Assessment and
Management of Co-existing Substance Use and Mental Health
Disorders (Todd, Robertson & Selman) was produced in 1998
and since that time there has been continua attempts to
promote CEP and ups-kill the workforce. This led to some
consciousness raising, pockets of improved and enhanced
practice, but in general there was a lot of resistance to
change.
There were several barriers to change.
1.While systems organisation was a major
problem, organisations tended to approach CEP
by simply providing some brief training for
practitioners. In other words, there was a belief
that improving treatments for people with CEP
was simply a matter of clinicians getting better at
their work.
2. There were widespread barriers to developing
integrated approaches to care. Specifically, mental
health and AOD practitioners held deep-seated
negative attitudes towards each other.
This was made worse by the prevailing view from
practitioners that they works with MH problems or
AOD problems and that the other was not their
business.
3.Oragnisations tended to see CEP as a separate
entity or specialty which required new resources,
rather than than core business.
CEP in NZ
Many of the early training initiatives were strongly bicultural, undertaken in collaboration with the Moana House
Training Institute in Dunedin. This infused CEP thinking with a strong bicultural influence.
From around 2007, a renewed effort to promote CEP led to the development of service level initiatives (Integrated
Solutions) alongside clinical framework (Te Ariari O Te Oranga) published in 2010 by the Ministry of Health (MOH).
The MOH led the service level change through Jenny Wolf, a
major influence on these developments. An advisory group in the
MOH was estabished headed by the Director of Mehtal Heath and
DHB’s were required to produce and implement action plans for
enhancing services for people with CEP.
Further, the national workforce development programmes, (Matua
Raki, Te Pou, Te Rau Matatini) have collaborate to develop
training, resources and networks. There now seems to be
considerable momentum among clinicians nationally to develop
their capability.
Key factors underpin these changes. First, focusing on the person
rather than the disorder and stressing well-being as a key
outcome appears to have shifted attitudes away from a service
and disorder focus. This has been the crucial factor in sparking
developments. Second, practitioners collaborating around this
person-centered focus has enhanced relationships between
sectors.
The Spirit of Te Ariari
The Spirit of Te Ariari O Te Oranga
Underpinning Te Ariari are a set of principles and values:
• person-focused
• wellbeing focused
• integrated care
• Walking the talk
– many pay lip service to the concept of patient-focused
care and wellbeing. It is seldom put into practice effectively.
Thinking About CEP
Thinking About CEP
Simple-Complicated-Complex:
Multi-dimensional problems involve so much information that it
is difficult for clinicians to manage all the information they need
to – they experience COGNITIVE OVERLOAD.
Making sense of the information available becomes highly
complicated.
The response is usually to focus on certain parts or details of
the problem they are familiar with. In the process, they miss
important details, or fail to integrate them all, or lose site of the
big picture.
The key to managing complicated problems is to connect the
details, to integrate them into a whole Complex things are multidimensional but manageable.
In other words, making the complicated (confusing) complex
(multi-faceted but able to be handled).
Thinking About CEP
Building Expert Knowledge Structures:
While expert practitioners do know more detail, the key
difference between them and novice practitioners is the
connections they make between their pieces of knowledge.
They integrate information by making connections and using
frameworks to hang details from and integrate them.
Thinking About CEP
Learning About CEP:
Similarly, learning about CEP is about using frameworks to
integrate knowledge and skills.
There are many frameworks that are useful. One example is the
structure for the comprehensive assessment we promote.
However, it is essential to begin with the ‘big picture’ frameworks.
In the case of CEP (and most complex health problems), the
overarching frameworks are those mentioned above that are the
spirit of CEP:
• Person-focused
• Well-being orientated
• Integrated care
…put into practice
These will be described in more detail in the next section.
Frameworks
Frameworks
Person-focused Care:
Not ‘patient/consumer/client’ centred (patient/consumer still define the person by
their help-seeking role)
Know the person in their social context
- Values, belief and culture
- Understand their hopes and aspirations
(what well being means to them)
Treat problems always in the context of persons values and vision of wellbeing
Empower – partnership & participation
Note that there is good evidence that taking a person-focused approach leads
to better:
• engagement
• motivation,
• treatment compliance
• satisfaction with services (for both the help seeker and the help-giver)
Frameworks
Person-focused Care – Tools and Strategies:
Identifying problems and implementing successful interventions are what, as clinicians,
we do best. It is the heart of our work. However, to deliver person-focused care, we must
always place this work in the context of the persons life and always remember that
our ultimate aim is to help a person improve their overall quality of life.
In clinical practice, a person-focused approach can be signaled very
simply and quickly by beginning the initial contact with questions about
the person, their social context, what matters to them in their life and their hopes
and aspirations (what well-being means for them or what a good life would
comprise of say, in a few years time).
This doesn’t need to be detailed and extensive, though it can be. Simply starting
with this approach, indicating its importance and noting that you will come back
to these things later or in further sessions makes it clear to tangata whaiora that
you are interested in them as a person and that the problem-focused questions that
follow are place in the context of them as people.
There are four interventions that can assist this process
1. Measuring treatment improvements by rating changes in overall quality of life:
WHOQOL (100 item quetionnaire)
WHOQOL-BREF (26 item questionnaire)
and Identifying:
2. Personal values (Values Card Sort Execise or Questionnaire (Paper Version))
3. Strengths (Character Strengths Assessment)
4. Identify Hopes, Aspirations &Wellbeing (Best Possible Self Exercise)
Frameworks
Well-being Orientated Care:
People desire a state of flourishing; a high degree of wellbeing
People seek help when there is discrepancy between there desired and their actual state of wellbeing – when they
feel they are languishing.
Well-being-orientated Care - Distress
Well-being Orientated Care – Distress:
They experience distress when they are
languishing i.e there is a significant gap
between their desired state of wellbeing
and their actual state of wellbeing.
This distress drives attempts to cope and
then seek help if their ability to cope is
insufficient to ease the distress
Frameworks
Well-being Orientated Care – Seeking Help:
They try many strategies to improve
their wellbeing before they seek help
from us – specialist services.
Specialist services therefore play a
bit-part in the overall helping
response.
It is therefore important that specialist
services understand that they play a
part,
but only a part in peoples journey
Towards enhanced well-being.
Specialist services serve – the
organisation of those services must
support the helping, rather than
dominate it or be an end unto itself.
Frameworks
Well-being:
Practitioner’s roles have become limited to
specializing in removing specific barriers to
wellbeing.
The role of ‘support’ agencies has developed to
‘support’ the treatment of barriers to wellbeing.
This is a small part of a person's overall movement
towards increased wellbeing.
We are well placed to help people take positive
steps toward enhanced wellbeing, and even if we
choose not to we should see our role as a part of the
‘bigger picture’.
Why? People who are no longer sick are not
necessarily well.
- people with depression that has been treated and
have no symptoms are less well than people whom
never had depression.
People who remain sick can enhance the positive
aspects of their wellbeing to good effect.
- people with chronic symptoms improve in a range
of outcomes with wellbeing-orientated treatment
Frameworks
Integrated Care:
Treatment integration = brining together the various treatments into a coherent system
Integrated care = identifying the needs of tangata whaiora and organising systems seamlessly around them
Integrated care comes from:
• Understanding what wellbeing means for the tangata whaiora
• Starting with the needs of tangata whaiora rather than the service
• Considering both pathways to wellbeing and barriers to wellbeing (deficits)
• Multi-dimensional integrated formulation using multiple paradigms
• Leading to an integrated management plan and treatment
• Systems that are oragnised to support integrated care
Frameworks
Integration - Tools and Strategies:
There are a number of key points in the clinical process, which
we can leverage to enhance integration.
The tools and strategies we use clinically include:
1. Taking a wellbeing perspective
2. Screening and assessment processes that integrate a range of
sources of information and information across multiple domains
3. Specific processes and structures within the assessment to
integrate issues such as MH and AOD problems – timelines,
ecograms
4. The process of forming an opinion and a multi-dimensional
formulation
5. Combining of perspectives within the multi-disciplinary team
6. Collaboration with others outside the MDT
Frameworks
Walking the Talk:
OR: Bringing these principles to life within the clinical relationship
• We are well aware of many of these concepts
• Indeed they may seem obvious and trite
• However, they are not often put into practice
• They need to become central principles or frameworks from which
we organise and link the details of our knowledge
• Clinical strategies to implement them need to be brief and easy to
use (or they won’t be used)
• These principles and strategies need to drive care, and systems
should exist only to support and organise them.
Background Information
Background Information
Definitions:
•
Coexisting substance use and mental health problems (CEP)
are known by many different names. They all mean much the
same thing.
•
The usual definition is the co-occurrence of mental health and
substance use problems in the same person at the same time.
•
Research definitions often report lifetime rates of CEP; the
person has MH and AOD problems at some point in their life,
not necessarily at the same time. Current CEP in research
usually means that the problems were present during the last
month.
Background Information
The Nature of CEP:
The Nature of CEP
CEP is not a single thing. Rather, there are as many different subtypes as
there are combinations of drugs and mental health problems.
Problems related to CEP range from the simple and straightforward to the
multi-dimensional and complicated.
The more complicated cases of CEP are among the most difficult to treat and
expose the weaknesses in the health system.
generic
As such, there are general or generic things that need to occur for all people
with CEP, as well as specific things for each combination of MH and AOD
problems.
In almost all cases, when a MH problem is complicated by AOD problems,
engagement, treatment outcome, suicide rates and psychosocial functioning
are much worse.
specific
Background Information
The Impact of CEP:
CEP is associated with:
• Poorer compliance
• More relapses
• More readmissions
• Poorer outcomes
• Treatment resistance
• Increased rates of suicide and violence
• Higher rates of unemployment
Background Information
General Epidemiology:
Psychiatric Disorder
% who suffer SUD
CEP is common.
Depressive
30
Bipolar
50
Schizophrenia
50
Antisocial PD
80
Anxiety
30
Bipolar disorder is the axis 1 disorder with
the greatest rate of comorbid substance use
problems.
Phobic
25
Rates in those with antisocial personality
disorder are up to 80%.
In general terms, the rate of AOD problems
in people with specific mental health
disorders ranges from 25-30% for most
anxiety disorders and major depression, to
50% of those with bipolar disorder and
schizophrenia.
Background Information
NZ Epidemiology:
Disorder
Current
Lifetime
Onset (SD)
53%
73%
19 (10)
34%
44%
20 (11)
65%
77%
13(10)
PTSD
31%
45%
19(11)
Social Phobia
31%
37%
12 (7)
Any Axis 1
74%
90%
13 (9)
ASPD
27%
41%
9 (4)*
Any Mood
MDE
Any Anxiety
* Childhood conduct disorder
In those in treatment for AOD problems, rates of comorbid
MH disorders appear to be very high. A New Zealand study
of two community AOD services showed that 90% had an
axis I non-AOD DSMIV diagnosis in Mood and anxiety
disorders were the most common.
Of note just under a third had a current diagnosis of PTSD,
and 10% had a current diagnosis of bipolar disorder, with
less than half of them being in current mental health
treatment.
Also of note are the very low rates of psychosis in those
with AOD problems, and even lower rates of schizophrenia.
This is very important given the past emphasis in CEP on
chronic psychotic disorders – they are uncommon.
In this study, approxiamately 10% of the sample had a
diagnosis of bipolar disorder. Most were not in the care of
mental health services and approximately 50% were not on
appropriate medication.
N=105, From Adamson, Todd et al Aust NZ J Psychiatry 2006;40:164-170
Background Information
The History of CEP:
CEP is an ‘artifact’ of the way health problems are diagnosed and health systems structured. It
emerged as an issue in the 1980s due to a number of developments in treatment, not least the move
of clients from hospital to the community. Increased access to alcohol and drugs undoubtedly played
a part, as did the advent of DSMIII and its insistence that if criteria for more than one diagnosis was
met, all diagnoses should be made.
Background Information
The History of CEP:
Large population studies such as the ECA and NCS studies also raised awareness of CEP and community
mental health clinicians began reporting on the high prevalence CEP and the poor outcomes it was associated
with.
Most of the treatment models used today were developed during the early 1990s, most prominently those by
Osher and Koefed, Drake, Carey and Mueser. At the heart of these models were the principles of
comprehensiveness and integration.
Background Information
The History of CEP:
During the 2000s, the need for widespread screening leading where appropriate to assessment was promoted
and several treatment guidelines were published including TIP42 and the UK Dual Diagnosis Toolkit. These
guidelines summarise the major ‘standard approaches’ to CEP that had been developed over the past decade
and are considered ‘best practice’
Background Information
Aetiology (Causes) – Traditional Views:
It is usual to think of the aetiology or causes of CEP
Involving three theoretical mechanisms:
1. Substance use causes mental health problems
2. Mental health problems cause substance use problems
3. Common factors underlying both lead to both occurring.
… and to take the position that common factors are the
most common reasons for CEP. However, the specific
common factors are seldom described.
There are several important considerations:
1. Prior to DSM (specifically DSMIII) , the usual approach to
understanding mental health problems was to look for a single
explanation rather than divide problems up into separate
diagnoses. DSM changed this – it insisted that if criteria was
met a diagnosis should be made leading to mutiople diagnoses
2. Over 50% of all people with mental health problems have more
than one diagnosis. Co-morbidity is the rule rather than the exception
3. Systems issues and structures, as well as the increasing detail we have
about problems has led to sub-specialisation, a narrow focus and silo-ing
of services
4. CEP is an artifact that simply highlights the weaknesses in our systems
and services
Background Information
Aetiology (Causes):
In reality, the three mechanisms mentioned above all
Together, and occur differently in different combinations
of AOD and MH problems.
Sometimes, the substance use may cause a mental health
Syndrome. For example, psychosis due to cannabis use or
stimulants (e.g. ‘P”)
The presence of substance use may bring out the
mental health worse in people who are predisposed to it,
and make it worse
Mental health problems may make the substance use worse
and move it towards dependence
Sometimes MH problems may drive the development
of substance dependence and addiction. This is especially
true of:
•Bipolar disorder
•PTSD
•Socail phobia
Often, both the two interaction mechanisms occur together
Background Information
Aetiology (Causes) – Common Factors:
Underlying the interaction between mental health
and substance use are the common factors mentioned
in the previous slides.
These are sometimes called trans-diagnostic factors;
factors that underlie and contribute to many different
Disorders and that increase the risk or cause multiple
disorders.
It is likely that these trans-diagnostic factors are
responsible for a significant amount of the comorbitdity
that exists.
Some which are supported by evidence are listed
in the diagram to the left.
These factors are crucial in case formulation and should
be targets of intervention if present.
Failure to address these factors when present is highly
likely to be a key factor in poor treatment response. Simply
combining standard MH and AOD treatments may be a first
Step for straight-forward cases of CEP, but will not be
sufficient for the more complex cases.
Background Information
Standard Approaches to CEP – Core Components:
There have been a variety of intervention models and programme types for CEP described in the literature.
Core components of effective models include the following:
• Comprehensiveness – assessing and addressing a broad range of concerns, not just immediate diagnoses
• Treatment integration – combining MH and AOD treatments in a single package
delivered by a single ‘team’
• Assertive Community follow-up
• Staged interventions (engagement-persuasion or stages of change)- fitting
treatment to the persons stage of change
• MI + CBT – combining motivaional interviewing and CBT approaches
• Harm reduction/minimisation – rather than insisting on abstinence from
the outset, reduced use may be associated with better quality of life
• Long-term perspective – treatment takes time and progress may
fluctuate on its way to a good outcome
• Recovery approach – going beyond a disorder focus to consider the
person’s broader life, identity, social functioning
• Integrated Continuous Systems of Care (Minkoff)
• Fully integrated team
• Multiple coordinated teams
Background Information
Current Approaches:
At at programme level, there are two main approaches to CEP. Both stress the need to integrate
MH and AOD treatments into a coherent package and incorporate similar components.
1. The first model focuses on developing a single programme, either residential or outpatient, which can
address both mental health and substance use problems in an integrated way (a fully integrated team)
2. The second model, which is more widely developed involves collaboration across existing services to reduce the
gaps between services and thereby integrating treatment (multiple integrated teams)
These two approaches are not mutually exclusive. The first model produces highly skilled, CEP ‘enhanced’ teams.
The second produces less skilled but arguably more flexible treatment. For most systems, the latter is more practical,
given the high prevalence of CEP. Note that there are degrees of CEP capability. Some specialist teams will, however,
benefit from being fully enhanced. Currently, services such as early psychosis intervention teams and some youth
AOD/MH teams are CEP Enhanced.
The diagram below (which we will return to later) presents a way of conceptualising the CEP capability of services
Background Information
Limitations of Current Approaches - Implementation:
Best practice guidelines for CEP covering the standard approaches are outlined in
TIP42 published by SAMHSA in 2005. It is an excellent resource and available free
to download or order:
http://www.ncbi.nlm.nih.gov/books/NBK64197/
However, the standard approach has a number of limitations.
First, the ‘gold standard’ integrated dual diagnosis team approach of Drake and
colleagues, as well as interventions such as motivation interviewing are very hard to
put into practice in clinical settings with fidelity. Pejorative attitudes between MH and
AOD clinicians remain significant barriers to implementation.
Background Information
Limitations of Current Approaches - Effectiveness:
Second, after the release of TIP42, a number of systematic
reviews have indicated that the best practice approaches are not
effective in changing both MH and AOD problems, and that while
these approaches have been shown to improve psychosocial
functioning, they do not appear to change symptoms.
The strongest evidence is for group approaches, long-term
residential treatments and contingency management
Background Information
Limitations of Current Approaches - Engagement:
Third, while there is some improvement in functioning with the standard CEP
approaches, engagement remains highly problematic.
Only 30-50% of people with severe CEP engage in treatment.
Engagement and its closes relative, motivation, are crucial for good outcomes for
people with CEP. Improvements in how we engage and motivate people may
provide the best opportunities to improve CEP treatment.
Background Information
Limitations of Current Approaches - Constructs:
Fourth, the standard treatments are built around the
paradigms for treating chronic illnesses such as
schizophrenia, which has a low rate of prevalence.
They may not be applicable to other types of CEP.
Most of the strategies for treating CEP involve change
at the level of the service and system, such as bringing
together AOD and MH treatments. At the clinical level
there remains a lack of guidance for how to implement
these change.
Finally, integration is a key principle, but is usually
thought of as integration of AOD and MH treatments.
For most people with CEP, there is a lot more to
integrate than just treatment for AOD and MH
problems. People with CEP experience high rates of
physical health problems which are often not
addressed, problems with employment, finance,
housing and so on. Each of these requires interaction
with systems outside MH and AOD.
Te Ariari O Te Oranga
Te Ariari O Te Oranga
The Assessment and Management of People with Co-existing Substance Use Problems
Te Ariari O Te Oranga is the clinical framework for the treatment of people
with CEP. It was published by the Ministry of Health in 2010
Te Ariari was designed as an update of an earlier set of guidelines (1998)
but is significantly different in its attempt to provide an integrating
framework that is person-centred and stresses wellbeing approaches to
address generic issues, as well as detailed and specific approaches for
specific subtypes of CEP.
http://www.health.govt.nz/publication/te-ariari-o-te-oranga-assessment-and-management-people-co-existing-mentalhealth-and-drug-problems
The 7 Key Principle and the CEP Frameworks
Te Ariari is organized around 7 key principles:
These principles are applied in each of five phases of
treatment:
1.Cultural considerations
2. Wellbeing
3. Engagement
4. Motivation
5. Assessment
6. Management
7. Integrated Care
1. Pre-treatment
2. Early treatment
3. Middle treatment
4. Late treatment
5. Autonomous independence
(These principles were chosen because they are the ones
that require enhancing in the context of our current
approaches to treatment. It is likely that in a few years,
different principles will need stressing.)
Thus the Te Ariari framework can be expressed as a matrix with
related goals at each phase of treatment.
Phases of Treatment, Key Goals and
Strategies
Referral from other services
Not in another services
Engagement Interview
Pre-Treatment:
Ascertain initial needs including cultural needs
Ensure service and staff prepared to meet needs
Early Treatment:
Safety
Values, Strengths, Personal definition of wellbeing
Assessment
Stabilisation
Engagement
From the 7 Key Principles, across
the 5 Phases of Treatment, key
goals ad strategies can be derived
Middle Treatment:
Active treatment of barriers and pathways to
wellbeing
Maintain engagement
Late Treatment:
Maintain gains
Restore wellbeing
Increasing self-care
Autonomy:
Self-motivation
Self-responsibility
Independence
For details of strategies see
Te Ariari pg
Enhancing Service Capability
Enhancing Service Capability
Quadrants of Care:
For the purposes of guiding service response to CEP,
Ken Minkoff divides service by the severity of the MH and
AOD problems they deal with and where people are best
treated. The implications of this are that Q1 problems may
be dealt with in primary care, Q4 problems probably
require either shared care or CEP enhanced programmes
able to treat both the MH and AOD problems they see, Q2
problems are best treated in an MH service with either
some AOD skills or a collaborative relationship with an
AOD service, and Q3 problems primarily treated in AOD
service.
This model is useful for guiding service planning with
some caveats, especially that diagnosis may not be the
best way to determine severity.
Enhancing Service Capability
Continuum of Service Capability:
Where a service sits in the quadrants gives and indication of the CEP skills needed. The particular details of these skills
will depend on the particular combinations of problems the service commonly deals with. Within this, services can rate
themselves on a continuum of service capability, from MH or AOD only (where the other problem is seldom even
recognised, through varying degrees of capability to CEP Enhanced. A CEP enhanced service would be one capable of
assessing and managing the CEP it sees with a high level of skill and without needing to collaborate with other services.
The majority of services do not need to be CEP Enhanced.
As mentioned, there are degrees of CEP Capability. The aim is for services to determine what level of capability they wish
to have and develop themselves to achieve that. There are service rating tools available to help with this process.
Enhancing of Service Capability
Determinants of Service Capability:
One way of thinking about levels of CEP Capable services and guiding service development is that at the most basic
level of capability, a service is able to screen for and detect the vast majority of the ‘other’ problems. A higher level of
capability involves the ability of a service to not only screen for but also undertake a comprehensive assessment of
both MH and AOD problems. The highest level of capability, after which a service would be considered enhanced,
involves the ability to not only undertake an effective comprehensive assessment, but also to develop an effective
management plan. They would still need to collaborate with others to provide that management.
Enhancing of Service Capability
Collaboration to Enhance Capability:
As noted, a CEP Capable service is able to provide some degree of screening, assessment
or management planning. At the point that their capability is exceeded, they will need to
collaborate with other services.
Integrated care goes beyond MH and AOD integration to involve areas such as physical health,
Housing and education and employment. Ultimately all services need to collaborate with others
to ensure comprehensive and integrated care.
Enhancing of Service Capability
Developing Capability:
As a service enhances its capability, the specific needs of collaboration change.
Enhancing of Service Capability
System Wide Development Model:
This diagram shows one model of systems wide enhancement of CEP capability.
This model is currently being applied in the Canterbury District Health Board.
It is comprised of three related parts:
1. Across-service Generic Training
Content: An overview of CEP based on Part A of this
SDL. The key content is the philosophy of patientfocused and wellbeing orientate care, including some
practical clinical strategies.
Delivery: A series of workshops for clinicians/managers
from a variety of services + a train-the-trainers
approach to disseminate the information more widely
across the DHB. Six subsequent workshops on the 7
Key Principles (Part B of the SDL)
2. Service-based Training
Content: Reinforcement of Part A philosophy of this SDL
and detailed learning on the 7 Key Principles of Te
Ariari as
Delivery: Initial workshop plus in-service training
3. Collaborative Learning
Content: Reinforcement of the above content on a caseby-case basis
Delivery: AOD liaison staff placed in MH services
involved in collaborative or shared care.
Tools for Enhancing Practitioner & Service
Capability
Tools for Practitioner & Service Capability
System Wide Development Model:
A number of tools have been produced to help services and practitioners self-assess their CEP capability:
1. Co-existing Problems (CEP) Resource Map
Part of the Te Pou website which includes a links to a large number of local resources CEP relevant resources
2. Co-existing Problems (CEP) Service Checklist
A checklist approach to service self-assessment of CEP capability developed by Matua Raki (National Addiction
Workforce Development Centre
3. Co-existing Problems (CEP) Tools and Resources
Downloadable PDF listing and linking to a range of local and international CEP resources and readings.