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In Episode 5 of our ASAM Criteria Unplugged series, we invited Dr. Ken Minkoff to share about recent updates to co-occurring care in the Fourth Edition of the ASAM Criteria. He gives guidance on how to foster person-centered, hopeful, strength-based and integrated mental health and substance use disorder services in your behavioral healthcare system.
Sitting down with The Change Companies Chief Program Officer Valerie Bagley and Train for Change Senior National Director Scott Boyles, Dr. Minkoff shares his insights on key updates to the Fourth Edition of the ASAM Criteria in regards to co-occurring treatment.
Jump ahead to questions covered in this blog:
2. How can we involve clients in this hopeful and strength-based approach?
4. Are there any final thoughts on integrated treatment you’d like to share?
Q: You recently published a guest editorial in ASAM Weekly titled “A radical advance in the integration of co-occurring mental health care within the addiction system.” Could you summarize what you’ve included there and what you see as the future of co-occurring care with the new edition of the ASAM Criteria?
Ken Minkoff: “The ASAM Criteria have been progressively gaining more ground in both designing systems and system standards, and informing how managed care organizations and state funders make decisions about what is the right level of service and type of service for people who are requesting help with substance use disorders… Helping people with addiction in an addiction [treatment] program means starting with day one. You have to help them figure out how they’re going to get through the day with whatever their mental health symptoms happen to be. What ASAM in the Fourth Edition has recognized — and what we talked about in the co-occurring disorder committee — is that the key message is that standard or normal programs are expected to be co-occurring capable.”
"You have to identify yourself in your mind as a co-occurring program and that means when people with co-occurring needs show up, you welcome them as they actually are. And when they share with you that they have these mental health issues, you say, ‘Thank you. I’m happy to see you. Thank you for coming. You’re in the right place. We love working with people who have addiction and all kinds of mental health symptoms. While you’re here, we’re going to try to help you with both of your issues and other things too. A day at a time, step by step, so you can make progress addressing these issues and go on to have the most happy, hopeful, meaningful life you possibly can.’
The next principle is we help people by helping them get connected to relationships that are empathic, hopeful, integrated and strength-based. And we work with people in small steps over time to help them be successful. So co-occurring aside, we’re increasingly recognizing that the population of people seeking addiction treatment have a chronic brain disease that we call addiction. We’re getting over the idea that people are going to be fixed with 30 days or 90 days of rehab, and from there they just can do self-help, and that’s all they ever have to worry about.”
Q: How can we involve clients in this hopeful and strength-based approach?
Ken Minkoff: “We want people to be inspired. The more issues you have, the harder it is for you to feel inspired and more likely you feel hopeless because you haven’t been able to figure it out.
So we want you to put out on the table your most beautiful, hopeful vision of a happy life and indicate that we’re going to work with you on both your issues to help you get there. We’re going to engage with you as an integrated team. Even though only some of us have identified mental health competencies or licenses, all of us are great partners who want to help you with all your issues.
And if there’s stuff we don’t know — which is highly likely — we’re going to allow you to teach us about your experience of having a mental health condition. And we’re going to help you learn. We’re going to learn with you, and ask for help together so that we can get more information about how to help you [one] day at a time.”
Q: Do you have any suggestions or creative workarounds to provide integrated care in the face of regulatory, financial and diagnostic silos from state and national levels?
Ken Minkoff: “The first thing to realize is integration does not require merging your state departments, merging all of your funding streams and redoing all that stuff up at the top of your state or your county. That stuff may or may not be helpful. In many systems, if the first thing everybody does is try to merge all the departments and the funding streams, everybody gets panic-stricken about their jobs and gets totally confused, and it actually slows usefulness down.
It's better for the integrated processes to start in the middle of the system at the provider level and then work with your leadership to help them figure out how to support you and make their existing limited resources go better. So the next piece I would recommend for you is to go into [integration] with what I call the Serenity Prayer of system change: the serenity to accept the things you cannot change, which is everybody else; the courage to change the things you can, your own work, your own team, your own program, your own span of control, wherever you happen to be; and the wisdom to know the difference. If you start making progress on your own and create it in such a way that it’s a program of attraction, so other folks are welcomed in and learn with you, then they can pick up their piece while you’re busy doing your piece.”
“And I’m not talking about doing psychotherapy that you’re not licensed to do. I’m talking about helping people negotiate the fact that they have these mental health symptoms or they have to learn how to take medication properly. They have to talk to their doctors. So if you start writing the list of what we can do within our funding stream, our license, our scope… and make it clear that within all that, there are instructions.
One of the things I included in the guest editorial is a reference to an article that we wrote called ‘Scope of Practice for Working with the Dually Diagnosed for Addiction Counselors.' I laid it all out [there].”
Q: Are there any final thoughts on integrated treatment you’d like to share?
Ken Minkoff: “The best thing you can do is just figure out how to talk to people in a way that helps you to understand what they're struggling with with their substances and be a partner with them. Help them figure out what it is that they want to change and how they’re going to go about it. It’s just another thing that you have to help people figure out. Just starting with the sense that, ‘We’re all in this together.’ Everybody’s brought their life experience; they brought their heart to this process.
[Providers] really want to be helpful. We’re giving them tools to be helpful to the people in front of them by engaging with empathy, hope, having conversations and helping people find their next steps and learning with people — not doing things to people — to help them down that journey.”
Dr. Minkoff is the Vice President and Chief Operating Officer at ZiaPartners, a Tucson-based behavioral health system consultation firm. As a board-certified addiction and community psychiatrist, Dr. Minkoff serves as Products and Services Committee Co-chair for the American Association for Community Psychiatry. He helps to develop and disseminate the LOCUS Family of Tools and co-authors the AACP’s Self-Assessment for Modification of Anti-Racism Tool (SMART).
Dr. Minkoff was an original member of the Federal Interdepartmental Serious Mental Illness Coordinating Committee and co-chairs the Community Psychiatry Committee of the Group for Advancement of Psychiatry, which authored the Roadmap to the Ideal Crisis System. He’s a recognized national and international leader in the strategic development of quality-driven managed behavioral healthcare systems. He’s been a contributor to the development of the ASAM Patient Placement Criteria for 25 years. His work with ZiaPartners focuses on helping systems reorganize within limited resources to better meet the needs of individuals and families with complex and co-occurring issues.
