Certification and Licensure Issues Related to the Treatment of Co-occurring Disorders

Certification and Licensure Issues Related to the Treatment of Co-occurring Disorders.SAMHSA’S Co-Occurring Center for Excellence (COCE)
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Overview• Purpose of licensure and certification for professionals is to protect the public and ensure that practitioners have meet standards for practice.• Purpose of licensure and accreditation of programs is to ensure that they meet state regulations and/or national operating standards and also protect the public.
--------------------------------------------------------------------------------
Page 3
Licensure and Certification of Professionals – Key Definitions• Licensure: A license is a property right of an individual and as a property right a license is backed by the laws of the State in which it is granted. (Shimberg &Roederer, 1994) “…it is illegal for a person to practice a profession without meeting standards imposed by the State.” (Schoon & Smith, 2000)
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Page 4
Licensure and Certification of Professionals - Key Definitions• Certification: A process established by a private sector body that defines standards for professional practice. It may prohibit the use of a title or designation but often does not restrict someone from practicing a profession. (Schoon & Smith 2000)
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Licensure and Certification of Professionals – Key Definitions• Difference between licensure and certification is that certification is voluntary, not overseen by a governmental body and usually does not prohibit someone from practicing• Some states use the term “certified to indicate a license-e.g. “certified independent social worker” instead of “licensed independent social worker
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Purpose of Licensure and Certification• Provides assurance that practitioners– have met standards of practice – Can perform scope of practice established for the profession– Have demonstrated knowledge and skill to practice• Provides protection from incompetent and unscrupulous professionals
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Page 7
Current Scopes of Practice and Core Competencies• Scopes of Practice for social workers, psychologists and psychiatrists include assessment, diagnosis, treatment of mental, emotional and behavioral disorders • The scopes of practice for psychiatrists, psychologists, social workers, mental health counselors, and marriage and family therapists also include addiction treatment • However, pre-service education for these disciplines contains little content on addictions
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Page 8
Specialty Credentials• Specialty credentials in addictions exist for psychiatrists, psychologists, social workers and licensed professional counselors• Fewer than 7 percent of practitioners hold these national credentials (Harwood, et al, in press)• Some States (e.g.CT, IL, PA) have developed or are in the process of developing specialty credentials in COD but they are generally for addiction counselors
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Page 9
Specialty Credentials Requirements• Mental Health Practitioners need to know the Transdisciplinary Foundations as described in the Addiction Counseling Competencies (CSAT 1998)– Understanding Addictions (models & theories; behavioral, psychological, physical health and social effects of psychoactive substances)– Treatment knowledge (continuum of care; importance of social, family and other support systems; understanding and application of research; interdisciplinary approach to treatment– Application to Practice (Understanding of diagnostic and placement criteria; understanding of variety of helping strategies– Professional Readiness (Understanding of diverse cultures; disabilities
MFT and LCSW Continuing Education Requirements --------------------------------------------------------------------------------
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Specialty Credentials• For addiction counselors providing COD treatment the domains that have been identified include:– Assessment/evaluation/diagnosis– Clinical Competence– Case Management– Pharmacology and medical issues– Systems Integration– Professional Responsibility (IAODAPCA 2002)
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Benefits and Risks Related to Specialty Credentials• Enhance competencies of practitioners in providing services to clients with COD • Integrates COD services into practice• Specialty credentials are voluntary and not required for those providing COD services• Lack of pre-service education in COD may preclude effective screening, assessment, intervention and referrals for COD clients
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Page 12
Elements of a COD Certification• Need comprehensive understanding of substance abuse & mental disorders– Remission– Recovery– Resilience• Competencies should include integrated assessment, engagement, integrated treatment planning and treatment, and long term integrated treatment methods (CSAT 2005)
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Page 13
Benefits and Risks of a COD Credential• Currently a specialty credential for COD practice exists mainly for substance abuse professionals in several states• Other disciplines have an addiction certification• Advantage of developing a national COD credential is the creation of a scope of practice and competencies specifically designed for working with COD clients• Risk is further splintering of the field and concerns that all patients would be perceived as needing COD treatment
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Page 14
Program Accreditation and Licensure• Accreditation is a voluntary performance-based process used to assess an organization or institution based on established quality and safety standards. Surveyors are carefully trained to conduct the evaluation; funders and third party payors usually require accreditation of institutions and agencies
--------------------------------------------------------------------------------
Page 15
Program Accreditation and Licensure• Licensure is a right or permission granted by the state to engage in a business, perform an act or engage in a transaction that would be unlawful with such a right or permission (Merriam-Webster 1996) • States regulate the licensing of programs & hospitals; regulations may include policies, procedures, types of staff, facility safety standards and types of care specific programs can offer
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Page 16
Core Capabilities for Programs Serving COD Clients• Following services are needed:– Integrated screening and assessment– Staged interventions– Assertive Outreach– Motivational interventions– Simultaneous Interventions– Risk Reduction– Tailored mental health and substance abuse treatment– Counseling– Social Support Interventions– Longitudinal view of remission and recovery– Cultural sensitivity and competence (CSAT 2005)
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Current Issues Regarding State Licensure of Programs• COD programs need to have appropriately trained & certified/licensed staff; comprehensive services including a full array of mental health and substance abuse treatment; supportive services; and implementation of evidence-based practices• Most programs are licensed by State mental health and substance abuse agencies respectively: funding streams are separate; different data collection systems; different staffing patterns; distinct service requirements
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Models of Licensure Standards for COD Programs • Comprehensive Continuous Integrated System of Care (CCISC) model is being implemented in several states (CSAT 2005)• CCISC integrates mental health and substance abuse systems to provide a comprehensive system of care including policies, financing, programs, clinical practices and basic clinician competencies (Minkoff 2003; CSAT 2005)
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Benefits of Licensure and Accreditation for COD Programs• Elimination of many obstacles that currently exist• Programs would be able to screen and assess for COD and some could be designated as programs to provide enhanced services• Programs that wish to specialize in COD treatment could be recognized• National accreditation would create consistent standards for programs including administrative, staffing and programmatic
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Page 20
Issues and Future Direction• Little research exists on whether licensed/certified clinicians have better outcomes than those not certified• Though competencies in substance abuse are being added to practice standards few curricula provide adequate education or training• Evidence-based practices for COD treatment need to be incorporated into education and training standards• State program licensure practices still make programs providing COD treatment jump through a maze of regulations• JCAHO has not yet established national standards for dual diagnosis programs
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References• American Association for Marriage and Family Therapy Core Competency Taskforce. (2004) The MFT Core Competencies, Alexandria, VA: AAMFT• Association of Social Work Boards. Model social work practice act. www.aswb.org/Model_law.pdf• Association of State and Provincial Psychology Boards. The practice of psychology. www.asppb.org/exam/practice.asp• Center for Substance Abuse Treatment. 2005. Substance Abuse Treatment for Persons with Co- occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No (SMA) 05-3992. Rockville, MD: SAMHSA
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References• Center for Substance Abuse Treatment (1998). Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice. Technical Assistance Publication Series No. 21. DHHS Publication No. (SMA) 98-3171. Rockville, MD: SAMHSA• Harwood, H.J., Kowalski, J., and Ameen, A. (In press). Training on substance abuse of behavioral health professionals. Falls Church, VA: The Lewin Group• Illinois Alcohol and Other Drug Abuse Professional Certification Association. (2002). Mental Illness/Substance Abuse Professional Role Delineation Study. www.iaodapca.org.• Merriwam-Webster. (1996) Merriam-Webster’s Dictionary of Law. Springfield MA: Merriam-Webster.
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References• Minkoff, K. (2003). Comprehensive, continuous, integrated system of care model description. http://www.zialogic.org/CCISC.htm.• Schoon, C.G. & Smith, I.L. (2000). The licensure and certification mission. In C.G. Schoon and I.L. Smith (Eds.) The licensure and certification mission: Legal, social and political foundations (pp1-3). New York: Professional Examination Services.• Shimberg, B. & Roederer, (1994). Questions a legislator should ask. Lexington, KY: The Council on Licensure, Enforcement and Regulation.• Substance Abuse and Mental Health Services Administration (2003).Strategies for developing treatment programs for people with co- occurring substance abuse and mental disorders.DHHS Publication No. (SMA) 03-3782. Rockville, MD: SAMHSA• Substance Abuse and Mental Health Services Administration. (2002) Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. http://als.samshsa.gov/reports/congress2002/CoOccurringRPT.pdf.SAMHSA’S Co-Occurring Center for Excellence (COCE)
--------------------------------------------------------------------------------
Page 2
Overview• Purpose of licensure and certification for professionals is to protect the public and ensure that practitioners have meet standards for practice.• Purpose of licensure and accreditation of programs is to ensure that they meet state regulations and/or national operating standards and also protect the public.
--------------------------------------------------------------------------------
Page 3
Licensure and Certification of Professionals – Key Definitions• Licensure: A license is a property right of an individual and as a property right a license is backed by the laws of the State in which it is granted. (Shimberg &Roederer, 1994) “…it is illegal for a person to practice a profession without meeting standards imposed by the State.” (Schoon & Smith, 2000)
--------------------------------------------------------------------------------
Page 4
Licensure and Certification of Professionals - Key Definitions• Certification: A process established by a private sector body that defines standards for professional practice. It may prohibit the use of a title or designation but often does not restrict someone from practicing a profession. (Schoon & Smith 2000)
--------------------------------------------------------------------------------
Page 5
Licensure and Certification of Professionals – Key Definitions• Difference between licensure and certification is that certification is voluntary, not overseen by a governmental body and usually does not prohibit someone from practicing• Some states use the term “certified to indicate a license-e.g. “certified independent social worker” instead of “licensed independent social worker
--------------------------------------------------------------------------------
Page 6
Purpose of Licensure and Certification• Provides assurance that practitioners– have met standards of practice – Can perform scope of practice established for the profession– Have demonstrated knowledge and skill to practice• Provides protection from incompetent and unscrupulous professionals
--------------------------------------------------------------------------------
Page 7
Current Scopes of Practice and Core Competencies• Scopes of Practice for social workers, psychologists and psychiatrists include assessment, diagnosis, treatment of mental, emotional and behavioral disorders • The scopes of practice for psychiatrists, psychologists, social workers, mental health counselors, and marriage and family therapists also include addiction treatment • However, pre-service education for these disciplines contains little content on addictions
--------------------------------------------------------------------------------
Page 8
Specialty Credentials• Specialty credentials in addictions exist for psychiatrists, psychologists, social workers and licensed professional counselors• Fewer than 7 percent of practitioners hold these national credentials (Harwood, et al, in press)• Some States (e.g.CT, IL, PA) have developed or are in the process of developing specialty credentials in COD but they are generally for addiction counselors
--------------------------------------------------------------------------------
Page 9
Specialty Credentials Requirements• Mental Health Practitioners need to know the Transdisciplinary Foundations as described in the Addiction Counseling Competencies (CSAT 1998)– Understanding Addictions (models & theories; behavioral, psychological, physical health and social effects of psychoactive substances)– Treatment knowledge (continuum of care; importance of social, family and other support systems; understanding and application of research; interdisciplinary approach to treatment– Application to Practice (Understanding of diagnostic and placement criteria; understanding of variety of helping strategies– Professional Readiness (Understanding of diverse cultures; disabilities
--------------------------------------------------------------------------------
Page 10
Specialty Credentials• For addiction counselors providing COD treatment the domains that have been identified include:– Assessment/evaluation/diagnosis– Clinical Competence– Case Management– Pharmacology and medical issues– Systems Integration– Professional Responsibility (IAODAPCA 2002)
--------------------------------------------------------------------------------
Page 11
Benefits and Risks Related to Specialty Credentials• Enhance competencies of practitioners in providing services to clients with COD • Integrates COD services into practice• Specialty credentials are voluntary and not required for those providing COD services• Lack of pre-service education in COD may preclude effective screening, assessment, intervention and referrals for COD clients
--------------------------------------------------------------------------------
Page 12
Elements of a COD Certification• Need comprehensive understanding of substance abuse & mental disorders– Remission– Recovery– Resilience• Competencies should include integrated assessment, engagement, integrated treatment planning and treatment, and long term integrated treatment methods (CSAT 2005)
--------------------------------------------------------------------------------
Page 13
Benefits and Risks of a COD Credential• Currently a specialty credential for COD practice exists mainly for substance abuse professionals in several states• Other disciplines have an addiction certification• Advantage of developing a national COD credential is the creation of a scope of practice and competencies specifically designed for working with COD clients• Risk is further splintering of the field and concerns that all patients would be perceived as needing COD treatment
--------------------------------------------------------------------------------
Page 14
Program Accreditation and Licensure• Accreditation is a voluntary performance-based process used to assess an organization or institution based on established quality and safety standards. Surveyors are carefully trained to conduct the evaluation; funders and third party payors usually require accreditation of institutions and agencies
--------------------------------------------------------------------------------
Page 15
Program Accreditation and Licensure• Licensure is a right or permission granted by the state to engage in a business, perform an act or engage in a transaction that would be unlawful with such a right or permission (Merriam-Webster 1996) • States regulate the licensing of programs & hospitals; regulations may include policies, procedures, types of staff, facility safety standards and types of care specific programs can offer
--------------------------------------------------------------------------------
Page 16
Core Capabilities for Programs Serving COD Clients• Following services are needed:– Integrated screening and assessment– Staged interventions– Assertive Outreach– Motivational interventions– Simultaneous Interventions– Risk Reduction– Tailored mental health and substance abuse treatment– Counseling– Social Support Interventions– Longitudinal view of remission and recovery– Cultural sensitivity and competence (CSAT 2005)
--------------------------------------------------------------------------------
Page 17
Current Issues Regarding State Licensure of Programs• COD programs need to have appropriately trained & certified/licensed staff; comprehensive services including a full array of mental health and substance abuse treatment; supportive services; and implementation of evidence-based practices• Most programs are licensed by State mental health and substance abuse agencies respectively: funding streams are separate; different data collection systems; different staffing patterns; distinct service requirements
--------------------------------------------------------------------------------
Page 18
Models of Licensure Standards for COD Programs • Comprehensive Continuous Integrated System of Care (CCISC) model is being implemented in several states (CSAT 2005)• CCISC integrates mental health and substance abuse systems to provide a comprehensive system of care including policies, financing, programs, clinical practices and basic clinician competencies (Minkoff 2003; CSAT 2005)
--------------------------------------------------------------------------------
Page 19
Benefits of Licensure and Accreditation for COD Programs• Elimination of many obstacles that currently exist• Programs would be able to screen and assess for COD and some could be designated as programs to provide enhanced services• Programs that wish to specialize in COD treatment could be recognized• National accreditation would create consistent standards for programs including administrative, staffing and programmatic
--------------------------------------------------------------------------------
Page 20
Issues and Future Direction• Little research exists on whether licensed/certified clinicians have better outcomes than those not certified• Though competencies in substance abuse are being added to practice standards few curricula provide adequate education or training• Evidence-based practices for COD treatment need to be incorporated into education and training standards• State program licensure practices still make programs providing COD treatment jump through a maze of regulations• JCAHO has not yet established national standards for dual diagnosis programs
--------------------------------------------------------------------------------
Page 21
References• American Association for Marriage and Family Therapy Core Competency Taskforce. (2004) The MFT Core Competencies, Alexandria, VA: AAMFT• Association of Social Work Boards. Model social work practice act. www.aswb.org/Model_law.pdf• Association of State and Provincial Psychology Boards. The practice of psychology. www.asppb.org/exam/practice.asp• Center for Substance Abuse Treatment. 2005. Substance Abuse Treatment for Persons with Co- occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No (SMA) 05-3992. Rockville, MD: SAMHSA
--------------------------------------------------------------------------------
Page 22
References• Center for Substance Abuse Treatment (1998). Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice. Technical Assistance Publication Series No. 21. DHHS Publication No. (SMA) 98-3171. Rockville, MD: SAMHSA• Harwood, H.J., Kowalski, J., and Ameen, A. (In press). Training on substance abuse of behavioral health professionals. Falls Church, VA: The Lewin Group• Illinois Alcohol and Other Drug Abuse Professional Certification Association. (2002). Mental Illness/Substance Abuse Professional Role Delineation Study. www.iaodapca.org.• Merriwam-Webster. (1996) Merriam-Webster’s Dictionary of Law. Springfield MA: Merriam-Webster.
--------------------------------------------------------------------------------
Page 23
References• Minkoff, K. (2003). Comprehensive, continuous, integrated system of care model description. http://www.zialogic.org/CCISC.htm.• Schoon, C.G. & Smith, I.L. (2000). The licensure and certification mission. In C.G. Schoon and I.L. Smith (Eds.) The licensure and certification mission: Legal, social and political foundations (pp1-3). New York: Professional Examination Services.• Shimberg, B. & Roederer, (1994). Questions a legislator should ask. Lexington, KY: The Council on Licensure, Enforcement and Regulation.• Substance Abuse and Mental Health Services Administration (2003).Strategies for developing treatment programs for people with co- occurring substance abuse and mental disorders.DHHS Publication No. (SMA) 03-3782. Rockville, MD: SAMHSA• Substance Abuse and Mental Health Services Administration. (2002) Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. http://als.samshsa.gov/reports/congress2002/CoOccurringRPT.pdf.

MFT Continuing Education, LCSW Continuing Education, LPC Continuing Education

Alabama
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Alaska
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW) and Marriage and Family Therapists (MFT, LMFT)
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)

Arizona
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Arkansas
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
No CE Provider status approval required for CE credit for licensed Social Workers (LCSW, LSW)

California
Approved by the California Board of Behavioral Sciences for licensed Marriage and Family Therapists (MFT, LMFT), Marriage and Family Therapist Interns/Trainee (MFTI), Licensed Clinical Social Workers (LCSW) and Associate Clinical Social Workers (ASW).
Approved by the California Certification Board of Alcohol and Drug Counselors for licensed Drug and Alcohol Abuse Counselors (CADC I & II, CPS, CSS, CADCA)

Colorado
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Connecticut
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Delaware
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Mental Health Counselors (MHC)
Meets qualifications in Rule 7.2.5 for licensed Social Workers (LCSW, LSW) (check with state board for further clarification)

Florida
Approved by the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)

Georgia
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Hawaii
No continuing education requirements for license renewal for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Idaho
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Not approved for licensed Social Workers (LCSW, LSW)

Illinois
Not pre-approved for licensed Marriage and Family Therapists (MFT, LMFT) and Social Workers (LCSW, LSW) (check with state board for CE requirements)
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)

Indiana
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Iowa
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
Meets requirements stated in Rule 645-281.3 standards of the Iowa Administrative Rules (see state board for further clarification) for licensed Social Workers (LCSW, LSW)

Kansas
No CE Provider status approval required for CE credit for licensed Social Workers (LCSW, LSW), Marriage and Family Therapist and Mental Health Counselors (MHC)

Kentucky
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW)
Check state board for approval requirements for licensed Marriage and Family Therapists (MFT, LMFT)

Louisiana
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)
Check state board for approval requirements for licensed Marriage and Family Therapists (MFT, LMFT)

Maine
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Check state board for approval requirements for licensed Social Workers (LCSW, LSW)

Maryland
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Check state board for approval requirements for licensed Social Workers (LCSW, LSW)

Massachusetts
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Mental Health Counselors (MHC)
Check state board for approval requirements for licensed Marriage and Family Therapists (MFT, LMFT)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Michigan
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)
No continuing education requirements for license renewal for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Minnesota
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
No CE Provider status approval required for CE credit for licensed Social Workers (LCSW, LSW)
Check with board for approval requirements for licensed Marriage and Family Therapists (MFT, LMFT)

Mississippi
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Not pre-approved for licensed Marriage and Family Therapists (MFT, LMFT) and Social Workers (LCSW, LSW) (check with state board for CE requirements)

Missouri
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Montana
Approved by the Montana Board of Social Work Examiners, Professional Counselors & Marriage and Family Therapists for licensed Social Workers (LCSW, LSW), Professional Counselors (LPC, LPCC), and licensed Marriage and Family Therapists (MFT, LMFT)

Nebraska
Meets criteria of an approved continuing education program provider for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Nevada
No CE Provider status approval required for CE credit for licensed Marriage and Family Therapist and Professional Counselors (LPC, LPCC)
Not pre-approved for licensed Social Workers (LCSW, LSW) (check with state board for CE requirements)

New Hampshire
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)

New Jersey
Accepts approval from the National Board for Certified Counselors (NBCC) for Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Not approved for Licensed Social Workers (LCSW, LSW)


New Mexico
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
No CE Provider status approval required for CE credit for licensed Social Workers (LCSW, LSW)

New York
No continuing education requirements for license renewal for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

North Carolina
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
No CE Provider status approval required for CE credit for licensed Marriage and Family Therapists (MFT, LMFT)
Not approved for licensed Social Workers (LCSW, LSW)

North Dakota
No CE Provider status approval required for CE credit for licensed Marriage and Family Therapist and Professional Counselors (LPC, LPCC)
Not pre-approved for licensed Social Workers (LCSW, LSW) (check with state board for CE requirements)

Ohio
Approved by the Counselor, Social Worker and Marriage and Family Therapist Board of Ohio for licensed Marriage and Family Therapists (MFT, LMFT)
Approved by the Counselor, Social Worker and Marriage and Family Therapist Board of Ohio for licensed Mental Health Counselors (MHC)
Not approved for licensed Social Workers (LCSW, LSW)

Oklahoma
Approved by the Oklahoma State Department of Health - Professional Counselor Licensing Board for licensed Marriage and Family Therapists (MFT, LMFT) and Licensed Professional Counselors (LPC)
Not approved for licensed Social Workers (LCSW, LSW)

Oregon
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Pennsylvania
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Rhode Island
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
Not approved for licensed Social Workers (LCSW, LSW)

South Carolina
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

South Dakota
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Tennessee
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Meets requirements stated in Rule 1365-01-.09 for CE credit for licensed Social Workers (LCSW, LSW) (see state board for further clarification)

Texas
Approved by the Texas Board of Examiners of Marriage and Family Therapists (MFT, LMFT) for licensed Marriage and Family Therapists (MFT, LMFT)
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Utah
Meets requirements stated in rule R156-60b-304 for licensed Marriage and Family Therapists (MFT, LMFT) (see state board for further clarification on CE requirements)
Meets requirements stated in rule R156-60c-304 for licensed Professional Counselors (LPC, LPCC) (see state board for further clarification on CE requirements)
Not pre-approved for licensed Social Workers (LCSW, LSW) (see state board for further clarification on CE requirements)

Vermont
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
Meets requirements stated in rule 3.3 Formal Activities (2), 3.4(2)(3) for licensed Social Workers (LCSW, LSW) (see state board for further clarification on CE requirements)

Virginia
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Washington
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)

West Virginia
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Not pre-approved for licensed Marriage and Family Therapists (MFT, LMFT) (check with state board for CE requirements)
No CE Provider status approval required for Category II (Individual Professional Activities) CE credit for licensed Social Workers (LCSW, LSW)

Wisconsin
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Wyoming
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Mental Health Counselors (MHC)
Not pre-approved for licensed Marriage and Family Therapists (MFT, LMFT) and Social Workers (LCSW, LSW) (check with state board for CE requirements)


MFT Continuing Education

LCSW Continuing Education

LPC Continuing Education Units, Credits, Hours

Drug and Alchohol Counselor Continuing Education CEUs

How to Cheer Yourself Up When Youre Down

Got the colder weather, sour relationshops, no money, poor health, plain ol' down 'n dirty blues? Try some of these strategies to blow away those dark clouds and let the sunshine into your life again.

1) Dance! Put on your favourite music, turn it up loud and dance! This is guaranteed to make you feel good. If you are unable to dance, don't let that stop you having fun - sing at the top of your voice instead.

2) Smile! Force yourself to smile even if you don't feel like it. This tricks your brain into thinking that you are happy. You do want to be happy don't you? Okay then - a great big cheesy grin. After three, one, two, three, - smile :0)

3) Spend time with children. Their natural zest for life is infectious. As well as the pleasures of a spontaneous hug or a chubby little hand in yours, try to take away with you some of their joy in simple things, licking an ice cream, playing with water, tramping through fallen leaves or following a butterfly.

4) Reward yourself. If there is a job that you hate to do, household accounts, home repairs etc. don't keep putting it off so that it is constantly nagging at you. Just get it done. Then reward yourself with whatever you love, a shiny new magazine, a bunch of flowers, a long soak in an aromatic bath, two bars of chocolate or an evening in front of the tv doing absolutely nothing. Or even all of the above if you can afford it. The peace of mind that comes from having got the job done will be the greatest reward of all.

5) Clear out your clutter. The ancient art of Feng Shui believes that getting rid of clutter rids your home or work space of negative stuck energy and allows space for positive energy to surge into all aspects of your life. Whether or not this is correct, it is an undeniable fact that clearing out what you no longer want or need makes life easier. Your home is neater, looks more spacious and is easier to clean. There can also be a tremendous feeling of freedom as you let go of the past and trust in the future to bring you what you will need. Emotional clutter can be even more damaging. We've all said or done things we regret, the trick is to do anything you can to repair the damage and if that is not possible, forgive yourself and toss it out of your life.

6) Take action. If something is worrying you, be it a health problem, or debt or divorce, make that doctor's appointment, get some debt counselling, find out your rights. The reality is often less stressful than sitting alone worrying about it. Try to talk over your problems with a friend, or if that is impossible find a support group on the Internet by typing debt, divorce or whatever into a search engine.

7) Positive thoughts. When you leave the house each morning, say and mean, I'm going to have a great day, it's going to be lots of fun, rather than thinking Oh no, another dreary day at the office to get through. The first attitude will attract good vibrations and positive fun people to you, the second will ensure a depressing day.

8) Have more fun. Apparently children laugh approximately 400 times a day yet adults laugh only about 20 times a day. When do we lose our sense of fun? Claim it back. Play games, watch comedies, have daily jokes delivered to your mailbox or throw a fancy dress party.

9) Make something. Being creative gives you such a buzz you won't stay down in the dumps for long. Stencil a room, make a cake, plan a garden, sketch or paint a picture. Express yourself with a modern collage, change your rooms around, display your collections or start a patchwork quilt.

10) Keep a gratitude journal. Write down half a dozen things every day that you are grateful for, from waking up and seeing your children's beautiful little faces to the smell of the roses in the local park. This cannot fail to cheer you up if you do it regularly as it gives you a whole new way of experiencing your life.

11) Start a new project. Learn a language, trace your family history, redecorate your home, learn to ride a horse, gain a new qualification, take music lessons, learn to make your own soft furnishings or do your own auto repairs. Visualize yourself successfully completing the project and the benefits it will bring to your life. Then make a start and follow it through to the end. An added bonus will be the increased self esteem that comes from having planned, problem solved and perfected the whole project yourself.

12) See your old friends. It's easy to get into a work, family, housework, shopping, sleep and back to work again routine that leaves you no time at all to be the person you once were. The funny, up for a laugh, outgoing young woman you used to be. Spending time with friends who knew the old you seems to resurrect that side of your character. You will come away feeling younger, more positive and more excited by life than you were before you met up. Go on, invite them over to share a pizza and catch up on each other's lives.

13) Paint or accessorize a room that you spend a lot of time in a lovely bright yellow. The colour of sunshine will lift your spirit and bring positive vibrations. We subconciously know about the effects of colour on our emotions which is why we talk about the future looking rosy or having the blues.

14) Take the happiness option. You have the choice whether to spend this day, which you will never live through again, in a state of happiness or unhappiness. Choose to spend it as happily as you possibly can.

Substance Abuse and Inhalants CEUs

The percentage of adolescents (i.e., youths aged 12 to 17) who used inhalants in the past year was lower in 2007 (3.9 percent) than in 2003, 2004, and 2005 (4.5, 4.6, and 4.5 percent, respectively)

Among adolescents who used inhalants for the first time in the past year (i.e., past year initiates), the rate of use of nitrous oxide or "whippits" declined between 2002 and 2007 among both genders (males: 40.2 to 20.2 percent; females: 22.3 to 12.2 percent)

In 2007, 17.2 percent of adolescents who initiated illicit drug use during the past year indicated that inhalants were the first drug that they used; this rate remained relatively stable between 2002 and 2007

Adolescents have easy access to some dangerous substances—ordinary household products such as glue, shoe polish, and aerosol sprays. These products are safe when used as intended, but they can be dangerous and even deadly when sniffed or "huffed" to get high. Preventing and treating inhalant use problems, as well as raising awareness about the dangers of inhalant use, are important ongoing goals of the Substance Abuse and Mental Health Services Administration (SAMHSA). Monitoring trends in inhalant use is vital to assessing policies intended to reduce inhalant use.
This issue of The NSDUH Report examines trends in the use, dependence or abuse,1 and initiation of inhalants among adolescents (i.e., youths aged 12 to 17). The National Survey on Drug Use and Health (NSDUH) defines inhalants as "liquids, sprays, and gases that people sniff or inhale to get high or to make them feel good." NSDUH collects data not only about the use of any inhalant, but also about the use of specific types of inhalants. Respondents who used inhalants were asked when they first used them, and responses to this question were used to identify persons who had initiated use in the 12 months before the survey. This report uses data from the 2002 through 2007 NSDUHs.

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Use and Dependence or Abuse
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In 2007, almost 1.0 million adolescents used inhalants in the past year; this represents 3.9 percent of adolescents, which was lower than the rate in 2003, 2004, and 2005 (4.5, 4.6, and 4.5 percent, respectively) (Figure 1). Past year dependence on or abuse of inhalants remained relatively stable between 2002 and 2007, with 0.4 percent of adolescents (around 99,000 persons) meeting the criteria for dependence or abuse in 2007.

Figure 1. Trends in Past Year Inhalant Use and Dependence or Abuse among Adolescents: 2002 to 2007



Figure 1 Table. Trends in Past Year Inhalant Use and Dependence or Abuse among Adolescents: 2002 to 2007 Trend 2002 2003 2004 2005 2006 2007
Past Year Use 4.4% 4.5%* 4.6%* 4.5%* 4.4% 3.9%
Past Year Dependence or Abuse 0.4% 0.4% 0.5% 0.4% 0.4% 0.4%
Source: 2002 to 2007 SAMHSA National Surveys on Drug Use and Health (NSDUHs).



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Past Year Initiation of Inhalant Use
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In 2007, 2.1 percent of adolescents who had not previously used inhalants began using them during the 12 months prior to the survey (Figure 2). This rate was lower than the rates of initiation for 2002, 2003, 2004, and 2005.

Figure 2. Trends in Past Year Initiation of Inhalants among Adolescents Who Had Not Previously Used Inhalants: 2002 to 2007**



Figure 2 Table. Trends in Past Year Initiation of Inhalants among Adolescents Who Had Not Previously Used Inhalants: 2002 to 2007** Trend 2002 2003 2004 2005 2006 2007
Past Year Initiation of Inhalants 2.6%* 2.6%* 2.6%* 2.6%* 2.4% 2.1%
Source: 2002 to 2007 SAMHSA National Surveys on Drug Use and Health (NSDUHs).



NSDUH also provides data on the first illicit drug initiated among past year initiates.2 In 2007, 17.2 percent of past year illicit drug initiates indicated that inhalants were the first drug that they used (Table 1). Marijuana was the first drug used by 56.3 percent of past year illicit drug initiates; nonmedically used prescription-type drugs were the first type of drug used by 23.5 percent of past year illicit drug initiates. These rates remained relatively stable between 2002 and 2007.

Table 1. Trends for First Drug Initiated in the Past Year among Adolescents Who Initiated Illicit Drug Use in the Past Year: 2002 to 2007** First Drug Initiated*** 2002
(%) 2003
(%) 2004
(%) 2005
(%) 2006
(%) 2007
(%)
Marijuana and Hashish 59.9% 57.6% 57.3% 55.0% 57.1% 56.3%
Nonmedical Use of Prescription-Type Drugs 22.2% 20.4% 21.3% 22.0% 22.0% 23.5%
Inhalants 14.5% 19.4% 19.2% 19.6% 17.4% 17.2%
Hallucinogens 2.9% 2.3% 2.1% 2.5% 3.0% 2.3%
Cocaine 0.7% 0.4% 0.5% 1.0% 0.9% 0.8%
Source: 2002 to 2007 SAMHSA National Surveys on Drug Use and Health (NSDUHs).


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Use of Specific Inhalants among Past Year Inhalant Initiates
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Among past year inhalant initiates, the percentage using most specific types of inhalants in 2007 did not differ significantly from the percentage in 2002 (Table 2); however, there were a few exceptions. Among past year inhalant initiates, use of nitrous oxide or "whippits" was lower in 2007 than in 2002 (16.3 vs. 31.6 percent), and use of aerosol spray other than spray paint3 was higher in 2007 than 2002 (25.0 vs. 12.6 percent).

Table 2. Trends in Past Year Use of Specific Types of Inhalants among Past Year Inhalant Initiates Aged 12 to 17: 2002 to 2007** Type of Inhalant 2002
(%) 2003
(%) 2004
(%) 2005
(%) 2006
(%) 2007
(%)
Amyl Nitrite, "Poppers," Locker Room Odorizers,
or "Rush" 14.0% 17.0% 12.6% 16.4% 16.5% 19.3%
Correction Fluid, Degreaser, or Cleaning Fluid 15.7% 19.7% 19.6% 19.6% 22.5% 19.3%
Gasoline or Lighter Fluid 26.2% 23.2% 25.3% 26.7% 27.0% 28.1%
Glue, Shoe Polish, or Toluene 32.9% 30.2% 27.6% 31.3% 25.6% 28.8%
Halothane, Ether, or Other Anesthetics 2.9% 2.9% 4.5% 3.4% 4.5% 5.7%
Lacquer Thinner or Other Paint Solvents 13.9% 10.7% 10.8% 13.3% 14.2% 12.8%
Lighter Gases, Such as Butane or Propane 9.3% 9.7% 9.2% 8.1% 7.1% 9.9%
Nitrous Oxide or "Whippits" 31.6% 23.0% 20.1% 21.3% 17.7% 16.3%
Spray Paints 21.4% 23.3% 25.4% 23.9% 28.1% 25.1%
Aerosol Sprays Other than Spray Paints+ 12.6% 17.6% 23.6% 25.4% 23.5% 25.0%
Source: 2002 to 2007 SAMHSA National Surveys on Drug Use and Health (NSDUHs).


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Discussion
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Although the rates of inhalant use and inhalant initiation appeared to be on a downward trend, particularly since 2005, the rates of dependence on or abuse of these substances remained stable between 2002 and 2007. Rates of use of specific types of inhalants among past year initiates generally did not differ significantly from 2002 to 2007, although a few types showed significant changes. Use of nitrous oxide or "whippits" decreased by half, and use of aerosol sprays other than spray paints doubled. Over the period from 2002 to 2007, 15 to 20 percent of past year illicit drug initiates indicated that inhalants were the first illicit drug they had used.

These findings highlight the ongoing need for prevention and treatment of inhalant use and abuse. Continuing efforts are needed among adolescents and their parents, other family members, teachers, service providers, and policymakers to increase awareness of the dangers of inhalant use. Awareness campaigns and prevention efforts may need targeted messages about the use of specific inhalants, such as aerosol air fresheners, aerosol sprays, and aerosol cleaning products.



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End Notes
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1 Substance dependence or abuse is defined using criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which includes symptoms such as withdrawal, tolerance, use in dangerous situations, trouble with the law, and interference in major obligations at work, school, or home during the past year.
2 Illicit drugs refer to marijuana/hashish, cocaine (including crack), inhalants, hallucinogens, heroin, or prescription-type drugs used nonmedically.
3 Aerosol sprays other than spray paint include products such as aerosol air fresheners, aerosol spray, and aerosol cleaning products (e.g., dusting sprays, furniture polish). The aerosol propellants in these products are commonly chlorofluorocarbons. By contrast, nitrous oxide is used as a propellant for whipped cream and is available in 2-inch tapered cylinders called "whippits" that are used to pressurize home whipped-cream charging bottles.


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Figure and Table Notes
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* Difference between this estimate and 2007 estimate is statistically significant at the .05 level.
** Past year initiates are defined as adolescents who used a drug for the first time during the 12 months prior to the survey.
*** First drug initiated is based on the date of the first use for each drug, with imputation for the day of the month and for the month of the year, if not reported. Respondents may be counted in more than one drug category if they reported initiating multiple drugs on the same day the first time that they used drugs.
+ See End Note 3.


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Suggested Citation
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Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (March 16, 2009). The NSDUH Report: Trends in Adolescent Inhalant Use: 2002 to 2007. Rockville, MD.

The National Survey on Drug Use and Health (NSDUH) is an annual survey sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). The 2002 to 2007 data used in this report are based on information obtained from 136,449 persons aged 12 to 17. The survey collects data by administering questionnaires to a representative sample of the population through face-to-face interviews at their place of residence.

The NSDUH Report is prepared by the Office of Applied Studies (OAS), SAMHSA, and by RTI International in Research Triangle Park, North Carolina. (RTI International is a trade name of Research Triangle Institute.)

Information on the most recent NSDUH is available in the following publication:

Office of Applied Studies. (2008). Results from the 2007 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 08-4343, NSDUH Series H-34). Rockville, MD: Substance Abuse and Mental Health Services Administration. Also available online: http://oas.samhsa.gov.

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Older Adults and Mental Health CEUs

Older Adults and Mental Health CEU Continuing Education--------------------------------------------------------------------------------

The past century has witnessed a remarkable lengthening of the average life span in the United States, from 47 years in 1900 to more than 75 years in the mid-1990s (National Center for Health Statistics [NCHS], 1993). Equally noteworthy has been the increase in the number of persons ages 85 and older (Figure 5-1). These trends will continue well into the next century and be magnified as the numbers of older Americans increase with the aging of the post–World War II baby boom generation.

Millions of older Americans—indeed, the majority—cope constructively with the physical limitations, cognitive changes, and various losses, such as bereavement, that frequently are associated with late life. Research has contributed immensely to our understanding of developmental processes that continue to unfold as we age. Drawing on new scientific information and acting on clinical common sense, mental health and general health care providers are increasingly able to suggest mental health strategies and skills that older adults can hone to make this stage of the life span satisfying and rewarding.

The capacity for sound mental health among older adults notwithstanding, a substantial proportion of the population 55 and older—almost 20 percent of this age group—experience specific mental disorders that are not part of “normal” aging (see Table 5-1). Research that has helped differentiate mental disorders from “normal” aging has been one of the more important achievements of recent decades in the field of geriatric health. Unrecognized or untreated, however, depression, Alzheimer’s disease, alcohol and drug misuse and abuse, anxiety, late-life schizophrenia, and other conditions can be severely impairing, even fatal; in the United States, the rate of suicide, which is frequently a consequence of depression, is highest among older adults relative to all other age groups (Hoyert et al., 1999).

Figure 5-1. Increases in the percent of the U.S. Population over age 65 years and over 85 years (Malmgren, 1994).

Click to enlarge

Table 5-1. Best estimate 1-year prevalence rates based on Epidemiologic Catchment Area, age 55+
Prevalence (%)
Any Anxiety Disorder 11.4
Simple Phobia 7.3
Social Phobia 1.0
Agoraphobia 4.1
Panic Disorder 0.5
Obsessive-Compulsive Disorder 1.5
Any Mood Disorder 4.4
Major Depressive Episode 3.8
Unipolar Major Depression 3.7
Dysthymia 1.6
Bipolar I 0.2
Bipolar II 0.1
Schizophrenia 0.6
Somatization 0.3
Antisocial Personality Disorder 0.0
Anorexia Nervosa 0.0
Severe Cognitive Impairment 6.6
Any Disorder 19.8


Source: D. Regier & W. Narrow, personal communication, 1999.

The clinical challenges such conditions present may be exacerbated, moreover, by the manner in which they both affect and are affected by general medical conditions or by changes in cognitive capacities. Another complicating factor is that many older people, disabled by or at risk for mental disorders, find it difficult to afford and obtain needed medical and related health care services. Late-life mental disorders also can pose difficulties for the burgeoning numbers of family members who assist in caretaking tasks for their loved ones (Light & Lebowitz, 1991).

Chapter Overview
Fortunately, the past 15 to 20 years have been marked by rapid growth in the number of clinical, research, and training centers dedicated to the mental illness- and mental health-related needs of older people. As evident in this chapter, much has been learned. The chapter reviews, first, normal developmental milestones of aging, highlighting the adaptive capacities that enable many older people to change, cope with loss, and pursue productive and fulfilling activities. The chapter then considers mental disorders in older people—their diagnosis and treatment, and the various risk factors that may complicate the course or outcome of treatment. Risk factors include co-occurring, or comorbid, general medical conditions, the high numbers of medications many older individuals take, and psychosocial stressors such as bereavement or isolation. These are cause for concern, but, as the chapter notes, they also point the way to possible new preventive interventions. The goal of such prevention strategies may be to limit disability or to postpone or even eliminate the need to institutionalize an ill person (Lebowitz & Pearson, in press). The chapter reviews gains that have been realized in making appropriate mental health services available to older people and the challenges associated with the delivery of services to this population. The advantages of a decisive shift away from mental hospitals and nursing homes to treatment in community-based settings today are in jeopardy of being undermined by fragmentation and insufficient availability of such services (Gatz & Smyer, 1992; Cohen & Cairl, 1996). The chapter examines obstacles and opportunities in the service delivery sphere, in part through the lens of public and private sector financing policies and managed care.

Finally, the chapter reviews the supports for older persons that extend beyond traditional, formal treatment settings. Through support networks, self-help groups, and other means, consumers, families, and communities are assuming an increasingly important role in treating and preventing mental health problems and disorders among older persons.

Normal Life-Cycle Tasks
With improved diet, physical fitness, public health, and health care, more adults are reaching age 65 in better physical and mental health than in the past. Trends show that the prevalence of chronic disability among older people is declining: from 1982 to 1994, the prevalence of chronic disability diminished significantly, from 24.9 to 21.3 percent of the older population (Manton et al., 1997). While some disability is the result of more general losses of physiological functions with aging (i.e., normal aging), extreme disability in older persons, including that which stems from mental disorders, is not an inevitable part of aging (Cohen, 1988; Rowe & Kahn, 1997).

Normal aging is a gradual process that ushers in some physical decline, such as decreased sensory abilities (e.g., vision and hearing) and decreased pulmonary and immune function (Miller, 1996; Carman, 1997). With aging come certain changes in mental functioning, but very few of these changes match commonly held negative stereotypes about aging (Cohen, 1988; Rowe & Kahn, 1997). In normal aging, important aspects of mental health include stable intellectual functioning, capacity for change, and productive engagement with life.

Cognitive Capacity With Aging
Cognition subsumes intelligence, language, learning, and memory. With advancing years, cognitive capacity with aging undergoes some loss, yet important functions are spared. Moreover, there is much variability between individuals, variability that is dependent upon lifestyle and psychosocial factors (Gottlieb, 1995). Most important, accumulating evidence from human and animal research finds that lifestyle modifies genetic risk in influencing the outcomes of aging (Finch & Tanzi, 1997). This line of research is beginning to dispel the pejorative stereotypes of older people as rigidly shaped by heredity and incapable of broadening their pursuits and acquiring new skills.

A large body of research, including both cross-sectional studies and longitudinal studies, has investigated changes in cognitive function with aging. Studies have found that working memory declines with aging, as does long-term memory (Siegler et al., 1996), with decrements more apparent in recall than in recognition capacities. Slowing or some loss of other cognitive functions takes place, most notably in information processing, selective attention, and problem-solving ability, yet findings are variable (Siegler et al., 1996). These cognitive changes translate into a slower pace of learning and greater need for repetition of new information. Vocabulary increases slightly until the mid-70s, after which it declines (Carman, 1997). In older people whose IQ declines, somatic illness is implicated in some cases (Cohen, 1988). Fluid intelligence, a form of intelligence defined as the ability to solve novel problems, declines over time, yet research finds that fluid intelligence can be enhanced through training in cognitive skills and problem-solving strategies (Baltes et al., 1989).

Memory complaints are exceedingly common in older people, with 50 to 80 percent reporting subjective memory complaints (cited in Levy-Cushman & Abeles, in press). However, subjective memory complaints do not correspond with actual performance. In fact, some who complain about memory display performance superior to those who do not complain (Collins & Abeles, 1996). Memory complaints in older people, according to several studies, are thought to be more a product of depression than of decline in memory performance (cited in Levy-Cushman & Abeles, in press). (The importance of proper diagnosis and treatment of depression is emphasized in subsequent sections of this chapter.) Studies attempting to treat memory complaints associated with normal aging—using either pharmacological or psychosocial means—have been, with few exceptions, unsuccessful (Crook, 1993). In one of these exceptions, a recent study demonstrated a significant reduction in memory complaints with training workshops for healthy older people. The workshops stressed not only memory promotion strategies, but also ways of dealing with expectations and perceptions about memory loss (Levy-Cushman & Abeles, in press).

One large, ongoing longitudinal study found high cognitive performance to be dependent on four factors, ranked here in decreasing order of importance: education, strenuous activity in the home, peak pulmonary flow rate, and “self-efficacy,” which is a personality measure defined by the ability to organize and execute actions required to deal with situations likely to happen in the future (Albert et al., 1995). Education, as assessed by years of schooling, is the strongest predictor of high cognitive functioning. This finding suggests that education not only has salutary effects on brain function earlier in life, but also foreshadows sustained productive behavior in later life, such as reading and performing crossword puzzles (Rowe & Kahn, 1997).

The coexistence of mental and somatic disorders (i.e., comorbidity) is common (Kramer et al., 1992). Some disorders with primarily somatic symptoms can cause cognitive, emotional, and behavioral symptoms as well, some of which rise to the level of mental disorders. At that point, the mental disorder may result from an effect of the underlying disorder on the central nervous system (e.g., dementia due to a medical condition such as hypothyroidism) or an effect of treatment (e.g., delirium due to a prescribed medication). Likewise, mental problems or disorders can lead to or exacerbate other physical conditions by decreasing the ability of older adults to care for themselves, by impairing their capacity to rally social support, or by impairing physiological functions. For example, stress increases the risk of coronary heart disease and can suppress cellular immunity (McEwen, 1998). Depression can lead to increased mortality from heart disease and possibly cancer (Frasure-Smith et al., 1993, 1995; Penninx et al., 1998).

A new model postulates that successful aging is contingent upon three elements: avoiding disease and disability, sustaining high cognitive and physical function, and engaging with life (Rowe & Kahn, 1997). The latter encompasses the maintenance of interpersonal relationships and productive activities, as defined by paid or unpaid activities that generate goods or services of economic value. The three major elements are considered to act in concert, for none is deemed sufficient by itself for successful aging. This new model broadens the reach of health promotion in aging to entail more than just disease prevention.

Change, Human Potential, and Creativity
Descriptive research reveals evidence of the capacity for constructive change in later life (Cohen, 1988). The capacity to change can occur even in the face of mental illness, adversity, and chronic mental health problems. Older persons display flexibility in behavior and attitudes and the ability to grow intellectually and emotionally. Time plays a key role. Externally imposed demands upon one’s time may diminish, and the amount of time left at this stage in life can be significant. In the United States in the late 20th century, late-life expectancy approaches another 20 years at the age of 65. In other words, average longevity from age 65 today approaches what had been the average longevity from birth some 2,000 years ago. This leaves plenty of time to embark upon new social, psychological, educational, and recreational pathways, as long as the individual retains good health and material resources.

In his classic developmental model, Erik Erikson characterized the final stage of human development as a tension between “ego integrity and despair” (Erikson, 1950). Erikson saw the period beginning at age 65 years as highly variable. Ideally, individuals at this stage witness the flowering of seeds planted earlier in the prior seven stages of development. When they achieve a sense of integrity in life, they garner pride from their children, students and protégés, and past accomplishments. With contentment comes a greater tolerance and acceptance of the decline that naturally accompanies the aging process. Failure to achieve a satisfying degree of ego integrity can be accompanied by despair.

Cohen (in press) has proposed that with increased longevity and health, particularly for people with adequate resources, aging is characterized by two human potential phases. These phases, which emphasize the positive aspects of the final stages of the life cycle, are termed Retirement/Liberation and Summing Up/Swan Song.

Retirement often is viewed as the most important life event prior to death. Retirement frequently is associated with negative myths and stereotypes (Sheldon et al., 1975; Bass, 1995). Cohen points out, however, that most people fare well in retirement. They have the opportunity to explore new interests, activities, and relationships due to retirement’s liberating qualities. In the Retirement/Liberation phase, new feelings of freedom, courage, and confidence are experienced. Those at risk for faring poorly are individuals who typically do not want to retire, who are compelled to retire because of poor health, or who experience a significant decline in their standard of living (Cohen, 1988). In short, the liberating experience of having more time and an increased sense of freedom can be the springboard for creativity in later life. Creative achievement by older people can change the course of an individual, family, community, or culture.

In the late-life Summing Up/Swan Song phase, there is a tendency to appraise one’s life work, ideas, and discoveries and to share them with family or society. The desire to sum up late in life is driven by varied feelings, such as the desire to complete one’s life work, the desire to give back after receiving much in life, or the fear of time evaporating. Important opportunities for creative sharing and expression ensue. There is a natural tendency with aging to reminisce and elaborate stories that has propelled the development of reminiscence therapy for health promotion and disease prevention. The swan song, the final part of this phase, connotes the last act or final creative work of a person before retirement or death.

There is much misunderstanding about thoughts of death in later life. Depression, serious loss, and terminal illness trigger the sense of mortality, regardless of age. Contrary to popular stereotypes, studies on aging reveal that most older people generally do not have a fear or dread of death in the absence of being depressed, encountering serious loss, or having been recently diagnosed with a terminal illness (Kastenbaum, 1985). Periodic thoughts of death—not in the form of dread or angst—do occur. But these are usually associated with the death of a friend or family member. When actual dread of death does occur, it should not be dismissed as accompanying aging, but rather as a signal of underlying distress (e.g., depression). This is particularly important in light of the high risk of suicide among depressed older adults, which is discussed later in this chapter.

Coping With Loss and Bereavement
Many older adults experience loss with aging—loss of social status and self-esteem, loss of physical capacities, and death of friends and loved ones. But in the face of loss, many older people have the capacity to develop new adaptive strategies, even creative expression (Cohen, 1988, 1990). Those experiencing loss may be able to move in a positive direction, either on their own, with the benefit of informal support from family and friends, or with formal support from mental health professionals.

The life and work of William Carlos Williams are illustrative. Williams was a great poet as well as a respected physician. In his 60s, he suffered a stroke that prevented him from practicing medicine. The stroke did not affect his intellectual abilities, but he became so severely depressed that he needed psychiatric hospitalization. Nonetheless, Williams, with the help of treatment for a year, surmounted the depression and for the next 10 years wrote luminous poetry, including the Pulitzer Prize-winning Pictures From Bruegel, which was published when he was 79. In his later life, Williams wrote about “old age that adds as it takes away.” What Williams and his poetry epitomize is that age can be the catalyst for tapping into creative potential (Cohen, 1998a).

Loss of a spouse is common in late life. About 800,000 older Americans are widowed each year. Bereavement is a natural response to death of a loved one. Its features, almost universally recognized, include crying and sorrow, anxiety and agitation, insomnia, and loss of appetite (Institute of Medicine [IOM], 1984). This constellation of symptoms, while overlapping somewhat with major depression, does not by itself constitute a mental disorder. Only when symptoms persist for 2 months and longer after the loss does the DSM-IV permit a diagnosis of either adjustment disorder or major depressive disorder. Even though bereavement of less than 2 months’ duration is not considered a mental disorder, it still warrants clinical attention (DSM-IV). The justification for clinical attention is that bereavement, as a highly stressful event, increases the probability of, and may cause or exacerbate, mental and somatic disorders.

Bereavement is an important and well-established risk factor for depression. At least 10 to 20 percent of widows and widowers develop clinically significant depression during the first year of bereavement. Without treatment, such depressions tend to persist, become chronic, and lead to further disability and impairments in general health, including alterations in endocrine and immune function (Zisook & Shuchter, 1993; Zisook et al., 1994). Several preventive interventions, including participation in self-help groups, have been shown to prevent depression among widows and widowers, although one study suggested that self-help groups can exacerbate depressive symptoms in certain individuals (Levy et al., 1993). These are described later in this chapter.

Bereavement-associated depression often coexists with another type of emotional distress, which has been termed traumatic grief (Prigerson et al., in press). The symptoms of traumatic grief, although not formalized as a mental disorder in DSM-IV, appear to be a mixture of symptoms of both pathological grief and post-traumatic stress disorder (Frank et al., 1997a). Such symptoms are extremely disabling, associated with functional and health impairment and with persistent suicidal thoughts, and may well respond to pharmacotherapy (Zygmont et al., 1998). Increased illness and mortality from suicide are the most serious consequences of late-life depression.

The dynamics around loss in later life need greater clarification. One pivotal question is why some, in confronting loss with aging, succumb to depression and suicide—which, as noted earlier, has its highest frequency after age 65—while others respond with new adaptive strategies. Research on health promotion also needs to identify ways to prevent adverse reactions and to promote positive responses to loss in later life. Meanwhile, despite cultural attitudes that older persons can handle bereavement by themselves or with support from family and friends, it is imperative that those who are unable to cope be encouraged to access mental health services. Bereavement is not a mental disorder but, if unattended to, has serious mental health and other health consequences.