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Introduction to the
Dual Diagnosis Capable Mental
Health Treatment (DDCMHT)
Framework
Detroit Wayne Mental Health Authority Systems
Transformation Project Provider Partners:
Tinetra Burns MS, LSST, CADC-M (Team Mental
Health)
Maeola Dacus LMSW, ACSW (Detroit Central City)
Dr. Beth Rutkowski, LP, CAADC (Hegira Programs)
Introduction
• Mental health treatment providers are
continually challenged to improve service
capability.
• Over the past 15 years, there has been an
increased awareness of the common
presentation of persons with co-occurring
(mental health and substance use)
disorders.
Why Use Change Processes?
Improve client outcomes
Increase access to effective treatment
Engage staff
Save time
Transform organizations
Introduction (continued)
• Research suggests that sequential treatment
(treating one disorder first, then the other) and
purely parallel treatment (treatment for both
disorders provided by separate clinicians or
teams who do not coordinate services) are not
as effective as integrated treatment (Drake,
O’Neal & Wallach, 2008).
Introduction (continued)
• National and state initiatives related to cooccurring disorders have been significant,
stimulating considerable interest in providing
better services for people with these
challenges.
• Although an understanding has been
established, mental health providers may lack
guidance on how to improve services.
Introduction (continued)
• Specific evidence-based treatment modalities
have been developed, including Integrated
Dual Disorders Treatment (IDDT; Mueser et
al., 2003; SAMHSA, 2003).
• However, providers continue to identify the
need for practical guidance to develop and
implement co-occurring services.
Introduction (continued)
• The DDCMHT index was first developed in
2004, as a parallel instrument to the DDCAT
(Dual Diagnosis Capability in Addictions
Treatment) Index developed in 2003.
• Both are based on the American Society of
Addictions Medicine (ASAM) taxonomy of
dual diagnosis capability for service programs.
Introduction (continued)
• The DDCMHT, which will be described more later
in this presentation, guides programs and system
authorities in assessing and developing dual
diagnosis capability of mental health treatment
(McGovern, Matzkin & Girard, 2007).
• Dartmouth’s Practice Demo Videos on Integrated
Treatment for Co-Occurring Disorders provides
useful resources including an overview, stages of
change and treatment, engagement stage
interventions, and assessment.
What is being assessed?
• The Dual Diagnosis Capability in Addiction
Treatment (DDCAT) Index, and the Dual
Diagnosis Capability in Mental Health Treatment
(DDCMHT) Index establish benchmarks for
providing evidence-based treatment services to
individuals with co-occurring disorders.
• These indices ask questions about seven
dimensions within the three primary areas of
Policy, Clinical Practice, and Workforce.
Policy
The 1st dimension is Program Structure, asking the
question:
•“Do your overall program structure and policies help or
inhibit providing services for individuals with co-occurring
disorders?”
To answer this question, the following is considered:
 the program’s mission statement;
 the organizational certification and licensure;
 coordination and collaboration with mental and/or
addiction health services;
 financial incentives.
Policy
The 2nd dimension is Program Milieu, asking the
question:
•“Are the staff and physical environment welcoming and
receptive to individuals with co-occurring disorders?”
To answer this question, the following is considered:
 the program’s expectation of welcome to treatment
for both disorders;
 the program’s display and distribution of literature
and patient educational materials.
Clinical Practice
The 3rd dimension is Assessment, asking the question:
•“How does your staff make distinctions between symptoms,
substance-induced disorders, or actual psychiatric disorders
that may need treatment?”
To answer this question, the following is considered:



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routine screening methods and assessment for both
types of disorders;
diagnoses made and documented;
recorded history of both types of disorders;
program acceptance based on acuity, severity &
persistence of the disabilities;
whether stage-wise assessment is present.
Clinical Practice
The 4th dimension is Treatment, asking the question:
•“How do your clinical assessment and treatment procedures and
protocols rate in relation to co-occurring disorder assessment and
treatment?”
To answer this question, the following is considered:



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
treatment planning;
assessment & monitoring of interactivity of both disorders;
procedures for emergencies & crisis management;
stage-wise treatment;
policies and procedures for medication evaluation,
management, monitoring, & compliance;
 specialized interventions, education & support for the client and
their family;
 use of peer supports/groups for planning or during treatment.
Clinical Practice
The 5th dimension is Continuity of Care, asking the question:
•“How does your program handle continuing care and monitoring for
individuals with co-occurring disorders?”
To answer this question, the following is considered:
 integration of co-occurring disorders in discharge planning
process;
 the capacity to maintain treatment continuity;
 a focus on ongoing recovery issues for both disorders;
 specialized interventions to facilitate use of community- based
peer;
 support groups during discharge planning;
 sufficient supply and compliance plan for medications.
Workforce
The 6th dimension is Staffing, asking the question:
•“Do any staff members have expertise in assessing and treating
individuals with co-occurring disorders?”
To answer this question, the following is considered:
 presence of a psychiatrist or other prescriber of psychotropic
medications;
 on-site clinical staff members with mental health licensure
(doctoral or masters level), competency or substantive
experience;
 access to mental health clinical supervision or consultation;
 case review, staffing or utilization review procedures
emphasizing and supporting co-occurring disorder treatment;
 peer/alumni support availability with co-occurring disorders.
Workforce
The 7th dimension is Training, asking the question:
•“Are staff members adequately trained and supported for the
assessment and treatment of individuals with co-occurring
disorders?”
To answer this question, the following is considered:
 whether all staff members have basic training in attitudes,
prevalence, common signs and symptoms, detection and
triage for co-occurring disorders;
 whether clinical staff members have advanced specialized
training in integrated psychosocial or pharmacological
treatment of persons with co-occurring disorders.
How is the measure scored?
Each of the 35 program elements of the DDCAT/DDCMHT is rated
on a scale of 1-5.
By considering the total scores across dimensions, DDCAT &
DDCMHT can help categorize a treatment program into 1 of 3
primary categories:
 Mental Health or Addiction Only Services (MHOS or AOS), if less than
80% of scores are 3s or greater
Dual Diagnosis Capable (DDC), if at least 80% of scores are 3 +
Dual Diagnosis Enhanced (DDE), if at least 80% of scores are 5 +
Scores of 2 and 4 are reflective of the levels between the standards
established at the 1=Alcohol or Mental Health Only, 3=Dual
Diagnosis Capable, and 5=Dual Diagnosis Enhanced levels.
What do those categories mean?
Addiction Only Services (AOS) or Mental Health Only Services
(MHOS) designate a program that is focused on providing services to
persons with only mental health, or only substance use disorders.
Dual Diagnosis Capable (DDC) indicates a program that is capable
of providing services to some individuals with co-occurring substance
use and mental health disorders, but has greater capacity to serve
individuals with whatever the primary designation of the program is.
Dual Diagnosis Enhanced (DDE) designates a program that is
capable of providing services to any individual with co-occurring
substance use and mental health disorders, and the program can
address both types of disorders fully and equally. Programs at the
DDE level are often indistinguishable as either an addiction or mental
health treatment program.
DDCAT/DDCMHT Methodology
• What To Expect at a Site Review When
Rating a Program’s Co-occurring Capability
o Site visit – Scheduled in advance with agency
director or designee.
o Site visit may take a full or half day, depending
upon the number of programs within the
agency being assessed.
DDCAT/DDCMHT Methodology
• Ideally a team of two assessors but may be
more conducting the review.
• Team consist of objective reviewers who score
independently but generally come to
consensus on the basis for scoring.
• Utilizes objective ratings, however,
understanding the definition and item response
coding for each element is critical.
DDCAT/DDCMHT Data Sources
• Observations of milieu and physical settings
• Tour of Program/Facility
• Focused, open-ended interviews with staff, e.g.,
agency leadership (administrative and supervisory),
staff clinicians, medical prescribers, support
personnel, and consumers, etc.
• Review of open and closed chart documentation
(screenings, assessments, med reviews, progress
notes, team meeting logs, etc.)
Sources of Data
(continued)
• Policy and procedure manuals, brochures,
patient/program schedules, patient/family
handouts, and other relevant forms/materials
• Observation of clinical treatment process (group
meetings, team meetings and supervision
sessions, etc.)
• Staff training records
• Information obtained from multiple sources
The Site Review Works Best As:
• A collaborative effort
• Positive and affirming, rather than punitive and
judgmental
• Emphasizing program strengths
• Identifying barriers/areas for growth/change
• Assessing organizational stage/readiness to
change
• Leading to themes/strategies to enhance
overall program and services
The Site Review Visit Includes:
• Initial and exit meetings
• Verbal feedback during the site visit
• Follow-up with written integrative summary report
following the site visit
• Results from the DDCAT/DDCMHT review can
be used as baseline data and a measure for
improvement of services over time.
• Annual reviews will be conducted and technical
assistance provided as needed.
Self Ratings
• Data shows that self assessors generally rate
themselves higher in all dimensions and view
themselves more co-occurring capable than they
are, as opposed to external objective assessors.
• Programs that desire to self-assess are
encouraged to use their quality assurance team or
staff from another program other than the one
being assessed. This helps minimize biases since
these are usually more familiar with the process of
record review, and are encouraged to base scores
on factual evidence rather than assumptions or
biases.
Practical Improvements
I. Program Structure
• Shift in mission statement from focus on one disorder only
to co-occurring disorders
• Clarification of myths about billing or service constraints
• Use of a collaborative model versus a consultation model
• Design policies to support integrated practice and service
documentation across various funding and licensing bodies
• Provide an equivalent focus on both co-occurring conditions
• Seek secondary or additional licensure to provide the other
service
Practical Improvements
II. Program Milieu
• Provide access to brochures that describe program
capability to address more than one presenting concern
• Address questions or raise awareness about co-occurring
concepts in orientation sessions
• Create an atmosphere that welcomes individuals
• Create a milieu or cultural shift to an equivalent focus on
substance abuse and mental health disorders
• Have readily available materials on the common occurrence
of co-occurring disorders and process of recovery
Practical Improvements
III. Clinical Process: Assessment
•Offer both a mental health and substance use assessment to
individuals identified via screening or history
• Utilize standardized screening measures that assess for
mental health and substance use problems or are sensitive to
identifying mental health and substance use problems
• Utilize a systematic substance use and mental health
assessment for all clients
Practical Improvements
IV. Clinical Process: Treatment
• Mental health and substance abuse problems are identified
or targeted by at least generic treatment interventions, and
monitored for treatment response
• Routinely assess motivational stage during treatment and
consider modifications of treatments accordingly
• Utilize individual family sessions or multi-family groups
that often present comorbid psychiatric problems as a
complicating factor in recovery
• Presence of a documented and equivalent focus on
treatment planning for both co-occurring disorders
Practical Improvements
V. Continuity of Care
•Implement a deliberate plan post-discharge that considers
the influence of the co-occurring disorders on one another
• Make efforts to match the individual with community
support groups, with a plan to foster the connection
• Place an equivalent focus on discharge planning for both
substance use and psychiatric disorders
• Treatment providers and interventions, medications and
dose, recovery supports and relapse risks for both disorders
are well described and documented
Practical Improvements
VI. Staffing
•Request medical provider attend clinical team meetings
• Increase the number of both mental health and substance
counselors and educated, trained clinicians who can deliver
the most basic and generic treatment
• Match persons with specific co-occurring disorders with
peer role models
• Consistently and systematically review client progress
related to substance abuse and mental health problems
Practical Improvements
VI. Staffing
•Make a more definitive practice of hiring and staffing the
program with personnel who can provide co-occurring
disorder assessments and treatment
•Capitalize on a network of community volunteers, alumni
and others to strategically connect individuals diagnosed
with COD with others
Practical Improvements
VII. Training
• Make commitments to have the majority of the staff trained
in basic issues pertaining to co-occurring disorders: attitudes,
prevalence, screening, triage, and brief interventions
• Organize a training strategy to track and direct staff needs
for training and document trainings received
• Make a substantial investment in creating a “no wrong
door” experience for individuals at the level of the program
and clinician
References
Center for Substance Abuse Treatment. Definitions and Terms Relating to
Co-Occurring Disorders. COCE Overview Paper 1. DHHS Publication No.
(SMA) 06-4163 Rockville, MD: Substance Abuse and Mental Health Services
Administration, and Center for Mental Health Services, 2006.
Implementing Change in Substance Abuse Treatment Programs. Technical
Assistance Publication Series 31. HHS Publication No. (SMA) 09-4377.
Rockville, MD: Substance Abuse and Mental Health Services Administration,
2009.
Substance Abuse and Mental Health Services Administration, Dual Diagnosis
Capability in Addiction Treatment Toolkit Version 4.0. HHS Publication No.
SMA-xx-xxxx, Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2011.
http://www.samhsa.gov/co-occurring/DDCAT/index.html
http://www.samhsa.gov/co-occurring/DDCAT/references-anddownloads/downloads.html