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Integrated Dual Diagnosis Treatment
Implementation and Program Maintenance
in Mental Health and
Substance Abuse Settings
Randi Tolliver, PhD, CADC
Illinois Co-Occurring
Center for Excellence
Training Objectives
 Review
Key Components of the Integrated
Dual Diagnosis Treatment Model
 Program
Implementation
 Organizational
Issues
 Programmatic Issues
 Agency Infrastructure
Training Objectives
 Program
Evaluation
 Agencies
 Other
in Transition
Management & Staffing
Considerations
SAMHSA Definition
“Co-occurring disorders may include any
combination of two or more substance abuse
disorders and mental disorders identified in the
Diagnostic and Statistical Manual of Mental
Disorders-IV (DSM-IV). There are no
specific combinations of….disorders that are
defined uniquely as co-occurring disorders.”
In “A Report to Congress on the Prevention and Treatment of CoOccurring Substance Abuse Disorders and Mental Disorders”
Comorbidity of Substance Use and Specific
AXIS I Psychiatric Disorders
Any
Substance
Alcohol
Diagnosis
Other Drug
Diagnosis
Schizophrenia
47%
33.7%
27.5%
ASPD
83.6%
73.6%
42%
Anxiety disorders
23.7%
17.9%
11.9%
Phobia
22.9%
17.3%
11.2%
Panic disorder
35.8%
28.7%
16.7%
OCD
32.8%
24%
18.4%
Bipolar Disorder
60.7%
46.2%
40.7%
Major depression
27.2%
16.5%*
18%
Regier DA et al. JAMA. 1990(Nov 21);264(19):2511-2518
Evidence-Based Practice
Two Directions in EBP
 Evidence-Based
•
EB Guidelines, EB Practices, Empiricallysupported (validated) Treatments
 Evidence-Based
•
Interventions:
Process for decision-making:
EB Process, EB Individual Practice
Evidence-Based Guidelines
(EBG)
 Different
methods for designing guidelines:
global subjective judgment or consensusbased, outcomes based, preference based,
expert opinion, evidence based
 Importance
of explicit, evidence-based
process in developing guidelines
Evidence-Based Process


EB Process is a way of doing practice which
involves an individualizing process whereby
evidence is used to make collaborative decisions
with clients and caregivers. (Mullen, 2004)
EB Process is the integration of best research
evidence with clinical expertise and patient values
(Sackett et al., 2000).
Quadrants of Care
Integrated Dual Diagnosis Services






Improve quality of life
Utilize biopsychosocial treatments
Promote consumer and family involvement in
service delivery
Promote stable housing
Promote employment as an expectation
Promote hopeful interactions
Integrated Dual Diagnosis Services






Promote a recovery concept
Increase continuity of care
Increase consumer quality of life outcomes
Increase stable housing
Increase employment
Increase independent living
Integrated Dual Diagnosis Treatment
Multidisciplinary Team



Views all activities of life as part of the
recovery process.
The Team provides each consumer with a
variety of service professionals that can help in
all aspects of life.
Members meet individually and as a group with
each consumer and their support network
(family, friends etc.) to discuss consumer’s
progress and goals.
Stage-Wise Interventions


Individuals with dual disorders gain the most
confidence with their ability to recover or develop
independent living skills and to meet daily living
needs when they experience incremental
successes through stages of treatment and
change.
Caregivers and professional service providers
should utilize the four stages of treatment to
guide every interaction with individuals who have
dual disorders.
Access to Comprehensive Services
 Programs
offer comprehensive services
because the recovery process occurs in the
context of daily living.
 Comprehensive
Services Include:
Case Management
Housing/Residential Services
Integrated Substance Abuse
and Mental Health Counseling
Supported Employment
Medical Services
Family Services
Assertive Community Treatment
or Intensive Case Management
Time-Unlimited Services


Consumers with dual disorders may
experience cycles of relapse and
recovery throughout their lives.
Consumers will achieve the highest
quality of life when they have access to
services all the time.
Assertive Outreach

Programs utilize assertive outreach to keep
consumers engaged in relationships (service
professional, family, friends)
Service professionals who use assertive outreach:
 Meet with their clients in the community
 Meet regularly with clients
 Offer practical assistance with daily needs and
living skills.
Motivational Interviewing
The role of Motivational Interviewing in IDDT:

Help consumers examine their ambivalence
about their goals and strategies

Help consumers identify their goals for daily
living

Help consumers develop strategies for
achieving those goals
Substance Abuse Counseling
Consumers are provided counseling that
promotes recovery skills during the
Active Treatment or Relapse Prevention
Stage of Treatment

In group treatment

•
•
Consumers can develop peer support
Consumers learn from each other
Group Treatment
Agencies that offer group treatment:
 Offer
 Offer
a menu of group treatment options
group treatment options to all
consumers who experience dual disorders
Family Psychoeducation


Social support plays a critical role in improving
assessments and reducing relapse and
hospitalization in persons with severe mental
illness.
Family psychoeducational programs can be a
powerful approach for improving substance
abuse outcomes in clients with severe mental
illness.
Participation in Alcohol &
Drug Self-Help Groups


Social support plays an important role in
reducing relapse for persons with dual
disorders
Self-Help Groups provide consumers
with opportunities to share and learn
from others who experience dual
disorders
Pharmacological Treatment


Medications are effective in the treatment of
persons with severe mental illness and dual
disorders
Medications are often most effective when
accompanied by comprehensive integrated
services and treatments.
Interventions to Promote Health
Individuals with dual disorders are at risk for
poor health including:

Hospitalization and emergency room visits

Suicide and violence

Infectious diseases

Complications resulting from chronic
illnesses
Secondary Interventions
for Non-Responders
to Substance Abuse Treatment


Have a specific plan to identify individuals who
are not responding to IDDT treatment
Questions to consider:



What are the criteria to identify non -responders?
What is the process for the secondary intervention?
How does this get followed up?
Delivery of Services
Guiding Principles for Effective Treatment
1
Employ a wellness & recovery perspective
2
Adopt a multi-problem viewpoint
3
Develop a phased approach
4
Address real-life problems early
5
Plan for cognitive and functional impairments
6
Use support systems to maintain and extend
treatment effectiveness
Adapted from SAMHSA Tip 42
Organizational Environment
Differences:



Treatment
philosophy
Treatment
practice
Relationships
Common ground:

Values and
principles

Guidelines

Outcome measures

Vocabulary

Basic competencies
Organizational Change

Understanding the organization’s model

Multi-level organizations
•
•
•
Mutual and conflicting needs
Traditional versus innovative ways of
communicating
Systems tend to resist substantial change
Adapted from Hendrickson, E. L (2006)
Program Development

Utilize evidence-based or best practices

Utilize a competency-based perspective

Employ recovery support specialists

Develop a plan to address housing needs

Employ employment specialists
Program Development



Develop policy & procedures for program
operations
Develop a clear understanding of target
population
Develop a marketing strategy that will
ensure adequate numbers of consumers
are engaged
Program Development



Develop a realistic time frame for hiring
and training staff
Establish a functional and clear admission
and referral process
Allow easy accessibility to program
services across the continuum of care
Necessary Infrastructure

Supervisor support for models or changes

Specific assessment instruments

Training protocol for providers




Implementation of treatment model
Utilization of outcome evaluation
Considerations of staff qualifications and
training needs
Recognition of additional/other needs
Questions to Consider
for Development and Implementation

Currently, which co-occurring treatment
services are being offered to which consumers?

Where in the continuum of care are the
services being offered?

Do current services demonstrate the qualities of
“effective” services?

Do the services meet the needs of the
community?
SAMHSA Tip 42
Questions to Consider


What is the capacity of the agency to
implement comprehensive, integrated
services?
What are the core competencies needed
for staff to provide effective services?
Implementation Challenges

Physician or psychiatrist staffing

Physical resources

Billing and reimbursement issues
McGovern, Xie, et. al. (2006).
Implementation Challenges



Identifying and responding to gaps in
workforce competencies, certifications,
and licensure
Addressing increases in staff concern
related to changes in roles and
responsibilities
Addressing discrepancies in record
keeping
Implementation Challenges



Addressing organizational structure and
policies
Resolving differences in treatment
philosophies
Establishing a cohesive multidisciplinary
team
Program Evaluation



General Organization Index (GOI)
Integrated Dual Diagnosis Treatment
(IDDT) Fidelity Scale
Dual Diagnosis Capability in Addiction
Treatment (DDCAT) Index
General Organizational Index
1.
2.
3.
4.
5.
6.
7.
Program Philosophy
Eligibility/ Consumer Information
Penetration
Assessment
Individualized Treatment Plan
Individualized Treatment
Training
General Organizational Index
8.
9.
10.
11.
12.
Supervision
Process Monitoring
Outcome Monitoring
Quality Assurance
Consumer Choice Regarding Service
Provision
IDDT Fidelity Scale
1.
2.
3.
4.
5.
6.
Multidisciplinary Team
Stage-Wise Interventions
Access to Comprehensive DD Services
Time-Unlimited Services
Outreach
Motivational
IDDT Fidelity Scale
7.
8.
9.
10.
11.
12.
13.
Substance Abuse Counseling
Group DD Treatment
Family Psychoeducation on DD
Participation in Alcohol & Drug Self-Help
Groups
Pharmacological Treatment
Interventions to Promote Health
Secondary Interventions to Substance Abuse
Treatment Non-Responders
Dual Diagnosis Capability
in Addiction Treatment
(DDCAT) Index
1.
2.
3.
4.
5.
6.
7.
Program Structure
Program Milieu
Clinical Process: Assessment
Clinical Process: Treatment
Continuity of Care
Staffing
Training
DDCAT (3.2): 7 DIMENSIONS
Dimension
Content of items
I
Program Structure Program mission, structure and financing, format for
delivery of mental health services.
II
Program Milieu
Physical, social and cultural environment for
persons with psychiatric problems.
III
Clinical Process:
Assessment
Processes for access and entry into services,
screening, assessment & diagnosis.
IV
Clinical Process:
Treatment
Processes for treatment including pharmacological
and psychosocial evidence-based formats.
V
Continuity of Care Discharge and continuity for both substance use
and psychiatric services, peer recovery supports.
VI
Staffing
Presence, role and integration of staff with mental
health expertise, supervision process
VII
Training
Proportion of staff trained and program’s training
strategy for co-occurring disorder issues.
McGovern, Giard, et al. (2006).
Measuring Changes

Client Readiness for Change
(Prochaska, DiClemente, and Norcoss, 1992)

Substance Abuse Treatment Scale
(Mueser, Drake, Clark, Mchugo, MercerMcFadden, Ackerson, 1995)

Stages of Change Readiness and
Treatment Eagerness Scale
(Miller & Tonigan, 1996)
Program Commitment Plan




Specific statements of services to be
implemented
Identification of individual(s) to monitor
implementation
Identification of ways to measure
effectiveness of services
Method for implementing services
Adapted from Hendrickson, E. L (2006)
Program Commitment Plan



Development of timeline for
implementation
Process to determine effectiveness of plan
implementation
Method for ongoing review and
modification of the plan
Adapted from Hendrickson, E. L (2006)
Agencies in Transition

Currently numerous agencies within Illinois are
providing a level of dual diagnosis services
•
•
•
Organizational level
Program level
Provider level
Program Management




Ensure compliance with all licensure
requirements
Develop policies and procedures for all
program activities
Maintain effective working relations with
other community agencies / Collaborate
Build consensus
Adapted from Hendrickson, E. L (2006)
Program Management



Maintain systems that ensure consumers
move through treatment services in the
easiest manner
Manage data systems
Ensure all information needed by funding
sources is provided accurately and on time
Adapted from Hendrickson, E. L (2006)
Program Management



Ensure compliance with all licensure
requirements
Develop policies and procedures for all
program activities
Maintain effective working relations with
other community agencies
Adapted from Hendrickson, E. L (2006)
Effective Management



The ability to communicate to all staff in a clear
and timely manner the decisions made and the
rationale for them
The ability to successfully develop relationships
with other community agencies
The ability to operate both as an ally and loyal
opposition when dealing with organizations the
that have authority over the program.
Adapted from Hendrickson, E. L (2006)
Effective Management

Understanding traditions, values, and
ethics that clinicians and administrative
staff follow

Leadership

Ensuring program survival

Being able to listen and consider all staff
input while being decisive when necessary
Adapted from Hendrickson, E. L (2006)
Essential Attitudes and Values
for Providers of Co-Occurring
Disorder Services
• Awareness of personal reactions and
feelings
• Recognition of limitations of one’s own
personal knowledge and expertise
• Recognition of the value of consumer input
into treatment goals and receptivity to
client feedback
TIP 42, Figure 3-7
Essential Attitudes and Values
• Desire and willingness to work with individuals
diagnosed with a co-occurring disorder
• Appreciation of the complexity of co-occurring
disorders
• Cultural competence
• Openness to new information
• Ability to employ diverse theories, concepts,
models, and methods
TIP 42, Figure 3-7
Essential Attitudes and Values
• Belief that all individuals have strengths and are
capable of growth and development
• Patience, perseverance, and therapeutic
optimism
• Recognition of the rights of consumers
diagnosed with co-occurring disorders, including
the right and need to understand assessment
results and the treatment plan
TIP 42, Figure 3-7
Additional Attributes
•
•
•
•
•
Flexibility
Optimism
Creativity
Respectfulness
Cooperativeness
References
• Evans, K. & Sullivan, J. M. (2001). Dual Diagnosis:
Counseling the Mentally Ill Substance Abuser (2nd Ed.).
New York: Guilford.
• Gibbs, L.E. (2003). Evidence-based practice for the
helping professions: A practical guide with integrated
multimedia. Pacific Grove, CA: Brooks/Cole-Thompson
Learning.
• Hendrickson, E. L (2006). Designing, Implementing,
and Managing Treatment Services for Individuals with
Co-Occurring Mental Health and Substance Use
Disorders: Blueprints for Action. Binghampton, NY:
Haworth Press.
References
• Hendrickson, E. L. & Schmal, M. (1993). Dual Disorders
Page, TIE Lines, 10 (3), 11.
• McGovern, M. P., Giard, J., Brown, J., Comaty, J., &
Riise, K. (2006). The Dual Diagnosis Capability in
Addiction Treatment (DDCAT): A Toolkit for Enhancing
Addiction Only Service (AOS) Programs and Dual
Diagnosis Capable (DDC) Programs. Unpublished
manuscript, Dartmouth Medical School.
• McGovern, M.P., Xie, H., Segal, S. R., Siembab, L., &
Drake, R. E. (2006). Addiction treatment services and co-
occurring disorders: Prevalence estimates, treatment
practices, and barriers. Journal of Substance Abuse
Treatment (31), 276-275.
References
•
Mullen, E. J. (2004). Facilitating practitioner use of
evidence-based practice. In A. R. Roberts & K.
Yeager (Eds.), Evidence-Based Practice Manual:
Research and Outcome Measures in Health and
Human Services. New York: Oxford University
Press.
•
Regier, D. A., Farmer, M. E., Rae, D. S., et al.
(1990). Comorbidity of mental disorders with
alcohol and other drug abuse: Results from the
Epidemiologic Catchment Area (ECA) Study.
Journal of American Medical Association, 264,
2511-2518.
References
• Sackett, D.L., Richardson, W.S., Rosenberg, W. M.
C., & Haynes, R. B. (2000). Evidence-Based
Medicine: How to Practice and Teach Evidence Based
Medicine (2nd ed.). London: Churchill-Livingstone.