Integrated Treatment Programs for Dual Diagnosis: (Psychiatric and Substance Abuse)

Substance abuse and mental illness, each separately, can have its bad impacts on both the persons diagnosed with either of them and the people surrounding them whether relatives or friends. The bad impact will be aggregated if the two illnesses coexist in or co-occur to the same person. Research in dual diagnosis has become crucial and urgent as the number of people who have dual diagnosis with both psychiatric illness and substance abuse is increasing (Timko, Dixon, and Moors, 2005). Hence, the need for integrated treatment programs has become urgent, rather than sequential or parallel treatment (Timko, et al., 2005). Although these integrated treatment programs have substantiated high success rate in some studies, the results were inconsistent in some other studies (Brunette et al, 2008; Chandler, 2011; Timko et al, 2005). In this paper, light will be shed on the definition of integrated treatment programs, and the ways these integrated programs are delivered. Also, the inconsistencies in programs implementations and results will be highlighted with the challenges, barriers and facilitators to find solutions to implementation problems.

There are different aspects that are involved in the essence of integrated treatment programs that can make them unique and clear in their definition. First, integrated program should be well-planned models to achieve identified goals of recovery. Second, these programs should be a double-phased treatment that manipulates both psychiatric and substance abuse disorders. Third, consumers who receive this kind of treatment programs should have dual diagnosis of both psychiatric and substance abuse disorders. Fourth, clinicians of psychiatric and substance abuse disorders should get together and work as one team to implement integrated treatment programs. Finally, these programs of treating psychiatric and substance abuse should be implemented simultaneously or at the same time, not in a parallel or sequential way. Thus integrated treatment programs are defined as planned models that include unified delivery for treating both mental and substance abuse disorder for consumers with co-occurring disorders simultaneously, and concurrently by the same staff or team of practitioners in a combined, mixed or unified way (Essock et al, 2006; Timko et al, 2005; Torrey et al, 2002).

Even though the need for integrated treatment programs is propagating, there are a variety of ways in which these programs can be delivered to people with dual diagnosis. A study called “The Connecticut Co-occurring Disorders Study” was conducted (Essock et al. 2006), at two state-operated centers for community mental health in Connecticut urban areas. A large rate of residents of these areas had incomes below the poverty line. The services of integrated treatment in assertive approach were compared to those delivered in standard clinical case management. Before starting the study, a well-prepared training and technical assistance were proffered to clinicians by two of the researchers (Essock et al., 2006). During the three years of the study, only 179 remained participating in the follow-up and in the research assessments every six months for three years out of 198 homeless or unstably housed clients with co-occurring disorders who were randomly enrolled in the two urban sites for one of the two treatment approaches between August 1993 and July 1998 (Essock et al., 2006). The two groups of assertive community treatment and standard clinical case management were compared “at baseline on several variables: demographic, psychiatric, and clinical characteristics; quality of life; alcohol and drug use; and residential status” (Essock et al., 2006 p. 189). There was a significant difference between the two treatment groups on clinician’s rating of substance abuse. Less treatment involvement concerning remission and recovery from substance abuse was rated by clinicians on the assertive treatment group than the standard clinical case management group. Concerning differences at baseline on a number of valuables of demographic and substance use, it was found that site 1 had more Caucasians and fewer African Americans, more married individuals with affective diagnosis, more hospitalization and less stable housing time, greater alcohol use symptoms, and in an earlier stage of treatment than site 2.

By reviewing regular provisions of data from information systems, researchers were able to measure fidelity to the assertive community treatment model; and also investigate the standard of the service that clinical case management model was offering (Essock et al., 2006). To achieve this, researchers considered three things as aspects of high fidelity: first, researchers considered the integrity of contacts between clinicians and clients. This contact integrity was manifested through how often the contacts took place; and how long each contact lasted. Second, they examined the shared caseload, which means the amount of services that clients received from multiple team members. Finally, the researchers investigated the mobility of the team which means the time rate spent in community location (Essock et al., 2006). It was found that the teams of assertive community treatment generally manifested great faithfulness to the model; the thing that distinguished between the one treatment group from the other. For instance, at site 1, the assertive community treatment group got significantly more services, and more monthly contacts from the team in the community per month, for the first 12 months (Essock et al., 2006).

As for longitudinal outcomes, both groups achieved improvement overtime. Concerning substance abuse, a steady and similar improvements manifested in treatment groups over time (Essock et al., 2006). In site 1, the improvement was more rapid in the assertive community group than the standard clinical case management group (Essock et al., 2006). Yet, the standard clinical case management group in site 2 achieved steady improvement during the 3 years of the study; and by the end of the study there was no difference in the two treatment groups. As for residential status, there was a significant difference between groups in site 2. The standard clinical case management group had significantly more days in hospital than assertive community group; but there was no significant difference between the two groups at site 1 (Essock et al., 2006).

In a second study done by Timko et al. (2005), the extent to which integrated treatment programs implemented in the residential and outpatient modalities was described and compared. The study aimed at pinpointing successes and failures in areas of a conceptual structure which were "organizational components, management practices, services and policies" (Timko et al., 2005. Pp. 330/331), when applying integrated treatment programs in residential and outpatient settings. Programs directors in the Department of Veterans Affairs completed surveys (Timko et al., 2005). They were asked about having a treatment course or regimen oriented specifically to dual diagnosis patients (Timko et al., 2005). The regimen concerns four domains which are organizational components involving staffing, training and treatment orientation; management practices including clinical practice guidelines and long term intensive case management; services such assessment and diagnosis, crisis management and peer counseling; and finally, policies concerning consumers’ choice in decision making (Timko et al., 2005). Again, the study included both inpatient/residential programs and outpatient programs.

On one hand, concerning inpatient/residential program, 114 substance abuse and 298 psychiatric programs were surveyed. Eighty four percent (96) of substance abuse and 74% (220) of the psychiatric programs had such a treatment regimen oriented specifically to dual diagnosis consumers. Of the 96 substance abuse programs, 45.5% of clients had co-occurring substance use and psychiatric disorders (Timko et al., 2005). Of the comparable 220 psychiatric programs, 45.3% of clients were dually diagnosed (Timko et al., 2005).

On the other hand, as for outpatient programs, 176 (100%) substance use and only 515 psychiatric programs categorized as standard or intensive were surveyed in the VA nationwide (Timko et al., 2005). A total of 81% (143) of the substance abuse programs, and 57% (294) of psychiatric programs had a treatment regimen oriented specifically to dual diagnosis clients (Timko et al., 2005). Again, out of the 143 of the substance abuse programs with a dual focused regimen, 45.8% of consumers had co-occurring substance use and psychiatric disorders. And out of the 294psychiatric programs, 40.3% of clients who attended psychiatric programs were dually diagnosed (Timko et al., 2005). This shows that integrated treatment programs can be applied successfully within residential and outpatient settings (Timko et al., 2005).

Even though integrated treatment programs generally have positively effective results (Brunette et al, 2008; Timko et al, 2005), it is noticeable that there have been some inconsistencies whether in the ways of delivery, in the components, in the implementations, retention, functionality, or in the outcomes/results of the integrated treatment programs. Reliability scores and results of dual diagnosis treatments of six sites in California were varied. This means that there is little association between fidelity scores and positive outcomes (Chandler, 2011)
The results of the study were as follows: There was high fidelity to evidence-based practices (EBP fidelity) in three sites; and moderate fidelity in the other three sites (Chandler, 2011). Individual programs results were efficacious in some program aspects such as treatment continuity, functionality, and stages but not consistent within programs or cross programs; besides there was little association between EBP fidelity and positive outcomes (Chandler, 2011). In the study done by Timko et al. (2005) which has been mentioned above, there were also varying degrees of implementation success on the levels of organizational components, management practices, services, policies and finance in both residential and outpatient programs. This means that there were still inconsistencies between the program outcomes and its implementation elements.

Despite the inconsistencies that may exist in the implementation components, or between EBP fidelity and the outcomes of the integrated treatment programs of dual diagnosis of psychiatric and substance abuse, the problems are not insurmountable. Applying some strategies can operate as facilitators or factors of success. However, deactivating these strategies can represent as barriers to implementing integrated treatment programs. In their 2-year study report by visiting, monitoring and interviewing key informant leaders at 11 community mental health centers in the National Implementing Evidence-Based Practices Project., Brunette et al (2008) found five of these strategies that can help overcome the barriers to integrated treatment programs implementations and effective outcomes. The five themes or factors were leadership, consultation and training, supervision mastery and supervision, staff turnover, and finance (Brunette et al., 2008). They found that 2 sites achieved high fidelity; 6 sites reached moderate fidelity; and 3 sites stayed at low fidelity over the 2-year duration.

Concerning leadership, factors of success included committed midlevel leader with sufficient authority to make changes, and appropriate attitudes of administrative leaders for challenges. A consultant-trainer with assessment and counseling skills is crucial for primary and continual plans to provide training material and interactions with the team members (Brunette et al., 2008). High-quality supervision is necessary for providing feedback for performance points of strength and weakness to decide on training programs (Brunette et al., 2008). Concerning staff turnover, flexibility in staff changes whether by moving, terminating, or hiring, is crucial for successful implementation of integrated treatment programs (Brunette et al., 2008). As for finance, low fidelity is associated with financial implication. Funds are very critical to providing training, supervision, consultation and spending on new staff hiring (Brunette et al., 2008). Again, using regular fidelity measures for service quality assessment with feedbacks to leaders was also crucial, and helped as a success factor (Brunette et al., 2008). The actions for improvement should be integrated (Brunette et al., 2008). Cooperative and coordinative relationships between organizations and state or county mental health authority had a significant impact on the success of the integrated disorders treatment implementation (Brunette et al., 2008).

Other strategies for successful implementation of integrated dual disorders treatment programs requires all stakeholders’ participation (Torrey et al., 2002). In a research paper written by Torrey et al. (2002), integrated treatment implementation strategies are outlined. The authors state that involving all major participants, whether they are clients, families, practitioners, leaders, and authority figures can ultimately lead to successful achievements. The researchers reached this outline of strategies from interviews with stakeholders involved in successful implementations (Torrey et al., 2002). Recovery is the first strategy outlined by Torrey et al. (2002) and is the ultimate goal of consumers; but without “hope, personal responsibility, illness management, healthy adult roles, or quality of life”, recovery cannot take place (Torrey et al., 2002, p. 510). The recovery model can help highlight and organize stakeholders’ efforts (Torrey et al., 2002).

The first strategy Torrey et al (2002) focus on is the consumer. Consumers’ first step to recovery is to learn to manage two co-occurring illnesses (Torrey et al., 2002). This can be achieved by other recovering individuals sharing their recovery experiences with other current consumers (Torrey et al., 2002). These recovering individuals can advocate integrated treatment programs state wide (Torrey et al., 2002).

Torrey’s second strategy involves families and friends as they can play an important role in the consumer’s recovery by learning how to deal with the consumer, and to co-operate with clinicians (Torrey et al., 2002). Families and friends of recovering consumers can also share their experience of integrated treatment programs with other consumers’ families and clinicians by explaining how the integrated treatment programs were effective (Torrey et al., 2002). They can help sustain good programs by serving as permanent promoters (Torrey et al., 2002).

The third strategy highlights the effective role of clinicians as they learn new skills to offer a new service (Torrey et al., 2002). Being strongly motivated by learning new skills, practices and getting feedback, clinicians can help their clients recover. This can be done by bringing formal and informal peers together to gain competency (Torrey et al., 2002).

The fourth strategy concerns program leaders who must be aware of managing dynamics that support clinical operations such as report, cost, staff training, and information (Torrey et al., 2002). Reading leadership and administration literature as a source of getting knowledge about waves of change that corresponds to their clinics can help program leaders to anticipate problems and hence solutions to them (Torrey et al., 2002).

Finally, policy makers can build up motivations, capability, and skills for co-occurring substance abuse (Torrey et al., 2002) by means of clarifying the ultimate goal of recovery for dual diagnosis clients. Policy makers must draw up plans for achieving the goal of recovery identifying hope, objectives, money supply, and supervision (Torrey et al., 2002). There must be regularly communicative cooperation and coordination between substance abuse authority and mental health authority to establish the effective vision. For the vision to be enacted and effectuated by local providers, the mental health authority can support by drawing up contracts, rules, expenses, training programs, and other mechanisms (Torrey et al., 2002).

So far, some aspects of integrated treatment programs for people with dual diagnosis have been highlighted. An integrated treatment program is a technique that amalgamates both psychiatric and substance abuse treatments as one delivery package to people with dual diagnosis (Essock et al, 2006; Timko et al, 2005; Torrey et al, 2002). Because the number of people with dual diagnosis has increased, implementing integrated treatment programs has turned out to be highly effective (Torrey et al., 2002). The integrated treatment programs can be carried out as an assertive community treatment, standard case management, residential programs, and outpatient programs (Essock et al, 2006; Timko et al, 2005). Despite being effective, integrated treatment programs have shown some inconsistencies in different aspects of implementations because of some challenges and barriers (Brunette et al, 2008; Timko et al, 2005). Yet, these barriers are not insurmountable. With high quality training and education that encompass all the stakeholders, clinicians, consumers, families, relatives and friends, the process of integrated treatment programs becomes a holistic domain where everyone can share to achieve better results (Brunette et al., 2008) & (Torrey et al., 2002)
(Ramsis Hanna)

References

1- Brunette, M. F., Asher, D., Whitley, R., Lutz, W. J., Wieder, B. L., Jones, A. M.,& McHugo, G. J. (2008). Implementation of integrated dual disorders treatment: A qualitative analysis of facilitators and barriers. Psychiatric Services, 59(9), 989-95.Retrieved July 12,2012, from http://search.proquest.com/docview/213099065?accountid=11809

2- Chandler, D. W. (2011). Fidelity and outcomes in six integrated dual disorders treatment programs. Community Mental Health Journal, 47, 82-9. doi: 10.1007/s10597-009- 92450

3- Essock, S. M., Mueser, K. T., Drake, R. E., Covell, N. H., McHugo, G. J., Frisman, L. K., . . . Swain, K. (2006). Comparison of ACT and standard case management for delivering integrated treatment for co-occurring disorders. Psychiatric Services, 57(2), 185-96. Retrieved July12,2012, from http://search.proquest.com/docview/213075699?accountid=11809

4- Timko, C., Dixon, K., & Moos, R. H. (2005). Treatment for dual diagnosis patients in the psychiatric and substance abuse systems. Mental Health Services Research, 7, 229-42. doi: 10.1007/s11020-005-7455-9

5- Torrey, C. W., Drake, E. R., Cohen, M., Fox, B. L., Lynde, D., Gorman, P., Wyzik, P. (2002). The challenge of implementing and sustaining integrated dual disorders treatment programs. Community Mental Health Journal. 38 (3), 507-21. Retrieved July 12,2012 from http://library.kean.edu:2048/login?url=http://library.kean.edu:2066/docview/220125940a ccountid=11809

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