As substance abuse treatment professionals recognize that the majority of their clients have co-occurring disorders, they are seeking better treatment approaches to address the needs of these clients (Helzer & Pryzbeck, 1988; Regier et al, 1990; Ross, 1995). There are several barriers to implementing more effective treatment. For example, there is no one acknowledged “best” practice for clients with co-occurring disorders because the unique combination of disorders means that there is wide heterogeneity among this population?a person with alcohol dependence and major depressive disorder differs dramatically from the person with a cocaine addiction and schizophrenia. Add differences in age, sex/gender, race, and other human differences, and treatment issues become quite complex. Two other barriers to implementing better treatment are the attitudes and knowledge of substance abuse treatment providers. Many providers are frustrated by clients with COD, are overwhelmed by the intensity of their needs, and/or believe that they are “hopeless” cases (Woody, 1996). Part of the problem is that most substance abuse counselors have not received training about the treatment of clients with COD in their formal education programs and because payment systems often do not allow for the lengthy integrated treatment needed by these clients.
The Iowa Practice Improvement Collaborative (Iowa PIC), part of a federal network funded by the Center for Substance Abuse Treatment, an agency of the Substance Abuse and Mental Health Services Administration of the U.S. Government, has developed several projects to address issues related to clients with co-occurring disorders. These are described briefly in this article. The Iowa PIC was established in the fall of 1999 with the purpose of building a strong collaboration among researchers, policy-makers, and practitioners in the state of Iowa. We have known about the large gap between research findings and actual practice in substance abuse treatment centers for a number of years, so the national PIC initiative was developed to “bridge the gap.” During the first year of the Iowa PIC, three committees were developed to address the different types of gaps in our state. One of those committees was the Treatment/Intervention Committee, co-chaired by a researcher from the University of Iowa, Dr. Anne Helene Skinstad. Comprised of about ten substance abuse providers and two policy-makers, this committee reviewed existing needs assessment data and conducted a focus group of provider concerns. Their conclusion was that the need of clients with co-occurring disorders (COD) was the highest priority need in our state. The Committee noted that most treatment of clients with COD currently was either parallel (the client was receiving mental health services and substance abuse services separately with no coordination) or serial (the client received one type of service then when completed, received the other type of service). Both of these methods of service delivery are ineffective and often provide conflicting treatment messages to clients. The Treatment/Intervention Committee recommended that the goal of the PIC should be to strive for integrated, simultaneous treatment of clients with COD. They recognized that substance abuse providers in the state were not currently skilled in mental health assessment and treatment and that mental health providers were not skilled in substance abuse assessment and treatment. In addition, negative attitudes about clients with COD were common. Therefore, a series of three studies related to COD were developed. These three studies will be conducted sequentially, with the first study completed in the spring of 2001, the second study underway at this time, and the third study to begin in the fall of 2001.
Study 1: Development of Agency and Staff Evaluation Tools The first study was designed to develop and pilot test an instrument for measuring knowledge and attitudes about clients with COD. Nearly 100 staff members at four substance abuse treatment agencies completed the staff tool, which has 27 multiple choice items and two open-ended items. Nineteen agency directors completed the agency tool with 28 multiple choice items and two open-ended questions.
Analysis of staff data indicated that 30% thought that their training about COD was inadequate, and only 3% said they had a solid understanding of the needs of these clients. The majority, 78% thought that substance abuse and mental health treatments should occur together and only 8% thought that these clients should get mental health treatment before entering substance abuse treatment. Most agreed that clients with COD require more time in treatment (87%) and take more effort from staff (78%). There was concern about the treatment climate as well?28% thought that clients with COD were disruptive and 29% said they make treatment for others more difficult. [more thought that they were not disruptive and did NOT make treatment of others more difficult, so while there was some worry about climate, most did not.] Nearly three-fourths (74%) felt that mental health professionals did not adequately understand substance abuse treatment, but 55% also thought that substance abuse counselors on the whole, do not really understand mental health treatment.
Most substance abuse counselors felt that they had access to information about best treatment practices (68%) and that their agencies supported staff efforts to improve their expertise (86%). All but one respondent (99%) supported a plan for initiating COD training at their agency and 82% support a state certification in COD. The staff believed that they were doing a good job of coordinating services with mental health agencies (88%), but fewer of them thought that mental health agencies were successfully coordinating care with substance abuse agencies (40%).
Program directors had very similar attitudes to the counselors, but there were a few differences. For example, program directors thought that their staff were better prepared to deal with clients with COD than the staff themselves did, and directors reported higher satisfaction with the care the clients with COD got at their agencies than were line staff. Program directors were more likely (58%) to think that mental health agencies were adequately coordinating care with substance abuse agencies.
The full results and copies of the instruments can be found at our website: www.uiowa.edu/iowapic. These results indicated that directors and line staff were already sold on the idea of integrated treatment and recognized the need for further training on COD. In addition, they believed that substance abuse treatment was the best place for the integrated treatment to occur, not mental health treatment. The findings of this study were helpful in developing the training program described below for Study 2.
Study 2: Cross-training for Co-Occurring Disorders The second study, which began in May of 2001, is a training intervention. Over 100 practitioners from three fields that deal with clients with CODs will be trained together: substance abuse counselors, mental health counselors, and treatment staff from the department of corrections. These disciplines too often work in isolation from each other, or sometimes, even at cross-purposes when caring for the same clients. The training program has several components: 1) a two day interactive, hands-on training program with a strong component on attitudes, knowledge, and collaboration; 2) a one day training on clinical supervision issues for clients with COD; and 3) monthly case study discussions to facilitate application of learning, delivered over a distance communications network. Because Iowa is a predominantly rural state, we must seek as many options for training as possible and use distance education options whenever feasible. Small treatment agencies in rural counties can ill afford to send their staff away for days at time for extensive trainings because of the lost revenue and long distances to cities where trainings usually occur.
The extensive training model outlined here was chosen because the literature suggests that long-term change in practice cannot be effected by one-shot trainings. Instead, long-term programs that reinforce learning and allow participants to discuss barriers to implementation are much more effective (Change Book, 2000). The evaluation tools developed in study 1 will be given prior to the training and at the end of the training components to determine if knowledge increases or attitudes change.
Study 3: Long-term Follow-up of the Effectiveness of COD Training When the COD training intervention study ends, a follow-up phase will begin. The purpose of this study is to evaluate the long-term effectiveness of the training program in changing attitudes about clients with COD and in increasing knowledge and skills of substance abuse counselors, mental health counselors, and staff of the department of corrections. We also hope to demonstrate greater collaboration or at least communication, among these disciplines.
Conclusions Clients with co-occurring disorders have complex needs that require skilled professionals to manage. However, neither substance abuse counseling programs nor mental health training has yet dealt effectively with the needs of these clients and as long as payment systems for mental health and substance abuse remain separate, the management of these clients will be difficult. The Iowa PIC has initiated steps to improve the treatment of clients with COD by providing training that addresses attitudes, knowledge, and skills and is on-going.
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