While the concept of integrated treatment is increasingly recognized as preferential over sequential and parallel models for individuals with co-occurring disorders, research and attendant documentation on integrated approaches is still in an infancy stage. Hence, providers continue to aspire to operationalize what it means to deliver practice-based integrated services. Foundations Associates, based in Nashville, Tennessee, is in the process of completing a three-year SAMHSA CSAT funded grant through the Department of Mental Health and Developmental Disabilities. The project?s objective was to evaluate efficacy of an integrated residential continuum and to define specific techniques unique to that integration. As preliminary outcomes are highly promising, this is the first in a series of articles describing the project?s efforts and efficacy. The objective of this article is to identify parallels in key program elements as they compare to the seven principles described by Minkoff1 as requisite in an integrated model of care:
1. Comorbidity is an expectation, not an exception.
Throughout its duration the project experienced few difficulties engaging participants, as community treatment programs were receptive to a program offering services to a “hard to treat” population. Based upon the 4-quadrant subtyping of disorders, Foundations Associates? consumer base was predominantly comprised of the high severity SPMI/substance dependency population, with the majority of participants having experienced multiple psychiatric and substance dependency treatment episodes prior to admission. Consumers consistently reported failed prior single system treatment experiences and favorable response to a program that combined aggressive psychopharmacologic treatment and behavioral health counseling with superimposed 12-step Dual Recovery Anonymous (DRA) tenets.
2. Successful treatment requires most importantly the creation of welcoming, empathetic, hopeful, continuous treatment relationships, in which integrated treatment and coordination of are sustained through multiple treatment episodes.
All program elements are directed toward emphasizing staff/client relationships in an engaging, non-punitive atmosphere, and
Motivational Enhancement concepts are adapted as the basis for treatment philosophy throughout all activities. From the initial assessment and throughout all treatment phases, the concept of “co-primary” and dual recovery is emphasized and based upon the individual?s readiness to change. Staff is directed not to impose traditional treatment goals, rather to establish client driven plans of care. Relapses and decompensations are viewed as characteristic of the pathology of the condition, and efforts are aggressively directed to re-engage the client whenever those events occur. Such episodes are used to enhance consumer introspection regarding triggers and symptoms of relapse and decompensation through community meetings and therapy sessions.
3. Within the context of the continuous integrated treatment relationship, case management and care-taking must be balanced with empathetic detachment and confrontation in accordance with the individual?s level of functioning, disability and capacity for treatment adherence.
Pacing treatment according to individual needs was early identified as essential, and assessment occurred ongoing to adjust technique to match changing symptoms and level of cravings or withdrawal. While programming includes daily individual and group educational components that address the confluence of disorders, these are provided in short sessions and are frequently repeated throughout the individual?s stay in the program. Weekly treatment meetings engage all team members and serve to actively refocus interventions according to the consumer?s needs and progress. Level systems, based upon symptom and withdrawal management and progress in the program, direct changes in the structure of the relationship. Treatment levels offer an earned system of privileges that combines completion of treatment goals with effective step work and milieu accomplishments to define when and how progression occurs. Hence, case management and care-taking efforts shift according to need, as do responsibilities the consumer bears in directing the course of treatment. While all infractions and relapses are addressed accordingly, motivational techniques are applied to evoke client insight into these experiences.
4. When mental illness and substance disorder co-exist, both disorders should be considered primary, and integrated dual primary treatment is required.
Aggressive psychopharmacologic treatment and monitoring, applied in conjunction with recovery principles such as sober, structured housing and DRA, is viewed as essential to a co-primary treatment approach. Given the severity of the treated population, the need to extend the length of program participation outside of normative single-diagnostic treatment periods is clear. Length of stay is evaluated individually according to progress in the program, level of stability attained, and related measures before movement to less restrictive care occurs. Even when consumers are moved to step down levels of care, medications continue to be monitored closely, as is attendance at 12-step meetings and participation in aftercare programs. In the event of relapse or decompensation, interventions are rapidly rallied either through intensive psychiatric evaluation and monitoring, relapse evaluation committees, modifications to the individual?s therapeutic contract/treatment plan, or a combination thereof. When decompensation in one sphere occurs, attendant monitoring of the other sphere is increased accordingly. While the goal was to recruit staff trained in integrated theories, where possible, bias within skill sets is a natural by-product of single system educational curricula and licensing bodies. Hence, staff trainings, workshops, and conferences are accentuated. Likewise, staff members rotate presentations in weekly meetings on contemporary treatment approaches to integrated care. As part of the Dual Diagnosis Recovery Network (DDRN), a library that serves as a national repository of dual diagnosis research, contemporary treatment information is available onsite.
5. Both psychiatric illnesses and substance dependence are examples of chronic, biological mental illness that can be understood using a disease and recovery model. Each disorder is characterized by parallel recovery phases: acute stabilization, engagement and motivational enhancement, active treatment, prolonged stabilization, rehabilitation and recovery.
Psychoeducation is a hallmark of this principle, in that education on the disease model, management strategies, medications, self-monitoring, and interrelatedness of conditions bring to bear the element of hope in recovery to facilitate movement through stages of change. Psychoeducation occurs through structured group programs, house meetings, residential therapy programs, family education programs, and use of a NAMI model, Bridges, which offers consumer led in-house education groups. All psychoeducational groups integrate parallels in dual recovery as a central theme, emphasizing methodologies for maximizing quality of life.
6. There is no single correct dual diagnosis intervention. Appropriate practice guidelines require that interventions must be individualized, according to the subtype of dual disorder, specific diagnosis of each disorder, phase of recovery/stage of change, and level of functional capability or disability.
Assessment strategies include multiple measures and sources to evaluate major life domains and placement/service needs. These include administration of a variety of objective indicators to determine the individual?s preparedness for services, along with use of multiple information sources to assess each outcome domain. The American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance-Related Disorders (ASAM PPC-IIR) is combined with those processes to assist in bench-
marking treatment levels according to need. In that the population treated at Foundations Associates predominantly consists of the 10% of the population using in excess of 70% of the healthcare resources, the impact of co-occurrence reinforces consumer-paced treatment that is fluid and allows for multidirectional movement. While early phases are directed at stability, medium phases at defining personal goals and plans for attaining those goals, and later phases toward reintegration, services are continually adjusted to match the consumer?s changing intensity needs. Given the composite psychopathology of the treated population, marked by multiple prior treatment episodes and a typical history of only short-term sobriety, enforcement of a zero tolerance model is counter to meaningful change. While abstinence is an ultimate goal, harm reduction must be emphasized as a measure of progress among both staff and participants. Non-punitive responses to lapses and relapses are central to ongoing engagement and eventual progression through stages of change.
7. Within a managed-care system, any of the individualized phase-specific interventions can be applied at any level of care. Consequently, a separate multidimensional level of care assessment is required.
Ongoing assessment is essential to service and intervention matching. While assessment techniques will be discussed in detail in a later publication, ASAM-PPC-IIR criteria, along with multiple standardized and non-standardized measures, are applied to direct the plan of care. Self- report is an important part of those measures as, while certain faults are inherent in self-report processes, the importance of client perception cannot be understated. Many practical questions required answers in order to develop a fully integrated program. At the program inception, there were no easily accessible residential models upon which to build. In intervening years, several examples of residential programs with proven effectiveness have emerged. It is our hope that the experiences of this project can inform other programs poised to make the leap from principle to practice, while leaving room for programs to tailor treatment elements to the needs of their consumer population. Nearing the completion of a 3-year longitudinal research investigation, the overall pattern of results supports highly promising outcomes from this modified integrated model. Outcome data from these efforts will be reported in a subsequent article in this series, reflecting follow-up data on 86% of the study participants.
Foundations Associates, located in both Nashville and Memphis, Tennessee, delivers an array of outpatient programs, along with a 72-slot residential treatment continuum that includes crisis stabilization, therapeutic community, halfway or step-up housing, and independent living services. All programming is designed specifically to provide integrated treatment for individuals with co-occurring disorders. For more information, contact Dick Clark, Chief Operations Officer at 615/345-3214.
Reference 1 Minkoff, K. (2000). An Integrated Model for the Management of Co-Occurring Psychiatric and Substance Disorders in Managed Care Systems. Dis Manage Health Outcomes, Nov: 8 (5): 251-257.