Mental and substance use disorders

Psychoeducational classes on mental and substance use disorders are important elements in basic COD programs. These classes typically focus on the signs and symptoms of mental disorders, medication, and the effects of mental disorders on substance abuse problems. Psychoeducational classes of this kind increase client awareness of their specific problems and do so in a safe and positive context. Most important, however, is that education about mental disorders be open and generally available within substance abuse treatment programs. Information should be presented in a factual manner, similar to the presentation of information on sexually transmitted diseases (STDs). Some mental health clinics have prepared synopses of mental illnesses for clients in terms that are factual but unlikely to cause distress. A range of literature written for the layperson also is available through government agencies and advocacy groups (see appendix I). This material provides useful background information for the substance abuse treatment counselor as well as for the client.

Relapse prevention

Programs also can adopt strategies designed to help clients become aware of cues or “triggers” that make them more likely to abuse substances and help them develop alternative coping responses to those cues. Some providers suggest the use of “mood logs” that clients can use to increase their consciousness of the situational factors that underlie the urge to use or drink. These logs help answer the question, “When I have an urge to drink or use, what is happening?” Similarly, basic treatment agencies can offer clients training on recognizing cues for the return of psychiatric symptoms and for affect or emotion management, including how to identify, contain, and express feelings appropriately.

Working in groups

Group therapy in substance abuse treatment settings is regarded generally as a key feature of substance abuse treatment. However, group therapy should be augmented by individual counseling since individual contact is important in helping the client with COD make maximum use of group interventions.

Group therapy should be modified for clients with COD. Generally, it is best to reduce the emotional intensity of interpersonal interaction in COD group sessions; issues that are nonprovocative to clients without COD may lead to reactions in clients with COD. Moreover, because many clients with COD often have difficulty staying focused, their treatment groups usually need stronger direction from staff than those for clients who do not have COD. Typically, some persons with COD have trouble sitting still, while others may have trouble getting moving at all (for instance, some people with depression); therefore, the duration of a group (and other activities) should be shortened to less than an hour, with the typical group or activity running for no more than 40 minutes. Because of the need for stability, the groups should run regularly and without cancellation.

Because many clients with COD have difficulty in social settings, group sizes may need to be smaller than is typical. There is benefit even to allowing a few individuals to be considered a group, so long as sessions are group-oriented and used as a means to introduce the client to a larger group setting. It is not uncommon for groups tailored to individuals with COD to consist of between two and four individuals in the early stages. Co-leaders are especially important in these groups, as one leader may need to leave the group with one member, while the group continues with the co-leader. With appropriate staff guidance, peers who have completed the program or advanced to its latter stages can sometimes be used as group cofacilitators.

Considerable tolerance is needed for varied (and variable) levels of participation depending on the client's level of functioning, stability of symptoms, response to medication, and mental status. Many clients with serious mental illness (e.g., those with a diagnosis of schizophrenia, schizoid and paranoid personality) may not fit well in groups and must be incorporated gradually at their own pace and to the degree they are able to participate. Even minimal or inappropriate participation can be viewed as positive in a given case or circumstance. Verbal communication from group leaders should be brief, simple, concrete, and repetitive. This is especially important to reach clients with cognitive and functional impairments. Affirmation of accomplishments should be emphasized over disapproval or sanctions. Negative behavior should be amended rapidly with a positive learning experience designed to teach the client a correct response to a situation. In general, group leaders will need to be sensitive and responsive to needs of the client with COD and the addition of special training can enhance his or her competency. TIP 41, Substance Abuse Treatment: Group Therapy (Center for Substance Abuse Treatment [CSAT] 2005) contains more information on the techniques and types of groups used in substance abuse treatment.

Involving clients in treatment and program design

Because clients can provide important guidance relative to their treatment and valuable feedback on program design and effectiveness, they should be involved in program discussions. Some guidelines for involving client/consumers include:

• Form a Consumer Advisory Group.
• Include both current clients from the program and past clients.
• Elect a client representative to discuss client concerns with staff.
• Provide a staff liaison to help coordinate client meetings and to provide a continuing link to staff.
• Hold regular meetings and phone conferences.
• Provide incentives to clients for participation.
• Solicit input on a variety of matters and in an ongoing way.
• Involve clients in meaningful projects.
• When client input is solicited and received, consider it respectfully, respond appropriately, and give the client feedback on your response.

Family education

It is important that family members and significant others who are close to the client receive information on mental disorders and substance abuse, as well as on how the disorders interact with one another. Particularly in cultures that value interdependence and are community and/or family-oriented, a family and community education and support group can be helpful. In an effort to build or maintain support for the client and his treatment, family members and significant others need to understand the implications of having COD and the treatment options available to the client. Programs must provide this instruction in an interactive style that allows questions, not in a lecture mode. The essentials of this information include:

• The name of the disorder
• Its symptoms
• Its prevalence
• Its cause
• How it interacts with substance abuse—that is, the implications of having both disorders
• Treatment options and considerations in choosing the best treatment
• The likely course of the illness
• What to expect
• Programs, resources, and individuals who can be helpful

Prevalence

COD is clearly a defining characteristic commonly found in clients who enter substance abuse treatment. A Drug Abuse Treatment Outcome Study (DATOS) of 99 treatment programs in 11 U.S. metropolitan areas between 1991 and 1993 found the following distribution of co-occurring mental disorders: 39.3 percent met DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised [American Psychiatric Association 1987]) diagnostic criteria for antisocial personality disorder, 11.7 percent met criteria for a major depressive episode, and about 3.7 percent met criteria for a general anxiety disorder (Flynn et al. 1996) (see also Figure 1-2 in chapter 1). DATOS and other data indicate that substance abuse programs can expect a substantial proportion of the clientele to have COD.

Empirical evidence of effectiveness

Evidence suggests that outpatient treatment can lead to positive outcomes for certain clients with COD, even when treatment is not tailored specifically to their needs. Outpatient substance abuse treatment programs can be effective settings for treating substance abuse in clients with less serious mental disorders. This conclusion is supported by evidence from the most current and comprehensive database on substance abuse treatment, the DATOS dataset (Flynn et al. 1997).

Clients who were in outpatient treatment, including individual and group counseling and mutual self-help groups, showed reductions in drug use after treatment. Clients with 3 months or more of outpatient treatment reported even lower rates of drug use compared to their rate of use prior to treatment (Hubbard et al. 1997; Simpson et al. 1997a ). These data show that substance abuse treatment outpatient programs can help clients, many with COD, who remain in treatment at least 3 months. However, modifications designed to address issues faced even by those with less serious mental disorders can enhance treatment effectiveness and in some instances are essential.

Screening and assessment

As chapter 4 provides a full discussion of assessment, this section will address only those screening and assessment issues of concern in outpatient settings or that deserve reiteration in this specific context.

Screening and assessment are used to make two essential decisions:

1. Is the individual stable enough to remain in an outpatient setting, or is more intense care indicated, warranting rapid referral to an appropriate alternative treatment?
2. What services will the client need?

To answer either question, staff must first determine the scope of the client's problems, including his physical and mental status, living situation, and the support he has available to face these problems. Whereas screening requires basic counseling skills, the consensus panel recommends that only specially trained or highly capable staff should perform assessments—not, as is too often the case, less experienced personnel.

A thorough assessment should establish the client's mental and physical status. The process should determine any preexisting medical conditions or complications, substance use history, level of cognitive functioning, prescription drug needs, current mental status, and mental health history.

Centralized intake

A centralized intake team is a useful approach to screening and assessment, providing a common point of entry for many clients entering treatment. When applied in an agency with multiple programs, centralized intake reduces duplication of referral materials as well as assessment services. At Arapahoe House (a model described later in this chapter), the information and access team manages hundreds of telephone calls weekly, conducts screenings, and sets appointments for admission to any of the programs within the agency, with the exception of three detoxification programs. Where centralized intake serves a multi-modality treatment organization or a community with multiple settings (the latter being especially difficult), the intake process can be used to refer clients to the treatment modality most appropriate to their needs (e.g., residential or outpatient), so long as careful attention is paid to the accurate coordination of intake information.

Reassessment

Once admitted to treatment, clients need regular reassessment as reductions in acute symptoms of mental distress and substance abuse may precipitate other changes. Periodic assessment will provide measures of client change and enable the provider to adjust service plans as the client progresses through treatment.

Referral and placement

Careful assessment will help to identify those clients who require more secure inpatient treatment settings (e.g., clients who are actively suicidal or homicidal), as well as those who require 24-hour medical monitoring, those who need detoxification, and those with serious substance use disorders who may require a period of abstinence or reduced use before they can engage actively in all treatment components. TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998e ), contains information on assessing physical and cognitive functioning that is relevant for all populations.

It is important to view the client's placement in outpatient care in the context of continuity of care and the network of available providers and programs. Outpatient treatment programs may serve a variety of functions, including outreach/engagement, primary treatment, and continuing care. Ideally, a full range of outpatient substance abuse treatment programs would include interventions for unmotivated, disaffiliated clients with COD, as well as for those seeking abstinence-based primary treatments and those requiring continuity of supports to sustain recovery.

Likewise, ideal outpatient programs will facilitate access to services through rapid response to all agency and self-referral contacts, imposing few exclusionary criteria, and using some client/treatment matching criteria to ensure that all referrals can be engaged in some level of treatment. In those instances where funding for treatment is controlled by managed care, additional levels of control over admission may be imposed on the treatment agency. The consensus panel has mentioned that treatment providers should be careful not to place clients in a higher level of care (i.e., more intense) than is necessary. A client who might remain engaged in a less intense treatment environment may drop out in response to the demands of a more intense treatment program.

Engagement

Clients with COD, especially those opposed to traditional treatment approaches and those who do not accept that they have COD, have particular difficulty committing to and maintaining treatment. By providing continuous outreach, engagement, direct assistance with immediate life problems (e.g., housing), advocacy, and close monitoring of individual needs, the Assertive Community Treatment (ACT) and Intensive Case Management (ICM) models (described below) provide techniques that enable clients to access services and foster the development of treatment relationships. In the absence of such supports, those individuals with COD who are not yet ready for abstinence-oriented treatment may not adhere to the treatment plan and may be at high risk for dropout (Drake and Mueser 2000).

Because clients with COD often have poor treatment engagement, it is particularly important that every effort be made to employ methods with the best prospects for increasing engagement. Daley and Zuckoff (1998) note a number of useful strategies for improving engagement and adherence with this population.

Improving Adherence of Clients With COD in Outpatient Settings

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• Use telephone or mail reminders.

• Provide reinforcement for attendance (e.g., snacks, lunch, or reimbursement for transportation).

• Increase the frequency and intensity of the outpatient services offered.

• Develop closer collaboration between referring staff and the outpatient program's staff.

• Reduce waiting times for outpatient appointments.

• Have outpatient programs designed particularly for clients with COD.

• Provide clients with case managers who engage in outreach and provide home visits.

• Coordinate treatment and monitoring with other systems of care providing services to the same client.

Source: Adapted from Daley and Zuckoff 1998.

Discharge planning

Discharge planning is important to maintain gains achieved through outpatient care. Clients with COD leaving an outpatient substance abuse treatment program have a number of continuing care options. These options include mutual self-help groups, relapse prevention groups, continued individual counseling, mental health services (especially important for clients who will continue to require medication), as well as intensive case management monitoring and supports. A carefully developed discharge plan, produced in collaboration with the client, will identify and match client needs with community resources, providing the supports needed to sustain the progress achieved in outpatient treatment.

Clients with COD often need a range of services besides substance abuse treatment and mental health services. Generally, prominent needs include housing and case management services to establish access to community health and social services. In fact, these two services should not be considered “ancillary,” but key ingredients for clients' successful recovery. Without a place to live and some degree of economic stability, clients with COD are likely to return to substance abuse or experience a return of symptoms of mental disorder. Every substance abuse treatment provider should have, and many do have, the strongest possible linkages with community resources that can help address these and other client needs. Clients with COD often will require a wide variety of services that cannot be provided by a single program.

It is imperative that discharge planning for the client with COD ensures continuity of psychiatric assessment and medication management, without which client stability and recovery will be severely compromised. Relapse prevention interventions after outpatient treatment need to be modified so that the client can recognize symptoms of psychiatric or substance abuse relapse on her own and can call on a learned repertoire of symptom management techniques (e.g., self-monitoring, reporting to a “buddy,” and group monitoring). This also includes the ability to access assessment services rapidly, since the return of psychiatric symptoms can often trigger substance abuse relapse.

Developing positive peer networks is another important facet of discharge planning for continuing care. The provider seeks to develop a support network for the client that involves family, community, recovery groups, friends, and significant others. Where a client's family of origin is not healthy and supportive, other networks can be accessed or developed that will support him. Programs also should encourage client participation in mutual self-help groups, particularly those that focus on COD (e.g., dual recovery mutual self-help programs). These groups can provide a continuing supportive network for the client, who usually can continue to participate in such programs even if he moves to a different community. Therefore, these groups are an important method of providing continuity of care.

The consensus panel also recommends that programs working with clients with COD try to involve advocacy groups in program activities. These groups can help clients become advocates themselves, furthering the development and responsiveness of the treatment program while enhancing clients' sense of self-esteem and providing a source of affiliation.

Continuing care

Continuing care and relapse prevention are especially important with this population, since people with COD are experiencing two long-term conditions (i.e., mental disorder often is a cyclical, recurring illness; substance abuse is likewise a condition subject to relapse). Clients with COD often require long-term continuity of care that supports their progress, monitors their condition, and can respond to a return to substance use or a return of symptoms of mental disorder. Continuing care is both a process of posttreatment monitoring and a form of treatment itself. (In the present context, the term “continuing care” is used to describe the treatment options available to a client after leaving one program for another, less intense, program.)

The relative seriousness of a client's mental and substance use disorders may be very different at the time she leaves a primary treatment provider; thus, different levels of intervention will be appropriate. After leaving an outpatient program, some clients with COD may need to continue intensive mental health care but can manage their substance abuse treatment by participation in mutual self-help groups. Others may need minimal mental health care but require some form of continued formal substance abuse treatment. For people with SMI, continued treatment often is warranted; a treatment program can provide these clients with structure and varied services not usually available from mutual self-help groups.

Upon leaving a program, clients with COD always should be encouraged to return if they need assistance with either disorder. Because the status of these individuals can be fragile, they need to be able to receive help or a referral quickly in times of crisis. Regular informal check-ins with clients also can help alleviate potential problems before they become serious enough to threaten recovery. A good continuing care plan will include steps for when and how to reconnect with services. The plan and provision of these services also makes readmission easier for clients with COD who need to come back. The client with COD should maintain contact postdischarge (even if only by telephone or informal gatherings). Increasingly, substance abuse programs are undertaking follow-up contact and periodic groups to monitor client progress and assess the need for further service.

Staffing

To accommodate clients with COD, standard outpatient drug treatment staffing should include both mental health specialists and psychiatric consultation and access to onsite or offsite psychopharmacologic consultation. All treatment staff should have sufficient understanding of the substance use and mental disorders to implement the essential elements described above. Ideally, this staffing pattern would include mental health clinicians with master's level education, strong diagnostic skills, and substantial experience with clients with COD. These clinicians could provide a link to psychiatric services as well as to consultation on other clinical activities within the program. It is important that the staff function as an integrated team. Staff cooperation can often be fostered by cross-training, clinical team meetings and, most importantly, a treatment culture that stresses teamwork and collaboration.

Training

An integrated model of treatment for clients with COD requires that each member of the treatment team has substantial competency in both fields. Both mental health and substance abuse treatment staff require training, cross-training, and on-the-job training to meet adequately the needs of clients with COD. Within substance abuse treatment settings, this means training in these areas:

• Recognizing and understanding the symptoms of the various mental disorders
• Understanding the relationships between different mental symptoms, drugs of choice, and treatment history
• Individualizing and modifying approaches to meet the needs of specific clients and achieve treatment goals
• Accessing services from multiple systems and negotiating integrated treatment plans

The addition of mental health staff into a substance abuse treatment setting also raises the need for training. Training should address

• Differing perspectives regarding the characteristics of the person with COD
• The nature of addiction
• The nature of mental disability
• The conduct of treatment and staff roles in the treatment process
• The interactive effects of both conditions on the person and his or her outcomes
• Staff burnout

Staff trained exclusively either in mental health services or in substance abuse treatment models often have difficulty accepting the other's view of the person, the problem, and the approach to treatment. Cross-training and open discussion of differing viewpoints and challenging issues can help staff to reach a common perspective and approach for the treatment of clients with COD within each agency or program setting. Chapter 3 provides a more complete discussion of staff training, while appendix I identifies a number of training resources.

Financing integrated treatment

As noted earlier, systemic difficulties related to the organization and financing of integrated treatment models, including funding for enhanced mental health services, have delayed implementation of integrated treatment models in many outpatient substance abuse treatment settings. Resources for funding extended continuity of treatment, which are available generally in mental health settings, are not usually provided in substance abuse treatment systems. Since the majority of substance abuse treatment agencies treat clients with COD, an obvious solution to funding shortfalls is to access funding streams that support mental health services. Such funding may be based on demonstrating the nature, severity, and extent of co-occurring mental disorders among their clients, with documentation of the full range of diagnosed disabilities of clients with COD. This information also helps programs to modify their programs to address current client needs, and to educate and promote an appreciation for the documented efficacy of integrated treatment for those with COD (Drake et al. 1998b ). Chapter 3 presents additional information on overcoming barriers and for accessing funding for COD in substance abuse treatment settings.

Planning for organizational change

Substance abuse treatment agencies should plan for any organizational changes needed to introduce new or altered approaches into program settings (e.g., adding and integrating mental health staff into the substance abuse setting). Agencies should be aware, however, that changing the processes and approaches in an organization is challenging. Strategies should be grounded in sound organizational change principles and may be effective in helping all parties understand, accept, and adjust to the changes. A recommended sourcebook administrators might find useful is The Change Book: A Blueprint for Technology Transfer (Addiction Technology Transfer Center National Office 2000).

Assertive Community Treatment

Developed in the 1970s by Stein and Test (Stein and Test 1980; Test 1992) in Madison, Wisconsin, for clients with SMI, the ACT model was designed as an intensive, long-term service for those who were reluctant to engage in traditional treatment approaches and who required significant outreach and engagement activities. ACT has evolved and been modified to address the needs of individuals with serious mental disorders and co-occurring substance use disorders (Drake et al. 1998a ; Stein and Santos 1998).

Program model

ACT programs typically employ intensive outreach activities, active and continued engagement with clients, and a high intensity of services. ACT emphasizes shared decision making with the client as essential to the client's engagement process (Mueser et al. 1998). Multidisciplinary teams including specialists in key areas of treatment provide a range of services to clients. Members typically include mental health and substance abuse treatment counselors, case managers, nursing staff, and psychiatric consultants. The ACT team provides the client with practical assistance in life management as well as direct treatment, often within the client's home environment, and remains responsible and available 24 hours a day (Test 1992). The team has the capacity to intensify services as needed and may make several visits each week (or even per day) to a client. Caseloads are kept smaller than other community-based treatment models to accommodate the intensity of service provision (a 1:12 staff-to-client ratio is typical).

Making ACT Work

Team cohesion and smooth functioning are critical to success. The ACT multidisciplinary team has shared responsibility for the entire defined caseload of clients and meets frequently (ideally, teams meet daily) to ensure that all members are fully up-to-date on clinical issues. While team members may play different roles, all are familiar with every client on the caseload. Additionally, the ACT model includes the clients' family and friends within treatment services.

Source: Wingerson and Ries 1999.

ACT treatment activities and interventions

Examples of ACT interventions include

• Outreach/engagement. To involve and sustain clients in treatment, counselors and administrators must develop multiple means of attracting, engaging, and re-engaging clients. Often the expectations placed on clients are minimal to nonexistent, especially in those programs serving very resistant or hard-to-reach clients.
• Practical assistance in life management. This feature incorporates case management activities that facilitate linkages with support services in the community. While the role of a counselor in the ACT approach includes standard counseling, in many instances substantial time also is spent on life management and behavioral management matters.
• Close monitoring. For some clients, especially those with SMI, close monitoring is required. This can include (Drake et al. 1993):
  • Medication supervision and/or management
  • Protective (representative) payeeships
  • Urine drug screens
• Counseling. The nature of the counseling activity is matched to the client's motivation and readiness for treatment.
• Crisis intervention. This is provided during extended service hours (24 hours a day, ideally through a system of on-call rotation).

Nine Essential Features of ACT

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1. Services provided in the community, most frequently in the client's living environment

2. Assertive engagement with active outreach

3. High intensity of services

4. Small caseloads

5. Continuous 24-hour responsibility

6. Team approach (the full team takes responsibility for all clients on the caseload)

7. Multidisciplinary team, reflecting integration of services

8. Close work with support systems

9. Continuity of staffing

Source: Drake et al. 1998a .

Key modifications for integrating COD

When working with a client who has COD, the goals of the ACT model are to engage the client in a helping relationship, to assist in meeting basic needs (e.g., housing), to stabilize the client in the community, and to provide direct and integrated substance abuse treatment and mental health services. The standard ACT model as developed by Test (1992) has been modified to include treatment for persons who have substance use disorders as well as mental disorders (Stein and Santos 1998). The key elements in this evolution have been

• The use of direct substance abuse treatment interventions for clients with COD (often through the inclusion of a substance abuse treatment counselor on the multidisciplinary team)
• A team focus on clients with COD (Drake et al. 1998a )
• COD treatment groups (Drake et al. 1998a )
• Modifications of traditional mental health interventions, including a strong focus on the relationships between mental health and substance use issues (e.g., providing skills training that focuses on social situations involving substance use [Drake and Mueser 2000])

Substance abuse treatment strategies are related to the client's motivation and readiness for treatment and include

• Enhancing motivation (for example, through use of motivational interviewing)
• Cognitive-behavioral skills for relapse prevention
• 12-Step programming, including use of the peer recovery community to strengthen supports for recovery
• Psychoeducational instruction about addictive disorders

For clients who are not motivated to achieve abstinence, motivational approaches are structured to help them recognize the impact of substance use on their lives and on the lives of those around them. Therapeutic interventions are modified to meet the client's current stage of change and receptivity.

Populations served

When modified as described above to serve clients with COD, the ACT model is capable of including clients with greater mental and functional disabilities who do not fit well into many traditional treatment approaches. The characteristics of those served by ACT programs for COD include those with a substance use disorder and

• Significant mental disorders
• Serious and persistent mental illness
• Serious functional impairments
• Who avoided or did not respond well to traditional outpatient mental health services and substance abuse treatment
• Co-occurring homelessness
• Co-occurring criminal justice involvement (National Alliance for the Mentally Ill [NAMI] 1999)

In addition to, and perhaps as a consequence of, the characteristics cited above, clients targeted for ACT often are high utilizers of expensive service delivery systems (emergency rooms and hospitals) as immediate resources for mental health and substance abuse services.

Empirical evidence for ACT

The ACT model has been researched widely as a program for providing services to people who are chronically mentally ill. The general consensus of research to date is that the ACT model for mental disorders is effective in reducing hospital recidivism and, less consistently, in improving other client outcomes (Drake et al. 1998a ; Wingerson and Ries 1999).

Randomized trials comparing clients with COD assigned to ACT programs with similar clients assigned to standard case management programs have demonstrated better outcomes for ACT. ACT resulted in reductions in hospital use, improvement on clinician ratings of alcohol and substance abuse, lower 3-year posttreatment relapse rates for substance use, and improvements on measures of quality of life (Drake et al. 1998a ; Morse et al. 1997; Wingerson and Ries 1999). It is important to note that ACT has not been effective in reducing substance use when the substance use services were brokered to other providers and not provided directly by the ACT team (Morse et al. 1997). Researchers also considered the cost-effectiveness of these interventions, concluding that ACT has better client outcomes at no greater cost and is, therefore, more cost-effective than brokered case management (Wolff et al. 1997).

Other studies of ACT were less consistent in demonstrating improvement of ACT over other interventions (e.g., Lehman et al. 1998). In addition, the 1998 study cited previously (Drake et al. 1998b ) did not show differential improvement on several measures important for establishing the effectiveness of ACT with COD—that is, retention in treatment, self-report measures of substance abuse, and stable housing (although both groups improved). Drake notes that “drift” occurred in the comparison group; that is, elements of ACT were incorporated gradually into the standard case management model, which made it difficult to determine the differential effectiveness of ACT. Further analyses indicated that clients in high-fidelity ACT programs showed greater reductions in alcohol and drug use and attained higher rates of remissions in substance use disorders than clients in low-fidelity programs (McHugo et al. 1999). Nevertheless, ACT is a recommended treatment model for clients with COD, especially those with serious mental disorders, based on the weight of evidence.

Advice to Administrators: Treatment Principles From ACT

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• Provide intensive outreach activities.

• Use active and continued engagement techniques with clients.

• Employ a multidisciplinary team with expertise in substance abuse treatment and mental health.

• Provide practical assistance in life management (e.g., housing), as well as direct treatment.

• Emphasize shared decisionmaking with the client.

• Provide close monitoring (e.g., medication management).

• Maintain the capacity to intensify services as needed (including 24-hour on-call, multiple visits per week).

• Foster team cohesion and communication; ensure that all members of the team are familiar with all clients on the caseload.

• Use treatment strategies that are related to the client's motivation and readiness for treatment, and provide motivational enhancements as needed.

Intensive case management

The earliest model of case management was primarily a brokerage model, in which linkages to services were forged based on the individual needs of each client, but the case manager did not provide formal clinical services. Over time, it became apparent that clinicians could provide more effective case management services; consequently, clinical case management largely supplanted the brokerage model. ICM emerged as a strategy in the late 1980s and early 1990s. It was designed as a thorough, long-term service to assist clients with SMI (particularly those with mental and functional disabilities and a history of not adhering to prescribed outpatient treatment) by establishing and maintaining linkages with community-based service providers.

ICM is not a precisely defined term, but rather is used in the literature to describe an alternative to both traditional case management and ACT. The goals of the ICM model are to engage individuals in a trusting relationship, assist in meeting their basic needs (e.g., housing), and help them access and use brokered services in the community. The fundamental element of ICM is a low caseload per case manager, which translates into more intensive and consistent services for each client. TIP 27, Comprehensive Case Management for Substance Abuse Treatment (CSAT 1998b ), contains more information on the history of case management, both how it has developed to meet the needs of clients in substance abuse treatment (including clients with COD) and specific guidelines about how to implement case management services.

Program model

ICM programs typically involve outreach and engagement activities, brokering of community-based services, direct provision of some support/counseling services, and a higher intensity of services than standard case management. The intensive case manager assists the client in selecting services, facilitates access to these services, and monitors the client's progress through services provided by others (inside or outside the program structure and/or by a team). Client roles in this model include serving as a partner in selecting treatment components.

In some instances, the ICM model uses multidisciplinary teams similar to ACT. The composition of the ICM team is determined by the resources available in the agency implementing the programs. The team often includes a cluster-set of case managers rather than the specialists prescribed as standard components of the treatment model. The ICM team may offer services provided by ACT teams, including practical assistance in life management (e.g., housing) and some direct counseling or other forms of treatment. Caseloads are kept smaller than those in other community-based treatment models (typically, the client-to-counselor ratio ranges from 15:1 to 25:1), but larger than those in the ACT model. Because the case management responsibilities are so wide ranging and require a broad knowledge of local treatment services and systems, a typically trained counselor may require some retraining and/or close, instructive supervision in order to serve effectively as a case manager.

Treatment activities and interventions

Examples of ICM activities and interventions include

• Engaging the client in an alliance to facilitate the process and connecting the client with community-based treatment programs
• Assessing needs, identifying barriers to treatment, and facilitating access to treatment
• Offering practical assistance in life management and facilitating linkages with support services in the community
• Making referrals to treatment programs and services provided by others in the community (see TIP 27 [CSAT 1998b ] for guidance on establishing linkages for service provision and interagency cooperation)
• Advocating for the client with treatment providers and service delivery systems
• Monitoring progress
• Providing counseling and support to help the client maintain stability in the community
• Crisis intervention
• Assisting in integrating treatment services by facilitating communication between service providers

Key modifications of ICM for co-occurring disorders

Key ICM modifications from basic case management for clients with COD include

• Using direct interventions for clients with COD, such as enhancing motivation for treatment and discussing the interactive effects of mental and substance use disorders
• Making referrals to providers of integrated substance abuse and mental health services or, if integrated services are not available or accessible, facilitating communication between separate brokered mental health and substance abuse service providers
• Coordinating with community-based services to support the client's involvement in mutual self-help groups and outpatient treatment activities

Empirical evidence

The empirical study of ICM for COD is not as extensive or as clarifying as the research on ACT; however, some studies do provide empirical support. ICM has been shown to be effective in engaging and retaining clients with COD in outpatient services and to reduce rates of hospitalization (Morse et al. 1992). Further, treatments combining substance abuse counseling with intensive case management services have been found to reduce substance use behaviors for this population in terms of days of drug use, remission from alcohol use, and reduced consequences of substance use (Bartels et al. 1995; Drake et al. 1993, 1997; Godley et al. 1994). The continued use and further development of ICM for COD is indicated based on its overall utility and modest empirical base.

Advice to Administrators: Treatment Principles From ICM

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• Select clients with greater mental and functional disabilities who are resistant to traditional outpatient treatment approaches.

• Employ low caseload per case manager to accommodate more intensive services.

• Assist in meeting basic needs (e.g., housing).

• Facilitate access to and utilization of brokered community-based services.

• Provide long-term support, such as counseling services.

• Monitor the client's progress through services provided by others.

• Use multidisciplinary teams.

Comparison of ACT and ICM

Recommendations for extending ACT and ICM in substance abuse treatment settings

It is not self-evident that ACT and ICM models translate easily to substance abuse settings. The consensus panel offers the following six key recommendations for successful use of ACT and ICM in substance abuse settings with clients who have COD:

1. Use ACT and ICM for clients who require considerable supervision and support. ACT is a treatment alternative for those clients with COD who have a history of sporadic adherence with continuing care or outpatient services and who require extended monitoring and supervision (e.g., medication monitoring or dispensing) and intensive onsite treatment supports to sustain their tenure in the community (e.g., criminal justice clients). For this subset of the COD population, ACT provides accessible treatment supports without requiring return to a residential setting. The typical ICM program is capable of providing less intense levels of monitoring and supports, but can still provide these services in the client's home on a more limited basis.
2. Develop ACT and/or ICM programs selectively to address the needs of clients with SMI who have difficulty adhering to treatment regimens most effectively. ACT, which is a more complex and expensive treatment model to implement compared with ICM, has been used for clients with SMI who have difficulty adhering to a treatment regimen. Typically, these are among the highest users of expensive (e.g., emergency room, hospital) services. ICM programs can be used with treatment-resistant clients who are clinically and functionally capable of progressing with much less intensive onsite counseling and less extensive monitoring.
3. Extend and modify ACT and ICM for other clients with COD in substance abuse treatment. With their strong tradition in the mental health field, particularly for clients with SMI, ACT and ICM are attractive, accessible, and flexible treatment approaches that can be adapted for individuals with COD. Components of these programs can be integrated into substance abuse treatment programs.
4. Add substance abuse treatment components to existing ACT and ICM programs. Incorporating methods from the substance abuse treatment field, such as substance abuse education, peer mutual self-help, and greater personal responsibility, can continue to strengthen the ACT approach as applied to clients with COD. The degree of integration of substance abuse and mental health components within ACT and ICM is dependent upon the ability of the individual case manager/counselor or the team to provide both services directly or with coordination.
5. Extend the empirical base of ACT and ICM to further establish their effectiveness for clients with COD in substance abuse treatment settings. The empirical base for ACT derives largely from its application among people with SMI and needs to be extended to establish firm support for the use of ACT across the entire COD population. In particular, adding an evaluation component to new ACT programs in substance abuse settings can provide documentation currently lacking in the field concerning the effectiveness and cost benefit of ACT in treating the person who abuses substances with co-occurring mental disorders in substance abuse treatment settings. The limitations of ICM have been listed above. The use of ACT or ICM should turn on the assessed needs of the client.

Prevalence

As noted, mental disorders have been observed in an increasing proportion of clients in many substance abuse treatment settings (De Leon 1989; Rounsaville et al. 1982a ). Compared to the rates found in clients in the outpatient programs of DATOS, slightly higher rates of antisocial personality disorder, and roughly similar rates of major depressive episode and generalized anxiety disorder, were found among adult clients admitted to the long-term residential programs that were part of DATOS (Flynn et al. 1996; see also Figure 1-2 in chapter 1 of this TIP). Of course, those admitted to long-term residential care tended to have more severe substance abuse problems. Additionally, in the year prior to admission to treatment, clients in long-term residential care reported the highest rate of past suicidal thoughts or attempts (23.6 percent) as compared to outpatient drug-free (19.3 percent) and outpatient methadone treatment (16.6 percent). Only the suicide thoughts and attempts rate for clients admitted to short-term inpatient treatment was higher (31.0 percent) (Hubbard et al. 1997, Table 2). This evidence points to the need for a programmatic response to the problems posed by those with COD who enter residential treatment settings.

Empirical evidence of effectiveness

Evidence from a number of large-scale, longitudinal, national, multisite treatment studies has established the effectiveness of residential substance abuse treatment (Fletcher et al. 1997; Hubbard et al. 1989). In general, these studies have shown that residential substance abuse treatment results in significant improvement in drug use, crime, and employment.

The most recent of these national efforts is NIDA's DATOS (Fletcher et al. 1997). The DATOS study involved a total of 10,010 adult clients, including many minorities, admitted between 1991 and 1993 to short-term inpatient substance abuse treatment programs, residential TCs, outpatient drug-free programs, or outpatient methadone maintenance programs across 11 cities (Chicago, Houston, Miami, Minneapolis, Newark, New Orleans, New York, Phoenix, Pittsburgh, Portland, and San Jose). Of the 4,229 clients eligible for follow-up and interviewed at intake, 2,966 were re-interviewed successfully after treatment (Hubbard et al. 1997).

Encouragingly, even with this high prevalence of clients with COD, DATOS study participants displayed positive outcomes for substance use and other maladaptive behaviors in the first year after treatment. Because studies of populations that abuse substances have shown that those who remain in treatment for at least 3 months have more favorable outcomes, a critical retention threshold of at least 90 days has been established for residential programs (Condelli and Hubbard 1994; Simpson et al. 1997b , 1999). Persons admitted to residential programs likely have the most severe problems, and those remaining beyond the 90-day threshold have the most favorable outcomes (Simpson et al. 1999).

Legal pressure and internal motivation among clients in residential programs have been associated with retention beyond the 90-day threshold (Knight et al. 2000). This relationship between legal pressure and retention supports practices that encourage court referrals to residential treatment for drug-involved persons (Hiller et al. 1998). Broome and colleagues (1999) found that hostility was related to a lower likelihood of staying in residential treatment beyond the 90-day threshold, but depression was associated with a greater likelihood of retention beyond the threshold.

Intake

Chapter 4 provides a full discussion of screening and assessment. This section will address intake procedures relevant to persons with COD in residential substance abuse treatment settings. The four interrelated steps of the relevant intake process include:

1. Written referral. Referral information from other programs or services can include the client's psychiatric diagnosis, history, current level of mental functioning, medical status (including results of screening for tuberculosis, HIV, STDs, and hepatitis), and assessment of functional level. Referrals also may include a psychosocial history and a physical examination.
2. Intake interview. An intake interview is conducted at the program site by a counselor or clinical team. At this time, the referral material is reviewed for accuracy and completeness, and each client is interviewed to determine if the referral is appropriate in terms of the history of mental and substance abuse problems. The client's residential and treatment history is reviewed to assess the adequacy of past treatment attempts. Finally, each client's motivation and readiness for change are assessed, and the client's willingness to accept the current placement as part of the recovery process is evaluated. Screening instruments, such as those described in chapter 4, can be used in conjunction with this intake interview.
3. Program review. Each client should receive a complete description of the program and a tour of the facility to ensure that both are acceptable. This review includes a description of the daily operation of the program in terms of groups, activities, and responsibilities; a tour of the physical site (including sleeping arrangements and communal areas); and an introduction to some of the clients who are already enrolled in the program.
4. Team meeting. At the end of the intake interview and program review, the team meets with the client to arrive at a decision concerning whether the referred client should be admitted to the program. The client's receptivity to the program is considered and additional information (e.g., involvement with the justice system, suicide attempts) is obtained as needed. It should be noted that the decisionmaking process is inclusive; that is, a program accepts referrals as long as they meet the eligibility criteria, are not currently a danger to self or others, do not refuse medication, express a readiness and motivation for treatment, and accept the placement and the program as part of their recovery process.

Assessment

Once accepted into the program, the client goes through an assessment process that should include five areas:

1. Substance abuse evaluation. The substance abuse evaluation consists of assessing age at first use, primary drugs used, patterns of drug and alcohol use, and treatment episodes. This information can be augmented by some basic standard data collection method such as the Addiction Severity Index (ASI).
2. Mental health evaluation. Upon placement in a residential facility, it is desirable to have a psychiatrist, psychologist, or other qualified mental health professional evaluate each client's mental status, cognitive functioning, diagnosis, medication requirements, and the need for individual mental health services. If individual treatment is indicated, it is integrated with residential treatment via contact among the client, the case manager, and the therapist.
3. Health and medical evaluation. Referral information contains the results of recent medical examinations required for placement. All outstanding medical, dental, and other health issues, including infectious diseases, especially HIV and hepatitis, should be addressed early in the program through affiliation agreements with licensed medical facilities. Each client should receive a complete medical evaluation within 30 days of entry into the program.
4. Entitlements. The counselor should assess the status of each client's entitlements (e.g., Supplemental Security Income [SSI], Medicaid, etc.) and assist clients in completing all necessary paperwork to ensure maximum benefits. However, care must be taken not to jeopardize a client's eligibility for SSI by inadvertently mischaracterizing the client's disability as substance abuse primary.
5. Client status. Staff members assess clients' status as they enter treatment, including personal strengths, goals, family, and social supports. A key assessment weighs the client's readiness and motivation for change.

Engagement

The critical issue for clients with COD is engaging them in treatment so that they can make use of the available services. A successful engagement program helps clients to view the treatment facility as an important resource. To accomplish this, the program must meet essential needs and ensure psychiatric stabilization. Residential treatment programs can accomplish this by offering a wide range of services that include both targeted services for mental disorders and substance abuse and a variety of other “wraparound” services including medical, social, and work-related activities. The extensiveness of residential services has been well documented (Etheridge et al. 1997; McLellan et al. 1993; Simpson et al. 1997a ).

The interventions to promote engagement described in Figure 6-1 incorporate Therapeutic Community-oriented methods described in other studies (Items 1, 3, 5–7) (De Leon 1995), as well as strategies employed and found clinically useful in non-TC programs (Items 2 and 4). This approach holds promise for expanding treatment protocols for TC and many non-TC programs to permit wider treatment applicability.

Continuing care

Returning to life in the community after residential placement is a major undertaking for clients with COD, with relapse an ever-present danger. The long-term nature of mental disorders and substance abuse requires continuity of care for a considerable duration of time—at least 24 months (see, e.g., Drake et al. 1996b , 1998b ). The goals of continuing care programming are sustaining abstinence, continuing recovery, mastering community living, developing vocational skills, obtaining gainful employment, deepening psychological understanding, increasing assumption of responsibility, resolving family difficulties, and consolidating changes in values and identity. The key services are life skills education, relapse prevention, 12-Step or double trouble groups, case management (especially for housing) and vocational training and employment. A recent study (Sacks et al. 2003a ) provided preliminary evidence that a continuing care strategy using TC-oriented supported housing stabilizes gains in drug use and crime prevention, and is associated with incremental improvement in psychological functioning and employment.

Discharge planning

Discharge planning follows many of the same procedures discussed in the section on outpatient treatment. However, there are several other important points for residential programs:

• Discharge planning begins upon entry into the program.
• The latter phases of residential placement should be devoted to developing with the client a specific discharge plan and beginning to follow some of its features.
• Discharge planning often involves continuing in treatment as part of continuity of care.
• Obtaining housing, where needed, is an integral part of discharge planning.

Staffing

Developing a new treatment model places unique demands on staff. Staff for clients with COD should contain a substantial proportion of both mental health and substance abuse treatment providers, include both recovering and nonrecovering staff, and be culturally competent with regard to the population in treatment. A typical 25-bed residential program should consist of about 15 staff, as follows:

• Program director (preferably with an advanced degree in the human service field or with at least 5 years' experience in substance abuse treatment, including at least 3 years of supervisory experience), a secretary, a program supervisor (preferably with a bachelor's degree), and 10 line staff (with high school diplomas or associate's degrees)
• A clinical coordinator, a nurse practitioner (half-time), an entitlements counselor (half-time), and a vocational rehabilitation counselor (half-time)
• Consultive and/or collaborative arrangements for medical, psychiatric, and psychological input or care

The optimal staffing ratio for morning, afternoon, and night shifts is 3:1, 3:1, and 8:1, respectively. The critical position is the clinical coordinator who will direct program implementation.

Training

Modified therapeutic communities for clients with COD

The MTC approach adapts the principles and methods of the TC to the circumstances of the COD client. The illustrative work in this area has been done with people with COD, both men and women, providing treatment based on community-as-method—that is, the community is the healing agent. This section focuses on the MTC as the potent residential model developed within the substance abuse treatment field; most of this section applies to both TC and other residential substance abuse treatment programs. A complete description of the MTC for clients with COD, including treatment manuals and guides to implementation, can be found in other writings (e.g., De Leon 1993a ; Sacks et al. 1997a , b , 1999).

Recommendations

A considerable research base exists for the MTC approach, and the consensus panel recommends the MTC as an effective model for treating persons with COD, including those with SMI. Recently, the MTC has been rated as one of a few promising practices for COD by the National Registry of Effective Programs and Practices (NREPP), as part of NREPP's ongoing evaluation of COD strategies and models. However, although improved psychological functioning has been reported, differential improvement in mental health functioning using the MTC approach in comparison to more standard treatment has yet to be demonstrated. The TC and MTC approach, although demonstrably effective with various populations of people who use drugs, including those with COD, encounters difficulty in achieving more widespread acceptance. To accomplish greater receptivity to TC and application of its methods, several developments are necessary:

• The principles, methods, and empirical data on MTC approaches need better articulation and broader dissemination to the mental health and other treatment fields. The development of MTCs in mainstream mental health programs is one useful approach (Galanter et al. 1993).
• The application of MTC methods for COD in non-TC medical and mental health settings needs to be established more firmly. It is especially important to ascertain whether, and to what extent, these methods can be separated from their TC framework and made “portable” as services to be used by other systems and approaches.
• As MTC programs continue to adapt for specific populations (e.g., adolescents, prison inmates, people with COD, women and children), their longer term effectiveness after treatment needs to be evaluated.
• Quality assurance of MTC programs is essential. The theory-based work of De Leon and his colleagues for standard TCs provides the necessary tools for this effort. Specifically, the development of an instrument for measuring the essential elements of TC programs (Melnick and De Leon 1999) and the development of standards for TC prison programs (with Therapeutic Communities of America 1999) enable the service and research communities to assess to what extent TC programs contain the essential elements and meet applicable standards. Further work is needed in adapting these instruments for MTC programs.