Description of intervention

The overall goal of this study is to provide insight into the development of case management models for substance abuse treatment and to improve quality of life for rural substance abuse clients. The purpose of this project is to conduct a full study of case management treatment services and to evaluate the effectiveness of three case management models: brokerage (IBCM), comprehensive (ICCM), and standard treatment (SCM). The conceptual model used is the health services framework of Aday et al. (1993). In this framework, the population at risk is evaluated for predisposing, enabling, and need variables.

Setting

Clients were recruited for the study from the residential program at the Mid-Eastern Council on Chemical Abuse (MECCA), which was also the site for our earlier study on case management. As a facility receiving State funds, MECCA participates in the State-funded managed care program. MECCA has a catchment area comprising four counties and is governed by community representatives from the four-county area. MECCA's main office is in Iowa City, IA, with satellite offices in Coralville, Marengo, and Washington, IA. Total population for MECCA's catchment area is 148,000 (1990 census), comprising 90 percent white, 2 percent African American, and 3 percent other races. Roughly 75 percent of MECCA's clients are insured by a source that falls under the IDPH managed care plan.

MECCA has a 20-bed residential unit with additional beds in a halfway house, a detoxification unit, and outpatient and educational programs for adults and adolescents. Adult clients are referred to MECCA from a variety of sources, including hospitals (7 percent), other health and social service agencies (7 percent), the legal system (30 percent), family and friends (6 percent), committals (10 percent), and self-referrals (40 percent). Approximately 2,400 people are evaluated in person by MECCA intake counselors annually to determine a treatment recommendation. The intake screening uses Iowa's Level of Care (LOC Determination Form), which determines treatment placement according to American Society of Addiction Medicine (ASAM) Criteria.

Client characteristics

The target population for this study of rural clients in substance abuse treatment is residential clients of one Midwestern not-for-profit substance abuse treatment center, MECCA. Approximately 380 clients per year meet criteria required for an admission to MECCA's adult residential program. Clients in the residential program may receive up to 50 hours of treatment services weekly, including group and individual therapy, life skills training, and other education classes. The average age of MECCA residential clients is 33.9. Forty-two percent are female, 84 percent are white, 12 percent are African American, 4 percent are other races. Fifty-eight percent are unemployed. Sixty-one percent have no health insurance, 19 percent have Medicaid, Medicare, or other public coverage. Eight percent are homeless. Forty-nine percent of residential clients have been diagnosed with a psychiatric condition prior to the admission. Ninety percent have used alcohol steadily for at least 1 year in their lifetime, 70 percent have used marijuana, 47 percent have used cocaine, and 48 percent have used amphetamines. Residential clients have been arrested an average 7.8 times in their lifetime. Data collected at MECCA during our previous study indicates that 49 percent of female and 13 percent of male residential clients have been sexually abused in their lifetime; 72 percent of female and 42 percent of male residential clients reported being physically abused in their lifetime. Regarding HIV-associated behaviors, 29 percent of MECCA clients have used substances intravenously and 29 percent have had sex with someone they knew was using substances intravenously.

Resources needed for implementation

In this study, we are evaluating two models of case management, comprehensive and brokerage, compared with standard treatment. Case managers who use the comprehensive model provide mental health counseling as part of that service. For those clients receiving services with the brokerage case manager, they are referred for mental health services (if needed) based on their ability to pay; those with insurance have more options in our area than those on public funding.

We have a manual for both models, but training would be needed to carry out either model with competency. In our area, cultural competency also includes working with those from rural areas as well as smaller towns. We have found that our case managers can help clients overcome barriers to services through education, direct referral, and transportation.

Empirical data

The primary analysis of outcome data focuses on drug use by condition. Preliminary analysis shows overall drug use decreased from intake through both follow-up evaluation points for each drug class. The main drugs of use were alcohol, cocaine, marijuana, and methamphetamine. For these four drug classes, clients receiving comprehensive case management reported a significant decrease from intake to the 3-month followup and then reported a smaller decrease by the 6-month session. Clients in the standard treatment condition also reported a significant decrease in use of these four drugs from intake to the 3-month session, although no decreases were noted by the 6-month session. Clients receiving brokerage case management reported a significant decrease in use from intake to the 3-month session, but at the 6-month point, they reported moderate increases.

Publications

1. Hall, J.A., Carswell, C., Walsh, E., Huber, D.L., and Jampoler, J. Iowa case management: Innovative social casework. Social Work, in press. [PubMed: 12019800]
2. Hall, J.A., Vaughan, M., and Rick, G. Iowa case management for rural substance abuse: Preliminary results. Journal of Case Management. Under review. [PubMed: 10879210]
3. Hall J A , Vaughan M S , Vaughn T , Block R I , Schut A . Iowa case management for rural drug abuse: Preliminary results. Care Management Journals. 1999;1(4):232–243. [PubMed: 10879210]
4. Huber D L , Hall J A , Vaughn T . The dose of case management interventions. Lippincott's Case Management. 2001;6(3):119–126. [PubMed: 16397997]
5. Ingram, J., Vaughan, M.S., and Hall, J. The effectiveness of case management for substance abuse clients with mood or anxiety disorders. To be submitted to Psychiatric Services.
6. Kehrli, A.J. Access and utilization of case management services with substance abusing clients. In development.
7. Vaughan, M.S., Hall, J.A., Richards, B., and Carswell, C. A comparison of computer-based versus pencil and paper assessment of drug use. Research on Social Work Practice, in press.
8. Vaughan M S , Hall J A , Rick G . Impact of case management on use of health services by rural clients in substance abuse treatment. Journal of Drug Issues. 2000;30(2):435–464.
9. Vaughan, M.S., Huber, D., and Hall, J.A. Impact of Iowa case management on family functioning for substance abuse treatment clients. Adolescent and Family Health, in press.
10. Vaughn, T., Vaughan, M.S., Saleh, S., and Hall, J.A. Participation and retention in drug abuse treatment services research. Submitted to Journal of Substance Abuse Treatment. [PubMed: 12495801]

Description of intervention

The Boley Homelessness Prevention Project provides quality housing, housing-related support services, and linkages to a wide array of psychosocial, clinical, and medical services. Services range from immediate needs (food, shelter, clothing) to permanent housing and vocational training for individuals who are homeless and have mental illnesses or co-occurring substance use disorders. The program provides housing or assists clients in finding housing of their choice, and then provides housing-related support services. The Boley Centers employ a psychiatric rehabilitation approach that incorporates the Fellowship House and Fountain House models and the case manager specialist model.

Setting

Located in West Central Florida, Boley Centers for Behavioral Healthcare, Inc., is a private nonprofit agency providing psychosocial rehabilitation services since 1970 for people with severe mental illnesses who may also have substance use disorders. Boley provides an array of residential and supportive services to over 600 persons at any given time and about 1,000 people in any given year.

Patient characteristics

The Boley Homelessness Prevention Project is an important program of Boley Centers. Of the 92 individuals served in 1996, all individuals had been homeless or at risk of homelessness when they entered the program. The “model” person served would be male, white, never married, in his forties, with a primary diagnosis of a psychotic disorder and a secondary diagnosis of a substance use disorder.

Resources needed for implementation

The most important aspect of staff training is training in a psychosocial rehabilitation model. This may come either from formal training outside the agency or through mentoring within the agency. Staff-resident interactions are considered vital to the effectiveness of the intervention and are based on mutual respect. The model emphasizes providing services as needed and or/requested rather than mandatory or prescribed services.

Funding for services in the project follows a fairly typical pattern of community mental health agencies, i.e., a combination of State ADM (alcohol, drugs, or mental disorders) and Medicaid funding with some county and other patient fees. Boley Centers is a model of innovation for funding the acquisition and rehabilitation of housing. Each housing site may have a different combination of HUD, City Revitalization, County, private gifts, and client fees. Although initially met with a “NIMBY” attitude, they have developed a reputation for revitalizing urban neighborhoods and are now sought-after partners in housing and planning.

Empirical data

The results of the meta-analysis of eight sites studied in the CMHS/CSAT Collaborative Program to Prevent Homelessness strongly supported programs, including Boley, that guarantee housing and provide housing support services. These significant effects are being written up have not been published to date.

In addition, our local analysis demonstrated that, for people with relatively high levels of psychiatric symptoms and substance use, the Boley intervention was more effective than specialized case management in helping to maintain stable housing. For people with relatively low or moderate levels of symptoms and substance use, specialized case management was equally effective. These findings are summarized in publications below.

Publications

Description of intervention

This program provides uninsured methadone clients with psychiatric evaluation, care, medication, and casework, all at no cost. It was developed on the premise that a client seeking treatment should find “no wrong door” that might impede progress in finding help of this nature. Given this, a client seeking help for emotional problems, lacking the means to access these services, is referred, evaluated, and treated onsite in the Co-Occurring Disorders Program. The program is a collaborative effort of CODAC Behavioral Health, a substance abuse and behavioral disorders treatment facility, and Gateway Healthcare, a large, multi-site, mental health center. It is staffed by a Psychiatrist (Gateway), Licensed Mental Health Professional (CODAC), and Caseworker (Gateway). Twice per week, onsite at the CODAC Providence methadone clinic, clients are seen and treated on referral from the methadone treatment staff. As a result, CODAC clients receive “methadone friendly” psychiatric care, in a timely fashion, onsite at their primary clinic. They are followed after-hours as if they were ordinary clients of the prescribing psychiatrist at Gateway Healthcare.

Setting

The Co-Occurring Disorders Program is located at CODAC Behavioral Health's Providence, RI, location. Gateway Healthcare, the collaborative psychiatric treatment component, is located in nearby Pawtucket, RI. CODAC Behavioral Health, historically a substance abuse treatment facility, is in its 30th year. CODAC serves approximately 2,200 clients, out of which 1,050 are agonist clients, utilizing both methadone and LAAM.

Client characteristics

All of the clients who participate in the Co-Occurring Disorders Program are opioid agonist clients of CODAC Behavioral Health. They are referred on a voluntary basis. None have health insurance or related benefits.

The gender breakdown is 60 percent female, 40 percent male. The average client age range is late thirties to early forties. The racial breakdown, from most to least, is Caucasian, Hispanic, and African American.

The most common diagnosis treated is that of Mood Disorder. This would include depressive disorders, dysthymic disorders, bipolar I and II, and cyclothymic disorders. Also common are Anxiety Disorders, to include panic, agoraphobia, obsessive-compulsive disorder, and posttraumatic stress disorder. Many clients also carry the diagnosis of Personality Disorder, coded on Axis II.

In terms of severity, all clients are outpatient and are required to make multiple trips to the clinic each week. Several clients have been hospitalized while under our care, and aggressive casework managed to provide continuity of treatment.

Resources needed for implementation

This project is entirely funded by a grant from the Department of Mental Health, Retardation, and Hospitals, Division of Substance Abuse, State of Rhode Island. We are in the first year of a 3-year project.

Medication is provided free of charge, through a State-administered program, the Community Mental Health Medication Assistance Program (CMAP).

Successful implementation required cooperation on a number of levels. CODAC and Gateway needed to effectively collaborate to design the program and win a competitive bid process. That accomplished, we desired regulatory cooperation to site the program at an existing methadone treatment facility, and practice psychiatric medicine. Further, we required regulatory approval to qualify our clients for CMAP, and free medication, if within a restricted formulary. Finally, the program was designed to be attractive to clients, and existing methadone staff. It needed to fit well with the present services and be accessible to referring staff and clients. Built into the program was a series of inservice trainings designed to educate the staff regarding the service, and its obvious benefits.

In summary, establishing a program of this nature requires collaboration between multiple systems. One must have the expertise to design and fund a project. Cooperation between three or more regulatory bodies is involved as you site a non-traditional service in an established, substance abuse treatment facility. Finally, the value of the service must be stressed to the ultimate consumers, and the intrasystem referral sources. Dependent on the demographics of your locale, it may be essential to have bilingual, culturally competent staff. The program's credibility will depend on it.

Empirical data

Program evaluation provides for a number of measures to assess the level of success. As these are clients on a methadone treatment program, some well-defined indicators emerge. First, toxicology screening tells us whether the client is drug-free. It is hoped an effective mental health intervention will reduce illicit drug use. Second, an empirical, 32-item scale, the BASIS-32, is administered at 3- and 6-month intervals. This scale rates a client's progress along five areas of difficulty: relation to self/others, depression/anxiety, living skills, impulsive/addictive, and psychosis. Third, the overall behavior and demeanor of the client is evaluated by the behavioral health specialist. We are still early on in the data collection process; however, the first set of results appears to be trending positive.

The data are unpublished at this point. Our plan is to collect 12 months' worth of evaluation data prior to publication.

Publications

There are no publications associated with this program.

Contact information

• Rebecca Wolfson Berley, M.S.W.
• Director of Trauma Education
• Community Connections
• 801 Pennsylvania Avenue, SE
• Suite 201
• Washington, DC 20003
• Phone: (202) 608-4735
• Fax: (202) 608-4286
• E-mail: [email protected]
• Web site: www.communityconnectionsdc.org

Description of Intervention

Community Connections, a provider of comprehensive human services in Washington, DC, is the lead agency for the DC Trauma Collaboration Study (DCTCS). This project was funded by SAMHSA to develop and evaluate the effectiveness of services for women trauma survivors with co-occurring substance use and mental disorders. Agency staff developed a comprehensive, integrated, trauma-focused network of services with four key intervention components: Trauma Recovery and Empowerment Model (TREM) groups, Integrated Trauma Services Teams (ITSTs), Collateral Groups (on issues such as substance abuse, parenting, domestic violence, and spirituality), and a peer support program.

Setting

The experimental sites are two community mental health and substance abuse treatment programs in Washington, DC: Community Connections and Lutheran Social Services. The control sites are two similar programs in Baltimore, MD: North Baltimore Center and People Encouraging People.

Client characteristics

Women enrolled in the study had histories of trauma (physical and/or sexual abuse) as well as a substance abuse diagnosis and a mental illness diagnosis (at least one current and one within the past 5 years).

Resources needed for implementation

Primary clinicians received cross-training in trauma, mental health, and substance abuse problems and related interventions. Consumer-survivors were involved in planning, implementing, and evaluating the project; they also developed a Women's Support and Empowerment Center to provide peer support services.

Empirical data

Preliminary findings from the DCTCS indicate that the TREM intervention is feasible (that clinicians can learn to implement it in a consistent way with fidelity to the treatment manual); that consumers complete it at high rates (over 75 percent of the women involved in the first eight groups completed more than 75 percent of the sessions); and that consumer satisfaction is very high. Other early outcome data suggest that this integrated package of services built around the central TREM group intervention is helpful to participants in both substance abuse and mental health domains. Pilot data collected in other program evaluation projects suggest potential benefits for TREM participants in a number of outcome domains: decreased mental health symptoms, increased recovery skills, and enhanced overall functioning; reduced utilization of inpatient hospitalization and emergency rooms; and decreased high-risk behavior.

Publications

1. Copeland, M.E., and Harris, M. Healing the Trauma of Abuse: A Women's Workbook. New Harbinger Press, 2000.
2. Fallot, R.D., and Harris, M. The Trauma Recovery and Empowerment Model (TREM): Conceptual and practical issues in a group intervention for women. Community Mental Health Journal, in press. [PubMed: 12474935]
3. Goodman L A , Dutton M A , Harris M . Physical and sexual assault prevalence among episodically homeless women with serious mental illness. American Journal of Orthopsychiatry. 1995;65(4):468–478. [PubMed: 8561181]
4. Goodman L A , Dutton M A , Harris M . The relationship between dimensions of violent victimization and symptom severity among episodically homeless, mentally ill women. Journal of Traumatic Stress. 1997;10(1):51–70. [PubMed: 9018677]
5. Goodman L , Fallot R D . HIV risk behavior and poor urban women with serious mental disorders: Association with childhood physical and sexual abuse. American Journal of Orthopsychiatry. 1998;68(1):73–83. [PubMed: 9494644]
6. Harris M . Modifications in service delivery and clinical treatment for women diagnosed with severe mental illness who are also the survivors of sexual abuse trauma. Journal of Mental Health Administration. 1994;21:397–406. [PubMed: 10138013]
7. Harris M . Treating sexual abuse trauma with dually diagnosed women. Community Mental Health Journal. 1996;32:4. [PubMed: 8840080]
8. Harris, M., ed. Sexual Abuse in the Lives of Women Diagnosed with Severe Mental Illness. Newark, NJ: Harwood Academic Publishers, 1997.
9. Harris, M., and the Community Connections Trauma Work Group. Trauma Recovery and Empowerment: A Guide for Clinicians Working with Women in Groups. New York: The Free Press, 1998.
10. Harris, M., and Fallot, R.D., eds. Using Trauma Theory to Design Service Systems. New Directions for Mental Health Services Series. San Francisco: Jossey-Bass, 2001.

Description of intervention

Consistent with findings from the literature, the Dual Assessment and Recovery Track (DART) uses the conceptual framework, structure, and principles of TC treatment found effective for clients with co-occurring substance abuse and mental disorders (e.g., fostering personal responsibility and self-help to cope with life difficulties, use of the peer community as the healing agent and as an essential support for attaining and sustaining recovery, and promoting a change in lifestyle) and (1) adds critical COD interventions (“Understanding the Inter-relationship of Mental Health and Substance Abuse Issues,” “Trauma-Informed Addictions Treatment”), (2) builds case management skills to help clients obtain appropriate services, and (3) improves comorbidity assessment and treatment planning to improve service delivery for individuals with COD in outpatient substance abuse treatment settings.

Staffing

DART is provided as a special treatment track within an Intensive Outpatient Program (IOP) that the clients attend 3 days a week for 5 hours per day; the IOP is part of a community-based substance abuse treatment program. One counselor, trained and experienced in providing treatment services for individuals with co-occurring disorders, provides the DART interventions that are incorporated within the standard IOP treatment program. The DART counselor reports to the IOP Program Supervisor. The DART counselor provides the two specialized weekly treatment groups (cited above) as well as individual case management services for 25 clients.

Setting

Gaudenzia, Inc. is a private, not-for-profit agency that was incorporated in Pennsylvania in 1968 to provide treatment, prevention, and other services to those with substance abuse treatment needs. Gaudenzia employs 350 people, operating 34 programs at 20 facilities, to provide residential services, traditional outpatient services (e.g., counseling, outreach), and intensive outpatient services. Target groups include adults, women with children, the homeless, people who are HIV/AIDS symptomatic, and those with co-occurring disorders.

The program is located in downtown Philadelphia on two floors of a recently renovated 8-story facility that houses the outpatient treatment program, administrative offices, and several specialized residential treatment programs.

Client characteristics

The DART program is designed to serve men and women who abuse substances and who have co-occurring mental disorders. The clients are primarily minority (75 percent African American; 12 percent Hispanic) adults, unmarried (71 percent) with an average age of 35. They are undereducated (on average, 11 years of education), unemployed (25 percent were employed in the last year), and 48 percent are on probation or parole. Cocaine is the major drug of choice (50 percent of the clients), followed by cannabis (32 percent). Eighty-three percent of clients report depression at some time; 24 percent have attempted suicide. Female clients report a high incidence of physical (76 percent) and sexual abuse (44 percent).

Resources needed for implementation

Training. The treatment program is best implemented by a substance abuse counselor trained and experienced in providing interventions for individuals with COD. Additionally, since DART is operated as a specialized treatment track within a standard outpatient treatment program, staff cross-training plays a key role in strengthening the dual diagnosis orientation of DART. Monthly training seminars were conducted to prepare staff for implementing DART. The cross-training curriculum included formal didactic training and technical assistance in program modification for co-occurring disorders.

Stakeholder Participation. The following principles were utilized to facilitate participation by key administrative and program staff: program planning and modification for COD are conducted within agency and system guidelines; all key stakeholders are involved in planning for implementation; and a collaborative relationship is fostered between administrative, service, and training staff.

Empirical data

The DART program is currently being evaluated for program effectiveness, costs, and cost-effectiveness. The examination of effectiveness compares DART with the standard substance abuse outpatient program.

Clients with COD are randomly assigned to either the DART program model, with enhanced interventions for individuals with COD, or to the standard outpatient substance abuse program. The study employs both GAIN M90 scales recommended by CSAT to assess client outcomes across several critical domains (Substance Use, Physical Health, Mental and Emotional Health, Environment and Living Situation, Legal, and Vocational), and two main standardized psychological scales—Brief Symptom Inventory, and Beck Depression Inventory-II (Beck et al. 1996)—to assess outcomes related to psychological, as well as other areas, of client functioning. Findings from the evaluation of this program will be applicable to both TC and non-TC agencies, thereby increasing the impact of the model.

Description of intervention

This eight-session TARGET model integrates cognitive-behavioral, motivational enhancement, relational/emotional focuses, and relapse prevention principles and procedures for trauma recovery and substance abuse recovery. It provides an alternative to exposure-based treatment for posttraumatic stress disorder that is based on recent research and clinical evidence.

Setting

Study participants are recruited from three outpatient substance abuse clinics in Connecticut: the Morris Foundation in Waterbury, the Rushford Center in Middletown, and LMG Inc. in Stamford. These private, non-profit agencies have extensive experience working with persons with co-occurring mental disorders. The Morris Foundation, in addition to outpatient services, operates a therapeutic shelter, a residential substance abuse program, and a women and children's residential program. Clients receive intense outpatient services with group therapy and psychoeducational groups, typically for 4 weeks.

The Rushford Center provides a continuum of progressive, multi-modal inpatient and outpatient treatment programs for adult men and women. Services include detoxification, residential programs, day and evening partial hospitalization, and a halfway house.

LMG offers outpatient and residential services for men, women, youth, and seniors. Services include detoxification, methadone maintenance, family treatment, and career development.

Patient characteristics

Study participants are adults (age 18 and over) with co-occurring substance use and trauma-related disorders. In order to enter the study, a participant must

Have a history of exposure to an event(s) fulfilling the conditions for DSM-IV posttraumatic stress disorder (PTSD) Criterion A psychological trauma.

Meet criteria for a substance use disorder.

Meet DSM-IV criteria for one of the following: (1) PTSD within the past year; or (2) Disorders of Extreme Stress, Not Otherwise Specified (DESNOS) plus at least one or more DSM-IV Axis I or II disorders including: major depressive disorder, dysthymic disorder, dissociative disorder.

Resources needed for implementation

In addition to the cost of the group clinician and center costs, we needed the following:

• Consultation with trauma expert (first year of implementation)
• Training in model and cultural competence
• Art supplies for creative arts exercises
• Gift incentives for group participation
• Snacks for groups
• Drug test supplies

Only the time of clinicians and related charges are reimbursed by most insurance plans; however, we cannot charge because of Medicare rules regarding research.

Empirical data

This study is still in the field; no findings are available at this time.

Publications

The TARGET manual is now available from the above address.

Description of the intervention

The program, for mothers and their children, uses TC principles and methods to address the problem of substance abuse, to provide a foundation for a full personal recovery or change, and to furnish an environment within which homelessness prevention interventions occur. The specific homelessness prevention activities include 14 distinctive interventions that address family preservation, work, housing stabilization, and building a supportive community. The mothers progress through program stages and typically move from residential to permanent housing.

Staffing

The residential program is staffed 24 hours a day, 7 days a week, with a combination of supervisors, counselors, and house managers. Three staff members, including at least one supervisor, are present during peak programming hours (9 a.m. to 9 p.m.); two staff members are present overnight. The Director and Clinical Supervisor are available for consultation on an emergency pager system when they are not on-site. The Prevention Specialist provides special parenting skills training groups on weekdays and substance abuse prevention groups for children during the family education activities on Sunday, enriching the staffing at those times. The Transitional program is staffed with one counselor/case manager for approximately 20 individuals. A Prevention Specialist and Child Care Worker staff the Child Care program with the help of two or three mothers who are assigned to participate in the Child Care program each day as part of their parenting training.

Setting

Gaudenzia is a private, not-for-profit TC-oriented agency, incorporated in Pennsylvania in 1968 to provide treatment, prevention and other services to people with substance abuse and related problems. Two of Gaudenzia's 34 programs, New Image in Philadelphia and Kindred House in West Chester, were developed in 1989 (in cooperation with the City of Philadelphia Health Department and the U.S. Public Health Service) as programs to prevent homelessness among those homeless, substance-abusing women who were pregnant and/or who were parenting at least one child. Each mother entering the program is allowed to bring up to two of her dependent children with her.

Both program sites share similar physical design elements, including: bedroom space occupied by two or three mothers and their young children; gender-specific dormitory bedrooms shared by up to four older children; communal dining and recreational space; infant and pre-school nursery/day care space; group meeting rooms and office space for administrative work, and individual counseling.

Client characteristics

The program is for homeless substance-abusing mothers (most with COD) and their children. The clients can be characterized as predominantly minorities (80 percent), average age 33, never married (66 percent), from broken homes (71 percent) and with less than a high school education (53 percent). The women reported three children on average, with only one child having primary residence with the mother at baseline. The women show a history of drug use (97 percent), arrest (76 percent), homelessness 62 percent), and moderate levels of psychological symptoms, as indicated by average Beck Depression Inventory (BDI) scores of 17.69 (SD=10.2) and average Symptom Check-List 90-Revised Global Severity Index (SCL 90-R) scores of 65.07 (SD=10.27).

Resources needed for implementation

Follow six principles for successful program implementation.

1. Work within the guidelines of agency and system.
2. Involve stakeholders in the project.
3. Use a strategic program planning approach and involve all key staff in program planning and refinement.
4. Employ active training and technical assistance during the refinement and implementation of new elements.
5. Review program fidelity periodically.
6. Develop ownership and a firm collaborative relationship among service, training, and evaluation staff.

Empirical data

This women's therapeutic community enhanced with programming focused on the prevention of homelessness was evaluated using a quasi-experimental design. Propensity analysis was used to select a subgroup in which the Experimental (E) and Comparison (C) participants were comparable. At the domain level, statistically significant relative improvement for the E group was found in psychological dysfunction and health. In the former domain, significant improvement was found on two standard psychological inventories measuring symptoms, for example, depression. In the latter domain, significant improvements included ratings of the women's health and adherence to medication regimens. No significant difference was found at the domain levels of family preservation and housing stabilization, but the results were mixed over specific outcomes in each; e.g., mothers in the E group showed better outcomes on the number of children residing with the mother and the number of children for whom the mother assumes financial responsibility. These results show the feasibility of extending the range and applicability of the TC model to address the specific problems of homeless mothers with COD and their children.

Publications

1. Sacks J Y , Sacks S , Harle M , De Leon G . Homelessness prevention therapeutic community (TC) for addicted mothers. In: Conrad, K.J., Matters, M.D., Hanrahan, P., and Luchins, D.J. (eds). Homelessness prevention in treatment of substance abuse and mental illness: Logic models and implementation of eight American projects. Alcoholism Treatment Quarterly. 1999;17(1/2):33–51.
2. Sacks, S., Sacks, J.Y., Bernhardt, A.I., Harle, M., and De Leon, G. Homelessness Prevention TC for Addicted Mothers: A Program Manual. Center for Mental Health Services (CMHS)/Center for Substance Abuse Treatment (CSAT), Rockville, MD, GFA SM 96-01, CFDA #93.230—Grant #1 UD9 SM51969-01. New York, NY: NDRI/CTCR, 1997.
3. Sacks, S., Sacks, J.Y., McKendrick, K., Pearson, F.S., and Banks, S. TC for Homeless, Addicted Mothers and Their Children: Change in Psychological and Health Status, Family Re-integration and Housing. Journal of Behavioral Health Services & Research (in review).

Description of intervention

The overall goal of the study is to document the effectiveness of a program to increase the identification of depression among people who abuse substances and to improve the treatment services offered to people with these complex co-occurring conditions. This goal is being addressed by conducting in-person psychiatric assessments on 500 consecutive adult admissions to the Chestnut Health Systems substance abuse treatment programs in Madison County, MO, using the Diagnostic Interview Schedule IV (DIS).

Setting

The program is located in rural Madison County, MO. Illinois Chestnut Health System is a community mental health agency.

Client characteristics

The populations are diverse—probation/parole, Department of Family Services, Department of Corrections, and public and private programs. This is primarily a population with substance use disorders, and 27 percent are currently diagnosed with depression.

Resources needed for implementation

Chestnut Health System is self-supportive through grants and State funding. Most barriers have been overcome by the staff from Washington University working closely with the Chestnut staff to solve problems on a weekly basis.

Empirical data

Outcome measures have not been evaluated as there is a 6-month and 12-month followup. Currently only baseline data are available, which do not lead to outcome measures.

Publications

1. Compton, W. Improving treatment services for substance abusers with comorbid depression. Journal of Substance Abuse Treatment, 2001. [PubMed: 15370949]

Description of intervention

Multi-disciplinary mental health and substance abuse treatment team with case management to coordinate HIV/AIDS primary care and other services. Study participants randomly assigned to integrated services or care-as-usual, which consists of limited availability of mental health and substance abuse services, and case management. To date, 159 individuals are enrolled in the study. Results are not yet available.

Setting

Community-based integrated mental health, substance abuse, and case management services provider.

Client characteristics

Multiply diagnosed individuals recruited from metropolitan area, Ryan White-funded case management providers.

Resources needed for implementation

Keys to successful implementation include (1) steering committee of target populations, Ryan White program staff, and other service providers; (2) assertive community treatment team that coordinates care of triple-diagnosed clients.

Description of intervention

The ON TIME project, a partnership of researchers and public and private agencies, is designed to address the need for timely intervention with women affected by substance abuse and child welfare. The goals of the project are: (1) to assess the ability of alcohol and other drug (AOD) and social service systems to respond to the new timelines of the Adoption and Safe Families Act (ASFA) among women who need AOD treatment; (2) to test the effectiveness of outreach, intervention, engagement, and re-engagement strategies with women who abuse substances under ASFA; and (3) to measure four primary outcomes: decrease substance use, increase treatment compliance, increase family stability, and increase participation in employment activities. This intervention is provided by outreach Recovery Mentors who are extensively trained in Motivational Enhancement Therapy and have personal experience in recovery and social service systems.

Setting

The ON TIME project is a county-wide program serving women in Orange County, California. The project is a collaboration among organizations in the county that serve in the best interests of children and their families. Orangewood Children's Foundation is the grantee, providing administrative support to the project through its role as a community leader on children's issues. Children and Family Futures is a non-profit organization that offers strategic planning and evaluation to local and State entities that provide services to children whose parents have substance abuse issues. Southern California Alcohol and Drug Programs run several substance abuse treatment agencies in surrounding areas and employ the Recovery Mentors. Finally, UCLA Drug Abuse Research Center provides the analysis of data involving follow-up interviews. These agencies work in collaboration with Children and Family Services, the county child welfare organization. The Recovery Mentors are outstationed at the dependency court. They provide Motivational Enhancement Therapy and serve as liaisons to treatment providers in the community.

Client characteristics

Women over the age of 18 are eligible for the project if they have substance abuse allegations in the dependency court petition. These women have a multitude of issues co-occurring with substance use such as mental health issues, domestic violence involvement, criminal backgrounds, and welfare and employment issues.

Resources needed for implementation

The key to implementation for ON TIME was the need for a communication protocol among partner agencies. Due to confidentiality ⁶ concerns, as well as the research protocol involving human subjects, clients sign a consent form for participation and to allow communication between social services, attorney groups, and the ON TIME project staff. The Recovery Mentors were extensively trained in Motivational Enhancement Therapy techniques, the Addiction Severity Index, ASAM Patient Placement Criteria, and other tools for intervention. Resources required for implementation include the curriculum and training materials for these tools as well as purchase of the tools themselves. It was essential in the recruitment of Recovery Mentors that they reflect the cultural diversity of the community. One of the mentors is bilingual in Spanish, reflecting the 50 percent Hispanic/Latino population in the county, and all four mentors are women in recovery from addiction.

Empirical data

Preliminary findings include: significantly fewer ON TIME mothers had positive urine toxicology tests between the Detention Hearing and the 21-day hearing than the comparison group of mothers who did not receive these services; a higher percentage of ON TIME women entered treatment prior to their 6-month review than the comparison group. Among current ON TIME clients, they significantly increased their readiness to make lifestyle changes in the first 3 weeks of participation; 86 percent and 82 percent of the clients had follow-up interviews at 3 and 9 months; mothers reported a significant decrease in illicit substance use and alcohol consumption at the 3- and 9-month interviews; and the ASI scores significantly decreased between baseline and 9-month interviews in all areas except employment.

Description of intervention

Project SPIRIT is an evaluation study designed to document and demonstrate the effectiveness of integrated treatment approaches for treating persons with co-occurring substance abuse and mental health problems. Study participants are naturalistically or quasi-randomly assigned to one of six treatment agencies depending on the recruitment source. Study participants are currently being recruited from central locations (i.e., family health clinic, detoxification agency) that subsequently refer these individuals to treatment and directly from the participating treatment agencies themselves. Each participating agency has been categorized as an integrated treatment program, a COD track program, or a nonspecialized program based on preliminary process information collected from each site.

Setting

The agencies involved in the study are all located in the Portland (Oregon) metropolitan area. They range from a small SA/MH treatment service-only agency to a large, multi-program social service agency dedicated to meeting the array of needs of the city's most indigent, disadvantaged individuals.

Patient characteristics

All potential study clients are screened using the Millon Clinical Multiaxial Inventory III (MCMI). Client eligibility is defined as having a clinically diagnosed alcohol or drug dependence or addiction treatment determined by a certified clinician and a suspected Axis I or Axis II mental health program detected by MCMI. The agencies range from 50 percent to 77 percent of their COD clients evidencing Axis I severe clinical syndromes.

Resources needed for implementation

MH services are covered in a managed care system that differs from the managed care system that governs substance abuse services. This poses serious obstacles to providers trying to treat individuals with co-occurring SA and MH disorders.

Empirical data

Baseline data collection is complete. Documentation of the three treatment approaches is ongoing and includes provider surveys, provider interviews, client focus groups, and document reviews. The baseline sample size is N=280, split among the three models under study: Integration (n=109), serial/parallel (n=98), and no MH services (n=73). As of September 1, 2002, the 6-month follow-up response rate is approximately 86 percent.

Publications

A progress report on Project SPIRIT activities will include the evolution of the client recruitment strategy to include multiple sources, modifications to the original study design and analysis plan, a detailed description of the screening process, current description of the study population, experiences working with health clinic physicians, and preliminary results from the provider survey. Current project reports include a Study Methods Report, detailing the design and instrumentation of the study; and a Baseline Report, characterizing the sample in terms of their demographics, treatment history, alcohol and drug use, MH symptomatology, and criminal justice history.

Contact information

• Kate Whettan-Goldstein, Ph.D., M.P.H., Principal Investigator
• Center for Health Policy, Law & Management
• Duke University
• 125 Old Chemistry Building, Box 90253
• Durham, NC 27708
• Phone: (919) 684-8012
• E-mail: [email protected]

• Rachel Stevens, M.P.H., Project Director
• Phone: (919) 684-3368
• Fax: (919) 681-9034
• E-mail: [email protected]

Description of intervention

Twelve months of intensive outpatient mental health and substance abuse counseling in conjunction with rural case manager contracts and transportation services to promote treatment adherence. Subgroups of study participants compared across time; care-as-usual for those who do not engage in intervention services consists of the limited amount of counseling available at the HIV/AIDS clinics.

Setting

Two integrated outpatient mental health and substance abuse service providers linked to nearby HIV/AIDS primary care clinics. One is based in Durham, NC (The Duke Addictions Program), the other in Fayetteville, NC (county mental health agency).

Client characteristics

Multiply diagnosed individuals from rural counties who receive care from one of the HIV/AIDS clinics.

Resources needed for implementation

This model program receives funding from NIDA, SAMHSA, HRSA, NIMH, and NIAAA. All of our staff have experience in a variety of settings in points of diverse backgrounds. Our main barriers are transportation costs which are continually being addressed by various AIDS-related service agencies. The addition of a recruitment and retention specialist who follows up on contacts has greatly increased the retention rate.

Description of intervention

This nine-session model integrates neurobiological, developmental, cognitive-behavioral, motivational enhancement, relational/emotion focuses, and relapse prevention principles and procedures for trauma recovery and substance abuse recovery. It provides an alternative to exposure-based treatment for PTSD that is based on recent research and clinical evidence. Participants learn a structured set of skills for managing traumatic stress symptoms in their current life, described by the acronym “FREEDOM” (Focusing to reduce anxiety and increase mental alertness; Recognizing specific stress triggers; identifying primary Emotions; Evaluating primary thoughts/self-statements; Defining an organizing personal goal; identifying one Option that represents a successful step toward that goal that the individual actually accomplished during a current stressful experience; recognizing how that option had the added benefit of Making a contribution), by reflecting the person's core values and making a difference in others' lives. The model assists participants in understanding the effects of trauma on the body, emotions, mind, relationships, and spirituality, and in using the FREEDOM skills to manage current stressors in ways that enable the person to shift away from “survival” coping to productive living. Participants are encouraged to focus on dealing with the impact that trauma experiences have had on their current lives rather than recounting detailed trauma memories, and the FREEDOM skills are used as a way to enable participants to examine trauma memories in a contained manner—and only if the participant feels that this would be helpful in dealing with current stressors. Most participants choose to examine trauma memories using the FREEDOM skills with an individual counselor rather than in the group, or in order to share a specific limited aspect of a key trauma memory in the group.

The TARGET model has the following theoretical/clinical base: Recovery from trauma is possible when a person is able to shift from living in “survival” mode to focusing on personal growth and effectiveness in intimate, family, friendship, and work relationships. Recovery is not based on “getting through” or becoming “desensitized” to trauma memories, but on having access to a support system and a way of making fully informed life decisions that fundamentally shift a person's bodily processes and mindset from surviving trauma to personal growth and development. Recovery is unique for each gender and each individual, but always involves three basic changes that occur gradually: isolation, betrayal, and abandonment, gradually changing to trust, mutuality, and engagement within safe, reliable, and emotionally sustaining relationships. Terror, hypervigilance, dissociation, and powerlessness gradually change to a realistic sense of personal effectiveness with a clear focus on immediate emotions, thoughts, and goals in each experience. Emotional numbing, spiritual alienation, and hopelessness gradually shift to involvement, self-esteem, faith, and hope as the person becomes able to recognize how she or he actually is living according to her or his true values and making a unique contribution to the safety and well-being of other people.

Setting

Study participants are recruited from three outpatient substance abuse clinics: the Morris Foundation in Waterbury, and The Connection and Rushford Center in Middletown. These private, non-profit agencies have extensive experience working with persons with co-occurring mental disorders. The Morris Foundation, in addition to outpatient services, operates a therapeutic shelter, a residential substance abuse program, and a women and children's residential program. Clients receive intense outpatient services with group therapy and psychoeducational groups, typically for 4 weeks.

The Rushford Center provides a continuum of progressive, multi-modal inpatient and outpatient treatment programs for adult men and women. Services include detoxification, residential programs, day and evening partial hospitalization, and a halfway house.

The Connection is a statewide agency operating over 30 separate programs. It offers assistance with a wide variety of behavioral and social problems, including homelessness, sex offenses, problem gambling, HIV-related needs, child abuse/neglect, and substance abuse.

Client characteristics

Study participants are adults (age 18 and over) with co-occurring substance use and trauma-related disorders. In order to enter the study, a participant must:

• Have a history of exposure to an event(s) fulfilling the conditions for DSM-IV PTSD Criterion A psychological trauma.
• Meet criteria for a substance use disorder.
• Meet DSM-IV criteria for one of the following: (1) PTSD within the past year, or (2) Disorders of Extreme Stress, Not Otherwise Specified plus at least one or more DSM-IV Axis I or II disorders including major depressive disorder, dysthymic disorder, and dissociative disorder.

Resources needed for implementation

In addition to the cost of the group clinician and center costs, the following were needed:

• Consultation with trauma expert (weekly during first year of implementation)
• Training in model and cultural competence
• Art supplies for creative arts exercises
• Incentives for group participation
• Snacks for groups
• Drug test supplies

Only the time of clinicians and related charges are reimbursed by most insurance plans; however, Medicare rules regarding research prevents the program from charging clients.

Empirical data

TARGET-RMI is in the second phase of a qualitative evaluation at Capitol Region Mental Health Center, with groups ongoing for hearing-impaired women, hearing women, hearing-impaired men, and hearing men. Between March and June 2002, three additional community mental health centers and one additional addiction agency received training and began 1 year of clinical pilot work in preparation for a multi-site controlled trial in the mental health sector to complement and extend the 3-year randomized controlled trial (separate men's and women's groups). The three addiction agencies now underway are under the auspices of the Co-Occurring Disorders study. Both versions of TARGET are being pilot tested by clinicians in Holland who were trained (April 2000) by Dr. Ford; a controlled clinical trial is scheduled to begin later this year.

Publications

The TARGET manual will be available soon; it is currently being modified. It is being translated into Spanish and has been translated into Dutch.