An Integrated Model for the Treatment of People with Co-occurring Psychiatric and Substance Disorders
Mental illness and addiction frequently occur together but have traditionally been treated separately – often in isolation and unsuccessfully. Dr. Kenneth Minkoff, a dynamic speaker and nationally known expert in dual diagnosis, outlines how care can be integrated despite differences in treatment philosophy. Well-versed in both the mental health and substance abuse systems, Dr. Minkoff illustrates how each system can learn from the other. He discusses an integrated model for helping conceptualize a hopeful path to dual recovery.
This article describes research-based principles of successful treatment interventions in individuals with co-occurring disorders. These principles are placed in the context of integrated model of service delivery that utilizes a common language or treatment philosophy that makes sense from the perspective of both mental health treatment and substance disorder treatment fields.
The article begins with an overview of the clinical and programmatic dilemmas faced by clinicians in treating these “dually diagnosed” individuals and then enumerates 7 principles of treatment. These are: (i) dual diagnosis is an expectation, not an exception, within any of the 4 subtypes of comorbidity (using a sub typing model based on high/low severity of each disorder); (ii) the most significant predictor of treatment success is the provision of an empathic, hopeful, continuous treatment relationship in which integrated treatment and care coordination are provided over time; (iii) within the context of this relationship, care taking and case management are balanced with empathic detachment, empowerment and confrontation at each point in time; (iv) within this ongoing treatment context, both mental illness and substance disorders are considered primary, and integrated dual primary treatment is provided; (v) both mental illness and addiction are examples of not just random primary disorders, but chronic biological mental illnesses which can be understood using a disease and recovery model; (vi) the specific treatment interventions; as a result, there is no single correct intervention in this model.
For each individual, the correct treatment must be matched to subtype, diagnosis, phase of treatment and extent of patient motivation and disability; and (vii) within a managed-care system, these interventions must be further individualized by a discrete level of care assessment for each disorder.
These principles provide a template both for developing practice guidelines to determine individualized clinical treatment matching, as well as providing a template for large-scale system initiatives for the creation of comprehensive continuous integrated systems of care, and for assigning roles for each type of program within those systems. These large systems initiatives are currently underway in several US states, and provide a laboratory for further research on this model.
During the past two decades, the problem of providing successful treatment to individuals with co-occurring psychiatric and substance disorders (ICOPSD) has emerged with considerable energy in both the mental health system and the substance disorder treatment system. Increasing volumes of data have supported the impression of clinical experience in both systems that ICOPSD have poorer outcomes across multiple domains, as well as being difficult to serve in traditional treatment venues.
Specifically, ICOPSD are more likely to relapse and be rehospitalized, to be treatment resistant and noncompliant, medically involved (e.g. HIV infected), criminally involved, and homeless, as well as impulsive, suicidal and violent.1-6 In addition studies in managed-care systems have identified ICOPSD as being over represented in populations of high utilizers of scarce systems resources, in both public and private sector systems. 7, 8
Successful treatment and disease management of either substance disorders or psychiatric disorders separately is highly challenging. Both disorders are chronic, relapsing, stigmatizing and potentially disabling. In addition, both disorders involve alteration of the individual’s mental status, so that disease management strategies are targeted at someone who is cognitively impaired, possibly with poor reality testing, and who may not adequately recognize the seriousness of his or her condition.
When the two illnesses co-occur, the problems of disease management are compounded dramatically. This occurs not only because of the potential for the two types of disorders to interact and create mutual symptomatic exacerbation, but also because of the fact that ICOPSD are essentially “system misfits” who dare to have more than one disorder in systems of care that are designed to deal with a distinct primary mental health or substance disorder only. 9 Furthermore, managed-care initiatives in behavioral health systems during the past decade have added a layer of funding complexity to the already difficult clinical, programmatic, and philosophical issues that result from intersystem conflict.
Fortunately, accumulating research – as well as clinical experience – over the past two decades, addressing comorbidity in both populations with serious mental illness and complex addicted populations (with less serious but still problematic co-occurring mental disorders), has begun to identify a variety of principles that guide successful intervention.
These research and clinical findings have been sufficiently elaborated to permit the development of expert consensus on an integrated model and standards of care for co-occurring disorder management in managed-care systems. This model, in turn, provides a template on which to base further clinical and systems research. The principles and standards, as well as the model, were disseminated in an expert consensus panel report generated by the Substance Abuse and Mental Health Services Administration, as part of its “managed care initiative.”
This article reviews those principles and illustrates their application, both to the model and to strategies for system change.
First Principle
Comorbidity is an expectation, not an exception.
The first principle derives from epidemiological research on comorbidity conducted both in the 1980s 11 and the 1990s.12 Both surveys illustrated that in a majority of individuals with serious mental illness, particularly those with unstable conditions, comorbid substance use disorders were present. Conversely, in individuals with substance disorders, 39% to 56% (according to one survey)11 had any psychiatric diagnosis.
The implication of this first principle is that the most cost-effective systems intervention is to create a process for integrated system planning to redesign the system so that all existing resources are used in accordance with this principle. This requires that all programs are planned and designed to be competent in dealing with the people with comorbidity that they are already treating, and that all system clinicians are expected, over time, to attain minimum required levels of dual competency.
It is also important to note that this principle applies regardless of the subtype of dual disorder under consideration. The most common sub typing models are 4-quadrant models 13, 14 involving high and low severity of psychiatric and substance disorders. In one model, 13 the 4 subtypes are defined as follows:
(i) severe and persistent mental disorder (SPMI) plus substance dependence; (ii) SPMI plus substance abuse; (iii) substance dependence plus non-SPM1psychiatric symptomatology; and (iv) substance abuse plus non-SPMI symptomatology. In each instance, the prevalence of comorbidity is significant.
Second Principle
Successful treatment requires most importantly the creation of welcoming, empathic, hopeful, continuous treatment relationships, in which integrated treatment and coordination of care are sustained through multiple treatment episodes.
This second principle is based on the findings of clinical research with hard-to-engage populations.7,15 It emphasizes that the first task of system and program design is to foster opportunities for integrated continuity of clinical care, rather than to emphasize any particular “program” model.
Disease management for chronic disabling conditions is a continuing process, in which the risk of decompensation due to inadequate treatment adherence persists over time. This is especially true for comorbid conditions in which the capacity for treatment adherence is impaired by the symptoms of either disease, and in which system discontinuity promotes the possibility of individuals receiving inconsistent messages regarding their treatment needs. Integrated continuous care coordination shifts the burden of making sense of disparate input from the client to the clinician, and creates the possibility of continuous learning through repeated collaborative trial and error.
Third Principle
Within the context of the continuous integrated treatment relationship, case management and caretaking must be balanced with empathic detachment and confrontation in accordance with the individual’s level of functioning, disability and capacity for treatment adherence.
This third principle addresses the apparent philosophical incompatibility between the nature of treatment relationships in mental health treatment and addiction treatment. In the former, the emphasis is on case management, care and continuous responsibility for the client. In the latter, the emphasis is on empathic detachment, confrontation and consequences, and the client’s responsibility to bear consequences of his or her own decisions.
However, research on the value of case management in successful interventions with complex addiction populations as well as with seriously mentally ill substance abusers.6 plus the growing emphasis of the mental health consumer movement on the need for consumer empowerment, has led to recognition that these relationship styles are not incompatible at all. Instead, they are absolutely complementary.
The value of this clinical principle (although not yet fully research tested) is that philosophical battles about the “right” relational style can be reframed as clinical strategic discussions about the most appropriate place to draw the line between what to do for the client and what responsibility the client must bear on his or her own. 16 The clinical challenge is that there is no “rule book” to tell clinicians where to draw the line; the balance must be derived in the context of an individual relationship, often through a process of trial and error over time.
Individuals with more serious disabilities require considerably more structure; the particular challenge is to provide that structure in the context of behavioral contingencies, which promote learning and responsibility. Recent research has introduced methods of utilizing payeeships and other behavioral rewards to create this structure. 17
Fourth Principle
When mental illness and substance disorder coexist, both disorders should be considered primary, and integrated dual primary treatment is required.
This fourth principle addresses the dilemma of determining which disorder should be considered primary. Each system’s regulations and clinical philosophy support the concept that its disease should be primary, and considerable conflict may emerge between systems in trying to determine which is the client’s “real” disease. Clients, in turn, often are caught in the middle of this split, experiencing what has been termed “ping-pong therapy” as they are bounced back and forth between mental health and addiction settings18. Treatment is often “sequential” (each disorder treated separately in isolation). The essence of integrated treatment, however, derives from principle four.
Thus, in the context of the continuing integrated treatment relationship, integrated coordination of primary treatment interventions for both disorders is provided. In fact, even though mental illness and substance disorders are interactive, the significance of the interactions is small compared with the importance of ensuring adequate attention to each primary disorder and making sure treatment is adequate, given possible interference from the other disorder.
Specifically, this means that it is important to maintain medication for serious mental illness (and in fact to use the best possible medication) even in the presence of continuing substance use.10 Similarly, it is also important to remember that individuals with psychiatric impairment require more addiction treatment to acquire recovery skills than comparably addicted individuals without impairment. This “additional” treatment often must be more simplified, not more complex, and provided in smaller increments with more support over a longer period of time in order to achieve comparable outcomes.19
Fifth Principle
Both psychiatric illnesses and substance dependence are examples of chronic, biological mental illnesses, which can be understood using a disease and recovery model. Each disorder is characterized by parallel phases of recovery: acute stabilization, engagement and motivational enhancement, active treatment and prolonged stabilization, rehabilitation and recovery. 16
This fifth principle expands on its predecessor to create a common language and integrated treatment philosophy that makes sense from the perspective of both the mental health system and the addiction system. In this model, both disorders are characterized by positive symptoms, which can be stabilized through ongoing participation in a treatment regime (e.g., medication, Alcoholics Anonymous); and deficit symptoms, which must be addressed through ongoing rehabilitation. Both disorders involve denial, despair, shame, guilt and stigma, which inhibit treatment participation, yet both offer the hope of recovery despite incurability, potential persistent disability and risk of relapse.
Recovery applies not to the disorder, but to the person who has the disorder, and involves recovering a sense of pride, self-worth, dignity and meaning in the face of an ongoing, stigmatizing and possibly disabling disease. 20
Sixth Principle
There is no single correct dual diagnosis intervention. Appropriate practice guidelines require that interventions must be individualized according to the subtype of dual disorder, specific diagnosis of each disorder, phase of recovery/stage of change, and level of functional capacity or disability. 10
Advances in clinical research in both systems during the last decade have recognized not only the presence of stages of change21 or phases of treatment22 consistent with this model, but have demonstrated that successful interventions tend to be phase or state-specific. Particular focus has been on the developing technology of motivational enhancement therapy23 in which individuals are engaged at their own level of readiness to change, and assisted, through a combination of both collaboration and empathic confrontation, to make better choices over time. Consequently, it has gradually become more apparent that interventions must be appropriately matched along a variety of dimensions.
Consequently, interventions which are apparently incompatible, such as “harm reduction” and “abstinence orientation,” can be seen as being valuable aspects of the same therapeutic armamentarium, provided that each is appropriately matched according to patient diagnosis and state of change. In addition, this same model can be applied to designing a comprehensive system of care, in which there is a full range of available programs to meet the needs of clients as they move through various phases of recovery with different levels of impairment and disability.24
Seventh Principle
Within a managed-care system, any of the individualized phase- specific interventions can be applied at any level of care. Consequently, a separate multidimensional level of care assessment is required.
The integrated model can be applied to disease management interventions in managed-care systems. In both addiction and mental health treatment systems, level of care assessment decisions for each type of disorder separately have been guided less by well documented research than by clinically derived assessment instruments that utilize multiple dimensions of assessment to attempt to predict service intensity requirements.
These assessment instruments have had, to date, only limited application to individuals with co-occurring disorders, but are beginning to be elaborated to better accommodate the needs of this population. Within the addiction system, for example, the most widely utilized level of care assessment instrument has been the American Society of Addiction Medicine (ASAM) Patient Placement Criteria (PPC)25, which have recently been revised (ASAM PPC 2R)26 to more appropriately incorporate individuals with co-occurring psychiatric impairment.
Within the mental health system, the American Association of Community Psychiatrists has recently disseminated a more psychiatric-based multidimensional assessment tool (LOCUS 2.0)27 which also includes a dimension evaluating substance-related, as well as medical comorbidity.
Conclusions
This article has presented an integrated model for treatment of individuals with co-occurring disorders, derived from research-based model treatment initiatives, that permits the use of a common language or treatment philosophy for all subtypes of dually diagnosed individuals throughout both the mental health system and the addiction treatment system.
This “integrated philosophy” emphasizes that both substance disorders and psychiatric disorders are “primary” when they co-exist, and that they both can be treated using a disease and recovery model, which defines parallel phases of treatment for each disorder, implying that clinical experience with the recovery process for one disorder can be informative regarding the recovery process for the other disorder.
In addition, this model provides a template for the development of individualized disease management strategies for individuals with co-occurring disorders that can be applied at multiple levels of care within a managed-care system. This template can be utilized to develop practice guidelines that assist clinicians in appropriately individualized clinical treatment matching (e.g. when to use harm reduction; when to use an abstinence orientation).
This template can also be used at the systems level to design a comprehensive, continuous integrated system of care, in which each component of the system plays a role in the provision of appropriately matched treatment. The model implies that the prevalence and variability of dual disorders result in a need for ‘dual diagnosis competency’ throughout the service system, and suggests that the most efficient approach is not only to develop specialized programs but also to initiate large scale systems change in which all programs in the system, at all levels, are expected to achieve this competency.
One of the major challenges that must be addressed in the application of this model is the development of well described and, hopefully, formally evaluated strategies for real world implementation of the model at the systems level. Currently, some of the most exciting innovations in dual diagnosis treatment are the applications of this model to systems change initiatives at the state or regional level in a number of U.S. states, including
Arizona, Louisiana, Pennsylvania, Florida, Michigan, Illinois, New York and Massachusetts.28
Although these initiatives are still in progress, early results seem to indicate that to overcome barriers to systems change, change efforts must address multiple levels of the system simultaneously. This can include:
* Systems level changes (e.g. large scale consensus building28, regulatory change to eliminate licensing and reimbursement barriers)
* Program level changes (e.g. creating structures for interprogram standards for both dual diagnosis-capable (DDC) and dual diagnosis enhanced (DDE) programs26, replicating established model programs11
* Clinical practice changes (e.g. establishing practice guidelines for assessment or psychopharmacology10, developing integrated screening tools)
* Clinician changes (e.g. adopting system-wide mandatory competencies29, developing advanced dual-diagnosis certification programs and creating systemic training initiatives emphasizing continued “on the job” training.30
As these strategies are more widely tested, program evaluation efforts at the systems level will hopefully be able to demonstrate which approaches to implementation are the most effective, as well as demonstrating the cost effectiveness of this model as a whole in promoting more successful disease management outcomes system-wide.
References
1. Abram KM, Teplin LA. Co-occurring disorders among mentally ill jail detainees: implications for public policy. AM Psychol 1991; 46: 1036-45
2. Drake RE, Osher PC, Wallach MA. Homelessness and dual diagnosis. Am Psychol 1991; 46: 1149-58
3. Bartels SJ, Drake RE, MCHugo GJ. Alcohol abuse, depression, and suicidal behavior in schizophrenia. AmJPsychiatry 1992; 149:394-5
4. cuffel BJ, Shumway M. Chouljian TL, et al. A longitudinal study of substance use and community violence in schizophrenia. J Nerv Ment Dis 1994; 182-704-8
5. Cournos F, Empfield M. Horwath E. et al. HIV seroprevalence among patients admitted to two psychiatric hospitals. Am J Psychiatry 1991: 148: 1225-30
6. RachBeisel J, Scott J. Dixon L. Co-occurring severe mental illness and substance use disorders: a review of recent research. Psychiatric Serv 1999; 50 (11): 1427-34
7. Quinlivan R. McWhirter DP. Designing a comprehensive care program for high-cost clients in a managed care environment. Psychiatric Serv 1996; 27 (8): 813-5
8. Hartman E. Nelson D. A case study of statewide capitation: the Massachusetts experience. In: Minkoff K. Pollack D. editors. Managed mental health care in the public sector: a survival manual. Amsterdam: Harwood Academic Publishers, 1997
9. Bachrach LL. The context of care for the chronic mental patient with substance abuse. Psychiatric Q 1986-7; 58: 3-14
10. Minkoff K. Center for Mental Health Services: Managed Care Initiative Panel on Co-Occurring Disorders. Co-occurring psychiatric and substance disorders in managed care systems: standards of care, practice guidelines, workforce competencies, and training curricula. Rockville (MD): Center for Mental Health Services, 1998 Jan
11. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. JAMA 1990: 264:2511-
12. Kessler RC, Nelson CB, McGonagle KA, et al. The epidemiology of co-occurring addictive and mental disorders: implication for prevention and service utilization. Am J Orthopsychiatry 1996; 66: 17-31
13. Ries RK, Miller NS. Dual diagnosis: concept, diagnosis, and treatment. In: Dunner DL, editor. Current psychiatric therapy. Philadelphia (PA): W.V. Saunders, 1993: 131-88
14. National Association of State Mental Health Program Directors, National Association of State Alcohol and Drug Abuse Directors. National dialogue on co-occurring mental health and substance abuse disorders: Washington DC, 1998 Jun 16-17
15. Drake RE, Bartels SB, Teague GB, et al. Treatment of substance use disorders in severely mentally ill patients. J Nerv Ment Dis 1993; 181:606-11
16. Minkoff K. An integrated treatment model for dual diagnosis of psychosis and addiction. Hosp Commun Psychiatry 1989; 40 (10): 1031-6
17. Ries RK, Contois K.A. Managing disability benefits as part of treatment for persons with severe mental illness and comorbid drug/alcohol disorders; a comparative study of payee and non-payee participants. Am J Addict 1997; 6 (4) :330-8
18. Ridgely MS, Goldman HH, Willenbring M. Barriers to the care of persons with dual diagnosis: organizational and financing issues. Schizophy Bull 1990; 16 (1): 123-32
19. Roberts LJ, Shaner A. Eckman TA. Overcoming addictions: skills training for people with schizophrenia. New York: W. W. Norton, 1999
20. Deign PE. Revovery: the lived experience of rehabilitation. Psychiatr Rehabil J 1988; 11 (4): 11-9
21. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors. Am Psychol 1992; 1102-14
22. Osher FC, Kofoed L. Treatment of patients with psychiatric and substance use disorders. Hosp Commun Psychiatry 1989; 40: 1025-30
23. Miller WR, Rollnick S Motivational interviewing; preparing people to change addictive behavior. New York: Guilford, 1991
24. Minkoff K. Program components of a comprehensive integrated care system for serious mentally ill patients with substance disorders. In: Minkoff K. Drake RE, editors. Dual diagnosis of serious mental illness and substance disorder. New Directions for Mental Health Services No. 50. San Francisco (CA): Jossey-Bass, 1991: 13-27
25. American Society of Addiction Medicine (ASAM), ASAM patient placement criteria. 2nd ed. (ASAMPPC2R). Washington, DC: American Society of Addiction Medicine, 1995
26. American Society of Addiction Medicine (ASAM). ASAM patient placement criteria 2nd rev. ed. (ASAMPPC2R) Washington, DC: American Society of Addiction Medicine. In press
27. American Association of Community Psychiatrists. Level of Care Utilization System (LOCUS) 2.0. Dallas (TX): American Association of Community Psychiatrists, 1998
28. Barreira P, Espey B, Fishbein R, et al. Linking substance abuse and serious mental illness service delivery systems: initiating a statewide collaborative. J Behav Health Serv Res 2000; 27 (1): 107-13
29. Arbour Health System Policy manual: basic required dual diagnosis. Competencies for adult clinicians. Boston (MA): Arbour Health System, 1998
30. Blaser B. MISA basic training curriculum completed. The Illinois MISA Newsletter, Springfield (IL): Illinois Department of Mental Health, 2000: 6