Understanding the Integrated
Dual Diagnosis Treatment Model
California Institute for Mental Health Webinar
April 7, 2012
Floyd M. Brown, M.D.
Medical Director, Bonita House, Inc.
TODAY’S SPEAKER
Floyd M. Brown, M.D.
2
Objectives
Understand the benefits of integrated
treatment for co-occurring mental health
and substance use disorders.
 Understand the elements of the Integrated
Dual Diagnosis Treatment model.
 Understand the relationship of evidence
based practice to the emerging recovery
movement.
 Understand how Mental Health Boards can
assist in the development and evaluation of
integrated treatment at the system and
program levels.

3
Disclosures
The speaker is Medical Director of Bonita
House, Inc., a community-based non-profit
organization headquartered in Oakland,
CA.
 No commercial affiliations.

4
Bonita House, Inc. Programs
Dual Diagnosis
Residential
Treatment
Program
Supported
Independent Living
Case Management
Creative Wellness
Center
Homeless
Outreach
Stabilization Team
Choices Housing
Program
5
Definitions




Dual Diagnosis: Co-occurring substance use
disorder (SUD) and mental illness (MI).
COD/COC: Co-occurring
disorders/conditions (mental illness +
substance use disorder)
IDDT: Integrated Dual Diagnosis Treatment
SPMI: Serious and persistent mental illness
(e.g.; schizophrenia, bipolar, schizoaffective,
major depression, etc.)
6
Definitions
Dual diagnosis capable (DDC): all
programs should have basic capability to
assess and provide treatment or referral
services to persons living with dual
disorders.
 Dual diagnosis enhanced (DDE): programs
with special capacity to serve individuals
with more severe mental health and
substance abuse issues (such as IDDT
trained teams).

7
Case Example

John S. is a 20 y/o male with a history of
crack cocaine use who presented at a
local mental health service seeking help
because of persistent and disturbing
voices.
◦ In a traditional mental health clinic John was
told he had a drug problem and the
psychiatrist told him he could not be given
medication until he was clean and sober for 3
months.
8
Case Example

John made an appointment at a local
substance abuse treatment center.
◦ When the intake counselor learned of his voices
John was told he was too psychiatrically ill for
treatment and told he needed mental health
treatment.
◦ If you were John what would you do?

Have any of you who are mental health
consumers or who are family members of
someone living with a mental illness had
similar experiences?
9
Why Integrated Treatment?

After multiple hospitalizations, including a
suicide attempt, John was referred to Bonita
House, Inc.
◦ He was assigned to a case manager, who assisted
John in finding housing and applying for benefits
even though he had not given up cocaine.
◦ He was seen by a psychiatrist who offered an
antipsychotic medication, which helped reduce his
voices, even though John was not ready to stop
using.
◦ Over time John’s drug use diminished and his
voices became more manageable.
10
Integrated Treatment


Consumer choice is an important aspect of
the IDDT model.
What happens if John was not open to
taking medications?
◦ Assess for safety (self/others).
◦ Assess John’s most pressing concerns and offer to
provide appropriate services based on his needs.
◦ Offer continuing service even if medications are
refused.
◦ Provide psychoeducation about treatment
options, including medication, if indicated.
11
Integrated Dual Diagnosis
Treatment

At Bonita House, Inc. we treat persons
living with severe mental illness and
substance abuse using the evidence-based
Integrated Dual Diagnosis Treatment
(IDDT) model developed at Dartmouth
University by Dr. Robert Drake and
others.
12
SAMHSA Evidence Based Practices
Integrated Dual Diagnosis Treatment
 Supported Employment
 Assertive Community Treatment
 Family Psychoeducation
 Illness Management and Recovery
 Toolkits available at www.samhsa.gov.

13
IDDT: Bringing Cultures Together
14
Traditional MH and AOD
Philosophical and Clinical
Differences
Addiction Treatment
Mental Health Treatment
Peer counselor model
Medical/professional model
Spiritual recovery
Scientific treatment
Self-help
Medication
Confrontation and expectation
Support and flexibility
Detachment/empowerment
Case management/care
Episodic treatment
Continuous treatment
Recovery ideology
Deinstitutionalization ideology
Psychopathology secondary to addiction
Addiction secondary to psychopathology
Relapse results in denial of service
Relapse results in increased service
15
New Directions for Mental Health
Treatment

The emerging treatment paradigm is
influenced by 3 trends:
◦ The Recovery Model, which is heavily influenced
by consumer input.
◦ Evidence-based medicine (based on the most
current available research outcomes).
◦ Integration of mental health, substance abuse and
primary care.

We believe that programs can be both
recovery oriented and rely on evidence
based technology.
16
Integrated Care: Expect Complexity
While Dual Diagnosis is used to refer to cooccurring MI and SUD, comprehensive
integrated care also includes addressing
other health issues as well.
 Statistics show that persons living with
chronic, serious mental illnesses are at high
risk for chronic medical conditions and a
reduced lifespan.
 BHI has developed partnerships with
Lifelong Medical Care to improve access to
primary care.

17
How Are IDDT Mental Health
Programs Different?
Anticipate the presence of dual disorders.
 Staff are trained to assess for the
presence of both disorders and a
multidisciplinary treatment team trained
to treat both conditions provides
services.
 Consumer choice is paramount.
 Shared decision making and individualized,
collaborative treatment planning includes
consumer, family, and provider input.

18
How Are IDDT Mental Health
Programs Different?
Stage based treatment.
 Spirituality and self-help groups are
utilized.
 Treatment is time unlimited.
 Psychopharmacologic (medication)
treatments are not dependent on total
abstinence.
 Strength based approach.

19
How Are IDDT Mental Health
Programs Different?
Respectful, non-judgmental, hopeful, and
welcoming.
 IDDT model programs, like all behavioral
health services, should be culturally
informed, sensitive, and should strive to
develop cultural competency.
 Goals are to reduce harm first and to
assist consumers to achieve recovery.

20
What Is Recovery?

Surgeon General David Satcher wrote:
"Recovery is variously called a process, an
outlook, a vision, a guiding principle. There
is neither a single agreed-upon definition
of recovery nor a single way to measure
it. But the overarching message is that
hope and restoration of a meaningful life
are possible, despite serious mental
illness.” (The President’s New Freedom Commission on
Mental Health, 2003)
21
“Believing You Can Recover is Vital to
Recovery” (Daniel Fisher, M.D., PhD., ED, National Empowerment
Center)

“Illnesses don’t recover,
people do” Mark Ragins, M.D.
(Medical Director, The Village, Long
Beach, CA)

“Recovery is
rediscovering meaning
and purpose …It is a
process, a way of life, an
attitude, and a way of
approaching the day’s
challenges…” (Pat Deegan,
Ph.D., recovery advocate)
22
How Do You Define Recovery?
23
Cultural Competency



Does the IDDT model apply to California’s
diverse population?
CIMH evaluation of 5 programs statewide
found no evidence that IDDT is less effective
for minority clients being served in mixed
ethnicity outpatient clinics.
However even with modifications,
monolingual clients in a site serving a
predominately Latino population had
comparatively poorer outcomes.
◦ (Chandler et al, CIMH, 2007)
24
Consumer Employment:
Opportunities and Challenges
Unlike mental health programs, addiction
treatment services have traditionally been
delivered by peer counselors but licensure or
certification is becoming an expectation.
 IDDT-based programs present an excellent
opportunity to integrate trained consumers
and/or family members as full team members.
 Issues to consider:

◦
◦
◦
◦
Role (peer/family specialist vs. generalist)
Training and prior experience requirements
Lived experience vs licensure (billing/reimbursement)
Documentation requirements (MediCal)
25
Co-Occurring Disorders are
Common

Lifetime prevalence of substance abuse in
persons with severe mental illness is estimated
between 40-60%. (Mueser, Nordsy, Drake, Fox, Integrated
Treatment of Dual Disorders: A Guide to Effective Practice, 2003)

Lifetime prevalence of substance abuse in the
general population is about 17% (ECA study)
(Regier et al, JAMA, 1990)I

(Clarification: in the following 2 slides the legend identifies
MDD=major depressive disorder and MD=major depression; refers
to same diagnostic condition)
26
Lifetime Prevalence (%) of Substance Use
Disorder
Regier,
et al,
JAMA,
1990
(ECA)
27
Lifetime Prevalence (%) of Any Alcohol
or Drug Use Disorder
Regier, et al,
JAMA, 1990
(ECA)
28
Adverse Outcomes Associated with
Co-Occurring SMI and SUD
Increased risk of psychiatric relapse and
hospitalization
Unemployment/poverty
Increased risk of incarceration
Family/interpersonal relationship
dysfunction
Increased risk of violence
Increased risk of domestic
violence/victimization
Increased risk of homelessness
Increased health risks, including early
death
Increased risk of exposure to HIV,
hepatitis
Increased risk of suicide
(Drake, Essock, Shaner et al, Psych. Services, 2001)
(RachBeisel, Scott, Dixon, Psych Services, 1999)
29
Treatment Models
Sequential
 Parallel
 Integrated
◦ Comprehensive integration of pharmacotherapy,
psychosocial treatments, and substance abuse
counseling results in improved patient outcomes.

(Drake, Meuser, Brunette et al, Psychosocial Rehabilitation Journal, 2004)
◦ Considered an evidence based practice
◦ SAMHSA toolkit: Integrated Dual Diagnosis
Treatment (IDDT) (www.samhsa.gov)
30
Disadvantages of Sequential and
Parallel Treatment Models
Sequential
Parallel
Untreated disorder worsens the
treated disorder
Treatments not integrated into a
cohesive package
Unclear which disorder should be
treated first; treatment may be denied
Providers fail to communicate
Unclear when one disorder has been
successfully treated so treatment for
the second can begin
Burden of integration falls on the
consumer
Consumer is not referred for further
treatment
Funding and eligibility barriers to
accessing both treatments
Incompatible treatment philosophies
No provider has final responsibility
and consumer “slips through the
cracks”
From: Mueser, Noordsy, Drake & Fox, Guilford
Press, 2003
Providers lack a common language and
treatment methodology
31
Advantages of Integrated Treatment
Organizational and administrative barriers
are eliminated.
 No coordination between providers
required.
 Both disorders considered primary and
are treated concurrently.
 Conflict over philosophical differences is
minimized and shared perspectives
evolve.

32
History of Dual Diagnosis
Treatment at Bonita House, Inc.
Serving SPMI population since 1971.
 Dedicated services to COD population
since 1991.
 IDDT training project (CIMH) 20042007)
 Alameda County-wide COCI (CoOccurring Conditions Initiative) 2008present

33
IDDT Basics




Priority population is SPMI but others may
benefit.
Evidence based model (research supported)
that results in improved clinical outcomes.
One multidisciplinary team provides mental
health and substance abuse services.
Coordination of treatment, incorporating
consumers, family/significant others,
providers.
34
Fidelity
Research suggests that programs with the
most similarity to evidence based
practices, such as the IDDT model, have
the best outcomes.
 IDDT contains elements of other
evidence based practices.
 Even if full fidelity isn’t achieved services
can be improved.

35
Fidelity Scale
Used in the SAMHSA funded study
conducted by CIMH as a pre and postassessment of programs in the project.
 Assesses fidelity across 13 domains using
a 5 point scale.

36
Fidelity Scale Domains www.cimh.org
Domain
Domain
Multidisciplinary Team
Group Dual Disorder Treatment
Stage-wise Intervention
Family Dual Disorder Treatment
Comprehensiveness of Dual Disorder
Services
Self-help Liaison
Long Term Services
Pharmacological Treatment
Outreach
Interventions to Reduce Negative
Consequences
Motivational Interventions
Secondary Interventions for
Treatment Non-responders
Substance Abuse Counseling
Integrated Assessment and Treatment
Planning* (added by CIMH)
37
IDDT: Practice Components
Components
Components
Multidisciplinary Team (includes
integrated substance abuse specialist)
Group Dual Disorder Treatment
Stage-Wise Interventions
Family Psychoeducation on Dual
Disorders
Access to Comprehensive Services
Pharmacological Treatment
Time Unlimited Services
Interventions to Promote Health
Outreach
Secondary Interventions for
Treatment of Non-Responders
Motivational Interventions
Substance Abuse Counseling
www. ohiosamiccoe.case.edu
38
Multidisciplinary Team
Includes professional and paraprofessional
clinicians with previous training or
background in mental health or substance
abuse treatment.
 Includes licensed professionals and
unlicensed clinicians, including persons
with lived experience.
 At Bonita House, Inc. clinical staff are
cross-trained in the IDDT model.

39
Multidisciplinary Team
In some mental health programs a
substance abuse specialist may be hired to
work collaboratively with the team.
 Vocational and housing specialists may be
integrated into the team (FSP).
 Primary care specialists may also be
included, especially in FSP programs.
 FSP=Full Service Partnerships

40
Stage-Wise Treatment
Based on the change theory first
described by Prochaska and DiClemente.
 Stages of Change

◦ Precontemplation: no problem, not ready to
change.
◦ Contemplation: maybe a problem; thinking of
change.
◦ Preparation: getting ready to change.
◦ Action: taking action to change.
◦ Maintenance: following a plan to avoid resuming the
behavior.
41
Stage-Wise Treatment
Treatment interventions are consistent
with the individuals readiness to change.
 Treatment occurs in stages as well.

◦ Engagement: (forming a relationship/alliance)
◦ Persuasion: (helping client to develop motivation to
participate in recovery-oriented interventions)
◦ Active Treatment: (helping client acquire skills and
supports for managing illness and pursuing goals)
◦ Maintenance: (helping client develop and use
strategies for maintaining recovery)
42
Access to Comprehensive Services
Residential services
 Supported employment
 Family psychoeducation
 Illness management and recovery

◦ Interventions to learn to manage illness, find
recovery goals, and make informed treatment
decisions.
43
Access to Comprehensive Services

Assertive community treatment (ACT) or
intensive case management
◦ Client to clinician ratio of 15:1 or less, 24
hour access, and at least 50% field based
contacts.
44
Time Unlimited Services

Long term treatment available, with
intensity modified according to need and
degree of recovery.
45
Outreach
Assertive outreach, especially in the
engagement phase but continuing as
needed.
 Provide practical assistance in the
consumer’s environment. Examples:

◦
◦
◦
◦
◦
Housing
Benefits
Crisis intervention
Medical
Legal
46
Motivational Interventions

Motivational interviewing (MI)
◦ Developed by Miller and Rollnick
◦ Collaborative, non-judgmental, patient
(consumer) centered approach grounded in
an attitude of respect.
◦ Focus on building rapport and identifying,
examining and resolving ambivalence about
behavior change.
47
Substance Abuse Counseling
Can be delivered by a substance abuse
counselor or by cross-trained MH staff.
 Includes:

◦
◦
◦
◦
Recognizing and managing triggers
Relapse prevention planning
Challenging beliefs
Skills training to deal with symptoms and
negative mood states
48
Group Dual Disorder Treatment

Group treatment specifically designed to
address both mental health and substance
abuse problems.
49
Family Psychoeducation

With permission from the consumer,
family and/or significant members of the
social support network are engaged to
provide education about dual disorders,
coping skills to reduce stress in the family,
and to promote collaboration with the
treatment team.
50
Participation in Alcohol or Drug
Self-Help Groups

Involvement in self-help groups such as
Alcoholics Anonymous, Narcotics
Anonymous, Rational Recovery, Dual
Recovery Anonymous (DRA) is
encouraged and facilitated, as appropriate
for a client’s stage of change.
51
Pharmacological Treatment

Psychiatrists or mid-level psychiatric
practitioners are trained in IDDT
principles.
◦
◦
◦
◦
◦
Prescribe medications despite active use.
Work closely with team & consumers.
Focus on increasing medication adherence.
Avoid/minimize use of addictive medications.
Use medications that may reduce addictive
behavior.
52
Interventions to Promote Health

Efforts to promote health and reduce
negative consequences of substance abuse
in areas such as:
◦ Physical conditions, including infectious
disease, chronic illness, etc.
◦ Social effects (e.g.; loss of family support,
victimization, etc.).
◦ Self-care and independent functioning.
◦ Use of substances in unsafe settings/situations.
53
Secondary Interventions for
Treatment Non-Responders

Higher levels of care or more intensive
services for individuals who do not
respond to outpatient IDDT.
54
Adapting IDDT
 Goals: Transformation
of….
◦ Service Systems
◦ Organizations
◦ Individual Clinical Practices
55
Transformational Levels
Systems
•
•
•
•
Policies and procedures
Fiscal support
Development and support resources
QA/QI
Organizations
• Leadership/organizational philosophy
• Resource allocation, training,
implementation, supervision
• Monitoring and evaluation
Clinical Practice
• Buy-in
• Training and supervision
• Skills acquisition and maintenance
56
Program Evaluation

According to California Welfare and
Institutions Code Section 5604.2 Mental
Health Boards are directed to:
◦ Review and evaluate the community’s mental
health needs, services, facilities and special
problems.
◦ Advise the governing body and the local
mental health director as to any aspect of the
local mental health program.
57
Program Evaluation: Systems

What efforts are being made in your local
communities to develop comprehensive
integrated services?
◦ Begin with assessment of systems; review data
collected by your local Mental Health
Department.
◦ Assist your local Mental Health Department
assess needs, set priorities, and plan for
program development.
58
Program Evaluation: Programs and
Organizations
Before initiating a review of a program or
organization it is helpful to establish a
relationship and create an atmosphere of
good will.
 Ensure that reviews are intended to assist
organizations develop improved quality of
care, rather than to penalize them for
failing to meet guidelines; report concerns
to the local Mental Health Department.

59
Evaluating Systems Change
Leadership and support from County
Mental Health Department senior and
middle management.
 Policies and procedures support program
adaption of COD treatment, including
IDDT.
 Fiscal policies reduce obstacles to the
development of COD treatment.
 Development of QA/QI systems to
support and evaluate COD programs.

60
Evaluating Organizational Change
IDDT Elements
IDDT Elements
PROGRAM/PHILOSOPY
TRAINING
ELIGIBILITY/CLIENT
IDENTIFICATION
SUPERVISION
PENETRATION (% of clients with
access compared to total who could
benefit)
PROCESS MONITORING
ASSESSMENT
OUTCOME MONITORING
TREATMENT PLANNING
(individualized)
QUALITY IMPROVEMENT
TREATMENT (individualized)
CLIENT CHOICE
61
Program Philosophy

Clearly articulated, shared philosophy
consistent with IDDT
◦
◦
◦
◦
◦
Executive Leadership/Program Leader
Senior management
Clinicians
Consumers/family members
Brochures and written materials
62
Eligibility/Client Identification

All clients screened for co-occurring
disorders using standardized tools or
admission criteria consistent with the
IDDT model.
63
Penetration

Number of clients in a program receiving
IDDT treatment divided by the number
of clients eligible.
64
Individualized Treatment Plan

Goals, objectives, services/interventions,
and intensity are unique to the individual
consumer.
65
Individualized Treatment
Progress notes reflect a focus on unique
and specific goals developed in
collaboration with the consumer.
 Interventions are appropriate for the
stage of treatment and stage of change.

66
Training
New clinical staff receive training in IDDT
practices and are assisted in identifying
and reducing knowledge gaps.
 Existing staff receive regular “refresher”
training.

67
Supervision

Clinicians receive weekly individual or
group clinical supervision from an
experienced practitioner trained in the
IDDT model.
68
Process Monitoring

Monitor the progress of IDDT
implementation and use data to improve
the program.
69
Outcome Monitoring

Client outcomes are regularly measured
and data are shared with clinical staff in an
effort to improve services.
70
Quality Assurance (QA)

A plan is developed to review fidelity to
the model, assess progress, make
recommendations to the organization for
service improvements, etc.
71
Client Choice
All clients are offered a range of choices
consistent with the IDDT model.
 All practitioners abide by client
preferences except when doing so would
result in risk or harm.

72
Evaluating Clinical Practice Change
Knowledge of substances of abuse and
how they affect mental illnesses.
 Ability to assess substance abuse and
mental illness
 Motivational counseling skills and stage
based treatment interventions.
 Integrated substance abuse counseling
skills.

73
The Bonita House, Inc. Experience

Successes:
◦ All staff trained in the use of stages of change
and stages of treatment concepts.
◦ All staff trained in motivational interviewing.
◦ Improved assessment process.
◦ Collaborative, client centered treatment
planning developed.
◦ New staff able to adapt agency culture and
philosophy due to strong and consistent
senior and middle management leadership.
74
The Bonita House, Inc. Experience

Challenges
◦ Training for new staff is time and resource
intensive.
◦ Comprehensive assessment instrument (FAI)
was difficult to use and time consuming.
◦ “Mission creep”; loss of skills; staff turnover.
◦ Monitoring, program evaluation and outcome
measures require resources not available to a
small agency.
75
The Bonita House, Inc. Experience

Challenges (con’t.)
◦ Difficulty recruiting and retaining consumers
for group interventions.
◦ Difficulty recruiting and retaining family
members for group psychoeducation;
engagement for individual family work more
successful.
◦ Less than optimal caseloads in the SIL
program.
76
The Bonita House, Inc. Experience

Lessons learned
 COD specialization resulted in agency
philosophy that closely aligned with IDDT
principles.
 Maintenance of newly learned skills requires
regular supervision and training updates.
 Staff turnover results in challenges in
orienting new hires to the agency mission
and philosophy in addition to “training up”
new staff in important skills such as
motivational illness in order to avoid
“mission creep.”
77
The Bonita House, Inc. Experience
 Unable to replicate the year long, 8 hour
monthly training sessions we received
from CIMH as part of the evaluation
project due to competing training
priorities.
 Fiscal realities may impede full adoption
of all IDDT elements but services at all
levels of care can be improved by
implementing as much of the IDDT
model as possible.
 Use of comprehensive assessment
instruments challenging for some staff.
78