EVALUATING THE STRENGTHS AND WEAKNESSES
OF A DUAL DIAGNOSIS PROGRAM
A Project
Presented to the faculty of the Division of Social Work
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
by
Aliya Martinez
Christina Andrade
SPRING
2013
EVALUATING THE STRENGTHS AND WEAKNESSES
OF A DUAL DIAGNOSIS PROGRAM
A Project
by
Aliya Martinez
Christina Andrade
Approved by:
__________________________________, Committee Chair
Francis Yuen, DSW
____________________________
Date
ii
Students: Aliya Martinez
Christina Andrade
I certify that these students have met the requirements for format contained in the
University format manual, and that this project is suitable for shelving in the Library and
credit is to be awarded for the project.
__________________________, Graduate Coordinator
Dale Russell, Ed.D, LCSW
Division of Social Work
iii
___________________
Date
Abstract
of
EVALUATING THE STRENGTHS AND WEAKNESSES
OF A DUAL DIAGNOSIS PROGRAM
by
Aliya Martinez
Christina Andrade
This qualitative study asks the question “What are the perceived strengths and
weaknesses of an outpatient dual diagnosis substance abuse program, and secondarily,
what are the implications for improvement?” Research participants included staff who
participated in one on one interviews and clients who participated in two focus groups.
The study obtained staff and client impressions and identified main themes leading to
program improvement. Emergent themes were client and practitioner access to resources,
peer support, community integration and isolation, clinical tools and training, and multidisciplinary team efforts. Recommendations for program improvement concentrated on
these key themes.
_______________________, Committee Chair
Francis Yuen, DSW
_______________________
Date
iv
ACKNOWLEDGEMENTS
We wish to thank the clients and staff members of the Dual Diagnosis Program
for their generosity in sharing their time, opinions and suggestions with us. Their input
demonstrated a strong sense of hope, creativity, and dedication. The clients and staff
member’s participation in this research project was greatly appreciated.
We would also like to thank Dr. Andrew Bein for his patience, wit, and
accessibility even while on sabbatical. His dedication to finding meaningful options for
people struggling with mental illness is admirable and important to all of us.
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TABLE OF CONTENTS
Page
Acknowledgements ........................................................................................................v
Chapter
1. DUAL DIAGNOSIS PROGRAM EVALUATION ................................................1
Background of the Problem ............................................................................. 1
Statement of the Research Problem................................................................. 5
Study Purpose .................................................................................................. 5
Theoretical Framework .................................................................................. 5
Definition of Terms ......................................................................................... 6
Assumptions .................................................................................................... 7
Social Work Research Justification ..................................................................8
Delimitations ................................................................................................... 8
Statement of Collaboration .............................................................................. 9
2. REVIEW OF THE LITERATURE ...................................................................... 10
Background and Context................................................................................. 11
Prevalence of Co-Occurring Illnesses ............................................................. 12
Models of Care ................................................................................................ 18
Evidence Based Practice ................................................................................. 19
Dual Diagnosis Capability .............................................................................. 22
Clinical Processes ........................................................................................... 24
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Assessment .......................................................................................................24
Addiction Only.................................................................................................25
Dual Capable ....................................................................................................25
Biopsychosocial ...............................................................................................25
Mental Status Exam .........................................................................................26
Treatment .........................................................................................................27
Twelve Step Facilitation Therapy ....................................................................27
Peer Support Groups ........................................................................................29
Harm Reduction ...............................................................................................30
Motivational Interviewing ...............................................................................31
Assertive Community Treatment .....................................................................32
Cognitive Behavioral Therapy .........................................................................33
Friend/Family Support & Dual Treatment .......................................................36
Crisis Management ..........................................................................................38
Summary ..........................................................................................................38
3. METHODS ............................................................................................................40
Study Design ................................................................................................... 40
Sampling Procedures .......................................................................................40
Data Collection Procedures..............................................................................41
Instruments .......................................................................................................42
Data Analysis ...................................................................................................44
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Protection of Human Subjects .........................................................................44
4. STUDY FINDINGS AND DISCUSSION ............................................................45
Background ..................................................................................................... 45
Overall Findings.............................................................................................. 46
Client Focus Groups ....................................................................................... 46
Staff Interviews ................................................................................................47
Specific Findings and Interpretations ..............................................................48
Client Focus Groups… ....................................................................................48
Peer Support .................................................................................................... 49
Isolation from the Community ........................................................................ 51
Group Environment ........................................................................................ 52
Curricula and Activities .................................................................................. 54
Resources and Case Management ....................................................................55
Staff Interviews ............................................................................................... 56
Mission Statement........................................................................................... 56
Defining Dual Diagnosis Treatment ............................................................... 57
Community Involvement ................................................................................ 58
Assessment Tools............................................................................................ 59
Treatment Planning ......................................................................................... 60
Role of Family ................................................................................................ 60
Recommendations and Areas for Growth ....................................................... 60
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Additional Findings ........................................................................................ 62
Staff
..............................................................................................................62
Community Supportive Services .................................................................... 62
Flexibility Versus Consistency ........................................................................64
Diversity Versus Predictability ........................................................................66
Community Integration ....................................................................................70
Holistic/Multidisciplinary Team ......................................................................73
5. DISCUSSION ........................................................................................................ 75
Summary of Study .......................................................................................... 75
Recommendations ........................................................................................... 76
Limitations ...................................................................................................... 81
Conclusion ...................................................................................................... 81
Appendix A. Human Subjects Approval Letter ..........................................................83
Appendix B. Focus Group Questions .........................................................................84
Appendix C. Interview Questions for Staff ................................................................85
Appendix D. Confidentiality Agreement (Focus Group) ...........................................86
Appendix E. Confidentiality Agreement (Staff) .........................................................88
References ....................................................................................................................90
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1
Chapter 1
DUAL DIAGNOSIS PROGRAM EVALUATION
A program evaluation provides an opportunity to examine current functioning and
capacity for meaningful services. It is most useful when clients and staff are included in
the evaluative process. For this study, CommuniCare Health Centers (CCHC) is
interested in an evaluation of its existing dual diagnosis program to explore needs and
areas for improvement, through current literature, client input and staff interviews. The
outcome of this evaluation can assist the agency in defining a clearer mission for dual
diagnosis services for adults in Yolo County.
Background of the Problem
According to a report by the Board on Health Care Services in 2006, more than 20
percent of U.S. adults aged 18–54 received care for substance use and a mental illness
during a 12-month period between 2001 and 2003. Additionally, mental and substanceuse illnesses are the leading cause of combined death and disability for women of all ages
and for men aged 15–44. In the last two decades, 51.4% of the population with substance
use illnesses were also identified with having co-occurring illnesses. Others indicate 4980% of clients in treatment have concurrent anxiety or depression (Daley & Moss, 2001).
The outcome of those studies alone, are indicative of a substantial health care
problem imposing a sizable cost to the nation in treatment and disability. Additionally,
costs associated with parents with co-occurring illnesses expand into struggles for their
children, including poor school achievement and increased burden on child welfare
2
systems. Mental illness and substance use problems represent the fifth most expensive
category of health care conditions (Board on Health Care Services, 2006).
Health care concerns have always been at the forefront of CommuniCare Health
Center's goals and mission. The agency has a long history of providing accessible
medical, dental, and substance use treatment to the rural community of Yolo County
beginning with the founding of the Davis Free Clinic in 1972 by Dr. John H. Jones. Dr.
Jones, a medical doctor, was committed to bringing affordable health care to those
traditionally without access. The substance use treatment programs were developed in
response to the unmet medical needs of residents battling substance use illnesses.
Three years ago, CCHC began a movement toward integrating systems of care
first by establishing the Integrated Behavioral Health Program (IBH), in which primary
care and behavioral health clinicians work side by side to address mental health issues
that occur within primary care. IBH is now well established. It provides an opportunity
to continue service integration throughout the Behavioral Health Department, including
substance use treatment in Adult Services. CCHC appears committed to enhancing
services for co-occurring illnesses believing that, when treated, clients can recover and
lead satisfying and productive lives.
In addition to recognizing the impact on overall health care, there have been
several challenges locally that have occurred. Service reductions in the Yolo County
mental health care system have shifted some responsibility for people suffering with
mental illness over to community-based organizations such as CCHC. In the past, county
mental health was known as the primary agent for this population. Recent shifts in
3
responsibility for services create major challenges in which community based
organizations (CBO’s) are expected to meet the increased need and to quickly develop
innovative, reliable services with few resources. Developing services for people with cooccurring illnesses is especially challenging since treatment for each disorder has
traditionally been separated into two systems of care.
Both mental health care systems and substance abuse treatment teams have
struggled to address both issues and have not yet established the best care options. As a
result, many of the clients frequently used both systems of care at a relatively high
frequency and are referred back and forth by both systems. Dual disordered clients also
tend to utilize a disproportionate amount of services compared to others, often
frequenting inpatient and outpatient addiction treatment, psychiatric hospital units and
partial hospitalization programs over several different treatment episodes. These
treatment modalities are fragmented and diff in their focus with the client.
Recent changes to the criminal justice system such as implementation of the
Criminal Justice Realignment (AB109) have also placed increased pressure on CCHC’s
Adult Services by increasing referrals for the forensic population. The forensic clients
present their own unique challenges. Many are have unstable housing, few resources,
and complications with legal issues. The correctional system tends to focus mostly on
addressing what they identify as criminogenic needs such as impulsivity and anger. Little
attention is dedicated to mental health and substance use issues.
County contracts with CCHC are constrained by funding limitations that
exclusively cover services with a primary diagnosis of substance use. The legitimacy of
4
treatment for co-occurring illnesses in a substance abuse treatment program has not been
established or recognized. Program designs that integrate mental health care, substance
use, and medical care are rarely funded, thus limiting the capacity to organize a multidisciplinary team approach. Only services such as group and individual sessions tend to
be covered, and there is no financial support for case management, psychiatric services or
medical interventions with current contracts.
New county contracts now require the use of evidence-based treatment
approaches for services as well as evaluation outcomes to report to the state for future
access to state funding allocations. Although this may be in the best interest of CCHC
since Adult Programs also benefits from the allocations it is a challenge to become fully
trained and proficient in EBP’s especially when the practices may also conflict with the
values and philosophies of the programs.
Most of these issues have been challenging to address and have placed a strain on
the Adult Services Team at CCHC. Staff concerns about burn-out, stress and an overall
lack of excitement about the services has left employees and management questioning the
focus of the programs and looking for meaning in the goals and mission of the existing
program and agency.
The lack of integration between substance abuse and mental health treatment
challenges Adult Services’ staff members who devote considerable time and attention to
engaging and supporting clients, but have few mental health resources to rely on. As a
result, clients and staff often find themselves in conflict with current substance abuse
focused strategies, and are limited by program structure and available resources.
5
This evaluation provides an opportunity to understand current program issues, clarify
direction, and unite staff in the process of defining mission, setting goals and evaluating
current work in order to chart a course for the future of Adult Services.
Statement of the Research Problem
The current Dual Diagnosis Program lacks an integrated focus on substance use
and mental illness needs. This study seeks to identify what the perceived strengths and
weaknesses of the program are, and secondarily, what the implications are for
improvement?
Study purpose
The purpose of the study is to assess the strengths and weaknesses of a dual
diagnosis services within an adult outpatient substance abuse treatment program. The
study will utilize the Dual Diagnosis Capability in Addiction Treatment (DDCAT) rating
scale to assist, in conceptually determining what is important to ascertain from
practitioners, clients and program leaders for needed improvements.
Theoretical framework. This study uses an ecological framework that emphasizes
a recovery-centered perspective when describing the research problem. The ecological
framework is helpful in terms of organizing and interpreting the experiences of
individuals living with a mental health and substance abuse. The ecological perspective
focuses on both the individual and the environment, integrating the connections between
the communications and functions of the two. The significant interactions involving
characteristics of the individual, characteristics of the environment, and characteristics of
the exchange between the individual and the environment, can promote or hinder
6
recovery. For example, a characteristic of the individual can be hope, and their
environment provides the characteristic of opportunity, thus understanding the connection
between the two can be seen as choice. With the ecological framework, recovery is
utilized or hindered through the dynamic relationship of influences that are intricate,
synergistic, and related (Onken, et al., 2007).
Recovery-centered approaches can be described as the therapeutic process in
which an individual tackles challenges using a unique arrangement of strengths,
vulnerabilities, and available resources. This approach utilizes a non-linear process of
recovery that involves taking steps forward, losing ground, and moving further again,
emphasizing the individual’s hopes and dreams. Recovery-centered approaches
emphasize individual motivations; such as hope, self-determination, organization,
worthiness, purpose, awareness, and possibilities. These elements are essential to
recovery and also involve contact with others; such as family, friends, and/or mental
health experts. These interactions can facilitate or debilitate the capacity of the individual
to achieve hope, take action in self-determined ways, develop belonging, and produce
meaning and purpose in life (Onken, et al., 2007).
Definition of terms. This study uses key words to identify elements of the study.
Dual Disorder refers to the occurrence of both a mental illness and substance abuse
disorder that an individual experiences simultaneously. Co-occurring, dual diagnosis, and
co-morbidity can be used interchangeably to define the dual disorder. The term disorder
can also be used interchangeably with illness and disease, specifically emphasizing the
array of symptoms, concerns, and risks of one’s mental and physical health. The
7
individuals experiencing a dual disorder are also referred to as clients, persons, and
patients who are used interchangeably throughout this study. Mental illness, mental
health, mental wellness, mental disorder, and mental concern are terms that define the
psychological impairment as diagnosed by a mental health professional. Addiction,
substance use disorder, and substance abuse are all terms that are used interchangeably to
describe the individual’s impairment in functioning and overall wellness due to misusing
substances, such as toxins, drugs and/or alcohol. The Substance Abuse and Mental Health
Services Administration will be referred to as SAMHSA throughout this literature.
SAMSHA created a measuring tool called Dual Diagnosis Capability in Addiction
Treatment, which will be referred to as DDCAT and will be used to help determine the
program’s capability in providing co-occurring services. CommuniCare Health Centers
is the agency that was targeted for this project and will be referred to as CCHC.
Assumptions. Treatments for dually diagnosed individuals have traditionally been
divided, separating treatment for substance use disorders from treatment for mental
illness. In this study, it is assumed that in order to provide the most effective means of
treatment, both diagnoses must be treated together. The notion that recovery treatment is
about the whole person and not their separate parts is highly emphasized throughout the
literature. This fits with SAMHSA’s Wellness Initiative (2012) which pledges to
integrate “eight dimensions of wellness for individuals experiencing a dual diagnosis by
promoting motivation of individuals, organizations, and communities to take action
toward improved quality of life, cardiovascular health, and decreased early mortality
rates. These eight dimensions include emotional, financial, social, spiritual, occupational,
8
physical, intellectual, and environmental wellness and are emphasized throughout this
literature to be the best way to provide quality and valuable treatment services.
Social work research justification. This research aims to provide an
understanding of what dual diagnosis treatment should look like as well as
recommendations for implementation of services within a dual treatment program. The
importance of dual treatment can be recognized within any human service and hospital
agency setting; and have been evolving towards improvements in providing services to
this unique population. Several statistics show that substance abuse treatment programs
report 50% to 75% of the individuals they serve also had a mental health concern.
Simultaneously, mental health treatment programs report 20% to 50% of the individuals
they serve have a co-occurring problem of substance use and/or abuse (Cherry, 2008).
These numbers relay a very important message to the field of social work in that
professionals must be prepared to clearly understand the complexity and diversity of the
varying needs these individuals posses as well as what services can be accessed and
utilized to provide quality care.
Delimitations. This study is not aimed at finding new treatment modalities to
address the coordination of care for substance use disorders and mental illness. This study
focuses on finding a combination of already existing treatment modalities that fit the
diversity of needs of persons who are dually diagnosed to provide quality care. This study
is focusing on providing a program evaluation and a needs assessment to one dual
treatment program already existing and limited to Yolo County, California. This study is
not intended to model a dual treatment program applicable to all areas and regions on a
9
global and/or national scale. This study only implemented focus groups and staff
interviews to individuals currently involved in CCHC’s dual diagnosis program; those
who are no longer involved with the program were not included in this study.
Statement of Collaboration. Christina Andrade and Aliya Martinez are working
in collaboration on this research study titled, “Evaluating the Strengths and Weaknesses
of a Dual Diagnosis Program: Needs for Improvement.”
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Chapter 2
REVIEW OF THE LITERATURE
The following analysis of literature covers themes of substance use, mental illness
and the co-occurrence of both conditions in an effort to provide a context for the study’s
examination of a dual diagnosis program. Special focus is given to the challenges,
history and implications of treating individuals in a parallel system versus integrating
services. Also significant, is information regarding individuals suffering from cooccurring illnesses, as well as the lack of services for these individuals.
Persons with mental illness and substance use problems represent a range of
different diagnoses, severity, and disability. Many often find themselves in complicated
systems of care that are fragmented with large discrepancies between care that is offered.
A study assessing the quality of care for a variety of different conditions including
substance use and mental illness, revealed that only 27 percent reported adequate
adherence to clinical practice guidelines (Institute of Medicine, 2006).
Not providing effective care also has serious personal and societal consequences
of a high prevalence of death and disability. Studies by the World Health Organization
examining the leading causes of death and disability found that mental illness and
substance use have a profound impact. Major depression was noted as the second leading
cause of death and disability in developed regions of the world for all ages (Institute of
Medicine, 2006).
11
For the purposes of this study, we will use the term co-occurring illnesses,
recognizing that it identifies individuals diagnosed with a substance use disorder and a
mental illness.
Background and Context
Historical analysis of substance abuse treatment in the early 20th century identifies
that treatment for substance use illnesses, was initially integrated with the mental health
system. Whether for better or worse, “patients with alcohol problems—if they received
treatment at all—received care from institutions and organizations charged with mental
health care, such as asylums and sanatoria” (Sterling, Chi & Hinman, 2011 p. 340). It
was not until well into the second half of the century that treating substance use disorders
began to change and the development of the substance use/addictions field began to
develop and move away from hospitalization.
The expansion of Alcoholics Anonymous and other self-help movements helped
mark the beginning of the division between the substance use field from mental health,
thus creating a separate care system and redefining the approach to treating substance use
problems. This approach had a less stigmatizing effect on the substance abusing
population and aided in the development of the “addictions” field. However, it also
developed into an exclusive system with the formation of such reputable organizations as
the National Institute for Drug Abuse (NIDA), and the National Institute on Alcohol
Abuse and Alcoholism (NIAAA). Although, legitimizing to the field of substance use
and vastly helpful in researching and understanding substance use issues, it was also
instrumental in reinforcing exclusivity and divisions amongst the two systems. As a
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result, policy issues between the two systems became rooted in purposeful positioning of
interests mostly in an effort to respond to the special treatment needs of each system’s
own vulnerable populations. Further complicating the division between substance use
and mental health fields are contentious debates amongst mental health workers and
substance use counselors. Some of these debates are grounded in distinctions between
education, certifications and credentialing for providing services with mental health
providers often requiring master’s degrees and supervised hours and substance use
counselors working more as an apprentice. (Mangrum & Spence, 2006; Sterling et al.,
2011; Institute of Medicine, 2006).
Prevalence of Co-Occurring Illnesses
Studies beginning in the 1980’s began to examine the enormity of the problem
with co-occurring illnesses finding that almost half of all individuals identified with a
substance use illness also suffered from a mental illness. They also found that among
individuals with a mental illness, 15-40 percent also had a substance use illness. In 1996,
a global study was conducted to understand the burden of diseases, injuries, and risk
factors by the World Health Organization and the World Bank. The study examined the
years of life lost to premature death and years of life lived with a disability. The goal was
to indicate the overall relative burden of major diseases and injuries. The results from
this study acknowledged for the first time, the “profound effect” of mental illness and
substance use illnesses on death and disability. In the United States, neuropsychiatric
conditions were responsible for more death and disability than any other health category,
even cardiovascular diseases and cancer. Mental illness, was also identified, as a risk
13
factor for developing other adverse behaviors such as smoking and overeating (Institute
of Medicine, 2006).
One of the first policies informed professional and expansive acknowledgements
of this problem occurred in 1998 when the National Dialogue on Co-Occurring Mental
Health and Substance Abuse Disorders was held. The executive summary emphasized
that barriers between the two systems were significantly affecting and complicating the
current “coordinated system of care for people with co-occurring disorders.” The
summary emphasized that coordination “must be the expectation, not the exception”
(National Association of State Mental Health Program Directors, 1999). The problem,
was identified in the executive summary:
There is no question about the need to improve treatment and support services for
people with co-occurring mental health and substance abuse disorders. As a
group, these difficult-to-serve individuals tend to have multiple health and social
problems requiring a variety of sometimes costly services. Traditional barriers
between the mental health and substance abuse systems – each with its own
treatment philosophies, administrative structures, and funding streams – have too
often prevented individuals from getting the care they need and deserve (National
Association of State Mental Health Program Directors, 1999).
In 2006, the Institute of Medicine proposed that mental health services were
needed by over 33 million Americans because of alcohol, illegal drugs, or the
inappropriate use of prescription medications. This evidence continues to be substantiated
by more recent data suggesting that in 2011, there were18.9 million adults with a past
14
year substance use illness and 42.3 percent (8.0 million adults) of them also had a cooccurring mental illness. In comparison, 17.6 percent of the general population had a
mental illness (Burnam & Watkins, 2006; SAMHSA, 2011).
According to the Institute of Medicine, mental and substance-use illnesses are the
leading cause of combined death and disability for women of all ages and for men aged
15–44, and the second highest for all men. However, when individuals receive quality
care for their conditions, they do have the chance for recovery. On the other hand, when
treatment is either not provided, or is provided with low quality, the consequences for
those individuals can be highly detrimental.
Individuals suffering from mental illness and substance use problems have often
been at a disadvantage in receiving effective, accessible health care for their conditions.
Most research indicates that despite advances in the development of effective treatment
therapies and access to care there continue to be difficulties. In 2006, the Board on
Health Care Services conducted a large-scale study on the quality of health care for
mental health and substance use conditions. The study, entitled “The Quality Chasm
Series” concluded that a strategy was needed, for improvement of some specific
characteristics of substance use and mental health care especially since, “when
appropriately treated, individuals with these conditions can recover and lead satisfying
and productive lives” (Board on Health Care Services, 2006 p. 29). Specific areas of
concern focused on broad based issues such as the need for less use of coercion into
treatment; struggles with integration of delivery systems between mental health and
15
substance use; the need for improved quality measurements and a differently structured
marketplace.
Philosophies and strategies of care between substance use treatment and mental
health tend to be disjointed and conflicting often reinforcing the separation of the two
systems. Disagreements are often found in discrepancies between older substance use/12
Step models of treatment and new models such as person-centered care that deemphasizes confrontational approaches.
The use of coercion in terms of an individual’s ability to receive care that is
respectful of and responsive to their individual preferences, needs, and values are a
particular challenge for the substance use field. Traditional methods of care rely on
interventions such as punishments and restrictions as a way to address or “break-through”
denial about an individual’s condition. These methods are not substantiated by any
evidence, nor is it a recommended approach to produce motivation (DiClemente, 2006).
Substance use treatment providers have recently been introduced to new developments in
addressing motivation for change, such as through Motivational Interviewing, however
traditional techniques continue to be widely used.
Mental health providers, although generally not supportive of coercive measures
used in substance use treatment, tend to reinforce service distinctions by not treating
patients until they are clean and sober. Other issues include not taking substance use
issues seriously, and instead viewing them as symptoms of deeper psychological
problems that will become less detrimental if the psychological issues are resolved. This
approach can result in care that is considered unsafe. Oftentimes, it is mental health
16
organizations that have demonstrated more resistance to collaboration with substance use
agencies than vice versa (Institute of Medicine, 2006; Sterling, et al., 2011).
The need to deliver services that are consistent with scientific evidence, or
evidenced based practices is also identified. The absence of clinical based practice
presents particular concerns for the quality of care individuals receive since it cannot be
measured, nor monitored for its effectiveness. Solutions to this problem include,
identifying and disseminating effective practices and applying and measuring the
practices for indications of quality improvement (Burnam & Watkins, 2006; Sterling et
al., 2011; Institute of Medicine, 2006).
Advances in the treatment of individuals with mental illness and substance use
has engaged many institutions of research such as the Substance Abuse and Mental
Health Services Administration (SAMHSA), and the National Institutes of Health (NIH)
toward the goal of recovery for co-occurring illnesses. Many advances in the research
offer developments in psychotherapies, drug therapies, brain functioning and genetic,
biological and psychosocial factors improving developments in areas that were
previously not explored, such as genetics, neuro-imaging and animal models of
behaviors. Many of these studies can provide growth in the area of cost effectiveness in
health interventions for example, in the treatment of depression. It can also lend
themselves to a more scientific understanding of substance use changes and
characteristics (National Institute of Medicine, 2006).
Literature in the last decade has focused on the value of integrating services in a
variety of populations including services to adolescents and families and integration with
17
the court systems including child welfare and criminal justice. These areas of study offer
support for the increased efficacy of services overall. As mental health and substance use
treatment programs recognize that they are serving more complex needs, the usefulness
of status quo services becomes more under question. There is urgent need for agencies to
recognize that co-occurring illnesses require that programs develop an infrastructure and
operational procedures that will provide services matching the needs of the individuals.
Health organizations can take a lead in promoting opportunities to change the face of
treatments urging agencies to adopt evidenced based clinical practices, train clinicians on
all levels and monitor efficacy of the models (Minkoff & Cline, 2006; SAMHSA, 2003).
Agencies serving individuals with co-occurring illnesses have increasing
difficulties addressing the increased numbers of people coming in for care, particularly
since the population has increased over the years. Individuals also tend to be difficult to
engage and to retain in treatment and generally have high levels of non-compliance to
medications. The mental health care and substance use treatment systems, have struggled
to address both issues and have not yet identified the best care options. As a result, many
of the clients frequent both systems of care at a relatively high frequency and are often
referred back and forth by both systems. Many individuals with dual disorders are
chronic patients who have very few resources to deal with challenging systems of health
care and community agencies. Frequently, service delivery has been disjointed,
inconsistent, and sometimes even unsafe. Complicating issues further, individuals with
mental and substance use illnesses range in varying levels of diagnoses, severity of illness
and disability. Fragmented systems of care also often result in adverse effects on the
18
nation. Studies indicate that the costs both direct and indirect for alcohol related illnesses
and injuries alone were estimated at $185 billion in 1998 (Institute of Medicine, 2006).
Models of Care
The limitations of traditional approaches to the management of co-occurring
disorders provide a context for the exploration of early efforts toward integration.
Examples of approaches used to integrate care started with the quadrant model proposed
in 1998, which categorized co-occurring mental health and substance abuse disorders
according to the symptom severity for each. Each quadrant had identified services that
might occur between systems. This approach, was considered integrated since it posited a
combined model where both disorders could be treated. However, it is also limited in its
validity and does not reflect the fact that most individuals would move between quadrants
depending on how their symptoms fluctuate. Known as, sequential treatment, this model
of care where the client is eligible for only one treatment at a time also requires that
either diagnosis must be addressed before the next service is utilized. This system
provided a “link” between systems when the individual was passed to the next system
(Mueser & Minkoff, 2006).Critiques of this model include concerns about ignoring one
problem for the other. For example, one disorder is placed on-hold, often worsening,
making it then difficult to stabilize the other.
Another approach is parallel treatment, in which both disorders are treated
together, but by different practitioners, and usually different agencies. While this model
is still often used as a way to foster cooperation between treatment agencies, it can
become a problem when practitioners fail to communicate with each other and the client
19
is then forced to communicate for both. In this case, the client often “slips between the
cracks” since no “one” provider is responsible for the client. In addition, it has been
noted that there is growing evidence showing a poor prognosis for individuals treated
with traditional sequential and parallel approaches (Mueser& Minkoff, 2006; Burnam &
Watkins, 2006).
It is important to note that despite current innovative and comprehensively
researched based treatments, many separate substance use and mental health programs
still exist often as a remnant of the organizational and administrative constraints between
the mental health care system and the substance use system.
Programs are still challenged by many smaller scale issues that remain
problematic such as practicing collaboration between systems and navigating
confidentiality and consent issues. It is difficult for mental health and substance abuse
programs to interface because of desires to protect client information. Confidentiality
and consent concerns make collaboration challenging. Currently federal and state
regulations also strongly restrict substance use information from being shared to prevent
potentially stigmatizing or damaging information from “falling into the wrong hands”
this can compromise the ability to collaborate effectively with insurance companies, as
well as other agencies (Sterling et al., 2011).
Evidence Based Practices
Research conducted on persons suffering with alcohol dependence in 2003
demonstrated that only 10.5 percent, were found to receive care that was consistent with
evidenced based practices. A national survey conducted in 1997–1998 by the National
20
Association of State Alcohol and Drug Abuse Directors, found that persons with cooccurring mental health and substance use conditions who received treatment for one
condition, fewer than a third (28.6 percent) received treatment for the other (Institute of
Medicine, 2006).
Within the context of scarce resources, how do programs provide services in a
manner that is consistent with their existing mission and program design, and also
recognize, accommodate, and incorporate attention to the increasingly complex needs for
their service? The answer to this still remains unclear since many agencies providing this
type of care have not yet applied evidenced based practices and are unable to measure
fidelity to any specified model or approach. The limited research conducted is still
largely inconclusive and has had many methodological problems including small sample
sizes. Most research also focused largely on severe mental illness. Some studies
however, have found that patients in programs with more services to meet the needs of
co-occurring illnesses such as groups and clinicians with co-occurring illness training had
better outcomes at 6 months. Another study examining outcomes of care, established that
when clinicians had comprehensive co-occurring illness training in assessment and
motivational interviewing techniques, they found that patients had better outcomes at 18
months than patients who received only mental health care (Sterling et al., 2011).
In an effort to provide program oversight and enhance information systems, some
states have developed standards for competencies for such things as “dual diagnosis
enhanced services” or clinician certification programs. Greater understanding of the
organization and the costs of these treatment systems is another area for research.
21
Increasing knowledge of mental disorders is prominent in most of the literature,
which tends to either, focus on the biology and environment and less on what is primary,
the mental illness or substance use disorder. Few focus as much attention on addiction
studies as a mental illness but there is an overall recognition of the relationship between
the two. The interaction between the two seems to be addressed mostly in examining
levels of risk such as the idea that substance use compounds the risk of developing a
psychiatric disorder or vice versa. Other relevant questions examine adherence to
treatment, outcomes and the question of simultaneous or sequential treatment. The
literature predominately supports the need for integration of treatment services
(SAMHSA, n.d; Minkoff & Cline; Sterling et al., 2011).
There are many people with co-occurring disorders who “fall through the cracks”
of fragmented systems that are lacking cohesiveness, clarity about philosophy, and
financial support. Current remedies range from collaborative research projects through
the National Institute on Mental Health and the adoption of performance measures
through the treatment parity legislations. Patient centered medical home, a model of care
including behavioral health services in primary care systems is another promising
approach that is consistent with integration.
Funding to support integrated systems of care has come in the form of block grant
funds and state dollars. Some states have focused their efforts on the eligible Medicaid
population, which often requires modifying rules regarding specific service definitions
and billing codes so that certain services are reimbursable.
22
Dual Diagnosis Capability
There are ongoing challenges to dual diagnosis program development including
integration, funding mechanisms, philosophical change, practitioner training and overall
capability. The term dual diagnosis capability was first proposed in 1991, by Kenneth
Minkoff, MD, a pioneer in dual diagnosis capability research. It was thought that by
developing a core capacity in behavioral health services, specific components of
infrastructure could be developed that would improve overall services for people with cooccurring disorders. Resultant services would meet SAMHSA’s expectation that, “a
coordinated system of care for people with co-occurring disorders must be the
expectation, not the exception” (SAMHSA, 2011). The intention of a dual diagnosis
capability scale is to address the inconsistencies created for specialized systems of care
that stand to provide limited services to a small group of people. Utilizing the scale is
meant to have an impact on the ability of a system as a whole to address the complex and
pervasive population of individuals with co-occurring disorders.
One particular scale developed in 2003, the Dual Diagnosis Capability in
Addiction Treatment (DDCAT) toolkit, is currently the only index developed for use in
addiction treatment settings. It was created by Dr. Mark McGovern, Associate Professor
of Psychiatry at Dartmouth Medical School and is endorsed by SAMHSA and the Center
for Substance Abuse Treatment (CSAT). It is recognized for its reliability and guidance
for both programs and system authorities and is being used in 32 states. It is also based
on the American Society of Addiction Medicine (ASAM) taxonomy, which is widely
used as a patient placement tool for substance using individuals (SAMHSA, n.d.).
23
The Integrated Dual Disorder Treatment (IDDT) service delivery model also
endorses the use of the DDCAT as a standard for exploring an organization’s policies,
clinical practices and workforce capacities and provides evidence based practices. It
promotes consumer and family involvement in service delivery, and was developed at
Dartmouth Medical School by fellow researchers Robert E. Drake, MD and Kim T.
Mueser, PhD. IDDT provides a systematic guide for organizational change, a clinical
guide for treatment and a booklet designed for medical professionals (Center for
Evidenced Based Practices, n.d.).
It is important to recognize that most programs already provide a range of
services to this population but have not had access to an assessment framework for
structure, program milieu, clinical process, administrative function and financial
assessment. By accessing this resource, programs already conducting services with
minimal support and infrastructure can reliably assess their services and make
improvements with the end result potentially being improved treatment for co-occurring
illnesses (Minkoff &Cline, 2006; SAMHSA,2003).
Programs that are identified as dual capable, have a routine set of standard
interview questions for assessing mental health issues utilizing biopsychosocial data. The
program conducts a screening with interview questions directed towards mental health
concerns. The information is then incorporated into a more inclusive evaluation process
that occurs routinely. This screening, is standardized, in that it consists of a set of
questions or items, a routine mental health status screening, and questions to assess risk
24
of harm to self or others. The format of the screening questions may be open-ended and
discrete (SAMHSA, n.d.).
Clinical Processes
Assessment
Individuals with co-occurring symptoms are regularly and thoroughly screened
for both substance use and mental health related illnesses. The following information
provides a standard definition of screening and its role within treatment, taken from the
Substance Abuse and Mental Health Services Administration’s website (SAMHSA, n.d.).
Screenings, are used by organizations to verify the likelihood of a co-occurring
mental health or substance use illness. It is not meant to establish the presence, absence,
or specific type of such an illness. The process is formal, brief, and typically occurs
shortly after the patient presents the need for services. The information gathered during
screening is significantly the same regardless of who collects it. The information must be
gathered in a way that ensures consistency and must be interpreted or used in the same
way for every person screened (SAMHSA, n.d.).
Screenings are conducted at the beginning of a person’s treatment, and should be
routinely conducted within the first four visits to the first month following treatment
initiation. Screenings can be implemented through means of interviews with program
leadership and staff, observations of medical record (or electronic medical record
system), or intake screening form packets (SAMHSA, n.d.).
25
Addiction only. Screening before admission into addiction only treatment is
based on the individual’s self-report. The decision for admission is based on clinical
involvement from the individual’s current presentation or by their history. There is also a
considerable variability across clinicians when deciding who would be a good fit for
admission. Addiction only programs do not typically screen for mental health illnesses.
Programs will conduct a basic screening for mental health problems prior to admission,
but it is not a routine or standardized component of the evaluation procedures. On
occasion, a program will offer a minimal screening for mental health disorders; which is
based on, the clinician’s initial observations and/or impressions. At this level, the screen
might include some symptom review, treatment history, current medications, and/or
suicide/homicide history (SAMHSA, n.d.).
Dual capable. Programs that are dual capable have a routine set of standard
interview questions for mental health using basic framework, such as the biopsychosocial
(BPS) data collection. The program conducts a screening process with interview
questions directed towards mental health problems. This screening is standardized in that
it consists of a set of questions or items, a routine mental health status screening, and
questions to assess risk of harm to self or others. The format of the screening questions
may be open-ended or discrete, but they are used consistently (SAMHSA, n.d.).
Biopsychosocial (BPS).George Engel, a doctor at Rochester University,
developed the biopsychosocial (BPS) model as a way to emphasize psychosocial factors
within the biomedical model of assessment. Engel believed that the individual’s medical
problems cannot be separated from their social environment and psychological
26
experiences, and that some risk factors of disease and illness stem from the individual’s
personality and societal upbringing (Margalit et al, 2007). The BPS method gathers
individual information through interviewing, asking questions that are both doctor and
patient-centered, while avoiding the doctor’s agenda. This method allows the patients to
have more control over their treatment options and providers to have a choice in their
healthcare management.
The BPS assessment creates an empathic way of consultation, where the patient’s
feelings and beliefs about their illness, are recorded, and integrated into treatment
planning. Clients are given the opportunity to express their health complaints and
collaborate with their health care provider about possible psychosocial connections that
may be directly affecting their wellbeing. This engagement process has been shown to be
extremely effective to improve patient satisfaction as well as decrease healthcare
expenses (Margalit et al, 2007). The BPS has made a significant change within the
healthcare field, and has been modified over the years to better meet the needs of the
patient. More recent models of the BPS now incorporate cultural and sexual factors when
assessing the overall individual experience.
Mental status exam (MSE).The Mental Status Exam is a screening tool utilized
to assess cognitive performance and other temperamental features relevant in assessing
ones overall functioning. The purpose of these types of screening tools are aimed to
briefly assess an individual’s cognitive functioning and determine if their scores indicate
an impairment in functioning. Ruling out organic reasons for cognitive impairment better
assesses the need for psychiatric services (Blais & Baity, 2005).
27
Research indicates that cognitive impairments often are associated with severe
psychiatric illnesses. The single best predictor of the need for psychiatric inpatient
admission at hospital emergency rooms is cognitive impairment, regardless of patient
diagnoses. There is evidence within the healthcare community that cognitive impairment
is quite common in severe psychiatric illnesses. Cognitive impairment can have a
negative impact on treatment outcomes, thus there is a need for cognitive screening for
all psychiatric inpatients, regardless of their age and diagnosis. Several types of mental
status exam screening tools have been devised to provide broad assessments of cognitive
functioning within all healthcare facilities (Blais & Baity, 2005).
Treatment
The average treatment for individuals with co-occurring illnesses in the United
States is separated into different agencies that specialize in treating either mental illness
or substance use. People with co-occurring illnesses, are frequently excluded from one or
both systems of care due to their complexity of concerns. When persons receive treatment
from both the mental health and the substance abuse systems, the care is rarely
coordinated or consistent. Research implies that individual outcomes in combined
treatment systems of care for co-occurring illnesses are unreliable (Calsyn et al., 2005).
Twelve step facilitation (TSF) therapy. Twelve Step facilitation (TSF) therapy
is a short, methodical, and manual-oriented approach to assisting early recovery from
alcohol and other drug use-related concerns. TSF is utilized with individuals over a
period of 12 to 15 sessions. The intervention is based on the behavioral, spiritual, and
cognitive principles of 12-step fellowships such as Alcoholics Anonymous (AA) and
28
Narcotics Anonymous (NA). These principles include acknowledging that willpower on
its own cannot accomplish persistent sobriety, that surrendering to the group morale must
replace self-centeredness, and that long-term recovery includes the practice of spiritual
replenishment (SAMHSA, 2012).
TSF focuses on two general goals: (1) acceptance of the necessity for complete
abstinence from all alcohol and other drug use and (2) the readiness to actively participate
in 12-step associations as a way to support sobriety. The TSF therapist evaluates the
client's alcohol or drug use, promotes abstinence, clarifies the basic 12-step model, and
actively encourages and supports involvement and ongoing participation in AA/NA. The
counselor also involves particular discussions from the AA/NA literature with the person
involved, and helps them to use AA/NA resources in times of crisis. The therapist will
also engage with the individual on more advanced concepts such as moral inventories
(SAMSHA, 2012).
The major difference between TSF and 12-step groups is that manual-driven TSF
groups are led by a team of professional therapists, while 12-Step community self-help
groups are led by peers. Similarly, TSF interventions focus on encouraging individuals
to get active in community 12-Step groups; studies, in fact, show greater consistency of
12-Step attendance during active treatment. Attendants of 12-Step groups during active
treatment may affect depressive symptoms by encouraging behavioral action (Brown et
al., 2006).
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Peer support groups (AA, NA, DRA, DTR). There are two main advantages of
using peer support group engagements for the co-occurring population: they have the
potential to change social attitudes and behaviors, and they are generally cost-effective
(Horsfall, Cleary, Hunt, & Walter; 2009). In particular, Alcohol Anonymous (AA) and
Narcotics Anonymous (NA) has shown lasting evidence that this specific type of group
intervention helps challenge the negative beliefs associated with their alcohol/substance
use. This process may lead to healthier coping behaviors. When individuals are receiving
support through their peers, their overall perspective of treatment and recovery changes.
Commitment to 12-Step and other self-help programs is associated with improving
socialization and inclusion; as well as involvement in the development of social networks
and support promoting recovery (Brown et al., 2006).
The treatments for substance use have a strong association with 12 step-related
programs and group involvement. Brown University’s study of Addiction Theory and
Application studied patients who have alcohol dependence who participated in AA. The
findings indicate that those who stayed in AA and worked through all 12 steps had
reduced levels of interpersonal insecurity than those who were just beginning the
program (SAMHSA, 2006). The research revealed a significant difference in
interpersonal insecurity between patients who completed all 12 steps in a communitybased AA curriculum and those who had started to work the steps but had not yet
completed all of them. Those who completed all 12 steps showed a decrease in
interpersonal insecurity; with no differences in gender, age, and ethnicity. This researcher
hypothesized that as the individual works the steps with the support of a community-
30
based AA group and sponsor, there is greater likelihood for change through acquiring
ability to relate to others.
Self-help groups that specifically target the co-occurring population are referred
to as Dual Recovery Anonymous (DRA) or Double Trouble in Recovery (DTR). These
groups are especially important and play a valuable role within the complexity of cooccurring illnesses within one’s life. These groups are unique in that they offer support
that comes from others who fully understand the difficulties of both illnesses, such as
remaining sober on top of coping with mental health symptoms. These groups provide a
structure for daily living alongside the commitment to eliminate substance use. Research
supports the notion that individuals who consistently attend these self-help groups for a
year or more accomplish a decrease in their substance use. The traditional 12-step
programs, on which DTR and DRA groups are based from, are unaccommodating for the
co-occurring population and their unique set of symptoms. The taboos of social and
emotional expression among many people with severe mental illness do not mesh well
with the AA/NA traditions of disclosing personal and intimate pieces of one’s life in a
group setting (Horsfall, Cleary, Hunt, & Walter; 2009).
Harm reduction (HR).Harm Reduction (HR) is an intervention strategy, which
aims to reduce the harm associated with using substances. The value of HR in cooccurring treatment focuses not on abstinence, but supporting the individual to decrease
harmful, drug-related behaviors by focusing on the risks involved. HR offers a pragmatic
solution as either a long or short-term strategy to support safer choices and decisions that
affect recovery (Laker, 2007). HR has a broad definition, yet can include any intervention
31
on an individual, family, or community level that concentrates on reducing the negative
consequences of drug and alcohol use without insisting upon absolute abstinence from
these substances (Mancini, Hardiman, & Eversman; 2008).
The nature of HR does indicate obstacles for the co-occurring population. One
difficulty in particular is that many mental health treatment programs traditionally offer
services dependent upon the individual’s abstinence from alcohol and/or substances.
These individuals with co-occurring symptoms often require the basic motivation and
resources needed to obtain abstinence, in order to access other services. As a result,
programs that serve the co-occurring population have began to see the need to initiate HR
principles and approaches (Mancini, Hardiman, & Eversman; 2008).
Harm reduction is a controversial approach within the United States due to the
power and influence of zero-tolerance drug policies and antidrug laws. It is also
important to consider the practicality and flexibility of HR when understanding the
adaptability of the approach to a variety of current mental health techniques for cooccurring individuals. Today, there is a lack of sufficient education and training regarding
HR practices. Research implies that clinical staff on the frontline may have doubts about
the message that HR techniques may send to their clients about drug use. Several
professionals remain unclear about how to best incorporate HR into their daily
interventions with the co-occurring population (Mancini, Hardiman, & Eversman; 2008).
Motivational interviewing (MI).A widespread lack in motivation adds to the
rejection or evasion of treatment by the co-occurring population. People with cooccurring illnesses who display a severity of symptoms most often have less motivation
32
to change, are more difficult to engage, drop out of treatment more easily, and make
slower progress towards their recovery goals. Without intrinsic motivation, one’s
dedication and loyalty to recovery is greatly at risk. Their substance use may threaten
their mental health stability, challenge engagement within treatment, and heighten
psychosocial insecurity (Horsfall, Cleary, Hunt, & Walter; 2009). Professionals often
grapple with the individual’s lack in motivation. Motivational interviewing (MI) is a
flexible and client-centered approach that is extremely useful within the treatment of cooccurring illnesses. This talk therapy model encourages the client to explore their own
ambivalence to changing harmful behaviors (Laker, 2007).
MI is especially useful during the early stages of treatment for the co-occurring
population. This approach recognizes that individuals may not understand that their
substance use is contributing to their psychosocial problems. These individuals may not
be aware that they even have a problem; let alone consider lessening or stopping their
substance use. Research indicates that people living with severe mental illness and
substance use need support to move from the stage of pre-contemplation to contemplation
of change. MI accentuates personal choice, responsibility, and awareness of the risks and
benefits of continued problematic behaviors (Horsfall, Cleary, Hunt, & Walter; 2009).
Assertive community treatment (ACT).Assertive Community Treatment (ACT)
is an evidence-based framework for providing services to individuals with severe mental
illness. ACT, a structured health care service approach to working with dual-diagnosis
clients. This unique approach utilizes a traditional model of case management to address
the needs of the dually diagnosed. The typical responsibilities of the case manager is to
33
develop a collaborative alliance with their consumers, link them with relevant resources
and other services, and advocate alongside them while receiving services from other
health professionals. Case managers maintain contact and provide ongoing need
assessments to support the consumer’s degree of engagement, treatment, and retention
(Horsfall, Cleary, Hunt, & Walter; 2009).
ACT produces better recovery outcomes than other treatments for individuals
with severe mental illness and several previous hospitalizations. The program is effective
with the homeless population. The main components of ACT approaches include:
services provided by a multidisciplinary team with a client to staff ratio of 10/1; services
provided in a community setting; services provided without any time limitations; team
discussions of clients and team member availability 24 hours a day. These main
components are supported and demonstrate how ACT programs generate better clinical
outcomes than other case-management approaches in terms of hospitalization, housing,
mental health, and substance misuse (Calsyn et al., 2005).
Cognitive behavioral therapy (CBT).The value of cognitive behavioral therapy
(CBT) for substance use has been confirmed by several research findings. Approaches
like relapse prevention, guided self-change, behavioral couples therapy, and the
community integration approach are all supportive efforts that contribute to significant
improvements in substance use symptoms. The benefits of CBT approaches to substance
use treatment are also prevalent for improving other major life areas such as employment,
family conflict and partner violence, hopefulness and thought repression, substance use in
34
particular populations, coping skills, psychosocial functioning, criminal behaviors, use of
health care services, and co-occurring psychiatric symptoms (Conrod & Stewart, 2005).
CBT is frequently used in therapeutic interventions with substance use as well as
for alleviating symptoms of severe mental illness, such as psychosis (Barrowclough,
Haddock, Fitzsimmons & Johnson, 2006). CBT helps individuals with co-occurring
illnesses in a way that addresses problematic thoughts and behaviors that directly affects
one’s road to recovery. When negative thinking induces problematic behavior, a person’s
ability to function within society becomes altered. Social skills and assertiveness training
provided by CBT in the management of co-occurring symptoms have been shown to be
key components within treatment modalities (Brown et al., 2006).
CBT is shown to be most useful when addressing the unique concerns of the cooccurring population. In treatment settings, professionals utilize the breakdown of how
cognitions, feelings, and behaviors are all connected and how restructuring certain beliefs
and ideologies can help, influence more positive behaviors and feelings. Specific areas
that CBT addresses is the recognition of escalating symptoms and other warning signs,
how to cope with cravings and triggers, discovering and implementing healthier
alternative behaviors, normalizing substance-use relapses, how to develop safety plans
for relapse, and cognitive reformation to challenge optimistic beliefs about their
substance use (Horsfall, Cleary, Hunt, & Walter; 2009).
There is verification from other research studies supporting the integration of
CBT and other therapeutic approaches to strengthen the treatment services provided. One
combination of techniques is called the cognitive-behavioral integrated treatment (C-BIT)
35
approach. This controlled but flexible integrated psychosocial treatment approach is
intended particularly for working with those experiencing severe mental health concerns
who are also struggling with substances use. C-BIT, is supported by the conventional
ideologies and practices of cognitive therapy for disorders such as mental health,
substance use, and psychosis. The fundamental belief for C-BIT combines CBT with
other therapeutic approaches such as substance use treatment, motivational interviewing,
and harm reduction (Graham et al, 2006).
Individuals who are dealing with both substance-related and mental health-related
issues are becoming more prevalent. Other countries are using integrated treatments
combining CBT with other promising approaches within dual diagnosis treatment. In the
United Kingdom (UK), a group of researchers conducted one of the largest randomized
controlled treatment trials to find an appropriate method of treatment for individuals
diagnosed with psychosis and a substance use illness. The trial used motivational
interventions for drug and alcohol use in schizophrenia (MIDAS), integrating individual
treatment for schizophrenia and co-morbid substance use. This 9 month trial used
motivational interviewing (MI) plus an individual and family cognitive behavior therapy
(CBT) treatment approach. Results indicated that after one year, MIDAS was found to be
better when compared to standard psychiatric care. There was an overall improvement in
the patients' general functioning, a reduction in positive psychotic symptoms, and a
reduction in the frequency of substance use (Barrowclough et al., 2009). This approach is
most effective when treatment conditions, are combined with flexibility in the location
36
and timing of appointments. Other treatment programs for psychosis and substance use
have a high (50%) drop-out rate.
It is important to note, when evaluating the effectiveness of CBT with cooccurring mental illness and substance use, criticism does exist. When looking at
traditional 12-step approaches, CBT approaches have not been proven, to be any more
successful in helping dually diagnosed individuals obtain abstinence, maintain
abstinence, or reduce their psychiatric and psychosocial symptoms. Others have indicated
that current CBT approaches to substance use treatment fail to focus on the crucial
content that deals with specific elements of co-occurring illnesses, and therefore only
provide individuals with a broad range of coping strategies for managing their symptoms
of mental illness. The literature on CBT treatment programs for co-occurring illnesses
also argues that combining CBT-oriented substance use treatments with specific CBT
treatments for psychiatric disorders is not so clear. Instead, it requires very careful
consideration of the unique relationship between specific disorders, patient reactions to
specific treatment components, and consideration of certain barriers to treatment in order
to reach an integrated co-occurring illness focus that is meaningful (Conrod & Stewart,
2005).
Friend/Family support & dual treatment. Family support for individuals with
co-occurring mental and substance use illnesses may improve treatment outcomes. When
a family member or friend provides direct support while a co-occurring person is
receiving treatment, substance use can be decreased. When individuals receive case
management services or assertive community treatment (ACT) with better substance use
37
treatment services on top of their personal support system, their treatment progress in
heightened. Family or friends who continue their contribution with these individuals are
an important, well-informed, and approachable resource that can contribute to more
positive outcomes in recovery (Horsfall, Cleary, Hunt & Walter, 2009).
Having a family member who is experiencing co-occurring illnesses influences
the family’s ability to functioning. The development of substance use and mental health
concerns frequently starts in adolescence and young-adulthood, and can last for many
years. The effects that these concerns have on people close to the dually diagnosed
individual are evident and can greatly affect the road to recovery. The family members
and/or close friends are the ones who are most likely to detect the early stages of these
problems and have important knowledge about how it affects the individual’s experience.
Problems associated with the impact on family, peer relationships, neighborhood,
community, school, and workplace is very powerful to the individual’s ability to engage
and maintain co-occurring recovery. Prior to involvement with the health care and/or
social service system, these problems are already deeply rooted in the life stories and
overall functioning of those close to the person with a co-occurring illness (O’Grady &
Skinner, 2012).
Family and close friend involvement with treatment is essential during the
beginning stages of co-occurring mental health and substance use illnesses. Participation
may help individuals to learn to develop safer coping strategies such as integrating a
strong support system. Once the individual is no longer involved with the program, they
38
are able to utilize the coping skills learned in treatment and can apply them to real-world
circumstances with the support of their family and friends.
Crisis management. Crisis management is a way of coping with a situation or
event that is perceived as intolerable. Crisis intervention is a short-term, solution-focused
strategy of, quickly and efficiently coping with the presenting problem. Strategies of
crisis work can be targeted to improve one’s perception of the precipitating event that
triggered a crisis state, and to enhance coping responses (Kanel, 2007). Crisis
management and intervention strategies aim to improve the individuals functioning to
pre-crisis levels or higher.
Some crisis services have created specialized methods and teams for addressing
the problems of co-occurring individuals. Typically, individuals dealing with crises are
admitted into acute care such as general hospitals for crisis stabilization. Suitable
diagnostic testing and assessments for changes in the treatment plan are major elements
of these admissions, as well discharge planning for continuity of care. These individuals
are regularly discharged back into the community, but those that do not respond to crisis
stabilization strategies are transferred to long-term care facilities, such as involuntary
commitment, regional programs, or state mental hospitals (Davis, Barnhill, & Atezaz
Saeed; 2008).
Summary
This literature review summarizes substance use and mental health treatment for
individuals experiencing co-occurring illnesses. The history of addiction and mental
illness treatment are highlighted to provide a foundation for current trends including the
39
distinctions between the two and the impacts of a binary system approach. Examination
of therapeutic techniques and clinical tools are included for their practical applications
and relevancy for treating the specific needs of this population. Integration of care is
emphasized as the most meaningful approach and is carried throughout the research
project.
In summary, this literature review aims to reflect the current challenges and issues
in providing treatment for the complex needs of individuals struggling with co-occurring
illnesses. It is specifically focused on providing relevant information that will assist in
assessing the current needs and implications for improvement for a dual-capable
program.
40
Chapter 3
METHODS
This research project utilized a qualitative non-probability sampling method in an
effort to obtain client and staff impressions of the dual diagnosis program.
Study Design
The project was evaluative using qualitative methods and consisted of gathering
data from staff interviews and client focus groups. Questions were generated from the
Dual Diagnosis Capability Assessment Tool (DDCAT) (public domain) as a point of
reference as well as from themes delineated within the literature that had indications for
program analysis and quality improvement.
Sampling Procedures
The data was gathered using a voluntary sampling of active clients and staff
clinicians. Individual interviews were used to collect information from clinicians
currently working in the program. Two focus groups were conducted with dual diagnosis
clients actively involved in the program.
Clients were given a flyer in their treatment group, two weeks before the
scheduled focus group. The flyer described the research project and the opportunity for
participation at a select time that would not interfere with or influence their treatment
program. Incentives to participate were described on the flyer and included lunch and a
small gift card to a local department store.
Program clinicians, were informed of their opportunity to participate in the project
during their regularly scheduled staff meeting. The clinicians were identified as those
41
who were directly involved with providing services to adult clients in the dual diagnosis
program. They were made aware that their participation was voluntary and that they
would be able to participate, if interested, during their regular working hours at their
office site. They were informed that the interview would be audio recorded with no
identifying descriptors and would remain confidential to any supervisors or managers in
accordance with the confidentiality agreement. The confidentiality of the interviews
served as an incentive for clinicians to answer honestly and openly in ways that can
improve their work within the dual diagnosis program. Seven staff members participated
which was the entire Adult Services team.
Data Collection Procedures
The clients were interviewed in a focus group setting at the site in which they
attend their program, with one researcher facilitating. Both groups were reminded of
their right to confidentiality and were required to first sign the consent to participate.
Both groups also had an opportunity to ask questions about the project prior to
participating.
Clients were asked 11 scripted questions with occasional prompting seeking
elaboration. The focus group was audio recorded and transcribed for increased
reliability. It was than synthesized and categorized for comparison and grouping of
common themes and verbatim quotes.
The focus group leader attempted to build a synergistic group discussion
addressing major issues while also seeking inclusion of minority opinions. The
researcher attempted to create a safe space where participants could feel comfortable and
42
free to engage in an authentic and genuine way. The researcher also emphasized the
importance of their role within this project as a way to improve the overall functioning
and effectiveness of the program. Clients were free to leave the group at any time and
were informed that they may debrief with their individual counselor should they be
distressed by the experience.
The participants’ right to privacy and safety was protected by the researchers’
confidentiality agreement, which outlined the project goal, participant role, and privacy
policies. The researcher and focus group members were the only individuals in the room
and had the door closed to outside individuals to ensure the privacy and protection of
participants.
Staff clinicians were interviewed on a one on one basis with one researcher present.
They were first contacted by the researcher, and then scheduled for an interview during
their regular working hours. They were informed, that they had the right to choose to
participate in the interview, and were informed that their decision not to participate would
not affect their employment with Adult Programs at CCHC. Clinicians who participated
were required to sign the confidentiality agreement and were given a copy for their
records.
Instruments
The focus groups consisted of 11 open-ended questions. The questions were
generated from elements within the DDCAT scale and the literature. The questions were
designed to stimulate thoughts, feelings, reactions, and ideas regarding the current
program as well as, ways to improve. The questions explored current attitudes and beliefs
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about the program procedures, function, and structure with a strong emphasis on the
current experience of receiving services as a client in the dual diagnosis program. The
researcher attempted to engage the clients in a free flowing discussion of their thoughts
and feelings.
The questionnaires were identified as having little to no psychosocial risk or
discomfort for client participants since the questions pertained to experiences with the
program as opposed to sensitive topics. It was anticipated that responses to these
questions might bring about minimal stress depending on the experiences within the
program as well as personal struggles. All client participants knew each other previously
and had participated in at least one or more group discussions potentially improving their
comfort level.
The clinician interviews consisted of 12 questions. The questions were also
designed to illicit feelings, thoughts, reactions, and ideas regarding the current program
experience as well as, ideas regarding the future of the program and suggestions for
improvement. The questions pertained to clinician perspectives of the program and
services as they related to service to clients.
The researcher used an audio recorder to collect data from the interviews. Each
interviewee and focus group participant was informed of the use of the instrument and the
procedures used to protect their information including the storage of the recorder and
destruction of its contents upon completion of the project.
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Data Analysis
The focus group researcher synthesized the data into a written format by
transcribing the audio recordings. Due to one researchers’ unique relationship with the
agency (employed by CCHC) there were no identifying markers for staff information
which was kept confidential and only viewed verbatim by the other researcher. This
process enabled both researchers to participate in reviewing and organizing the
transcription looking for major themes, issues and concerns. Early themes were revealed
during a de-briefing session with the project advisor, and comparisons, with subsequent
interview date, were made to initially identified themes. This process is referred to as the
constant comparison method. The researchers developed an organized system of
mapping responses to develop common patterns and to draw meaningful conclusions.
Verbatim quotes were chosen that illuminated major themes.
Protection of Human Subjects
The Institutional Review Board process approved this project as exempt from risk in
the letter of approval #12-13-064.The participants’ right to privacy and safety was
protected by the researchers’ confidentiality agreement, which outlined the project goal,
participant role, and privacy policies. Each participant was informed of the
confidentiality agreement and signed the agreement before participation with this project.
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Chapter 4
STUDY FINDINGS AND DISCUSSIONS
Background
Interviews with staff were conducted to better understand perceptions, beliefs, and
personal recommendations regarding CommuniCare Health Center’s (CCHC’s) dual
diagnosis program. All seven staff members within Adult Services volunteered for the
interview with the incentive of improving the quality of their work in the program. The
interview consisted of one staff member and one researcher utilizing a semi-structured
instrument with 12 questions. Each interview was audio recorded and later transcribed
and organized into overarching themes and recommendations for overall program
improvement. One researcher, who was not an employee of CCHC, conducted the
interviews. Staff identity was protected.
Focus groups with current participants in the program were also conducted on two
separate occasions using eight semi-structured questions to facilitate thoughts, opinions
and suggestions about the program. The focus groups were lead by one researcher and
were also audio recorded in an effort to capture relevant information and intriguing ideas.
Once the transcriptions were completed, they were categorized into themes; both
researchers created a visual chart to find patterns and connections between each theme,
creating an organized and structured interpretation of the information collected. Specific
quotes from clients and staff were chosen to illuminate those particular themes and were
indicated in the findings.
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Overall Findings
Client Focus Groups
Client backgrounds based from agency records indicate that on average, the
Woodland location tends to serve more clients in the program than West Sacramento.
During 2012, the average group size in Woodland was 10, while West Sacramento was 6.
Client ages range between 20 – 56 years. Female focus group participants represented
33% in the West Sacramento group and 25% in the Woodland group.
Most are mandated to treatment by various entities such as Child Welfare
Services, Yolo County Probation, local courts and transitional housing programs. Clients
are often funded by Medi-Cal or indigent funding through a SAMHSA grant for people
who have limited to no access to health care. Clients on average stay in the program for
nine months before completion.
Both groups engaged actively in the focus groups and were asked 8 questions
relevant to the study. The Woodland group took a little more time to become
comfortable with the focus group process; however, each group used examples of
specific experiences to substantiate their input and often appeared passionate and excited
in their responses. The Woodland group especially became vocal when the opportunity
to discuss program shortcomings was presented. One participant left the room after
becoming upset after discussing his dislike of a particular clinician in the program. The
impact of this reaction was unsettling to other focus group members however; there was
agreement by several other members that the participants’ perception was shared overall.
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The West Sacramento group reported only positive feedback about staff and
engaged in a lively discussion about the ways they feel supported including “feeling
listened to” and “cared about.” This group appeared to share a level of group intimacy
that was not present in the Woodland group. The West Sacramento group is, on average,
smaller than the other is which may have bearing although the group also shared many
examples of peer interactions outside of the program and strongly emphasized their own
sense of community as well as the need for community and peer support to be integrated
into the program.
Staff Interviews
Participants consisted of all staff members involved with providing direct services
to clients within the dual diagnosis program. All staff participants have master level
degrees in social services and/or humanities. Three are associate clinical social workers
(ASW), two are marriage and family therapists (MFT), and two are marriage and family
therapist interns (MFTI). Two staff members are male and five staff members are
female. One female staff member holds two master’s degrees in marriage and family
therapy as well as public administration. Staff ranges in professional experience; one has
five years, two have six years, one has seven years, one has eight years, one with ten
years, and one with eleven years. One staff member disclosed that she, herself, was a
client within a dual diagnosis program in the past. Some staff members hold specific
certifications and trainings pertinent to the work they do with the client population.
These areas of expertise include mental health, substance use, trauma-focused, strengthbased practices (SBP), Harm Reduction (HR), Motivational Interviewing (MI), Cognitive
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Behavioral Therapy (CBT), and Moral Reconation Therapy (MRT). These trainings and
certifications are integral elements in providing effective services to the dual population.
Specific Findings and Interpretations
Client Focus Groups
There were five main themes synthesized from the focus group participants that
are generalized into the following categories; peer support, group environment, resources,
community isolation, and engaging activities. Themes were consistent across both
groups. Discussions were expansive regarding substance use issues with participants
often expressing well-informed views on their own personal and collective needs for
treatment. They often used recovery language, personal examples and 12-Step
philosophies to support their perspective.
Neither the topic of substance use nor mental illnesses were directly used in the
focus group questions allowing for natural responses regarding overall program focus and
conditions. The resulting discussions were significantly limited, with little to no mention
of the topic of mental illness or co-occurring illnesses. Participants spoke loosely
regarding their mental illness only in the context of situations in which they made the
distinction between themselves and the rest of the recovery community. No participant
directly identified himself or herself as a person struggling with co-occurring illnesses.
The meaning of the absence of mental illness discussion is significant for the
program and may be an indication of an over emphasis on substance use treatment goals
versus mental illness treatment. This presents a noteworthy challenge to the program’s
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current capacity for dual diagnosis treatment, about, program focus, philosophy and
goals. It should also be noted, that a similar finding emerged from the staff interviews.
The five main themes delineated from the focus group sessions represent an overarching overall theme on the importance of relationships. Whether the discussion
focused on peer support or access to resources, there was significant importance given to
the role of a trusting and non-judging relationship with someone who shares common
values and experiences, and can offer valuable assistance. Areas of assistance expected
from a provider included case management, referrals, crisis counseling, relapse support
and follow up for those clients who struggle with attendance.
Peer support. Although peer support is often considered a key component of
most treatment programs, focus group participants were specifically interested in peer
support as a means to relate to others and to find things in common with. Participants
identified several ways in which they would participate as a peer, also indicating a need
for purposeful and supportive roles for themselves.
Peer support occurs when people share common concerns or problems in an effort
to promote emotional support and coping strategies. It has been used most commonly in
mental health recovery models as a way of creating natural networks that are person
centered. Peer support places value on life experiences reducing stigma and creating a
culture of acceptance.
This notion was a common theme in the focus group discussions and, was cited as
being an important aspect to program improvement or “what is missing from the
program.” One participant noted that having shared experiences with staff in particular,
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served as “proof” that they “went through the same thing I did.”This statement signifies
the importance of disclosure as a means for giving clients hope and feeling a sense of
shared connectedness.
Peer support was also discussed as a way to help clients move through the often
difficult process of entering treatment and following through to completion. Many focus
group participants gave examples of times where peer support would have been
beneficial to have early in the program and after graduation from the program. One
participant shared that she might have stayed sober the first time, if she could have
reached out to a peer, however she felt too embarrassed. “Once you leave here you lose
these friends, this is your circle of power.”
Suggestions were made about improving client participation in easing the stress
and pressures of being a new client in the program. “We can tell people how everything
is safe, and what things they might expect to help ease the emotional stuff, to get past all
the crazy.” This perspective not only supports newcomers but also becomes a way to
provide purpose and a sense of belonging for those who have already gone through the
treatment experience.
Peer support, for people with substance use and mental illness, has long been
provided by consumers who have lead self-help and support groups such as Alcoholics
Anonymous. Many have provided service work as sponsors, case managers, and crisis
workers in a variety of settings. This perspective was a consistent theme in each focus
group, as participants often made specific suggestions about ways to incorporate
themselves into the program in a more meaningful way. One particular participant
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expressed his desire to share a special talent to his group, “I wanted to bring in my bonsai
trees and teach how to take care of them, I have been doing this for 25 years so I would
love to teach others, something to take away from here.”
Isolation from the community. It is significant to note that the programs are
located in small rural communities with populations less than 60,000. Woodland serves
as the county seat of Yolo County and houses most of the county offices including the
courts. West Sacramento is contiguous with Sacramento with only the Sacramento River
between them. Resources in the community have suffered in the last several years with
the loss of the only detox facility and cut-backs to mental health services previously
provided by the county. Clients in a mental health crisis must be severely at risk to
access services and those who are not in an immediate crisis state, are often left with
minimal resources. As a result, clients with co-occurring illnesses have little to rely on in
the community.
When participating in outside supports, participants expressed concerns about the
traditional 12-Step community such as Alcoholics Anonymous or Narcotics Anonymous
(AA/NA). Common statements made relating to the comfortability of going to meetings
were: “you go to a meeting in a room where you are around a lot of parolees and it
doesn’t feel as safe.” Others noted that, “12-Step meetings can feel more isolating.”
Participants often identified concerns about not having any particular outside connections
for support. They expressed specific concern about the impact on their ability to stay
stable, and clean and sober without the outside support. Participants also suggested the
agency should consider providing a space for a 12-Step meeting, to occur regularly on
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site. They offered unique ways in which they could be in charge of facilitating it, as one
person stated, “People in the third phase should just run an NA/AA meeting here in this
facility.” Participants often referred to various aspects of the 12-Step meetings they
found valuable. They expressed an overall desire to incorporate elements of the meetings
into their treatment however; there was a specific focus on having the actual 12-Step
meeting on site in an environment they value as safe and structured.
There was some discussion about the actual effects of the community
environment on the participants themselves. The level of stigma in the community is an
important indicator of where clients will seek out resources and support. Several
participants indicated that they mostly found safety at the agency. This infers a sense of
disconnection and distrust of the community at large. Their sense of isolation mirrored
an increased dependence on the program to meet those needs.
Group environment. Clients spend most of their time interacting with each other
and staff in the group environment, at least 4 ½ hours per week. It serves as the primary
modality of care and has multiple functions for the clients and clinicians. Focus group
participants noted several positive aspects of being part of the group including feelings of
inclusiveness and safety. They also noted that they struggle with the group to stay
focused and attentive without becoming bored and disengaged. Several participants
commented on how they find the group to be a “safe haven” away from the risks of using
and chaos, as one participant stated, “we look forward to seeing each other and hanging
out in a sober place.” Another stated it was as simple as “it gives me something to do to
keep my mind off drinking.”
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For many, the group environment served as a place of bonding where there was
little chance of being ostracized, “we don’t exclude anyone, we make new people feel
comfortable” and another who shared, “everyone shows concern about each other, if one
isn’t here we ask why.”
The notion that the group provides a safe place to be was also interpreted as a
place where there is no form of judgment or stigma. The idea that “we are all in the same
boat” became a familiar mantra from many in each group. Participants shared several
examples of feeling a sense of closeness and bonding with each other. Even the
Woodland group, who had shared the experience of disliking a particular clinician, found
the group overall to be an important component of their care. “When I leave group, I feel
like my spirits are better.”
Participants gave many examples of ways to improve interaction in the group
environment suggesting that their relationships are only a part of the importance of a
group atmosphere. Examples of ways to improve interest and interaction were also
shared as important to preventing boredom and disengagement. Participants identified a
desire to have, “something to look forward to” such as fun activities and events, even
having coffee or watching videos. Having fun and laughing, was noted as important to
participation rather than just “passing the time.” Most participants became excited when
discussing ideas for improvement; they displayed a sense of investment in their group.
One person noted that, “taking your mind off of things like sharing something you are
passionate about doing” as significant, while another noted that it was as simple as
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making activities that kept his interest since, “by the end of the hour and a half all I’m
thinking about is that cigarette and it’s distracting.”
For the agency the challenge of providing customization of services based on
client needs and values can be difficult, however participants referenced this as an
important value for instance, one person stated, “What I love about this place is that they
take into account our lives and don’t sum us together as one big group.” Another
participant suggested having a “council of members who can go to staff meetings,” to
represent the group’s interests. Overall, there was a desire to have a focus of care
designed to meet the most common types of needs, but also having the capability to
respond to individual client choices and preferences.
Curricula and activities. “Staying awake is hard sometimes,” was a comment
made by one participant describing her own desire to engage, yet finding herself
struggling with “boring” activities or topics discussed in group. The focus group
participants introduced the idea of working on the program’s providing services that
clients are likely to benefit from and decreasing use of ineffective materials that are only
relevant to some. Participants also identified need for current information based in
research even suggesting that they participate in seeking the information to contribute.
Participants discussed the importance of different learning skills and being able to
integrate those skills with the curricula. Both groups clearly made the point that more
“hands on” learning activities are needed. Concern about repetition of curricula from
other programs and relevance to individual participants were shared. Participants
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suggested incorporating workbooks, journals and visual learning aids that would provide
more “clarity” about “what to do when you face certain problems.”
This particular topic was the only time in which the participants discussed mental
illness specifically. It was introduced more as a means of learning information about
their particular diagnoses, potentially in an effort to understand it better, although one
participant in particular made the reference that he would like to “have more information
about his illness and learn how to overcome it.”Perhaps this is also another indication of
the large discrepancy around the goals of the program and its secondary, rather than
integrated focus on co-occurring illness. As was indicated in the literature, the
integration of substance use and mental illness treatment continues to be a challenge for
many programs. It is especially indicated when programs providing substance use
treatment attempt to shift over to an integrated system of care.
Resources and case management. Many participants indicated, both, a lack of
resources and of access to information about resources. They cited that the most help
they receive on resources is coming from peers in group. As one person stated, “I was
having problems with housing and talking about it in group helped me, I may have things
I need but don’t know how to say it, so having a library or list of resources can really help
me.” Another participant spoke of how he had trouble with transportation reporting, “My
struggle is getting here, I used to get free bus passes and now I have already missed 5
days and that’s because I couldn’t get here from Davis.”
Limited access to resources was the most common area of concern. Issues such
as dental care, prescription medications and financial struggles were viewed as reasons
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clients fall out of treatment. “When you fall off it is really hard to suck it up and admit to
it.” The connection between resource acquisition and success in treatment are strongly
correlated for participants who clearly believed that better access to resources could
substantially improve their treatment experience.
Participants suggested having extra staff or peers that could provide additional
help outside of group and counseling. An important connection was made between
providing relevant resources and immediate assistance before it is “too late”. Participants
noticed that resources were limited but also believed that they just did not know about
services that may be out there. Again, this stated concern is another example of the
isolation within the community especially for those with co-occurring illnesses.
Participants believed it was a failure on the part of the agency for not knowing the
resource environment.
Staff Interviews
Mission statement. Two questions addressed the staff’s interpretation of the
agency’s mission statement, as well as their perception of the shared clarity of the mission
statement. Responses indicated that the majority of the staff understood and defined the
agency’s overall mission to serve adult clients who were experiencing a range of mild to
moderate mental health issues that complicate and contribute to their drug use. The
majority of staff members elaborated on the mission statement to include themes such as
“treating the whole person,” “serving those who are underserved/without access to
services,” and “serving everyone regardless of their inability to pay/doesn’t turn anyone
away.”
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The clarity of the mission statement was shared between staff, with responses such
as “we all have a vested interest”, and “we all come together and our goal is to help as
many people as we can.” Two staff members felt that there was a difference in the
application of the mission statement identifying it as, “not anything relevant to what I do
on a regular basis,” and “we are all doing our own thing; in general we all have the
general mission but we all do it our own ways, our roles are hugely variable.”
There is a general understanding that the purpose of the program is to serve clients
suffering from co-occurring illnesses, in spite of the complexities of the client’s needs or
program difficulties. Most staff agreed that there was a common goal yet different
directions with which to reach that goal.
Defining dual diagnosis treatment. Two questions were developed to illicit an
interpretation of what dual diagnosis treatment means, as well as what is needed in the
program to address both substance abuse and mental health disorders. The majority of
the staff responded that dual diagnosis treatment means, “to treat both mental illness and
substance abuse disorders consecutively”, suggesting an overall belief in integration as a
valuable approach to the services.
Many also indicated an interest in providing individualistic, person-centered care
recognizing the diverse and complex issues clients come into treatment with and wanting
to have more ability and flexibility to cater to specific needs. “Looking at the individual,
their trauma, and finding resources that are useful “was one example of the desire to treat
clients as individuals but also have the important resources to offer them. Overall, staff
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suggested a strengths-based perspective that does not induce stigma or apply “cookie
cutter” approaches for clients. One particular staff person indicated a strong perspective
in this area stating:
I don’t think that there is a dual population, [the term] dual doesn’t even describe the
challenges that people are coming in with. I really don’t see that there needs to be a
separation, the separation feeds into their own belief that there is something so
wrong with them that not only are they at a treatment program but they are in a
specialized treatment program for people that are even worse than the other people
here. I really don’t think that is helpful, the name is horrible which focuses on
diagnosis and my work focuses on humans. I think the whole thing is stigmatizing,
diagnoses don’t matter and grouping them into categories doesn’t help, we are
supporting people not labeling them (Staff member 6).
Staff responses strongly indicated the value of integrating services and treating the
whole person, meaning both their mental illness and substance use disorder at the same
time by good professional staff. Many felt that they were already doing so, but with very
limited resources. Their desire to improve the integrity of the services was exemplified
by several staff and connotes a hopeful atmosphere with which change can be made.
Community involvement. There are two questions in the interview pertaining to
the staff’s perception of community involvement. One question asked the staff to
interpret the program’s role within the community. Staff overwhelmingly agreed that the
program’s role within the community is very important and that more efforts should be
made toward improving it. Staff member 3 reported, “we are the only dual program in
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the entire community” when emphasizing the program’s importance, later explaining that
the dual program “catches those who have nothing else.” Overall, there was a consensus
that the dual diagnosis program is only “scratching the surface” in reaching out into the
community.
Clients are encouraged to participate in the community, yet staff seem to have
differing ideas of what community participation and integration look like. Some staff
members feel that supportive community services differ on a client to client basis,
whereas others felt that specific supports for substance use, especially 12-Step meetings,
are helpful and encourage their clients to connect to these supportive community
services. In general, the majority of staff felt that there are “limited resources” within
Yolo County making it difficult to access services even if it is a goal for improvement.
Assessment tools. Three questions addressed staff interpretations of current
assessment tools, treatment planning, and treatment interventions. Most staff described
the current assessment tool as basic, generic, and good when screening for depression
and/or anxiety. Most staff also reported adding their own supplemental questions to
further screen clients and obtain a more accurate understanding of individual treatment
needs. One staff member suggested:
Assessments should be an ongoing process; it should be stretched out to three or four
sessions. I worked with a client for six months, did their assessment, had them in
group, then at the six month mark they dropped some bomb shell and I’m like how
did I not know that (Staff member 3).
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Staff member 2 responded that the current screening tool “asks if you have
symptoms specific to depression but not another tool for other mental illness.” Several
staff members referred to the current assessment tool as being good but basic, and were
hopeful to incorporate more in depth tools to assess for other mental illnesses.
Treatment planning. The majority of the staff agreed that treatment plans were
lacking a strengths-based focus. Staff member1 indicated, “Treatment planning is more
Medi-Cal compliant which isn’t strength-based, but used for billing. Sometimes it is
strength-based and sometimes not; the deficiency is in the wording.” Another staff
member responded with “our treatment plans tend to be cookie-cutter, which is okay
because people are predominantly diagnosed with substance abuse and their ultimate goal
is abstinence.” Overall, staff felt that the treatment plans were not strength-based, and
only addressed broader treatment goals rather than more individualized personal goals.
Role of family. When asked about their perceptions on the importance of the role of
family in the treatment process all staff members agreed that there was extreme value in
the importance of including family in treatment. Staff also recognized that this is a big
area for growth in the program. The definition of family for most was loosely identified
and inclusive of a variety of supportive relationships including close friends and even 12Step Sponsors for family sessions. Others believed that education for supportive friends
and family about mental illness and substance use issues were crucial to providing
effective treatment.
Recommendations and areas for growth. The final question on the interview
addressed the staff’s recommendations for improvement of the program. The question
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proposed that staff think forward two to three years in the future and imagine what
successes they would like to see. This question produced several recommendations for
program improvement that would not only benefit the client experience but also support
staff with providing effective treatment. Two major themes were addressed, relating to
community integration and providing a holistic or multi-disciplinary team of
professionals. Efforts toward community integration involved recommendations for peer
supported groups, volunteer opportunities, and providing outreach services and education
for clients. Other recommendations included implementing a multi-disciplinary team of
professionals. These professionals would include a case manager as well as, responsive
and cohesive medical, psychiatric, and medication management services.
When looking at the current assessment tool used for screening mental illness and
substance abuse concerns, staff feel that a more detailed assessment can be utilized to
gather more accurate information. Many staff mentioned they were optimistic for
implementing the GAIN assessment tool, which staff member 2 believes is “more
cohesive, useful for disorders such as bipolar, schizophrenia, and anxiety.” Staff member
4 responded, “GAIN is an extremely long assessment tool, but in the end it provides a
very detailed printout that categorizes where the needs are and the current assessment
tool doesn’t even do that.” One concern about the GAIN is that it is an extremely long
assessment, according to staff who has utilized this tool in the past. The GAIN does;
however, seem to provide more clarity on what kind of treatment interventions are
needed to address the varying needs of the dual diagnosis population.
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Providing family sessions where individuals can learn about their loved one’s daily
challenges was an extremely important consideration for improvement. Staff firmly
believes that when family members are provided with psychoeducation regarding their
loved one’s challenges and responsibilities in treatment that they can learn ways to better
support the client’s treatment and recovery goals.
Additional Findings
Staff
This study found additional themes throughout the staff interviewing process that
highlighted key elements recommended for overall program improvement. These
additional themes were grouped together by the researchers to provide an overall matrix
of staff program recommendations to improve the functionality and effectiveness of the
program. These additional themes involve issues related to community supportive
services, flexibility vs. consistency, diversity vs. predictability, community integration,
creativity, and holistic team efforts.
Community supportive services. Enhancing community supportive service
integration was a theme that highlighted the staff differences. The program currently
utilizes “support slips,” which require clients to attend supportive community events
related to their recovery. These slips are used to track an individual’s ‘efforts and is a
collaborative effort made by both the client and their individual counselor. However,
some staff find that these support slips are limited in terms of what type of supportive
efforts can be made to address a particular need as well as what efforts within the
community can be deemed as a support activity.
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Traditionally, the support slips were used to encourage clients to attend 12-Step
meetings within the community. Individual staff preferences played a role in the varying
opinions regarding support. Varying beliefs about the 12-Step model and its effectiveness
for dual diagnosis treatment was part of this discrepancy. For example, staff member 3
who was unsupportive of 12 -Step participation responded:
Before, we required 12 -Step meetings which weren’t always the best, but we forced
clients to go there which is unethical. Going to a 12-Step meeting exacerbates
paranoia for someone who has schizophrenia and who experiences religious
preoccupations and ruminations and obsessions and fears as a part of her
schizophrenia symptoms. She goes to 12-Step meetings here in Woodland which are
also religious based, she walks out of that meeting every single time believing that
she is going to hell and she spins on it and I still have to make her go? That’s dumb,
unethical and bad therapy (Staff member 3).
This response not only addressed the importance of client-centered approaches to
treatment, but also brought up the challenges of finding supportive resources for this
particular population in a small rural county with limited resources.
Staff members felt that the support slip’s intention on re-integrating clients into the
community was helpful, however, there was a lack of clarity on which activities count as
community support. To address the ambiguity, some staff members recommended
having a structured way of approaching community supportive services. There was a
consensus amongst staff recommending the implementation of case management
services. These services would provide more structure towards linking clients with
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community supportive services and help gain clarity on supportive activities. Staff
member 1 addressed the lack of clarity amongst staff as having a negative effect on
clients, emphasizing the knowledge base of community services differs from clinician to
clinician. This inconsistency affects clients who need a particular support within the
community.
Flexibility versus consistency. The contradiction between having flexibility to
provide services that supports a clinician’s theoretical orientation or interest versus
having a clearly defined structure with little room for individualization was a consistent
theme introduced in almost every area of discussion. Staff often had varying views on
how they would interpret a particular perspective of the agency and had strong opinions.
The following issues discussed were particular areas in which these contradictions
emerged.
Staff expressed concern regarding the need for a particular curriculum for the
program. They felt that by not having this it effectively contributed to the lack of
distinction between the agency’s two programs Outpatient Substance Abuse Recovery
Program (OSARP) and Dual Diagnosis. One member supported this claim with the
response:
The only difference between OSARP and Dual is that you place the severely
mentally ill in Dual. There is not much difference between the two programs,
sometimes we put all people with mental illness in the same group but it doesn’t
mean that we have a specific way of doing anything different. I feel like OSARP and
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Dual are similar in curriculum so having a clearer separation of the two would help.
Feels like you do the same in both groups (Staff member 2).
Other staff members emphasized the lack of mental health treatment interventions in
the program. Since there is no clear distinction between the curriculum for OSARP,
which is solely substance abuse treatment, and the dual diagnosis program, both
programs tend to overlap when providing treatment interventions. These treatment
interventions mostly emphasize substance abuse related issues, and mental health related
treatment interventions are not as integrated. One staff member responded that treatment
interventions “vary from client to client; it depends on how invested they are in their
diagnosis and what that means.”For some staff, this case-by-case approach provided the
flexibility they were interested in when working with clients. “Mental health symptoms
are really important to them but for others, they want to talk about their substance abuse;
so it is very individualized.” This response is an example of a client-centered approach
that focuses on what the client wishes to work on, however it could also potentially leave
the key element of co-occurring illness treatment.
Another area where contradictions were identified was in the utilization of treatment
plans. Some staff members feel that the plans did not utilize a strength based approach,
and used language solely to satisfy strict billing requirements. Many of the staff also
provided their own utilization of treatment plans that reflected the work they do with their
clients. There is, therefore, inconsistency of treatment plans due to staff’s varying styles
of organization and interpretation. Some staff reported using their own language to alter
the treatment plan so that it will meet the needs of their client, others will create a plan
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that meets billing requirements but will set aside a separate plan to meet the individual
goals that clients set in treatment. Staff member 4 responded:
We are not using a cookie-cutter treatment plan so everyone is different. I try to look
at the client needs and account for those in the initial treatment plan. I have worked
in previous agencies that used a standardized treatment plan which sounded
wonderful but oftentimes were unrealistic. We currently have flexibility and I think
that is a good thing (Staff member 4).
Staff member 5 responded, “I think we aren’t as good at incorporating individual
goals; like getting a driver’s license, going back to school, they are just too broad and we
aren’t good with incorporating those goals in their treatment plans.”
There was one question in the interview asking the staff what the most meaningful
elements of the program were for both the clients and themselves. The staff responded
that the group process was the most meaningful, emphasizing the value of peer support
within the group process. A few staff members emphasized how they value the flexibility
and lack of structure within the group that accentuate the meaningfulness of the process.
Another question asked if the treatment focuses on specific interventions related to
the treatment of dual disorders. The majority of the staff recognized that treatment
interventions varied amid staff but generally, all staff provided strength-based approaches
to treatment. There was a split between staff members who value evidence-based
practices to achieve more structured approaches, and other staff members who value the
lack of structured approaches and preferred flexible treatment interventions that were
creative and individualized.
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Diversity versus predictability. Other staff members feel that there is a lack of
training amongst the staff in regards to providing effective interventions and utilizing
therapeutic techniques related to the needs of the dually diagnosed. Some staff members
have worked with the dual diagnosis population from previous work experience, whereas
others may have limited work experience. Staff also differs in expertise from their
varying licensures and educational trainings around mental health and/or substance abuse
related services.
The variations in staff qualifications and perspectives indicate a challenge for
incorporating curricula that staff can not only agree on but also have the appropriate skills
and training to implement. Staff member 4 responded, “We do okay with the addiction
stuff, but we have staff that haven’t been doing work with mental health in a long time.
Training…is a good opportunity for those people.”
A key element of the curricula involve the types of treatment interventions that staff
feels best fits the dual population and their varying needs. Staff felt that there was no
specific, cookie-cutter treatment intervention used within the dual diagnosis program.
There was, however, a significant difference in responses amongst staff when it came to
utilizing evidence based practices. Some staff felt that structured evidence based
practices would not only help distinguish the separation between the dual program and
OSARP, but would also create a way of measuring and evaluating the specific treatment
interventions used and their effectiveness. Other staff disagreed with structured
interventions, emphasizing the value of flexibility and creativity within their approach to
addressing client needs. For instance, one staff member stated:
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We can improve interventions by having a focus and more structured plan for groups
and one on ones. Having one theoretical framework and sticking to it will not only
make it easier but it can also be better to track outcomes (Staff member 2).
Another staff member paradoxically stated:
We can improve interventions by addressing people’s specific diagnosis and their
symptoms, with more attention paid towards the whole person and their
spiritual/moral/physical health, interventions the clients can craft themselves, maybe
we don’t utilize evidence based practices for every client but we have to offer it
(Staff member 3).
Overall, staff is in consensus when it comes to utilizing several different treatment
interventions; however, the difference in responses raises questions regarding the use of
evidence-based practices.
There was also difference amongst staff in terms of how family is defined. Some
family members of clients may not be supportive, so forcing the family to be involved
may not be the best treatment modality. Some clients may refer to close friends as their
family, and some staff members feel is important for those individuals to be included
within treatment. Staff member 4 reported, “Relationships are the key to mental health;
the need for satisfying relationships affects the client’s functioning. I feel like it should be
a requirement to involve the family.” On the other hand, one staff member responded, “A
lot of the times, people are stigmatized by their family. Family education is super
important but only if clients want their support. It all goes back to goals; I think clients
have the right to privacy.”
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As mentioned earlier, staff disagreed on several aspects of recommendations to
improve the work they do as clinicians. One example of individual preferences included
implementing structured evidence based practices versus keeping the loosely structured
and flexible treatment intervention strategies. The differences between staff preferences
here may be individualized, with different staff members valuing different aspects of
their clinical role when working with the clients. Some staff members felt that providing
a structured approach would actually help the consistency of treatment modalities
amongst the clients, to provide better and more successful outcomes that are reliable
amongst all clinicians. Other staff members felt that too much structure is not a
meaningful approach when addressing the varying needs of dually diagnosed individuals.
Since clients experience mental illness and substance use disorders at the same time, their
needs vary from individual to individual therefore utilizing one standardized approach for
all clients may not address all of their needs.
Staff also differ individually within their training and clinical experience before and
during their position within Adult Services at CCHC. As noted earlier, staff members
vary in their years of experience and their specialized certifications and licensures. Staff
member 6 responded, “Staff need to be better trained, it is really hard to work as a team
when staff has a lack of training.” The staff have various areas of expertise and
education but they all seem to clearly understand the agency’s mission. The means and
methods of how staff provides these services remain flexible, with variations of treatment
interventions being utilized to address the client’s individual needs. One Staff member
speaking with regard to the rest of the staff claimed, “We are strength-based. We have
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shifted towards a more professional staff, which creates a higher standard.” Overall,
there seems to be a standardized approach amongst all staff that includes strength-based,
client-centered, and recovery-oriented practices to best support the clients at this time.
Staff also differed in their individual preferences when it came to meaningful
elements within the dual program. For example, many staff valued the group process and
peer support as the most meaningful aspects of the program.
I love group work and have always been partial to group work. To foster a
community where people can talk about their using in an environment of support and
respect is very important; we continue to make it a safe place to come in (Staff
member 2).
Other staff members felt that individual counseling was the most meaningful element
of the program.
I love the fact that we get to meet with clients individually every week, to have that
full hour and get a chance to really connect is huge and makes a big difference. So
much can happen in that one hour whether it is phone calls or coordination of care
(Staff member 5).
Overall, staff agreed that the most meaningful elements of the program are their own
interaction with the clients as well as peer to peer interactions.
Community integration. Several elements were recommended for program
improvement; such as implementation of peer-to-peer mentorship, community outreach,
volunteer opportunities, and creating a community center for clients. Staff believes that
these elements can encourage client engagement within the community as well as
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improve recovery follow through finding meaning and purpose as members serving the
community. Staff member 6 responded, “we need to immediately start planning their
goals for discharge; intake planning is also discharge planning, focusing on their larger
goals to promote motivation.”
This comment suggests the importance of getting clients linked into the community
to prepare them to experience the real world in a way that motivates recovery. The idea
that individuals can practice and engage in activities in a sober and healthy way is an
integral part of the therapeutic process. For example, staff member 3 supports this claim
in regard to physical activity, “Implementing an activity where folks who have
experienced trauma can learn how to be in their body in a positive way, the power and
integrity of just being in your body is huge.”
Peer to peer mentorship was recommended by staff to fill in certain gaps within the
program. One gap in particular was to reduce the rate of recidivism by offering alumni
programs. One suggestion was to provide groups where alumni of the dual program can
come back and offer their support on a peer-to-peer level. Staff believes that this kind of
engagement and connection is meaningful.
Volunteer opportunities in the community as well as within the agency were also
recommended as an integral part of community integration. Clients linked with volunteer
work help them feel a part of their treatment by empowering their role as a contributing
member of society. Staff member 3 was recently trained in a specific type of training
(MRT), which emphasized community integration through volunteer opportunities. The
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staff member voiced excitement about being able to incorporate this element into the
programs.
Volunteer opportunities also support peer-to-peer relations. Staff member 2
supported this claim with the response, “People who come together with the same
problems and issues find cohesion amongst others and realize ‘hey, I’m not alone in this;’
they find courage and hope from other people and are not judged or ridiculed.”
Volunteer opportunities for clients can also address outreach to inform the
community of the dual program and what services are offered. To support client and
alumni efforts to continue community engagement and integration, they can become
community representatives of the program to educate the community as well as promote
services and accessibility. Volunteers can educate the community to advocate for not
only themselves but for others who experience similar diagnoses; these efforts can reduce
the amount of stigma from the community. Outreach can allow volunteers to take on
leadership roles, finding community members who can benefit from the dual program as
well as offer networking opportunities for client integration.
“When doing discharge planning, we need to have a place they can go and have
something to do, something that they can invest in [so] that they are giving back whether
it be mentoring, volunteering, or getting a job back.”
A center for client and alumni access and opportunities, that help connect them with
the larger community, was suggested as being extremely beneficial.
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Holistic/Multidisciplinary team. Another important theme for staff involved the
incorporation and facilitation of a holistic team of professionals. The team would include
a case manager, medical professional, and a psychiatrist as part of the professional
clinical staff serving the needs of the dual diagnosis population. The case manager would
serve as a referral specialist, specifically linking the clients with community services. All
staff agreed that case management was necessary.
We can always improve the amount of resources to clients which is where a case
manager would work, have that person focus on those resources and integrating our
clients into those resources would be awesome. Right now, it is counselor-bycounselor knowledge based but not every counselor has the same knowledge base,
which is inconsistent between clients (Staff member 2).
The case manager would serve as a way to increase community integration as well as
assist clients with other needs so that clinicians can focus more on the mental health and
substance abuse issues during their one-on-ones and groups. Clients will also be able to
access the same information from one resource, maintaining consistency.
A medical professional on the team currently exists in the program, yet staff felt that
the service should be increased. This professional can provide education about the
physiological, biological, and neurological components of client mental illness and drug
abuse. Being able to have direct access to a medical professional and having a well
developed relationship with that person (or persons) can be instrumental facilitating
productive and positive medical appointments.
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Increasing the accessibility of the psychiatrist was highly suggested and an important
component that was missing. “I think a psychiatric assessment should be standard for
clients who are just coming into the program. There should be collaboration to assess’ for
lethality. Also, staff mentioned that following up with a psychiatrist every three months
is just good protocol.” Many staff felt that psychiatric support when conducting
assessments would be extremely helpful when diagnosing and treatment planning.
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Chapter 5
DISCUSSION
Summary of Study
The purpose of this study was to evaluate the strengths and weaknesses of dual
diagnosis services in an adult outpatient substance abuse treatment program. The
researchers based their study from CommuniCare Health Centers (CCHC) in Yolo
County, California. The researchers specifically targeted the Adult Services Dual
Diagnosis program to assess, the perceived strengths and weaknesses of the outpatient
dual diagnosis substance abuse program, and secondarily, to determine the implications
for improvement.
Eight staff members and fourteen active clients involved in the Dual Diagnosis
program volunteered to participate in the study. The staff members received an interview
with twelve questions pertaining to their perceptions of the overall program functionality.
The questions addressed specific elements of the program to generate implications for
overall program improvement. The clients participated in two focus groups at separate
locations and addressed eight questions pertaining to their personal experience, attitudes,
and perceptions of the program’s functionality as well as implications for improvement.
All interviews and focus groups were audio recorded and later transcribed by the
researchers; the data was analyzed for emergent themes. The identified themes were:
community integration and engagement, team approach, curricula, peer-to-peer
connections, staff individualized preferences, and community supportive services.Each
theme was carefully evaluated by the researches to create a list charting recommendations
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for overall program improvement. The researchers utilized the Capability in Addiction
Treatment (DDCAT) rating scale as a supplemental guide to assist conceptually in what
was important to ascertain from practitioners and clients.
Recommendations
Specific findings indicated both strengths and areas of growth in the program.
Program strengths included overall agreement about the mission of the agency, a shared
understanding of the varying needs of the clients, and the commitment to integrate
substance use and mental illness services.
Both staff and clients found it pleasant and meaningful to work together in the group
environment and individually. Staff clearly agreed on the importance of providing
services that are strength-based as well as individualized to meet specific needs, even
within an evidence-based model. Clients reported that they would like to see more
engaging and informative curricula while staff would like to see the implementation of a
particular curriculum but without too many prescribed restrictions.
Both were also consistent in the belief that the agency must work toward developing
community relationships as a central aspect of full service care, with the agency thought
of as the main change agent in being able to create this service. Both sides discussed, in
depth, the meaning of having increased resource access, volunteer opportunities, and
meaningful activities outside of the agency setting. Concerns about the ability of the 12Step community to provide community support was noted on both sides, and identified as
a conflictual resource for both clients and staff. This is unfortunate since 12-Step
programs can also be helpful to many. This area should be explored further and, perhaps
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the agency should implement a Dual Recovery Anonymous (DRA) chapter to create a
safer, less stigmatizing support group for clients and a meaningful resource for staff.
Peer oriented support was discussed by both staff and clients as a means to engage
with the community, with one another, and for providing an opportunity for clients to
develop a positive and productive role. Significant effort can be made in this area. Both
clients and staff agreed that peer to peer support is especially important for incoming
clients as well as those who can serve as a role model for others. Having the opportunity
to offer support to others based on personal experiences can contribute to improved selfefficacy and is especially significant for those clients who are transitioning out of the
program and looking to establish meaningful roles outside the program. Efforts should
be made to establish peer supports throughout the duration of the program by investing in
training for such skills as case management, peer group facilitation or even in as simple a
role as alumni coordination. Investing in and recruiting clients to establish themselves in
these roles upon completion of the program provides opportunities for the agency to
integrate consumer supported roles. The recovery model organizations support these
kinds of innovative efforts.
Efforts to increase community resource integration should also be considered.
Both clients and staff pointed out the value of resources such as housing, transportation
and benefits. Clients often found themselves negatively impacted by limited access to
resources and staff found them feeling helpless in being able to assist them. These
dilemmas can be addressed in two ways. First, it is necessary to improve staff awareness
of already existing community services and ancillary programs that can be coordinated
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into the care of the clients in the program- potentially in a client directed care plan.
Secondly, the agency can collaborate with the outside community to stay aware of the
changing needs of the community and to play a role in assisting clients to establish
relationships as they end their treatment episodes and re-integrate. Community
connection also serves as an important factor in countering the effects of stigma for
clients who have often little trust in their communities.
The challenges of the program include these areas: curricula, clinical tools, resource
knowledge, and access to a multi-disciplinary team.
The need for consistent curricula was clearly agreed upon; however, the type of
curricula to be used could be quite controversial. Evidence-based Practices (EBP’s) have
pertinent value to programs in terms of offering a clearly defined model of care that is
geared toward a particular treatment philosophy. EBP’s are generally rich in research
data and offer a specific format that when carried out to fidelity can provide important
measurement tools and outcomes. These outcomes often provide programs with much
needed information for grant applications and funding options.
On the other hand, EBP’s do not allow for much flexibility when implemented to
fidelity and are often based in research that is centered on populations that may differ
from the population served in the community. Staff members had mixed feelings in
whether they would like to implement an EBP into the program since it can largely
reduce flexibility, which staff members valued.
Useful and available clinical tools were identified as an area of growth to the
program. Staff were not consistent in the way they used the tools, nor were they aware
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of other tools that could be used. Often staff had developed their own preferences for the
use of assessment, treatment planning, and diagnosing. Most seemed comfortable in the
way they implemented the program’s tools but also saw an opportunity for improvement
and training. Several staff were looking forward to the implementation of a new
assessment tool called the GAIN in which they believed they might get better outcomes
for treatment needs and diagnostic criteria for mental illness.
Some clinicians believed that they would benefit from having a multi-disciplinary
team for support. This team would include medical professionals including a psychiatrist
and case manager. Specialized services were acknowledged as necessary to improve the
overall care of clients. They were also viewed as important to allowing clinicians the
time to focus specifically on treatment issues while providing access to other services that
may improve client stress.
Incorporating family into the program was highly valued by the staff that recognizes
the importance building relationships with their clients support people and loved ones.
There was some discrepancy regarding the definition of a support person or family
member, however, overwhelmingly the staff viewed the lack of consistent family practice
as an important missing component of the program.
The current strengths of the program are building blocks for the agency. The
overall finding of comfortability and safety at the agency speaks to the ability of staff to
engage the clients, listen to them and express care and empathy. The staff emphasized
the ability to connect with participants on a genuine level.
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The sense of comfort clients experience in the program could be capitalized upon
by establishing other services that are important for support such as 12-Step meetings on
site or a community area where clients can come to visit with each other for coffee or
informal interactions with counselors and other staff. The importance of relationships
should not be underestimated, as it was clearly a key component of engaging clients with
the program. These elements may affect client success with the program.
Most limitations to program enhancements can be addressed by developing a
clearly defined structure that establishes a framework and context for providing services.
Maintaining focus on the integration of services by making substantial efforts to balance
the current focus on substance use issues toward a more holistic and client centered
approach to co-occurring illnesses must be a stated goal.
The Dual Diagnosis Capability Assessment Tool (DDCAT) available to the
agency through SAMHSA’s online resources would be an important step toward
thoroughly assessing the agency’s capacity for dual diagnosis enhanced services. The
DDCAT index can be easily conducted, and provides a framework for an evidence-based
model that can be implemented in order to provide maximum outcomes that are
measurable and systematic. The DDCAT scale can provide an overall rating on 35
program elements including Program Structure, Program Milieu, Clinical Process,
Continuity of Care, Staffing and Training. Each dimension provides a score, rating
services along a continuum of from Addiction Only Services (score of 1) to Dual
Diagnosis Capable (score of 3) to Dual Diagnosis Enhanced (score of 5).
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Conducting the DDCAT can provide a base of information for conducting a
structural critique for implementing the change process. This process would assist the
agency to create specific goals and recommendations offered within the DDCAT to
improve functioning further up the scale toward Dual Diagnosis Enhanced.
Other approaches such as the Integrated Dual Disorder Treatment (IDDT) model,
can offer meaningful insights and follow up from the DDCAT outcomes. Developing
program efficacy by establishing and improving curricula, clinical services and on-going
training are a start. The IDDT website is easily accessible and can be reviewed for
suitability by the agency. It also aligns with the DDCAT focus and is geared toward the
integration of mental health and substance use care rather than a parallel or sequential
process, which is recommended.
Limitations
The study is limited in that the agency studied. The findings reflect a small number
of research participants and focus group data may be compromised by social desirability.
The information collected was qualitative.
Conclusion
The information collected by the participants reflected significant implications for
program evaluation and improvement. The perceived strengths and weaknesses of the
program were carefully and strategically identified based on specific comments and
recommendations of current clients and staff members. The questions asked were
developed as a means to illicit meaningful information relevant to program
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improvements. Recommendations were based upon the answers to the questions and
represent a genuine response to quality improvement.
CommuniCare's capacity to provide a dual enhanced program appears reachable.
The dedication and care of the dual diagnosis program staff is an important characteristic
of the program despite its limitations. The level of training and education is also
substantial and is an important characteristic of their capacity to serve the population.
Their input and the considerations from client input have strong implications for
improvement of the program’s direction in terms of program goals and structure as well
as clinical training and services.
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Appendix A
CALIFORNIASTATEUNIVERSITY, SACRAMENTO
DIVISION OF SOCIAL WORK
To:
Aliya Martinez & Christina Andrade
Date: January 30, 2013
From: Committee for the Protection of Human Subjects
RE: YOUR RECENT HUMAN SUBJECTS APPLICATION
We are writing on behalf of the Committee for the Protection of Human Subjects from
the Division of Social Work. Your proposed study, “Strengths and Weaknesses of Dual
Diagnosis Program: Needs for Improvement.”
__X_ approved as _ _X
_EXEMPT
____ MINIMAL RISK
Your human subjects approval number is: 12-13-064. Please use this number in all
official correspondence and written materials relative to your study. Your approval
expires one year from this date. Approval carries with it that you will inform the
Committee promptly should an adverse reaction occur, and that you will make no
modification in the protocol without prior approval of the Committee.
The committee wishes you the best in your research.
Professors: Maria Dinis, Jude Antonyappan, Teiahsha Bankhead, Serge Lee, Kisun
Nam, Maura O’Keefe, Dale Russell, Francis Yuen
Cc: Bein
84
Appendix B
Focus Group Questions
Introduction:
-Introduce researchers, project, and purpose of this research. Discuss
confidentiality agreement and allow for questions or concerns to be answered
about the project.
-Purpose: To encourage and invite group of participants to share their thoughts,
feelings, attitudes and ideas on the Dual Diagnosis program at John H. Jones
(JHJ) CommuniCare Health Centers (CCHC).
-Allow for participants to get food and beverages
Agenda:
-Invite participants to sit in a circle.
-Discuss the group process, and group rules to ensure the confidentiality and
participation of each member.
Question 1: What do you like the most about the program?
Question 2: What is your biggest struggle with the program?
Question 3: What could be done to help others gain better access to the program?
Question 4: What is getting in the way of this program being the best? What is missing?
Question 5: What changes would you like to see in the program? How can it improve?
Question 6: How have you changed since being in the program? What has worked for
you?
Question 7: What is the experience of being a JHJ Adult Services client?
Question 8: What is the experience of receiving group and individual services at JHJ?
Closing:
-Thank group members for participating, give member a gift card, and
acknowledge their role within this project.
-Allow members to respond to focus group process by providing an opportunity to
debrief with their individual counselor.
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Appendix C
Interview Questions for Staff
Introduction:
-Introduce researcher, project, and purpose of this research. Discuss
confidentiality agreement and allow for questions or concerns to be answered
about the project.
-Purpose: To encourage and invite staff to share their thoughts, feelings, attitudes
and ideas on the Dual Diagnosis program at John H. Jones (JHJ) CommuniCare
Health Centers (CCHC).
Agenda:
-Invite staff member to sit in a private office with researcher.
Question 1: How do you characterize the JHJ mission?
Question 2: To what degree does staff share clarity of mission?
Question 3: What does dual diagnosis treatment mean to you?
Question 4: What is the role of the dual diagnosis program in the community?
Question 5: In your opinion, what does the current program need in order to integrate the
treatment of both substance abuse and mental health disorders?
Question 6: In what ways do you find the current assessment tool effective in gathering
information needed to diagnose and identify the needs of the client? If so,
what is effective about it? If not, what would be your suggestion for changes?
Question 7: How do the treatment plans reflect the actual needs of the client and project a
strength based approach to goal planning?
Question 8: In what ways do the treatment interventions focus on specific techniques
related to the treatment of specific disorders? In what ways can the
interventions improve?
Question 9: How does the program currently encourage engagement in community
supportive services and make efforts to collaborate with them on a regular
basis?
Question 10: What do you think is important about the role of family in the treatment
process?
Question 11: What are elements of the current program that you find to be the most
meaningful for both you and the clients?
Question 12: Imagine it is two to three years in the future and JHJ Adult Services is going
to be recognized for its excellence. A reporter is interviewing you about the
clinic. You are proud of your work with the program, and excited to share its
success with the newspaper and the public. What is happening in the program
to make you so excited? How are people interacting? What changes or events
have made this success possible?
Closing:
-Thank staff member for participating and acknowledge their role within this
project.
-Provide staff member an opportunity to debrief with researcher and ask any
questions at this time.
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Appendix D
Confidentiality Agreement
Consent to Participate in Research
You are being asked to participate in research, which will be conducted by Aliya
Martinez, a student of Social Work at California State University, Sacramento and
Christina Andrade, employee of CommuniCare Health Centers and student of Social
Work at California State University, Sacramento. The project will investigate factors
related to the Dual Diagnosis program’s treatment and effectiveness.
You will be asked to participate in a focus group about your thoughts, feelings, and
experiences within the Dual Diagnosis program at CommuniCare Health Centers. The
focus group will be conducted by the researchers mentioned above and may require up to
one and a half hours of your time. If you agree to participate, food, beverages and a gift
card will be made available for your contribution.
Most of the topics of discussion in the focus group may seem personal or intrusive, but
you do not have to answer any question if you do not want to and may participate as
much or as little in the discussion as you wish. You may also leave the focus group at any
time, in which your contribution within your participation period will be utilized for the
purposes of this study. You may also have the opportunity to debrief with your individual
counselor should you be distressed by the experience.
You may gain additional insight into factors that affect success within your recovery, or
you may not personally benefit from participating in this research. It is hoped that the
results of this project will be beneficial for the Dual Diagnosis program at CommuniCare
Health Centers to improve treatment modalities and overall effectiveness of services
provided.
The focus group will be audio recorded for accurately interpreting the information from
your response(s). To preserve the confidentiality of your information discussed and
shared, your responses in the focus group will be anonymous. No names will be used in
the focus groups, and you may use something other than your real name if you wish.
Only group results for the project will be reported.
You will be provided with food, beverages and a gift card as compensation for
participating in this study.
If you have any questions about this research, you may contact _Andrew Bein, LCSW,
PhD___________ at (916) 278-6170 or by e-mail at emsam23@saclink.csus.edu. You
may contact researchers Aliya Martinez and Christina Andrade at (XXX) XXX-XXXX.
87
Your participation in this research is voluntary. Your signature below indicates that you
have read this page and agree to participate in the research.
________________________________ ___________________________
Signature of Participant
Date
88
Appendix E
Confidentiality Agreement for Staff
Consent to Participate in Research
You are being asked to participate in research, which will be conducted by Aliya
Martinez, a student of Social Work at California State University, Sacramento and
Christina Andrade, employee of CommuniCare Health Centers and student of Social
Work at California State University, Sacramento. The project will investigate factors
related to the Dual Diagnosis program’s treatment and effectiveness.
You will be asked to participate in an interview about your thoughts, feelings, and
experiences within the Dual Diagnosis program. The interview will be conducted by the
researcher Aliya Martinez and may require up to one and a half hours of your time.
Most of the topics of discussion in the focus group may seem personal or intrusive, but
you do not have to answer any question if you do not want to and may participate as
much or as little in the discussion as you wish. You may also leave the focus group at any
time, in which your contribution within your participation period will be utilized for the
purposes of this study.
You may gain additional insight into factors that affect success within your role in Adult
Services, or you may not personally benefit from participating in this research. It is hoped
that the results of this project will be beneficial for the Dual Diagnosis program at
CommuniCare Health Centers to improve treatment modalities and overall effectiveness
of services provided.
The interview will be audio recorded for accurately interpreting the information from
your response(s). To preserve the confidentiality of your information discussed and
shared, your responses in the interview will be anonymous. No names will be used in the
interview, and you may use something other than your real name if you wish.
You will not receive any compensation for participating in this study.
If you have any questions about this research, you may contact __Andrew Bein, LCSW,
PhD__________ at (916) 278-6170 or by e-mail at emsam23@saclink.csus.edu. You
may contact researchers Aliya Martinez and Christina Andrade at (XXX) XXX-XXXX.
89
Your participation in this research is entirely voluntary. Your signature below indicates
that you have read this page and agree to participate in the research.
________________________________ ___________________________
Signature of Participant
Date
90
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