ABSTRACT
A number of states in the US have undertaken efforts to improve both access and quality of integrated services for people with co-occurring disorders, including educational initiatives, agency incentives, and legislation (Rapp et al., 2005). New York, for example, established the State Social Work Mental Health Education Consortium as a formal partnership between the Dean’s Consortium of Schools of Social Work and over 100 agencies providing Evidence-Based Practice treatment, resulting in the creation of an educational workforce development model (Easterly, 2009). In Minnesota, recent legislation requires programs that offer IDDT to meet national standards that have been developed for such programs (Department of Human Services, 2012). Providers working in licensed substance abuse treatment facilities are required to document proof of a minimum of 12 hours of COD training and an additional eight continuing education credits of dual disorders annually to meet program-licensing rules (Department of Human Services, 2008). Additionally, the Minnesota Department of Human Services has recently recruited agencies to engage in a pilot study on the effectiveness of IDDT training for providers currently using the Illness Management & Recovery model for individuals with COD. Nevertheless, despite growing interest in integrated approaches (Sterling, Chi, &
Hinman, 2011) and growing evidence examining factors that enhance their effectiveness as described above, integrated treatment in the US and Europe remains relatively uncommon, with services most often provided by different treatment systems addressing each disorder separately (Crome et al., 2009; Institute of Medicine (US), 2006; Sterling et al., 2011). Often, consumers are screened and assessed for co-occurring disorders, but treatment programs lack the adequately trained personnel necessary to deliver treatment as intended (Hoge, Huey, & O’Connell, 2004). A review of practice guidelines available through the National Guideline Clearinghouse of the Department of Health and Human Services and developed for treatment of substance use or serious mental illness found only two out of 11 guidelines that specifically provided recommendations for co-occurring disorder treatment. Outcomes targeted by the guidelines were primarily focused on a single disorder, even though the assessment and treatment issues addressed co-occurring disorders (Perron, Bunger, Bender, Vaughn, & Howard, 2010). In the United States, social workers serve as primary providers of mental health
services for people with COD in a wide range of settings, including screening, diagnostic assessment, case management, treatment team supervisors, and agency administrators. Whether treating clients directly or providing case management and referral for ancillary support services, social workers represent a key component in the various systems where this population seeks services. Given that fidelity of treatment delivery is critical for achieving positive outcomes for clients with co-occurring disorders (Drake et al., 2006), a workforce that is capable of providing high-fidelity integrated treatment must have sufficient knowledge and training in both mental health and substance use, and the confluence of the two. The Institute of Medicine (US). Committee on Crossing the Quality Chasm,
Adaptation to Mental Health, and Addictive Disorders (2006) and other behavioral health leaders have called for expedited curriculum reform,more permeable boundaries
treatment approaches, integrated treatment considers the interaction between disorders, and the potential of one disorder to influence the outcome and severity of the other (Hien et al., 2010). Although the body of research on integrated treatment is still relatively small, an
integrated approach treating both disorders in a coordinated fashion has been considered the ‘most promising treatment strategy’ for some time (RachBeisel, Scott, & Dixon, 1999, p. 3). A recent meta-analysis of 13 studies reported that integrated treatment compared favorably to parallel or sequential treatment delivery for adults with co-occurring disorders (Chou, Bourgeois, & Tan 2013). Research has also suggested that integrated treatment is effective for achieving abstinence among adults (Chi, Satre, & Weisner, 2006) and adolescents with co-occurring disorders (Sterling & Weisner, 2005). Other findings have been more mixed, pointing to effectiveness with some outcomes but not others and highlighting the need for more rigorous evaluations of integrated treatment approaches (Drake, Mueser, Brunette, & McHugo, 2004). One systematic review of studies on integrated treatment reported that
comprehensive integrated treatment delivered in outpatient settings achieved the most favorable outcomes with regard to substance use, with less consistent evidence for effective improvement across mental health outcomes (Drake et al., 2004). Results of a subsequent systematic review found that three different types of interventions were likely to be effective for people with dual diagnoses; however, the authors reported numerous limitations among the studies reviewed, including standardization, fidelity, intervention lengths, and measurement, which limited the ability to draw conclusions about effectiveness. Unsurprisingly, results of integrated treatment depend on the extent of program fidelity (Drake et al., 2006). Other factors that affect integrated treatment outcomes, including treatment setting, practitioner training, and practitioner to client ratio, require further investigation. Some studies have examined the effectiveness of particular integrated treatment
models such as Illness Management & Recovery (IMR), Assertive Community Treatment (ACT), and Integrated Dual Disorder Treatment (IDDT). IMR, IDDT, and ACT are intervention models originally developed for individuals with serious and persistent mental illness (SPMI), a term that is used when a client is diagnosed with one or more major mental disorders such as major depressive disorder, bi-polar disorder, and schizophrenia. The designation often entitles the client to increased publically supported services that exclude those with less serious disorders. While all mental and substance disorders are debilitating to some degree, one must be careful to avoid generalizing. Symptom severity and chronicity, impairments of daily living, relapse potential, suicide potential, frequency of hospitalization, legal, occupational, and social problems are oftenmore severewith the SPMIpopulation. This is one of the reasonswhy integrated treatment was developed for this population. Assertive Community Treatment, for example, has demonstrated improved outcomes related to hospitalization, housing stability, quality of life, and psychiatric symptoms compared to treatment as usual (Bond, Drake, Mueser, & Latimer, 2001). Equally important, ACT, IMR, and IDDT have valid and reliable fidelity measures that can assess the integrity of treatment delivery, with successful outcomes associated with higher fidelity (Bond et al., 2001).
