IDDT Treatment Characteristics

For an 18-minute introduction to Integrated Treatment for Co-Occurring Disorders, navigate to the  YouTube Integrated Treatment for Co-Occurring Disorders Playlist link, and click on the 1st video option on the menu entitled, “Introductory Video – English” (also available in a Spanish version).

 

T-1a. Multidisciplinary Team

Definition

All clients targeted for IDDT receive care from a multidisciplinary team.  A multidisciplinary team consists of, in addition to a dual diagnosis clinician, two or more of the following: a physician, a nurse, a case manager, or providers of ancillary rehabilitation services (therapy, vocational, housing, etc.). Collaboration suggests that team members regularly communicate about the client’s progress and are not merely component parts.

> Click here to view or download a copy of Case Western Reserve University’s Ohio Substance Abuse and Mental Illness Coordinating Center of Excellence (SAMI CCOE) Integrated Dual Disorder Treatment: An Overview of the Evidence-Based Practice.

 

T-1b. Integrated Substance Abuse Specialist

Definition

A substance abuse specialist who has at least 2 years of experience works collaboratively with the treatment team.  The experience of this clinician can be from a variety of settings, preferably working with clients with dual disorders, but any substance abuse treatment experience will qualify for rating this item.

> In the State of Michigan, Addictions Counselor certification is managed by the Michigan Certification Board for Addiction Professionals, with certification requirements, application packets, and training options all available at the MCBAP website.

 

T-2. Stage-Wise Interventions

Definition

All interventions (including ancillary rehabilitation services) are consistent with and determined by the client’s stage of treatment or recovery. Stages of treatment are understood to include Engagement (forming a trusting working alliance/relationship), Persuasion (helping the engaged client develop the motivation to participate in recovery-oriented interventions), Active Treatment (helping the motivated client acquire skills and supports for managing illnesses and pursuing goals), and Maintenance/Relapse Prevention (helping clients in stable remission develop and use strategies for maintaining recovery).

>> Click on the links below to view, download, or order the following recommended resources:

> The Substance Abuse Treatment Scale which defines the stages of treatment for dually diagnosed individuals. Also available is the foundational research (Evaluating Substance Abuse in Persons with Severe Mental Illness) that led to the development of this framework.

> The Stages of Change and Treatment crosswalk chart.

To view a 4-minute demonstration video, navigate to the YouTube Integrated Treatment for Co-Occurring Disorders Playlist link, and scroll down to the 4th video menu option entitled, “Practice Demonstration Video – Stages of Change & Treatment”.

> The Stages of Change and Dual Recovery powerpoint presentation (Wiland);

> Prochaska, Norcross and DiClemente’s book Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively;

T-3. Access for IDDT Clients to Comprehensive Services

Definition

To address a range of needs of clients targeted for IDDT, the provider agency offers the following five ancillary rehabilitation services (for a service to be considered available, it must both exist and be accessible within 2 months of referral by clients targeted for IDDT who need the service):

  • Residential services:  Supervised residential services that accept clients targeted for IDDT, including supported housing (i.e., outreach for housing purposes to clients living independently) and residential programs with on-site residential staff.  Exclude short-term residential services (i.e., a month or less).
  • Supported employment:  Vocational program that stresses competitive employment in integrated community settings and provides ongoing support.  IDDT clients who are not abstinent are not excluded.
  • Family psycho-education (FPE):  A collaborative relationship between the treatment team and family (or significant others) that includes basic psycho-education about SMI and its management, social support and empathy, interventions targeted to reducing tension and stress in the family as well as improving functioning in all family members.
  • Illness management and recovery (IMR):  Systematic provision of necessary knowledge and skills through psycho-education, behavioral tailoring, coping skills training and a cognitive-behavioral approach, to help clients learn to manage their illness, find their own goals for recovery, and make informed decisions about their treatment.
  • Assertive community treatment (ACT) or intensive case management (ICM):A multidisciplinary team (client-to-clinician ratios of 15:1 or lower) with at least 50% of client contact occurring in the community and 24-hour access.

T-4. Time-Unlimited Services

Definition

Clients with dual disorders are treated on a long-term basis with intensity modified according to need and degree of recovery.  Examples of services available on a time-unlimited basis include:  substance abuse counseling, residential services, supported employment, family psychoeducation, illness management, and ACT or ICM.

 

T-5. Outreach

Definition

For all IDDT clients, but especially those in the engagement stage, the IDDT program provides assertive outreach, characterized by some combination of meetings and practical assistance (e.g., housing assistance, medical care, crisis management, legal aid, etc.) in their natural living environments as a means of developing trust and a working alliance.  Other clients continue to receive outreach as needed.

 

T-6. Motivational Interventions

Definition

All interactions with DD clients are based on motivational interviewing that includes:

  • Expressing empathy; Developing discrepancy between goals and continued use; Avoiding argumentation; Rolling with resistance; Supporting self-efficacy and hope.

>> Click on the links below to view, download, or order the following recommended resources:

> The official Motivational Interviewing website (contains a wealth of information and resources);

> William Miller & Stephen Rollnick’s seminal text, Motivational Interviewing, Third Edition: Helping People Change;

> David B. Rosengren’s Building Motivational Interviewing Skills: A Practitioner Workbook (Applications of Motivational Interviewing);

To view a 5-minute demonstration video, navigate to the YouTube Integrated Treatment for Co-Occurring Disorders Playlist link, and scroll down to the 7th video option on the menu entitled, “Practice Demonstration Video – Motivational Counseling”.

T-7. Substance Abuse Counseling

Definition

Clients who are in the action stage or relapse prevention stage receive substance abuse counseling aimed at:

  • Teaching how to manage cues to use and consequences of use
  • Teaching relapse prevention strategies
  • Teaching drug and alcohol refusal skills
  • Problem-solving skills training to avoid high-risk situations
  • Challenging clients’ beliefs about substance use; and
  • Coping skills and social skills training to deal with symptoms or negative mood states related to substance abuse (e.g., relaxation training, teaching sleep hygiene, cognitive-behavioral therapy for depression or anxiety, coping strategies for hallucinations)

The counseling may take different forms and formats, such as individual, group (including 12-Step programs), or family therapy, or a combination.

>> Click on the links below to view or download the following no-cost counseling resources:

> SAMHSA’s Anger Management for Substance Abuse and Mental Health Clients – CBT Manual for Practitioners, and Anger Management for Substance Abuse and Mental Health Clients – Participant Workbook;

> SAMHSA’s Brief COUNSELING for MARIJUANA DEPENDENCE: A Manual for Treating Adults;

> NIAAA’s Project MATCH study’s Cognitive-Behavioral Coping Skills Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence;

> NIAAA’s Project MATCH study’s Motivational Enhancement Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence;

> NIAAA’s Project MATCH study’s Twelve Step Facilitation Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence;

> NIDA’s Therapy Manual for Drug Addiction, Cognitive Behavioral Approach to Treating Cocaine Addiction;

> NIDA’s Principles of Drug Addiction Treatment: A Research-based Guide.

> The University of South Florida’s Louis de la Parte Florida Mental Health Institute’s Co-occurring Disorders Treatment Manual (2002), and corresponding Co-occurring Disorders Treatment Workbook (2002).

> To view a 23-minute demonstration video, navigate to the YouTube Integrated Treatment for Co-Occurring Disorders Playlist link, and scroll down to the 9th video option on the menu entitled, “Practice Demonstration – Substance Abuse Counseling”.

T-8. Group Dual Disorder Treatment

Definition

All clients targeted for IDDT are offered a group treatment specifically designed to address both mental health and substance abuse problems, and approximately two-thirds are engaged regularly (e.g., at least weekly) in some type of group treatment.  Groups could be family, persuasion, dual recovery, etc.

>> Click on the links below to view, download, or order any of the following resources:

> The University of South Florida’s Louis de la Parte Florida Mental Health Institute’s Co-occurring Disorders Treatment Manual (2002), and corresponding Co-occurring Disorders Treatment Workbook (2002).

> The Mid-Atlantic Addiction Technology Transfer Center’s 2007 Motivational Groups for Community Substance Abuse Programs, by Karen Ingersoll, Christopher Wagner and Sandra Gharib.

> SAMHSA’s Anger Management for Substance Abuse and Mental Health Clients – CBT Manual for Practitioners, and Anger Management for Substance Abuse and Mental Health Clients – Participant Workbook.

> Coping Skills Group: A Session-by-Session Guide, by Kim Mueser & Susan Gingerich.

> Overcoming Addictions: Skills Training for People with Schizophrenia, by Thad Eckman, Lisa Roberts, & Andrew Shaner.

> To view a 14-minute demonstration video, navigate to the YouTube Integrated Treatment for Co-Occurring Disorders Playlist link, and scroll down to the 12th video option on the menu entitled, “Practice Demonstration – Groups for Clients with Co-Occurring”.


T-9. Family Psychoeducation on Dual Disorders

Definition

Where available and if the client is willing, clinicians always attempt to involve family members (or long-term social network members) to give psychoeducational information about dual disorders and coping skills to reduce stress in the family, and to promote collaboration with the treatment team.

>> Click on the links below to view or download the following free powerpoint presentations, which can be used for family psychoeducation, for staff education and/or for a didactic engagement group with clients:

> Anxiety Disorder and Addiction (Wiland);

> Bipolar Disorder and Addiction (Wiland);

> Brain Chemistry and Dual Disorders (Wiland);

> Coping Tools in Dual Recovery (Wiland):

> DBT Dual Recovery Tools (Wiland);

> Depressants and Dual Disorders (Wiland);

> Depressive Disorders and Addiction (Wiland);

> Dual Recovery and the 12 Steps (Wiland);

Family Issues in Dual Recovery (Nathan Rahn);

> Hallucinogens and Dual Disorders (Wiland);

> Integrated Relapse Prevention in Dual Recovery (Wiland);

> Personality Disorder and Addiction (Wiland);

> Post-Acute Withdrawal in Dual Recovery (Wiland);

> Posttraumatic Stress and Addiction (Wiland);

> Principles of Integrated Dual Disorders Treatment (Wiland);

> Spirituality and Dual Recovery (Wiland);

Stages of Change and Dual Recovery (Wiland);

> Stimulants and Dual Disorders (Wiland);

> The Need for Support in Dual Recovery (Wiland);

> Thought Disorder and Addiction (Wiland);

 

T-10. Participation in Alcohol & Drug Self-Help Groups

Definition

Clinicians connect clients in the action stage or relapse prevention stage with substance abuse self-help programs in the community, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Rational Recovery, Double Trouble or Dual Recovery.

>> Click on the links below to view, download, or order the following resources:

Dual Recovery and the 12 Steps powerpoint (Wiland);

> The website of Alcoholics Anonymous (AA);

> The AA General Service Conference-approved literature addressing the appropriate use of psychiatric medication by members of Alcoholics Anonymous, entitled The AA Member: Medications & Other Drugs

> The website of Narcotics Anonymous (NA);

> Hazelden’s The Twelve Steps And Dual Disorders: A Framework Of Recovery For Those Of Us With Addiction & An Emotional Or Psychiatric Illness by Pat Samples and Tim Hamilton;

> Hazelden’s The Dual Disorders Recovery Book: A Twelve Step Program for Those of Us With Addiction and an Emotional or Psychiatric Illness.

 

T-11. Pharmacological Treatment

Definition

Physicians or nurses prescribing medications are trained in DD treatment and work with the client and the IDDT team to increase medication adherence, to decrease the use of potentially addictive medications such as benzodiazepines, and to offer medications such as clozapine, disulfiram, or naltrexone that may help to reduce addictive behavior.  Five specific indicators are considered.  Do prescribers:

  1. Prescribe psychiatric medications despite active substance use
  2. Work closely with team/client
  3. Focus on increasing adherence
  4. Avoid benzodiazepines and other addictive substances
  5. Use clozapine, naltrexone, disulfiram

>> Click on the links below to view, download, or order the following resources:

> The Mid-America Addiction Technology Transfer Center’s BHMEDS: Behavioral Health Medications (2014);

The Mid-America Addiction Technology Transfer Center’s Medicamentos Psicoterapéuticos del 2013 (Psychotherapeutic Medications 2013, Spanish edition);

> Dr. Kenneth Minkoff’s Psychopharmacology Practice Guidelines for Individuals with Co-occurring Psychiatric and Substance Use Disorders (COD)

> The University of Utah’s “Mouse Party” educational website on the brain chemistry of addiction, and corresponding “Mouse Party” worksheet.

> NIDA’s Drugs, Brains and Behavior: The Science of Addiction publication (2010).

> SAMHSA’s General Principles for the Use of Pharmacological Agents to Treat Individuals with Co-Occurring Mental and Substance Use Disorders publication (2012).

> SAMHSA’s Pharmacologic Guidelines for Treating Individuals with Post-Traumatic Stress Disorder and Co-Occurring Opioid Use Disorders publication (2012).

 

T-12. Interventions to Promote Health

Definition

Efforts are made to promote health through encouraging clients to practice proper diet and exercise, find safe housing, and avoiding high-risk behaviors and situations.  The intent is to directly reduce the negative consequences of substance abuse using methods other than substance use reduction itself.  Typical negative consequences of substance abuse that are the focus of intervention include the following:

  • physical effects (e.g., chronic illnesses, sexually transmitted diseases),
  • social effects (e.g., loss of family support, victimization),
  • self-care and independent functioning (e.g., mental illness relapses, malnutrition, housing instability, unemployment, incarceration), and
  • use of substances in unsafe situations (e.g., driving while intoxicated).

Examples of strategies designed to reduce negative consequences include:

  • teaching how to avoid infectious diseases;
  • supporting clients who switch to less harmful substances;
  • providing support to families;
  • helping clients avoid high-risk situations for victimization;
  • encouraging clients to pursue work, exercise, healthy diet, and non-user friends; and
  • securing safe housing that recognizes clients’ ongoing substance abuse problems.

 

T-13. Secondary Interventions for Substance Abuse Treatment Non-Responders

Definition

Secondary interventions are more intensive (and expensive) interventions that are reserved for people who do not respond to basic outpatient IDDT.  To meet the criterion for this item, the program has a specific plan to identify treatment non-responders, to evaluate them for secondary (i.e., more intensive) interventions, and to link them with appropriate secondary interventions.  Potential secondary interventions might include special medications that require monitoring (e.g., clozapine, naltrexone, or disulfiram); more intensive psychosocial interventions (e.g., intensive family treatment, additional trauma interventions, intensive outpatient such as daily group programs, or long-term residential care); or intensive monitoring, which is usually imposed by the legal system (e.g., protective payeeship or conditional discharge).

> Click here to view or download some strategies for Secondary Interventions for Substance Abuse Treatment Non-Responders.