Reprinted from "Concurrent Disorders" issue of Visions Journal, 2004, 2 (1), p. 43
Providing services for clients with concurrent disorders has historically been laden with chal lenges originating from a divided treatment system that is ill-prepared to meet client needs. Clients accessing mental health services may not receive the attention required to address their drug or alcohol use issues. In the addictions field, eligibility thresholds for treatment programs are sufficiently high to exclude many clients presenting with mental health disorders. This has often resulted in treatment that is provided either sequentially, (first one issue, then the other) or in parallel form (in which two treatment providers at separate locations use separate treatment plans to treat each condition separately but at the same time). In both versions of this scenario, it has been largely up to the client to navigate through the two streams of services themselves.
In North America, we are starting to acknowledge and address these issues. Both Canada, through Best Practices: Concurrent Mental Health and Substance Use Disorders, and the United States, through TIP 9: Assessment and Treatment of Patients with Co-existing Mental Illness and Alcohol or Other Drug Abuse, have recently developed standards for the best evidencebased practice in treating clients with concurrent disorders. Based on best practice research, these two documents address needs, issues, interventions and approaches determined to be most effective in treating clients with concurrent disorders. Three key elements – integrated services, ongoing support and case management – are essential to effective treatment and are discussed below.
Today we know through research that integrated treatment for co-occurring disorders is far more effective than treating these disorders separately, particularly for those with severe mental illness. The merging of services, philosophies and therapeutic approaches allows the strengths of what were two distinct streams of treatment to collectively provide clients with the most comprehensive treatment possible: this is the first of the three key concepts in the treatment of concurrent disorders. This blending process, however, involves systemic changes as well as philosophical ones which have been slow to materialize in our current service system. The wide range of services, breadth of issues addressed and diverse range of practitioners in BC’s mental health and addictions service system make this an important challenge.
Integrating treatment for co-occurring disorders challenges some of the more traditional streams of thought in the world of addictions treatment. For instance, there are many clients for whom total abstinence is inappropriate or unachievable, and ‘hitting rock bottom’ may be dangerous. This is particularly the case when working with persons with concurrent disorders. Rather than waiting for a person to reach their lowest point of functioning before finding them ‘ready for treatment,’ we instead need to meet the client at their current level of functioning, selecting from a range of supportive services that encourages their movement towards increased stability and life improvement goals. Pharmacological interventions are likely a necessary part of ongoing health, and should be considered as a standard part of an individual’s treatment plan.
The issue of what are the best kinds of therapeutic interventions for persons with concurrent disorders is presently an active topic of research and debate. Traditional addictions treatment approaches have proven consistently ineffective when used with persons who have concurrent disorders. Rather than being time-limited, therapeutic support for persons with concurrent disorders is now consistently recognized as requiring an ongoing process. This recognition – that the challenges of concurrent disorders are lifelong processes, with varying rates of healthiness and relapse – is the second key therapeutic concept. Removing the time-constrained approach to intervention allows greater creativity in exploring ways to meet the lifestyle goals of our clients. Many different treatment interventions may be required, and the appropriateness of specific interventions may vary over time. Interventions should respond to client needs, recognizing that these are not static, but fluctuate with the cycling of an individual’s substance use, mental illness severity, and life experiences.
The concept of case management, which originated in the mental health field, is the third key concept of a successful intervention process. Case management provides engagement, support, assessment and linkage for a client on an ongoing basis throughout the treatment process. While the setting in which a client receives specific services may change over time, the case manager ultimately coordinates this process, providing the client with the continuity necessary for ongoing personal growth. With the complexity of the mental health and addictions system and the variety of interventions available, the case manager supports the client in navigating through the system. This ongoing relationship and monitoring also facilitates identifying signs of trouble as early as possible, allowing earlier intervention and minimizing the chances of relapse.
Opportunities for intervention can come from a variety of resources and in a multitude of settings. Primary health providers, who often are the first source of contact, have the opportunity to direct clients to other parts of the service system. The greater their level of knowledge regarding concurrent disorders, the more easily they are able to catch signs and symptoms and refer clients to appropriate agencies for ongoing support.
It is critical that services designed to specifically address the needs of clients with concurrent disorders are broadened significantly, creating a whole continuum of supports and services. Programming must be implemented in ways consistent with best practice research as outlined above. In the meantime, it is imperative that all service providers in the myriad of agencies serving these clients receive training and information regarding the multifaceted issues of concurrent disorders. Additionally, we must communicate both individually between service providers and collectively between agencies to ensure that clients using various services are able to do so in the most effective and supportive manner possible. It is through this collective approach that we can continue building a service system truly designed to meet the needs of the clients that we serve.
About the Author
Deb is a researcher at the Kaiser Foundation, a BC addictions charity. For more information, see kaiserfoundation.ca
Centre for Addiciton and Mental Health. (2012) Best practices: Concurrent mental health and substance use disorders. Ottawa: Health Canada. See www.cds.sca.com
Ries. R (1994). (Consenus Panel Chair). Assessement and treatment of patients with coexisting mental illness and alcohol and other drug abuse: Treatment improvement protocol (TIP).Series No.9. Rockville, MD: Centre for Substance Abuse Treatment See www.health.org/pubs/catalog ordering.htm