Integrated Dual Disorders Treatment (IDDT)

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An intensive approach to treating dual disorders which combines elements of both mental health and addictions treatment into a unified, comprehensive, and continuous program. The SAMHSA-endorsed evidence-based practice IDDT model features 26 domains, including both treatment and organizational elements viewed as important for providing optimally effective, integrated treatment for individuals facing the dual recovery challenges of serious mental illness and addiction.

IDDT Treatment Elements

T-1a. Multidisciplinary Team
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.

T-1b. Integrated Substance Abuse Specialist

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.

T-2. Stage-Wise Interventions

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).

T-3. Access for IDDT Clients to Comprehensive Services

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

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

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

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.

T-7. Substance Abuse Counseling

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.

T-8. Group Dual Disorder Treatment

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.

T-9. Family Psychoeducation on Dual Disorders

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.

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

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.

T-11. Pharmacological Treatment

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

T-12. Interventions to Promote Health

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

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).

IDDT Organizational Elements

G1. Program Philosophy

The program is committed to a clearly articulated philosophy consistent with IDDT, based on the following 5 sources:

  • Program leader
  • Senior staff (e.g., executive director, psychiatrists)
  • Practitioners providing IDDT services
  • Clients and/or family members
  • Written materials (e.g., brochures)

G2. Eligibility/Client Identification

1. For IDDT implemented in a mental health center: All clients in the community support program, crisis clients, and institutionalized clients are screened using standardized tools or admission criteria that are consistent with IDDT.

2. For IDDT implemented in a service area: All clients within the jurisdiction of the services area are screened using standardized tools or admission criteria that are consistent with IDDT.

  • The target population refers to all adults with severe mental illness (SMI) served by the provider agency (or service area) who have a co-occurring substance use disorder. If the agency serves clients at multiple sites, then assessment is limited to the site or sites that are targeted for IDDT. If the target population is served in discrete programs (e.g., case management, residential, day treatment, etc.), then ordinarily all adults with SMI and co-occurring substance use disorders would be included in this definition.
  • The intent is to identify any and all for who could benefit from IDDT. For Integrated Dual Disorder Treatment, the admission criteria are specified by the EBP and specific assessment tools are recommended.
  • Screening typically occurs at program admission, but for a program that is newly adopting IDDT, there should be a plan for systematically reviewing clients already active in the program.

G3. Penetration

Penetration is defined as the percentage of clients who have access to an EBP as measured against the total number of clients who could benefit from the EBP. Numerically, this proportion is defined by: (# of clients receiving an EBP) divided by (# of clients eligible for the EBP). As in the preceding item, the numbers used in this calculation are specific to the site or sites where the EBP is being implemented.

G4. Assessment

All EBP clients receive standardized, high quality, comprehensive, and timely assessments.

  • Standardization refers to a reporting format that is easily interpreted and consistent across clients.
  • High quality refers to assessments that provide concrete, specific information that differentiates between clients. If most clients are assessed using identical words, or if the assessment consists of broad, non-informative checklists, then this would be considered low quality.
  • Comprehensive assessments include: history and treatment of medical, psychiatric, and substance use disorders, current stages of all existing disorders, vocational history, any existing support network, and evaluation of bio-psycho-social risk factors.
  • Timely assessments are those updated at least annually.

G5. Individualized Treatment Plan

For all EBP clients, there is an explicit, individualized treatment plan (even if it is not called this) related to the EBP that is consistent with assessment and updated every 3 months. “Individualized” means that goals, steps to reaching the goals, services/ interventions, and intensity of involvement are unique to this client. Plans that are the same or similar across clients are not individualized. One test is to place a treatment plan without identifying information in front of the supervisor and see if they can identify the client.

G6. Individualized Treatment

All IDDT clients receive individualized treatment meeting dual recovery goals. Individualized” treatment means that steps, strategies, services/interventions, and intensity of involvement are focused on specific client goals and are unique for each client. Progress notes are often a good source of what really goes on. Treatment could be highly individualized despite the presence of generic treatment plans.

An example of a low score on this item for Integrated Dual Disorders Treatment: a client in the engagement phase of recovery is assigned to a relapse prevention group and constantly told he needs to quit using, rather than using motivational interventions.

G7. Training

All new practitioners receive standardized training in the EBP (at least a 2-day workshop or its equivalent) within 2 months of hiring. Existing practitioners receive annual refresher training (at least 1-day workshop or its equivalent).

G8. Supervision

EBP practitioners receive structured, weekly supervision from a practitioner experienced in the particular EBP. The supervision can be either group or individual, but CANNOT be peers-only supervision without a supervisor. The supervision should be client-centered and explicitly address the EBP model and its application to specific client situations.

Administrative meetings and meetings that are not specifically devoted to the EBP do not fit the criteria for this item. The client-specific EBP supervision should be at least one hour in duration each week.

G9. Process Monitoring

Supervisors/program leaders monitor the process of implementing the EBP every 6 months and use the data to improve the program. Process monitoring involves a standardized approach, e.g., use of a fidelity scale or other comprehensive set of process indicators. An example of a process indicator would be systematic measurement of how much time individual case managers spend in the community versus in the office. Process indicators could include items related to training or supervision. The underlying principle is that whatever is being measured is related to implementation of the EBP and is not being measured to track billing or productivity.

G10. Outcome Monitoring

Supervisors/program leaders monitor the outcomes of EBP clients every 3 months and share the data with EBP practitioners in an effort to improve services. Outcome monitoring involves a standardized approach to assessing clients.

G11. Quality Assurance (QA)

The agency’s QA Committee has an explicit plan to review the EBP or components of the program every 6 months. The steering committee for the EBP can serve this function. Good QA committees help the agency in important decisions, such as penetration goals, placement of the EBP within the agency, hiring/staffing needs. QA committees also help guide and sustain the implementation by reviewing fidelity to the EBP model, making recommendations for improvement, advocating/promoting the EBP within the agency and in the community, and deciding on and keeping track of key outcomes relevant to the EBP.

G12. Client Choice Regarding Service Provision

All clients receiving EBP services are offered a reasonable range of choices consistent with the EBP; the EBP practitioners consider and abide by client preferences for treatment when offering and providing services.

Choice is defined narrowly in this item to refer to services provided. This item does not address broader issues of client choice, such as choosing to engage in self-destructive behaviors.

To score high on this item, it is not sufficient that a program offers choices. The choices must be consonant with EBP. So, for example, a program implementing supported employment would score low if the only employment choices it offered were sheltered workshops.

A reasonable range of choices means that EBP practitioners offer realistic options to clients rather than prescribing only one or a couple of choices or dictating a fixed sequence or prescribing conditions that a client must complete before becoming eligible for a service.

Sample of Relevant Choices in IDDT:
 

  • Group or individual interventions
  • Frequency of DD treatment
  • Specific self-management goals