Service Models are therapeutic interventions and support that are provided to psychosis and coexisting substance misuse.
As substance abuse treatment professionals recognize that most of their clients have co-occurring disorders, they seek better treatment approaches to address these clients' needs. There are several barriers to implementing more effective treatment. For example, no one acknowledged “best” practice for clients with co-occurring disorders because the unique combination of diseases means wide heterogeneity among this population? A person with alcohol dependence and major depressive disorder differs dramatically from a person with a cocaine addiction and schizophrenia. Add differences in age, sex/gender, race, other human differences, and treatment issues become pretty complex. Two other barriers to implementing better treatment are the attitudes and knowledge of substance abuse treatment providers. Many providers are frustrated by clients with Co-Occurring Disorder, are overwhelmed by the intensity of their needs, and believe that they are “hopeless” cases. Part of the problem is that most substance abuse counsellors have not received training about the treatment of clients with Co-Occurring Disorder in their formal education programs and because payment systems often do not allow for the lengthy integrated treatment needed by these clients.
INTEGRATED SERVICE MODELS
Integrated service models were defined as service mode that unifies services at the provider level rather than requiring service users to negotiate separate mental health and substance misuse treatment programmes.
It has been proposed globally that effective treatment for psychosis and coexisting substance misuse usually requires an integrated treatment approach. An integrated system incorporates mental health and substance misuse service models in one delivery procedure. This approach was initially pioneered in the U.S. in the 1980s and contrasted with traditional treatment approaches that provided separate services, either parallel or sequentially. It was felt that such services were unable to meet the needs of people with severe mental health and drug/alcohol problems; typically, service users perhaps got only one or the other factor, incompatible or inconsistent treatment from both, or worse still, fell somewhere between the two and obtained little care. Department of Health policy U.K. proposes that service delivery's primary focus should be within mental health services. Both problems and the relationship between them are addressed simultaneously.
Integrated service delivery models that have been evaluated have involved healthcare systems changes to accommodate interventions delivered in various service configurations. Different interventions have been produced in multiple combinations and with varying intensity, including motivational interventions, numerous group forms, individual and family counselling, and housing interventions. Integrated service delivery models have also differed in structure, varying from different case management models in CMHTs, to more intensive, outreach-oriented services. There have also been staffed accommodation evaluations (usual comparisons of integrated residential treatment with non-residential treatment).
The integrated service model, as defined in 1994 to support real-time and non-real-time services. It relies on resources reservation mechanisms to effectively reserve resources in the network for critical flows. Resources reservation is performed using the RSVP protocol.
IntServ has not been as popular as Diffserv in core networks because of its limited scalability. Still, it is being used more often at the edge of the network for call admission control.
The use of the Integrated service model in an intelligent object network is not likely to occur shortly because it requires non-negligible control plane overhead and state maintenance unless a lightweight version is designed to be combined with the routing functions.
Models for Integrated Residential Care
Exploring the core elements of this Model occurs through an overarching Residential Care Model, the four models and the Transition Pathways Model.
These models are:
• the overarching Residential Care Model draws together all
components of the Model
• the Residential Care Systems Model places residential care in the context
of the range of systems that all contribute to outcomes for children and young people in residential care, and essentially need to work together if residential care moves forward.
• the Service and Practice Model for Residential Services focuses on the essential components of effective direct care provided by residential care services.
• the Trauma-Informed Response to young people.
Transition Pathways for Young People in Residential Care Services requires interventions to positively affect young people's negotiating residential care's complex processes.
A. The overarching Residential Care Model
The three models below support are developing a residential care system responsive to young people's needs.
• Residential Care Systems Model
• Service and Practice Model for Residential Services
• Trauma Informed Response and Intervention Models
Thes models together show interrelationship in an overarching model.
B. Residential Care Systems Model
This Model is a broad systems view of residential care:
• focusing on the key stakeholders who will determine the effectiveness of a residential
• the child and young person as central, bringing their own stories and strengths and
vulnerabilities into their care experience
• non-government organisations (NGOs) providing the core day-to-day care
• Department of Communities responsible for assessment, planning and resourcing
• the connections to community and family that are central to the child or young person's
sense of meaning, wellbeing and future
• the array of agencies and services involved in a young person's life.
This Model indicates the essential requirement that all key stakeholders in the service system work together in the best interests of children, young people and their families. It places children and young people as prominent to the assessment and intervention process. It outlines all other key relationships required in supporting children and young people through trauma towards well being. The participation of young people in shaping their futures is central to this Model. It is a vital component of them being rated and empowered and responsible for all residential care contributors.
C. Service and Practice Model for Residential Services
This Model focuses on non-government organisations (NGOs), residential care direct service, and the critical components of beneficial service delivery and care in the day to day life of children and young people in residential care. It is overlaid by clear philosophies, principles and commitment to child-focused, quality and sound organisational governance and congruity across each service.
The consultation explored the implications of several key themes — young people and relationships, family and culture, staffing and organisation. This Model expands on these themes, identifying key areas that will ensure the quality of care and satisfying futures for children and young people beyond residential care.
For residential services to offer quality assistance to children and young people, solid work in the five key areas outlined below is essential:
Children and young people are central.
Children and young people and respond to their needs are central to Residential Care. Services and systems exist to meet their needs.
Participation of children and young people in shaping their lives and futures has been linked to research outcomes. Participation by children and young people is a fundamental right, a legislated requirement (Child Protection Act, 1999, S5(2) and Schedule 1) and is reflected in the Children and Young People's Participation Strategy 2008-2011. This strategy was developed collaboratively by government and non-government agencies and establishes exercise standards concerning participation. Effective participation by young people requires all agencies, government and non-government, involved in residential care, to have models and processes in place, including examination processes that gauge whether young people participate in decisions affecting their lives.
Healthy relationships for children and young people
Both the literature and consultations demonstrated that relationships are central to children and young people's wellbeing. Quality connections across all critical stakeholders, including family members, the residential care service staff supporting the young person, other NGO staff, and Child Safety Services staff, are essential. In terms of building and maintaining relationships and on-going support systems, both team of NGOs and the department must prioritise placement and support options that allow children and young people to remain within one community to strengthen relationships, educational outcomes, and their short and long term assistance and wellbeing.
Quality staff and practice with children and young people is key to creating positive support processes and healing outcomes. As such, staff employ significant resources in fulfilling this multi-faceted and highly skilled role within residential services. Quality staff require on-going training and skills development, supervision with experienced supervisors, and qualifications commensurate with the functions they are required to undertake.
Family and culture
Through all residential care intervention processes, families need to be included in decisions regarding their children. This needs to be an on-going process of inclusion and consultation.
Families require significant support in enhancing their relationships and rebuilding whatever issues have occurred. All these processes need to occur with safety as a priority and the knowledge that 80 per cent of children and young people return home regardless of the plan. Healthy development to family needs to be strongly encouraged and promoted to ensure long term well being for children and young people in the company of their families.
Each child needs a family map identifying all significant family members. Life-story work needs to be built into each child's intervention to support family knowledge and connection. Particularly given the prevalent trauma, attachment, abuse and neglect histories for children and young people in residential care, processes for family healing need to be considered and implemented (family therapy, family connection, life stories), and this work needs to be prioritised with young people and families in the case and care plans. Further, residential care does not provide family-based environments, so family connection for these young people takes on particular significance. Staff need to work collaboratively beyond historical demarcations to ensure positive, supported family contact. Families need to be involved in opinions about placement, change, transition and intervention. Practitioners need to creatively look at facilities and resources and explore how they can best serve family connection and healing.
The organisation and relationships with the broader service system
Organisations need the appropriate resources and systemic support to provide the level of care required to ensure the quality support and wellbeing of this particularly marginalised group of children and young people. Organisations need transparent governance and management to reflect sound philosophical and practice frameworks. Qualified, skilled and trained staff are also vital to ensuring quality services to children and young people. The complexity of the service system and the intricacies of work with children, young people and their families require integrated service delivery and strong linkages between all key stakeholders. Suppose government and NGO staff work closely and collaboratively to ensure they are responding to each child's needs and the young person. In that case, the system is more likely to produce far more positive outcomes in the lives of children, young people and their families.
The Commission for Children and Young People and Child Guardian (CCYPCG):
performs a particular role and function within the residential care system and provides:
• independent systemic monitoring
• a mechanism for children and young people to communicate their needs and
experiences and express complaints
• independent systemic and individual advocacy about children and residential care needs.
D. The Trauma-Informed Intervention in Residential Care Models
Given the information surrounding residential care, the histories of young people most likely to be in residential care, and the lack of outcomes for young adults who have been through the residential care system, a framework for practice must:
• recognise the traits that compound trauma for young people through the process of entering care, being in care and exiting care
• provide a system of care that facilitates healing rather than aggravation for these young people who have already experienced great pain and dislocation
• ensure that interventions focus on enabling young people's recovery, self-valuing and supportive connections with family and community.
Providing care for young people who are responding strongly out of histories of relationship alienation, abuse and trauma, requires highly skilled responses to behaviours. The Positive Behaviour Support Policy provides a framework for responsive care. Development of care responses and processes by residential care agencies, consistent with this framework, is essential.
Working with family contexts and relationships is also a complex task, requiring skilled and conscious work in managing tensions within the family and with the family.
Some of the concepts that emerged from both the consultation and literature as themes for systems to consider are autonomy, normality, wellbeing, connection to family, relationships and community. Participation of children and young people is fundamental to quality care. They must be empowered to define their own goals and be supported to develop their sense of meaning. Young people's voices must be kept in all aspects of their care, including family and community connection decisions.
The three trauma-related Models build on the premise that children and young people are the focal point throughout their residential care pathways and require intervention that is responsive to their histories of trauma.
Compounded Trauma for Young People Moving through Residential Care
This Model provides the backdrop to the Model for change, tracing the familiar pathway for many young people who experience trauma in their home lives and are removed to care where systems and processes fused their trauma. They then exit care into a post-care, unsupported and stigmatised setting where they suffer further dislocation, alienation and trauma.
Transition Pathways for Children and Young People in Residential Care
Residential care forms a brief part of any young person's life journey. All planning and interventions are in the context of change and transition, as there is always a future beyond residential care. With informed and sustained planning, residential care can contribute to positive outcomes whatever the future for each child and young person.
General Model Studies summary:
The Iowa Practice Improvement Collaborative (Iowa PIC), part of a national network funded by the Center for Substance Abuse Treatment, an agency of the Substance Abuse and Mental Health Services Administration of the U.S. Government, has developed several projects to address issues related to clients with co-occurring disorders. These are described briefly in this article. The Iowa PIC was established in the fall of 1999 to build a strong collaboration among researchers, policy-makers, and practitioners in Iowa. We have known about the large gap between research findings and actual practice in substance abuse treatment centres for several years, so the national PIC initiative was developed to “bridge the gap.” During the first year of the Iowa PIC, three committees were designed to address the different types of gaps in our state. One of those committees was the Treatment/Intervention Committee, co-chaired by a researcher from the University of Iowa, Dr Anne Helene Skinstad. Comprised of about ten substance abuse providers and two policy-makers, this Committee reviewed existing needs assessment data and conducted a focus group of provider concerns. They concluded that the need for clients with co-occurring disorders (COD) was the highest priority need in our state. The Committee noted that most clients with COD were either parallel (the client was receiving mental health services and substance abuse services separately with no coordination) or serial (the client received one type of service then, when completed, received the other kind of service). These service delivery methods are ineffective and often provide conflicting treatment messages to clients. The Treatment/Intervention Committee recommended that the PIC's goal be to strive for integrated, simultaneous treatment of clients with COD. They recognised that substance abuse providers in the state were not currently skilled in mental health assessment and treatment. Mental health providers were not professional in substance abuse assessment and treatment. Besides, negative attitudes about clients with COD were common. Therefore, a series of three studies related to COD was developed. These three studies will be conducted sequentially, with the first study completed in the spring of 2001, the second study underway at this time, and the third study to begin in the fall of 2001.
Study 1: Development of Agency and Staff Evaluation Tools The first study was designed to develop and pilot test an instrument for measuring clients' knowledge and attitudes with COD. Nearly 100 staff members at four substance abuse treatment agencies completed the staff tool, which has 27 multiple-choice items and two open-ended items. Nineteen agency directors met the agency tool with 28 multiple-choice items and two open-ended questions.
Analysis of staff data indicated that 30% thought their training about COD was inadequate, and only 3% said they had a solid understanding of these clients' needs. The majority, 78%, thought that substance abuse and mental health treatments should occur together, and only 8% believed that these clients should get mental health treatment before entering substance abuse treatment. Most agreed that clients with COD require more time in treatment (87%) and take more effort from staff (78%). There was concern about the treatment climate as well? 28% thought that clients with COD were disruptive, and 29% said they make treatment for others more complex. [more felt that they were not disruptive and did NOT make treatment of others more difficult, so while there was some worry about the climate, most did not.] Nearly three-fourths (74%) felt that mental health professionals did not adequately understand substance abuse treatment, but 55% also thought that substance abuse counsellors, on the whole, do not understand mental health treatment.
Most substance abuse counsellors felt that they had access to information about best treatment practices (68%) and that their agencies supported staff efforts to improve their expertise (86%). All but one respondent (99%) endorsed a plan for initiating COD training at their agency, and 82% support a state certification in COD. The staff believed that they were doing an excellent job coordinating services with mental health agencies (88%). Still, fewer thought that mental health agencies successfully coordinated care with substance abuse agencies (40%).
Program directors had very similar attitudes to the counsellors, but there were a few differences. For example, program directors thought that their staff were better prepared to deal with clients with COD than the team themselves did, and directors reported higher satisfaction with the care the clients with COD got at their agencies than were line staff. Program directors were more likely (58%) to think that mental health agencies were adequately coordinating care with substance abuse agencies.
The instruments' full results and copies can be found on our website: www.uiowa.edu/iowapic. These results indicated that directors and line staff were already sold on the idea of integrated treatment and recognised the need for further training on COD. Besides, they believed that substance abuse treatment was the best place for integrated treatment to occur, not mental health treatment. This study's findings helped develop the training program described below for Study 2.
Study 2: Cross-training for Co-Occurring Disorders The second study, which began in May of 2001, is a training intervention. Over 100 practitioners from three fields that deal with clients with CODs will be trained together: substance abuse counsellors, mental health counsellors, and treatment staff from the department of corrections. These disciplines too often work in isolation from each other, or sometimes, even at cross-purposes when caring for the same clients. The training program has several components:
A two-day interactive, hands-on training program with a vital part in attitudes, knowledge, and collaboration.
- One-day training on clinical supervision issues for clients with COD.
- Monthly case study discussions to facilitate learning application delivered over a distance communications network.
Because Iowa is a predominantly rural state, we must seek as many training options as possible and use distance education options whenever feasible. Small treatment agencies in rural counties can ill afford to send their staff away for days for extensive training because of the lost revenue and long distances to cities where activity usually occur.
The extensive training model outlined here was chosen because the literature suggests that one-shot training cannot effect long-term change in practice. Instead, long-term programs that reinforce learning and allow participants to discuss barriers to implementation are much more effective (Change Book, 2000). The evaluation tools developed in study 1 will be given before the training and at the end of the training components to determine if knowledge increases or attitudes change.
Study 3: Long-term follow-up of COD Training Effectiveness When the COD training intervention study ends, a follow-up phase will begin. The purpose of this study is to evaluate the long-term effectiveness of the training program in changing attitudes about clients with COD and in increasing the knowledge and skills of substance abuse counsellors, mental health counsellors, and staff of the department of corrections. We also hope to demonstrate greater collaboration or communication among these disciplines.
Conclusions Clients with co-occurring disorders have complex needs that require skilled professionals to manage. However, neither substance abuse counselling nor mental health training has yet dealt effectively with these clients' requirements. As long as payment systems for mental health and substance abuse remain separate, these clients' management will be complex. The Iowa PIC has initiated steps to improve clients' treatment with COD by providing training that addresses attitudes, knowledge, and skills and is on-going.
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Regier, D., Farmer, M., Rae, D., Locke, B., Keith, S., Judd, L., & Goodwin, F. (1990). ComorbidityComorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiological Catchment Area study. JAMA, 264, 2511-2519.
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