Section III: Desirable Characteristics of the System

SECTION III: Desirable System Characteristics

Do you know that substance abuse can be linked to co-occurring disorders? Before I buttress this point, let’s know what co-occurring disorder is. Co-occurring disorders can be defined as when an individual has two or more mental health illnesses. These illnesses may begin simultaneously, or one may appear before or after another or overlap. There have been experiences where mental illness leads to substance abuse, while in others, the opposite is true. Examples of co-occurring disorders include panic disorder and alcohol addiction, cocaine addiction and anxiety disorders, trauma and drug/substance abuse, cocaine addiction and significant depression, opioid abuse and self-harm behavior, cocaine addiction and anorexia nervosa, alcohol addiction and panic disorder, Episodic poly-drug abuse and borderline personality disorder.

According to a recent study, about half of the individuals with one disorder will, in time, develop at least one more co-occurring mental health/substance abuse issue illness in the nearest future. Hence, a few factors may explain why co-occurring diseases are so frequent.

• Self-medication
• Unemployment
• Low self-esteem
• The loss of a loved one
• History of trauma or abuse.
• Exposure to environmental toxins
•  Poor nutrition
• Family history
• Genetic patterns
• Unstable relationships
• Substance abuse

An adequate system of care for people with co-occurring disorders ? one that encourages and allows for consultation, collaboration, and integration? Will have several overarching characteristics in such vital areas as philosophy, services, staffing, and funding. These qualities are described in this section and specific strategies for improving consultation, collaboration, and integration.

Overarching System Characteristics

Treatment Comprehensiveness: This refers to the overall system for treating co-occurring disorders, which includes mental health and addiction treatment problems (preventing or limiting substance abuse). They also have collaborative, integrated programs. Hence these programs are put in place to:

• Be able to engage individuals suffering from a co-occurring disorder
• Aid several levels of disability and severity
• Accommodate various levels of compliance and motivation
• Accommodate clients in different phases of treatment.
• Keeping clients clean and away from substance abuse

Abstinence-oriented programs, abstinence-mandated programs, various levels of care should also be made available.

An Ongoing Commitment. A service system that can efficiently care for people with co-occurring disorders must be built on a solid foundation of shared values and principles. All stakeholders must have an agreement. They include policymakers, community officials, state and federal government, primary health providers, substance abuse treatment providers, advocates, and consumers. There should be an agreement concerning the need for and the value of treatment systems to improve patients outcomes. Whether such an arrangement is simply acknowledged to be the case or is spelled out in a formal memorandum of understanding, there should be ongoing and shared commitments to discuss the needs of this group. And even when the client is battling with an addiction problem, helping the client staying away from substance abuse is key. It should be made understandable to all parties that collaboration, integration and consultation are not only allowed but are encouraged and programmatically supported, depending on the patients’ demands. The States will play a crucial role in implementing and defining these policy changes. And this is because of their role to ensure suitable treatment for the client while also operating in the public interest. There should also be a commitment of the client staying clean and not go back to substance abuse, in the case of addiction.

Treatment Continuity

In order to treat individuals with co-occurring disorders, it is essential to develop continuity between treatment components and treatment programs, as well as treatment continuity over time. However, many clients participate in treatment at various sites. Due to this reason, the treatment should consist of an integrated dual disorder case management program. This program can be located within a collaborative program, an addiction treatment, or a mental health setting. When treating co-occurring illness, substance abuse cannot be ruled out, in most cases patients treated for co-occurring illness has to be checked or treated for substance abuse as well.

Consumer-Centred. Because the fundamental aim of working together is to improve clients’ outcomes, any successful service system must be consumer-centered and culturally competent. A consumer-centered system can be referred to as one in which mental health and substance abuse individuals and their families/carers are actively involved not only in treatment decisions. They are also involved in administration, program design, and evaluation. The role of mental health clients or substance abuse clients in advancing care for people with severe mental health illnesses may be revealing in this regard, various meeting members noted.

“No-Wrong Door.” Members of the meeting were united in their belief that services for people with co-occurring disorders must be available and accessible wherever and whenever the person enters a service system. Often called a “no wrong door” approach, this ensures that a client can be treated, or referred for treatment, whether he or she seeks help for a substance abuse problem, mental health problem, or a general medical condition. This obliterates unnecessary duplication of services and reduces the likelihood that an individual will fall through the cracks of an uncoordinated system of care. Taking care of people with substance abuse or addiction issues can be challenging, but taking a professional approach is the way to a successful treatment.

Individual Responsibility and Empowerment

The recovery perspective emphasizes the responsibility and Empowerment of the individual and their family members and carers. A pessimistic attitude is a barrier in clients experiencing the co-occurring disorder. This attitude may prevent them from an effective treatment intervention recovery. An effective treatment intervention recovery is defined as a process whereby a client with resolute, disabling disorders recovers their self-worth, pride, dignity, self-esteem, and sometimes substance abuse or character altering drug, by increasing their ability to stabilize the illnesses and maximize functioning within the constraints of the diseases. Every client, irrespective of the disability or severity associated with each disorder, is allowed to experience the hope and promise of recovery.

The Use of Therapeutic Alliance to Engage the Consumer in Treatment: This method of engagement is one of the most efficient predictors of treatment outcome in psychotherapy, according to Najavits and his colleagues. A few studies in the drug/substance abuse treatment field have found an association between counseling effectiveness and the strength of the therapeutic alliance. Several researchers have discovered that consumers are more responsive when the therapists regularly act as supporting and neutral partners. However, there are a few challenges the therapist might face with this system. For instance, If the therapist is not comfortable, it can affect the effectiveness of the therapeutic alliance. This discomfort may be due to a lack of training, mentoring, or experience. Another instance is the difficulty of achieving a therapeutic partnership with clients with critical mental illness and drug/substance abuse disorders. Individuals with co-occurring disorders need a therapeutic alliance to facilitate not only their engagement process but their recovery process as well.

Long- Term and Comprehensive Care. In addition, because of the acute and severe nature of many co-occurring conditions, treatment for such individuals must be complete, staying clean and away from substance abuse, longitudinal, and increased or decreased according to changing needs and client motivation.

Engagement. Since many individuals with co-occurring disorders are not currently receiving any treatment at all, a strong recommendation was made that providers focus on engaging those who are not now in the substance abuse or mental health treatment systems. Significant attempts should be made to reach out to children and adolescents at risk for developing mental health and substance abuse disorders, many of whom present in primary care settings or school-based clinics. Besides, individuals with co-occurring disorders are found in the hospital emergency rooms, jails and prisons, living on the streets or uncompleted buildings and living in shelters. These sites act as primary sources for case finding and service delivery.

Continuous Support

This means that the service provider encourages patients to build a supportive network that offers acceptance, appreciation and respect. For instance, offering a place of belonging called home is an essential element of long-term participation in Alcoholics Anonymous (AA). AA accomplishes this by ensuring that the client is not overdependent, having substance abuse issue, and contributes, as well as support and receive.

Therapeutic Optimism 

Doctors/ therapists should demonstrate a genuine belief in the recovery process. Interaction and engagement with clients should be positive and optimistic. A whole-person approach should be adopted, supporting individuals to enjoy their rights and responsibilities of active participation in the community and, for instance, making sure that their needs are understood and met. This system may also require the help of family members and close friends. Making the client see good reason why they should refrain from a destructive lifestyle like substance abuse or any other lifestyle that will jeopardize their health

Integrated Service Delivery. 

While service delivery for some persons with co-occurring disorders should be combined (i.e., those with the most severe conditions), service program or agencies need not be. Because both the substance abuse and mental health systems have unique characteristics that will be important in an overall care strategy, their efforts should be combined. Still, it may be neither desirable nor practical to merge the systems themselves. Notwithstanding the specific organizational structure of the mental health and substance abuse treatment systems in a particular community, however, the system must be experienced seamless by the consumer. The use of common intake forms to facilitate a “no- wrong door” approach is an integrated/combined service delivery technique.

Trust and Respect. A complete service delivery system for co-occurring disorders will be as successful when the staff can be trusted and respected. The clients and staff’s ability to work together begins with an appreciation for providers’ skills and strengths in both systems. Also, front- line staff must be able to trust one another and know that they are working together for the good of the client. Although the character of those having mental issues or substance abuse issue can be mean to the staffs, but handling the situation professionally is key.

Cross-Training. Mental health and Substance abuse staff must be oriented toward and have a basic understanding of each other’s disciplines in order to be effective with consumers who have co-occurring disorders. However, participants offered the caveat that crosses- training alone does not make a person an expert in the other field. Further, credentials in a particular area do not necessarily equal competence. To be efficient, mental health and substance abuse, staff must have enough knowledge to know what they don’t know and seek appropriate advice from one another. Furthermore, primary health care providers would also gain from extra training in substance abuse and mental health disorders.

Episodes of Intoxication/substance Abuse Should Be Managed Appropriately.

Individuals can be at risk of harm to themselves and others when experiencing a mental health breakdown/crisis/ addiction or substance abuse. When intoxicated, they are at a higher risk. The system should ensure that there are procedures in place when this occurs. Staff should always be alert and adequately equipped to respond. Staff/practitioners should be able to identify the signs and indications of intoxication immediately. 

Common Data, Assessment Tools, and Performance Indicators. Because one of the most significant barriers to coordinated care for people with co-occurring mental health and substance abuse disorders is the lack of joint assessment tools, meeting participants strongly recommended that such instruments either be developed specifically for this purpose or selected from among existing tools. The use of standard devices will help providers in both systems determine the importance of an individual’s mental health and substance abuse disorders and plan effective treatment and follow-up care.

The movement of consumers between the mental health and substance abuse systems will be further enhanced by collecting common data. Moreover, when both systems are using a shared performance index to assess the treatment of co-occurring disorders, consumers, family members, program planners, advocates, and funders can better determine whether stated outcomes are being met.

Workforce Development

To deliver efficient care to individual experience, co-occurring disorders, substance abuse a workforce with the necessary values, knowledge and skills is needed. There is a need to ensure that people working in mental health possess different levels of skills and understanding, depending on their role and experience.

Flexible Funding Streams. Flexible funding is a mandatory tool if local substance abuse and mental health providers are to meet the needs of individuals whose disorders don’t fall neatly into one or another definite funding stream. Maintenance of independent funding streams at the Federal and/or State level may help to ensure that the substance abuse and mental health systems remain feasible and able to complement one another, each retaining and refining their areas of competence. In the concluding analysis, coordination of those funding streams at the local level by community providers may allow the most effective response to consumers’ unique needs with co-occurring disorders.

Support Against Smoking or Substance Abuse Should Be a Routine Part of The Care.

Practitioners should ensure that they constantly advise individuals suffering from co-occurring conditions to stop smoking or stop substance abuse. There should be opportunities made available for harm reduction to those individuals who are unwilling or unable to stop smoking. Access to nicotine replacement therapies and behavioural support should be made available for persons in this category.

Specific Funding Mechanisms. To support a philosophy of collaboration, consultation, and integration, local and state planners may need to develop particular funding mechanisms that allow such partnership activities (e.g., special workgroups or task forces) to be reimbursed.

Environment

Services should ensure that the environment is positive and safe. Clients should engage in honest conversations about their condition and aim for treatment.

Flexibility

Practitioners should recognize that every client is different, and change can be slow. The pace of recovery of clients would differ regularly. It is essential to ensure that the practitioners are patient with clients, especially when there are various play needs.

Specific Strategies for Consultation

For a consultation to be productive, substance abuse, mental health, and primary care providers will need to know what the other system expects of them. Meeting participants recommended the following general groups of knowledge exchange:

From the mental health field, substance/drug abuse providers need information about how to recognize the signs of mental health illness/substance abuse and differentiate them from the signs of substance use/abuse; how to plan effective treatment interventions for mental illness that co-occurs with substance abuse illnesses; how best to take advantage of client participation in treatment planning; and how to immediately and directly access the mental health services available to their consumers.

From the substance abuse sector, mental health providers need details about how to assess and recognize patterns of substance use/abuse, particularly as they relate to mental health illnesses; how to help clients through the phases of substance abuse treatment (persuasion, engagement, treatment, prevention); how to plan effective treatment interventions for substance abuse that co-occurs with mental illness; and how best to use the self-help perspective to healing from substance abuse.

From the significant health care sector, both the substance abuse and mental health systems need to know more about the medical consequences of co-occurring disorders and how to manage diseases that may result from, or co-occur with, substance abuse mental health disorders.

From the substance abuse and mental health fields, primary care practitioners need more education, information, and training about how to recognize the indications of mental health illness and substance abuse, especially as they relate to one another; and how to make appropriate referrals for mental health and substance abuse treatment, particularly for those individuals with co-occurring disorders.

In addition to knowledge about each other’s disciplines, substance abuse, mental health, and primary care providers need to know how best to construct and use the consultation process. Providers should be trained to understand who they should ask for help when they should seek it and what types of assistance they can expect.

Involvement of Family Members and Carers

In order to deliver timely, efficient and compassionate care to individuals suffering from co-occurring disorders, Services should be able to identify family members and carers whose needs are not met. It is crucial for practitioners to note the following:

• That there is a need to create support networks
• The effect of caring on their physical and mental health
• The level of support the carer or family members are willing to give.

Specific Strategies for Collaboration: Collaboration will be simple to achieve if the substance abuse and mental health systems have a joint vision that defines the importance of their endeavors. A vision/mission statement might refer to the need to enhance client outcomes, ensure the most appropriate services, and use resources more adequately.

System planners can consolidate their commitment to work together by signing a formal memorandum of understanding (MOU) to initiate their joint vision. In the agreement, parties may specify the specific areas of collaboration, such as using standard data, performance indicators, and assessments for substance abuse.

A Memorandum Of Understanding or other formal agreement should specify how the key players will track their progress. For this effort, substance abuse will require ongoing communication mechanisms. These should include both administrative and front-line staff responsible for maintaining the spirit of collaboration and ensuring that specific consumers’ needs are met. If these players do not participate in the communication process, the chances of developing an effective program for substance abuse are significantly reduced.

The participants overwhelmingly agreed that sharing resources at a local service delivery level is the best way to ensure that individuals get the substance abuse treatment they need. Together, financial support and resources can be used to make the best use of limited resources, enabling consumers to receive the best mix of substance abuse services.

Monitor Psychiatric Symptoms

It is essential to monitor individuals with a co-occurring disorder, especially those receiving therapy from a mental health service provider or those requiring medication. It is also crucial for the drug/substance counsellor to monitor psychiatric symptoms, controlling substance abuse and participate in developing the treatment plan. The mental health part of the project should be reinforced and the part specific to recovery from addiction. The client should also participate in the development of a treatment plan. For instance, for an individual suffering from both alcohol addiction (substance abuse) and bipolar disorder, the treatment plan might include medication management, group therapy and treatment counselling. In another situation, the practitioner may assist in the medication monitoring of a client taking lithium. The practitioner can ask questions like, do you remember to take them? Are you having problems with them? How are you feeling? The practitioner can ask the individual to bring in all his medication and find out when, how, and how much he is taking, this will also help limit or get rid of substance abuse.

Countertransference Management.

The concept of countertransference helps understand how a practitioner’s previous experience can affect his current attitude towards another client. Transference refers to the process whereby individuals project reactions, feelings, images, and perspectives from the past unto the practitioner. For instance, the client may see the practitioner as an authoritative parent or know-it-all sibling. This occurs primarily when working with complicated and various problems. Inexperienced practitioners are often ashamed and confused when faced with this situation. And the practitioner must know that the way to handle a patient with substance abuse issues would be quite different from a client’s dementia. Co-occurring disorders are illnesses that are stigmatized by the general public, likewise substance abuse issue. These same attitudes can be found among practitioners. Practitioners are advised to understand and get familiar with most of the countertransference issues and strategies to manage them. Being aware of countertransference issues helps the practitioner not feel angry, overwhelmed, anxious, confused, or used. They will even be able to handle their clients conditions, be it substance abuse, bipolar etc.

Specific Strategies for Service Integration 

One of the foremost integrated service mechanisms through which providers can serve individuals with co-occurring disorders is the addition of substance abuse specialists to mental health crisis and treatment teams and the addition of mental health specialists to substance abuse crisis and treatment teams. Integrated treatment teams provide “one-stop shopping” for consumers, and they help providers in both systems be more aware of and more knowledgeable about co-occurring illnesses.

When substance abuse and mental health providers are part of the same treatment team, they can develop and monitor a joint treatment plan that serves each individual’s unique needs with co-occurring disorders. Typical treatment plans and services consider the individual’s specific diseases’ interactive nature. They are designed to provide appropriate support for recovery from mental health and substance abuse disorders.

Additional funding specifically geared to people with co-occurring illnesses may be identified at some future point. However, providers and planners may choose to use existing funds, including state and federal monies, to leverage new resources. These might include, for instance, housing funds tied to the provision of supportive services or foundation monies targeted to a specific population.

 Managed Care Contracts 

Members of the meeting noted that there is a trend for many states to contract with managed care organizations to provide mental health and/or substance abuse services. Concern was expressed about managed care organizations’ ability to effectively serve individuals with co-occurring disorders. Because their needs are complex and lengthy-term, such individuals are likely to be ill-served by the short- term treatment approaches that tend to be favoured within the managed care environment. Mental health and substance abuse policymakers and funders can significantly impact this group’s care by reinforcing comprehensive and integrated models of care in managed care contracts that will cover people with co-occurring disorders throughout their recovery process.

Supportive and Empathetic Counselling

This counselling style is a crucial way to establish an efficient therapeutic alliance. Empathy should be the foundation adults use for interacting and relating with other adults. A practitioner’s heart enables a patient to recognize and own their feelings. Supportive counselling must be used overtime continually to keep that alliance going. This counselling is very efficient in dealing with clients with lower motivation to address their mental health and substance abuse issues.

The Use of Culturally Appropriate method

A practitioner should try as much as possible to learn about the cultural groups of his/her client. Characteristics of the cultural group to consider include expectations from family, communication style and interpersonal interactions. However, a practitioner should not make assumptions about any patient based on their perception of the patient’s culture.

Next Steps 

The group acknowledged that the type of system changes outlined in this dialogue would not happen overnight and certainly cannot happen in a vacuum. Do they require a coordinated effort at all levels? Local, State, and Federal to have a remarkable impact. Recommendations for moving forward with these vital suggestions are highlighted in the final section. Creating a cleaner environment free from substance abuse starts with you, so get more information, treatment suggestions about substance abuse, kindly contact us 615-490-9376.