Abstract: This paper reviews the central issues in treatment strategies and program development for mentally ill chemical abusers (MICA patients). Patient treatment needs, historical context for divisions of service/system, treatment philosophies, and program model components are discussed in the context of treatment efficacy, program funding and community based treatment policies with regard to comorbidity. An integrated services approach, utilizing symptom and deficit reduction, within a combined holistic and patient centered treatment philosophy is outlined. A comparison of patient outcomes between a traditional disease specific program and an integrated program is provided. The potential benefits of treating MICA patients in integrated treatment programs are discussed.
Deinstitutionalization and the corresponding increase in the number of homeless mentally ill has been associated with the emergence of a growing population of patients with concomitant mental illness and chemical abuse (MICA patients).
Numerous studies have demonstrated a rate of substance abuse and or dependency among the mentally ill at between 32 and 85 percent (Schwartz and Goldfinger, 1981; Safer 1987; Drake, Osher and Wallach, 1989). MICA patients are the most frequently cited population of dually diagnosed patients in the professional literature (Psycinfo, 1993). They have been reported to utilize increased rates of acute hospitalization, have histories of more housing instability, homelessness, criminality and homicidal/suicidal behavior than either the mentally ill or chemical abusers alone (Caron, 1981; Drake 1989;Osher & Kofoed, 1989; Safer, 1987). Poor medication compliance and response to treatment and services has also been linked to this dual disorder (LaPorte, 1989; McLellan, 1986).
MICA patients have not only created significant treatment challenges for traditional treatment programs, but for the entire mental health and addiction treatment care systems (Minkoff, 1991). Bachrach (1986 87) has referred to MICA patients as "system misfits" who do not measure up to the typical 'patient profile' within either the mental health or addiction systems of care. Traditional mental health programs are often poorly equipped to address dependency and ongoing intensive recovery needs of MICA patients, while addiction programs generally have difficulty treating MICA patients with psychotic symptoms or who require medication and psychotherapy to resolve a variety of various mental health issues.
Historically, treatment modalities for all dual diagnosis populations have been developed to deal specifically with symptom reduction and long term rehabilitation for each particular population. However, these programs have met with limited degrees of success in treating the dually diagnosed (McLellan, 1986; Schuckit, 1985). MICA patients have complex treatment needs and interactive symptomatology, requiring a more integrated approach than is generally employed (Breakey, 1987). Depression, delusions, and hallucinations, for example, are often related to, caused by, or intensified by substance abuse and addiction.
A variety of hybrid program models have been proposed and developed to meet the multiple clinical needs of MICA patients (Evans and Sullivan, 1990; Osher and Kofoed, 1989, Minkoff 1989).
These models generally fall into one of three categories.
1. Disease specific models with modifications: These traditional substance abuse or mental health programs attempt to treat the multiple symptoms of MICA patients by incorporating techniques of mental health or addiction counseling into their spectrum of services. Despite these enhanced techniques, the primary clinical focus in such program generally remains on the principal diagnosis of mental illness or substance abuse.
2. Linkage programs: Though similar to disease specific models in that they maintain a traditional approach to treating either mental illness or substance abuse, these programs generally deal with additional MICA treatment needs by referring patients to other clinics to treat the concomitant mental illness or addiction issues. Because of this, linkage treatment programs are more of a treatment strategy than an independent model and can be considered hybrids of existing disease specific program models.
3. Integrated programs: Incorporate the clinical resources and systems necessary to not only meet the multiple clinical needs of MICA patients within a single program, but to do so in an individualized manner; customizing treatment planning and services to meet the needs of individual MICA patients.
Most disease specific treatment models for MICA patients emphasize sequential program modeling, in which patients attend collateral treatment after they have met their current treatment goals in substance abuse or mental health (Minkoff, 1991). Linkage program models generally emphasize a parallel treatment model that requires patients to attend collateral treatment in another program for the mental health or substance abuse treatment they cannot receive in their current program. This parallel service system, used in linkage models, attempts to deal with both addiction and mental illness simultaneously, while disease specific, sequential models, first treat the mental illness or substance abuse, then send the patient to another program to work on the remaining symptomatology.
However, in both disease specific and linkage program, generally only one treatment philosophy is stressed for MICA patients; and it is typically substance abuse treatment (Minkoff, 1991). In such programs, mental illness and underlying pathology are often treated as secondary to the substance abuse, and the primary treatment phases and components generally mirror that of traditional substance abuse treatment programs (Osher & Kofoed, 1989).
Effective treatment for either the addiction or mental illness symptomatology, first requires clinician understanding of the interaction between all presenting symptoms. Thus, the first step in meeting the treatment needs for MICA patients is a complete assessment of all presenting symptoms. However, in many traditional disease specific and linkage program models, initial assessment and instrumentation are often selected to measure only the aspects of the patients' symptom constellation that can be treated at that facility. As a consequence, other deficits, such as medical illness, history of trauma, skill deficits or inadequate/antisocial support systems, perceptual disturbances, and deficits in cognition are neglected (Koegel & Burnam, 1988; Wright and Weber, 1987). On the other hand, integrated programs are generally designed to take into account the full range of patient symptoms and distress and customize treatment to meet these patient needs.
The use of an integrated model has clear advantages over disease specific models of care for MICA patients. A detailed review of the historical development, theoretical/philosophical assumptions, model components and efficacy punctuates its advantages as a model for effective treatment.
Over time, established research and treatment programs for population specific diagnostic categories have produced barriers to patient care. This is due to over specialization of treatment programming and tends to limit access or reduce services for the dually diagnosed. Clinician, program, institution and funding bias have contributed to the development of programs that are focused on treatment within disease specific categories, such as mental illness or substance abuse. This bias is generally in the direction of treatment of primarily single diagnosis symptomatology. It has resulted in the development of treatment programs and associated techniques that concentrate on one aspect of patient pathology while excluding others, such as psychotic spectrum and mood disorder symptomatology. The traditional, 12 Step Method of Alcoholic's Anonymous and Narcotics Anonymous are examples of such treatment strategies (Cummings, 1993). These treatment programs generally discourage the use of all foreign substances, even medication to treat mental illness. In many of these programs, all aspects of care that appear to be in conflict with the 12 step model are discarded as potentially harmful to the substance abuse treatment.
In general, this bias within systems of care, or paradigmatic bias, is due to evolution of separate administrative divisions and funding pools which foster effective political and administrative organization at the expense of creative and innovative clinical care. Artificial and arbitrary divisions at the federal, state and local government levels continue to promote this process and consequently prevent programs from developing joint projects or crossing service boundaries to more effectively treat and manage patients with multiple diagnoses (Drake et al, 1991; Ridgley et al, 1990). Often otherwise eligible patients who seek treatment at single diagnosis facilities and who happen to have co existing disorders are refused admissions to or are prematurely discharged from such treatment programs solely on the basis of their category of pathology (Galanter et al, 1988). This situation has caused many population specific treatment programs to be over utilized and restrict entry due to space limitations, while other, less restrictive community mental health programs remain under utilized.
Prior to deinstitutionalization, almost all types of dually diagnosed patients received care from an integrated state hospital system. However, with the reduction of long term, state and federal institutional beds came a corresponding rise (albeit slow) in various streams of funding for community mental health centers and more recently for substance abuse programs. In addition, separate funding streams were also developed for the long term community based treatment of mental retardation and child/adolescent disorders. Each of these funding streams produced a corresponding division in both clinical research and service delivery.
The philosophies of treatment tended to vary as new funding streams and divisions of services developed. Mental health center models tended to adopt a medical/biochemical deficit philosophy, while substance abuse programs developed treatment programs that were based on an internal character deficit philosophy (Valliant, 1983). Other funding streams for MRDD and adolescent disorders produced programs based on combined medical and social environmental/ecological deficit philosophies (Humphreys & Rappaport, 1993).
Brower (1989) identified five distinct treatment philosophies that have emerged in disease specific treatment program models. He writes that many programs typically employ moral deficit, learning/behavioral, disease, self medication, or social deficit philosophies of treatment. Though each of these treatment philosophies have advantages when applied to a target population, each are compromised by their rigid adherence to that particular philosophy and are therefore limited in their efficacy.
The moral deficit philosophy is historically the oldest model for both substance abuse and mental health treatment. In this model, illness results from a moral weakness and lack of willpower. The goal of rehabilitation is to increase the patients willpower to resist their evil cravings for substance or resist the irrational urges of mental illness and become good. Though the moral deficit philosophy has the advantages of holding patients accountable and responsible for the consequences of their actions, the major disadvantage of this treatment philosophy is that it places the treating clinician in an antagonistic relationship with the patient. In such programs, clinicians must adopt a judgemental stance that is blaming and punative. The moral deficit philosophy is often embraced by patients themselves who feel guilty for their past actions and who readily assess themselves as bad and weak willed. And though this treatment philosophy may help some chemical abusers, it could be disastrous for the MICA patient who has no control over the biochemical imbalances that caused the mental illness and/or the substance abuser who may be hypersensitive to criticism or blame.
Disease specific programs utilizing a learning/behavioral philosophy assume that substance abuse and other deficit behaviors are caused by the learning of maladaptive habits (Marlett, 1985). In this case, the patient is viewed as someone who has learned 'bad' habits through no particular fault of their own. The goal of treatment is to teach new behaviors and cognitions that are more adaptive. The main advantages of utilizing this model are that clinicians are neither punitive or judgemental in their service delivery and the learning of new, more adaptive habits is the primary focus of treatment. Unfortunately, such models shift the focus of 'control' to the patient. Thus, fueling the patient's denial of either mental illness or substance abuse. Since they may deny that they are out of control, they may deny that any problem exists. For MICA patients who may resolve their chemical abuse or mental illness problem, this could have serious consequences because the remaining clinical deficits will not be resolved.
The disease/deficit philosophy is perhaps the dominant model used among disease specific program providers today (Brower, 1989). In programs that adopt this philosophy, substance abusers are seen as individuals who are ill and unhealthy, not because of an underlying mental illness, but due to the disease of chemical dependency itself. Because there is no known cure for this 'disease', the patient is considered always and forever ill. The treatment in this case is complete abstinence. Chemical abusers are expected to "change from using to not using, from ill to healthy, and from unrecovered to recovering" (Brower, 1983, p.150). Although guilt is relieved because patients are not held responsible for developing chemical dependency, and treatment is neither punitive or judgemental, this treatment philosophy cannot account for people who return to normal asymptomatic drinking. When applied to mental health, this model cannot account for spontaneous remission either. Since these 'diseases' are considered incurable and only manageable, no spontaneous recoveries or remissions are possible. And for MICA patients with interacting symptomatology, what portion of their multiple problems can be considered part of a disease and what part is not even considered under this set of assumptions?
Programs that adopt a self medication philosophy assume that chemical dependency occurs either as a symptom of mental illness or as a coping mechanism for underlying psychopathology. The patient is viewed as someone who uses chemicals to alleviate the symptoms of a mental disorder such as depression. The goals of treatment for these programs emphasizes improvement in mental functioning. Chemical abusers and the mentally ill are expected to change from mentally ill to psychologically healthy. The major advantage with these programs is that psychiatric problems are diagnosed and treated along with the substance abuse symptoms. However, this is also the model's main disadvantage as well. Assuming mental illness as the etiology for chemical abuse negates the possibility that chemical abuse causes the psychopathology. Because the focus of treatment is on the resolution of underlying mental illness, the chemical abuse problems that may be the true clinical etiology may not be resolved for MICA patients. Social deficit philosophies of treatment tend to view chemical dependency and mental illness as a result of environmental, cultural, social, peer or family influences (Beigel & Ghertner, 1977). Substance abusers and the mentally ill are viewed as products of external forces such as poverty, drug availability, peer pressure, and family dysfunction (Brower, 1989). The goal of treatment in these programs is to improve social functioning by altering their environment or their coping responses to perceived stressors. This may involve group therapy, attending self help groups, residential treatment, and interpersonal therapy; all with the goal of improving social skills. An advantage in assuming a social deficit philosophy is that the role of the social environment is brought into clinical focus and treatment is geared toward reintegrating patients into their social milieu. The main disadvantage in adopting this treatment philosophy for the treatment of MICA patients lies in its exclusive treatment of social factors for problems that are often multifactored. This again implies the need for the adoption of additional treatment strategies that are based on often competing philosophies.
By accepting any of these underlying assumptions alone, and relying solely on one philosophic stance, researchers and practitioners perpetuate the status quo by remaining uncritical about the problems inherent in their models. This process has, as a consequence, produced service barriers that have discouraged or excluded large numbers of dually diagnosed patients from seeking, being admitted to, or successfully completing appropriate professional treatment programs (Bachrach, 1987; Humphreys & Rappaport, 1993). Instead of creating additional subpopulation and philosophic barriers, the critical question for both MICA treatment providers and researchers should be how we can best match MICA patients during their courses of treatment to the various programs and models in order to maximize outcomes in biopsychosocial and multivariate treatment programs. (Glaser, 1980, Marlatt, 1988).
An integrated system of care for MICA patients incorporates more comprehensive treatment philosophies and strategies than traditional disease specific models. Integrated approaches allow for the use of the most appropriate level and type of treatment technologies available to rehabilitate patients at his or her particular level of need. Thus, integrative treatment plans can be customized to meet both the mental health and addiction needs of the patient.
Traditional disease specific and linkage programs tend to be more generic in nature, requiring patients to conform to the expectations of the program, as opposed to the program conforming to the needs of the patient. Many substance abuse models emphasize group and individual counseling in a highly structured, substance free, restrictive environment. These programs generally enforce abstinence from all substances, including psychotropic medication. Long term aftercare treatment focuses solely on sobriety issues. On the other hand, disease specific models in mental health concentrate on functional adaptation and rehabilitation in a less restrictive milieu, but minimize the problems of addiction. It is assumed in each of these program models that patients will be motivated to participate in treatment to alleviate their distress. Those who do not conform to the mandates of these programs are considered treatment resistant or treatment refractory and are encouraged to seek help elsewhere or discharged from the program.
Developing a comprehensive and more effective system of care requires the use of a wide array of services delivered under a conceptual framework that merges both addiction recovery and psychiatric rehabilitation. Minkoff (1989) has identified an integrated conceptual framework for treatment of MICA patients and the key concepts for developing such programs. The critical elements for developing such a system are as follows:
"1. Chronic psychotic disorders and substance dependency are both viewed as examples of chronic mental illness, with many common characteristics (biological etiology, hereditability, chronicity, incurability, treatability, potential for relapse and deterioration, denial and guilt), despite distinctive differences in symptomatology.
2. Each illness can fit into a disease and recovery model for assessment and treatment, where the goal of treatment is to stabilize acute symptoms and then engage the person who has the disease to participate in a long term program of maintenance, rehabilitation and recovery,
3. Regardless of the order of onset, each illness in considered primary. Further, although each illness can exacerbate the symptoms of and interfere with the treatment of the other, the severity and level of disability associated with each illness is regarded as essentially independent of the severity and level of disability associated with the other.
4. Both illnesses can be regarded as having parallel phases of treatment and recovery. Those phases include acute stabilization, engagement in treatment, prolonged stabilization/maintenance and rehabilitation/recovery. Osher and Kofoed (1989) have further subdivided the engagement phase into engagement, persuasion, and active treatment; prolonged stabilization is the intended outcome of active treatment.
5. Although, in dual diagnosis patients, progress in recovery for each diagnosis is affected by progress in recovery for the other, the recovery processes commonly proceed independently. In particular, progress in recovery may depend on patient motivation, and patient motivation for treatment of each illness may vary. Thus, patients may be engaged in active treatment to maintain stabilization of psychosis, while still refusing treatment for stabilization of substance abuse." (Minkoff, 1991, p.18)
Such a conceptual framework has a number of implications for program model design. Each system of care, within the integrated model, must include programs elements the meet the needs of the patient in every phase of recovery and rehabilitation. In addition, the program must address levels of severity and disability within each phase of rehabilitation. For example, programs must provide for acute detoxification services for both psychotic and/or non psychotic patients; deliver services for the stabilization of psychosis, whether the patient is in active substance withdrawal or not; and provide individual and group therapy services that are designed for various degrees of dysfunction in both substance abuse or mental illness.
To operate this under this combined conceptual framework, integrated
models must be staffed with sufficient numbers and types of clinicians
to provide the customized, comprehensive treatment inherent in such a model.
The following abbreviated list and description of service elements exemplifies
the range of services that may be incorporated into integrated program
model (Finney & Moos, 1984; Hellerstein, 1987; Hendrickson 1989; Kofoed,
1986; NYSOMH, 1990; Ridgely, 1987):
In addition to the comprehensive provision of the 'mix' of services, an integrated program should provide for acute stabilization, continuity of care, and ongoing stabilization and rehabilitation for both addiction and mental illness symptomatology. Relapse occurs often in both mental illness and substance abuse. Programs must possess or link with adequate facilities to stabilize patients during acute episodes and relapses. In addition, maintaining a vast array of services under one program umbrella, provides for continuity of care by short circuiting the "ping pong treatment" of bouncing back and forth between various programs (Ridgely, Goldman and Willenbring, 1990) . This usually occurs in linkage programs and creates a discontinuity of services for the patient and confusion in treatment planning for clinicians.
Finally, ongoing stabilization and long term rehabilitation must be designed into the phases of treatment to enable patients to build on the gains made within the integrated program. This may take the form of case management or ongoing day treatment. These program components reduce the incidence of relapse for both mental illness and addiction and promotes patient re integration into the community (Harris and Bergman, 1987).
The characteristics and program elements listed above generally describe common characteristics for integrated programs in residential and hospital settings. A review of the literature on integrated MICA programs also identifies five common characteristics for outpatient programs as well.
"1. Abstinence is a goal, not a requirement.
2. Patients with substance abuse and substance dependence are treated together.
3. Group models, with either staff of peer leaders, are fundamental.
4. Patients progress from (a)low level education or "persuasion" groups, in which patients have high denial and low motivation, to (b) "active treatment" groups, in which they are more motivated to consider abstinence and are willing to accept more confrontation, to (c) abstinence and support groups, in which they have mostly committed to abstinence and help each other to learn new skills to attain or maintain sobriety.
5. Involvement of available family members is recommended." (Minkoff, 1991, p.23)
By incorporating this vast array of services under an integrated conceptual framework, MICA patients, who typically fail in traditional treatment due to low levels of motivation or programmatic/system bias against either substance abuse or mental health issues, can be treated at their individual level and scope of dysfunction. The development of an integrated program model builds on the most effective treatment technologies available in addiction and mental health, while overcoming the differences that separate the systems and treatment programs. This comprehensive integration, serves not only the MICA patients who receive treatment in the programs, but strengthen both mental health and addiction care systems as well.
A COMPARISON OF INTEGRATED AND DISEASE SPECIFIC MODELS
Anderson (1993) evaluated the treatment outcomes of two transitional living communities in Bellevue Hospital Center, New York City. This study illustrates the differential efficacy for a traditional, disease specific treatment model and an integrated program approach. The Transitional Living Community Program (TLC) was described as a hospital operated, residential rehabilitation facility for mentally ill, homeless men that utilized an integrated approach to treatment. This unit had been in operation since January, 1987. In this study, patient treatment outcomes of the TLC are compared with those of the Mentally Ill, Chemical Abusers Transitional Living Community (MICA TLC). The MICA TLC began operations to specifically treat patients diagnosed with both mental illness and substance abuse in May, 1991. This unit utilized a more traditional disease specific approach to substance abuse treatment.
Both units accepted MICA patients, have identical staffing patterns and patient mix, operated in the same location on the Bellevue Hospital campus, and had the goal of rehabilitating patients over a six month period for eventual long term placement in the community. They only differed in their respective models of service delivery.
The TLC Program was a voluntary unit that engaged each patient in a contractual agreement for all therapeutic services delivered within an integrated treatment environment. This unit accepted dually diagnosed patients of all types, provided they were homeless, had an Axis I diagnosis of Mental Illness, and were ambulatory. As patients entered the program, the patient and the treatment team consulted and contracted for the amount and type of services the patient would receive. Patients who were not scheduled for group or individual therapy could leave the unit at will. Abstinence from intoxicating substances on this unit was encouraged but not mandated. Psychiatric rehabilitation was the main focus of all individual and group therapy sessions. This program customized the array of services delivered to each patients in a integrative model.
The MICA TLC operated within a modified therapeutic community (TC), disease specific program model. This program accepted all patients who were homeless, had Axis I and concomitant substance abuse diagnosis, and who were ambulatory. Within this model, all patients were required to remain on the unit and participate in all available services, including group therapy, activity therapy, and substance abuse counseling. Though the overall goal of this unit was identical to that of the TLC Program in terms of rehabilitation and placement into community based settings within a six month period, this program emphasized traditional 12 Step and substance abuse treatment and only minimally addressed psychiatric rehabilitation issues in one group therapy session per week. In addition, as in other traditional substance abuse treatment programs, all patients on this unit received the same level and type of treatment. In both programs patients only graduated and were placed into community based housing programs when they were functionally able to live independently. This required a global level of functioning of at least 75.
TLC and MICA TLC patient dispositions for a 30 month period are demonstrated in Figure 1. Within the context of this investigation, Graduates were defined as those patients who had completed the therapeutic program, had reached and maintained a Global Level of Function of at least 85, and had remained in community based placement for at least three months. AMA patients are defined as those who left the program against medical advise or who were requested to leave the program for violence or threatening behaviors on the unit.
With no significant differences found in patient age, SES, race, or hospitalization history, and including only the 110 MICA patients of the TLC unit, the TLC Program more than doubled the rate of the positive therapeutic outcomes of the MICA TLC Program. This was in spite of the fact that the MICA TLC had delivered 35% more service hours per patient than the TLC program during the same period.
The TLC program had delivered an average of 22.3 hours of group and individual treatment to patients weekly, while the MICA TLC program had delivered an average of 30.1 hours per week.
The results of this study suggest that the level of structure and/or the lack of individualized treatment of the traditional, disease specific therapeutic community model did not meet the needs of the patients diagnosed with psychotic spectrum disordered, chemical abusers on this unit. On the other hand, the TLC Program's individualized, integrative approach more effectively served the needs of most patients on the unit and did not have a differential impact on any sub population of MICA patients.
This review of the historical development, theoretical/philosophical assumptions, model components and efficacy of MICA treatment models clearly demonstrates the advantages of using integrated treatment models to treat the dually diagnosed. The advantages of the model use were not only demonstrated on theoretical level but in clinical use as well. The efficacy rates of the two transitional living communities suggest that the use of an integrated approach which emphasizes the individualized 'mix' of treatment options produces greater patient satisfaction, and yields higher levels of efficacy than traditional, disease specific programs currently provide. In addition, integrating services within a single program reduces costs and duplication of effort because patients are treated within the same facility. Adoption of a integrated program model allows for the customization of program services to meet the needs of individual MICA patients, instead of matching patients to rigidly structured, generic programs that may or may not meet their treatment needs. (Jolivet, 1993).
Though the integrated model presented in this paper is not a magic bullet and cannot resolve all the problems that emerge in treatment for the dually diagnosed, full and comprehensive treatment can occur simultaneously for the dually diagnosed patients of many categories, provided sufficient levels of staffing/staff training and program organization exist. Additional programmatic measures to discourage substance abuse, linkages with specialized medical facilities to treat compromising medical disorders, and adoption of level systems and/or other programmatic enhancements and technologies provides greater therapeutic treatment value for a variety of dual diagnosis categories, than current disease specific models provide in community based residential settings. (Polcin, 1992).
For integrated programs to effectively deal with a wide range of therapeutic issues, professional level training must include integrative treatment technologies and strategies for multiple, interacting symptoms. Mental health education programs generally include some form of training in various psychotherapeutic paradigms. This may include cognitive behavioral, client centered, interpersonal, psychoanalytic, family, systems, and other paradigmatically based treatment modalities and technologies. Additional professional training in the eclectic and/or integrative use of these therapeutic technologies with a variety of dually diagnosed patients can empower clinicians to more accurately assess and treat multiple categories of dual diagnosis within the same community mental health center.
Careful integration of program services will also allow for the normalization and destigmatization of many coexisting disorders. In traditional dually diagnosed and single diagnosis program models, many patients tend to view and identify themselves as part of the community within those programs. Upon completion of the program, they also tend to add the prefix ex to this identification (i.e., ex alcoholic, ex schizophrenic). In traditional, disease specific aftercare and community programs they often tend to identify themselves by their diagnosis as well (i.e., identification of self as an alcoholic in Alcoholics Anonymous)(Jolivet, 1993). Additional research may show that integrating a variety of MICA and single diagnosis patients within the same community based program may reduce this stigmatization. An integrative program approach may also encourage patients to assist in helping their "fellow community members" toward reaching their treatment goals and eventually maintain themselves more successfully in the community.
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