Professional Documents
Culture Documents
December 8, 2010
Candace Mills
Abstract
This literature review looks at the integrated service models for treatment of co-occurring and
dual diagnosed individuals, and how to offer a more cost effective and efficient way to meet the
service needs of the community. This paper will compare the current models of integrated
treatment with the effectiveness of cross training mental health and substance abuse
professionals and teaching them to recognize DSM-IV personality disorder categories, in order
to provide effective services to dual diagnosed clients and clients with severe mental illness in an
The National Alliance on Mental Illness states that even though there is research
supporting the success of integrated services, it is not offered consistently to consumers. Dual
diagnosed consumers face numerous problems. Most mental health providers are not able to help
consumers suffering from co-occurring disorders because they are not trained to identify co-
occurring problems; if they do recognize a dual diagnosed consumer, the consumer is sent back
and forth between providers or may be refused treatment. This causes gaps in service, which
Consumers who receive effective integrated treatment with the same provider, in the
same setting, and receive treatment for both mental health and substance abuse, receive the most
effective services in a coordinated fashion. Interventions are bundled together and consumers
receive consistent mental health and substance abuse assistance treatment. There is no need to
LITERATURE REVIEW
for treating co-occurring disorders; assertive community treatment and standard clinical case
management. The assertive community treatment model is for individuals with severe mental
illness who tend to not use outpatient services locally, have frequent relapses and
rehospitalizations, and have severe psychosocial impairment. The standard clinical case
management treatment model is for individuals with serious mental illness to be treated in an
outpatient setting with a case manager coordinating all necessary medical and mental health care
and supportive services. Adding cross training or education for mental health workers in dual
Integrated Treatment for Co-occurring Disorders
diagnosis treatment and/or integrated treatment for drug and alcohol addictions would aid in the
Essocks and collogues studied the comparison between the two different models of
integrated treatment to ascertain if clients with co-occurring severe mental and substance use
disorders were at a higher risk of institutionalization and other adverse outcomes. The study also
compared the effectiveness of the two treatment methods and was conducted in a predominately
rural area of New Hampshire and an urban area of Connecticut; the baseline data from the
Connecticut group was compared to baseline data from the New Hampshire group.
Demographics of the participants indicated that this particular study was dominated by male
participants, most were unemployed, and 90 percent were from a racial or ethnic minority group
(African Americans 55 %, Hispanics 14 %, and 7% were from another minority group). Only
The participants in this study suffered from severe mental illnesses, such as
schizophrenia, bipolar disorder, and alcohol abuse. Some participants had lifetime substance use
disorders and some were current substance abusers. Because of the clients circumstances, they
to their family, economic hardship, and infectious diseases. Clients in both the rural New
Hampshire and urban Connecticut groups improved using the assertive community treatment
over the standard clinical case management, but also showed that clients in urban areas had
higher rates of drug use, housing instability, and more legal situations. It was thought that these
urban areas would benefit more from assertive community treatment than from the standard
Essocks and colleagues concluded that integrated treatment for both of these groups can
there may be a greater positive effect on the lives of the clients by just using integrated treatment
for co-occurring disorders (Essocks, Mueser, Drake, Covell, McHugo, Frisman, Kontos, Jackson,
Although there is a high prevalence of personality disorder among consumers that abuse
substance abuse, there is limited literature available on the co-occurring condition. Substance
abuse disorder and personality disorder are among the most common co-occurring mental health
diagnoses. They report 14.8 percent of adults with one personality disorder, 28.6 percent with a
personality disorder and alcohol abuse disorder, and 47.7 percent with a personality disorder,
alcohol abuse disorder, and substance abuse disorder (Ashenberg Straussner & Nemenzik, 2007).
A national epidemiological study done by Grant, Stinson, Dawson, Chou, Ruan, & Pickering
Ashenberg and collogues report that 15% of the population that meets the DSM-IV
criteria for the 11 personality disorders is divided into three clusters. The first cluster includes
Paranoid personality type, Schizoid personality type, and the Schizotypal personality type. The
second cluster includes the dramatic, emotional, and erratic personalities, better known as the
Antisocial, Borderline, Histrionic, and Narcissistic personalities. The third cluster includes
anxious and fearful personalities, such as are found in individuals with Avoidant, Dependent, and
Ashenberg et al., (2007) state that understanding the different clusters and types of DSM-
IV diagnostic criteria is also important for the treatment of co-occurring disorders. More often
than not patients that have personality disorder or are borderline type are excluded from clinical
Integrated Treatment for Co-occurring Disorders
trials and treatment for substance abuse diagnoses and patients that have substance abuse
The lack of cross training between substance abuse professionals and mental health
professionals is also a barrier to those facing co-occurring diagnoses. Substance abuse and
personality disorders are common to co-occurring dysfunctional clients and they can be lifelong
problems as they represent separate and complicated disease processes. Receiving appropriate
treatment of both disorders can be successful and lessen mental health recidivism in correctional
facilities and help society to provide services for person with mental illnesses (Ashenberg
Roskes &Feldman (1999) report on a study done in Baltimore City based on the
community mental health model. Participants were each assigned a psychiatrist, therapist, and
would continue working with a probation officer. At the start of the study this group of offenders
had a violation rate of 56% before their current release. The programs intervention may have
had an impact in decreasing from 56 % to 19 %. With the consumer working with the
community supervision system and the correctional system together, the co-occurring mental and
addictive disorders can be dealt with in a more integrated fashion and thereby help to reduce
recidivism (1999).
METHODOLOGY
Based on the above information identifying if cross training of mental health and
substance abuse professional is a more effective and cost efficient way to offer integrated
services and help to reduce recidivism will be answered. It is also noted above that the lack of
cross training between substance abuse professionals and mental health professionals is a barrier
Integrated Treatment for Co-occurring Disorders
to those facing co-occurring diagnoses and receiving appropriate treatment for disorders can be
The purpose of this study is to ascertain the effectiveness of cross training case managers
and intensive case managers in substance abuse, addictions, and DSM-IV codes, will better
enable them to work with dual diagnosed and co-occurring individuals in the community. The
study will focus on self direct learning and attending company paid trainings.
The participants will be case managers for NHS Human Services. The case management
unit, consisting of intensive case managers and resource coordinators, will participate in a pretest
and post-test to find out how knowledgeable they were about integrated services for dual
diagnosed and co-occurring disorders, if they would they be willing to attend training for dual
diagnosis and co-occurring disorders, and how often they would be willing to attend training.
The survey will be created using Survey Monkey, a free online survey website (Appendix
A), and training will be offered through Drexel University. This will be cost effective also
because of the partnership between Drexel University and NHS Human Services. The case
management unit will be resurveyed after three months. The data collected in the second survey
will be measured against the data collected in the first survey to determine if the training has
CONCLUSION
Mental health workers, working with consumers that are already dual diagnosed need to
know what type of behaviors are normal in substance abuse and mental illness consumers, so that
the consumers receive effective treatment. Implementing integrated services for clients with co-
occurring or dual diagnoses can initially be costly, but training staff in understanding the
relationships between substance use and personality disorder, understanding that even a single
Integrated Treatment for Co-occurring Disorders
diagnosis may be part of a co-occurring disorder, and recognizing the DSM-IV personality
disorder categories and clusters, is one way to ensure that clients with a co-occurring disorder
receive effective treatment. Offering integrated training to mental health professionals using
models such as the community treatment model, to more effectively work with consumers with
both a substance abuse diagnosis and a mental health diagnosis would better serve the consumer
The community mental health model shows how progress can be made when all services
are provided by a single agency through coordinated services in a cost effective/efficient manner.
The lack of cross training between substance abuse professionals and mental health professionals
is a constant barrier to those with co-occurring diagnoses. Training would build communication
and trust with the dual diagnosed consumer, and help providers understand the consumer’s needs
TIMELINE
This study will be conducted in two parts, beginning in February 2011 and ending in
April 2011.
BUDGET
This study will be cost free because the survey will be produced from a free online survey
website (Appendix A), the researcher will perform the work of administering the survey and the
IRB
Attached please find Appendix B, a letter from NHS Human services, dated December 9,
2010, giving permission to conduct this research project at this work site.
Integrated Treatment for Co-occurring Disorders
References
Ashenberg Straussner, S.L., & Nemenzik, J. M. (2007). Co-occurring substance use and
Essocks, S. M., Mueser, K. T., Drake, R. E., Covell, N. H., McHugo, G. J., Frisman, L.K.,
Kontos, N. J., Jackson, C. T., Townsend, F., & Swain, K. (2006). Comparison of act and
standard case management for delivering integrated treatment for co-occurring disorders.
Grant, B. F., Stinson, F.S., Dawson, D., Chou, S.P., Ruan, W. J., & Pickering R. P., (2004). Co-
occurrence of 12 month alcohol and drug use disorders in the United States: Results from the
National Alliance on Mental Illness. Dual diagnosis and integrated treatment of mental illness
and substance abuse disorder. Nami.org. 05/2003. Retrieved December 7, 2010 from
http://www.nami.org/Template.cfm?Section=By-
_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=23049
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Appendix A
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Appendix B
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Appendix C