June
18, 2001
AACP POSITION STATEMENT ON PROGRAM COMPETENCIES IN A COMPREHENSIVE CONTINUOUS INTEGRATED SYSTEM OF CARE
FOR INDIVIDUALS
WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE DISORDERS
Introduction:
In June, 2000, AACP released a consensus
position statement entitled Principles of Treatment for Individuals with
Co-occurring Psychiatric and Substance Disorders, indicating the need for
welcoming, accessible, integrated, continuous, and comprehensive treatment
interventions and treatment programs, organized into a comprehensive,
continuous, integrated system of care (CCISC).
The
current document builds upon that position statement, by indicating AACP
support for recently disseminated program categories for mental health and
substance disorder programs, that define Dual Diagnosis Capable (DDC-MH,
DDC-CD) programs and Dual Diagnosis Enhanced (DDE-MH, DDC-CD) programs within each
service system, and recommend the following important principles of system
design:
1.
All MH and CD programs
should be expected to be Dual Diagnosis Capable, according to the definitions
below.
2.
Within any system of care,
at each level of care, there should be a plan for appropriate DDE capacity.
3.
Within any system of care,
there needs to be a full range of housing options for individuals with
psychiatric disabilities, as described below.
Definitions:
System of Care: For purposes of this document, mental health
(MH) programs are any programs organized, licensed, and/or funded to
specifically treat individuals with psychiatric disorders, often prioritizing
individuals with serious mental illness; the array of such programs serving a
defined population is termed the mental health system of care for that
population. Similarly, addiction or
chemical dependency (CD) programs are any programs organized, licensed and/or
funded specifically to treat individuals with substance disorders; the array of
such programs serving a defined population is termed the chemical dependency
system of care for that population.
Program Categories: DDC-CD; DDE-CD;DDC-MH;DDE-MH
DDC-CD: The concept of Dual Diagnosis Capability in
CD programs is incorporated in the ASAM PPC2R (ASAM, 2001), in which DDC is
described as a standard of care for ALL addiction treatment programs, based on
the high prevalence of expected comorbidity among individuals seeking addiction
treatment.
DDC-CD
represents a measurable basic standard of care, which can be implemented within
the context of existing program requirements, with additional technical
assistance and training support, but without additional clinical operational
cost, and can be reliably assessed through routine program audit, such as would
occur during licensure review.
DDC-CD
applies to any and all levels of care in the addiction treatment system, and
implies that the program routinely admits individuals with co-occurring
disorders, provided that the symptomatology and disability associated with
those disorders is not severe enough to substantially interfere with
participation in routine program functions or require substantially increased
levels of staff support in order to sustain such functioning.
Thus, an individual may have baseline psychotic
symptoms or suicidal ideation, but these symptoms are sufficiently limited or
controllable that the individual can participate in groups, complete
assignments, perform independent ADLs, etc.
The
measurable criteria that define DDC status are as follows:
1.
Mission and Philosophy: The
program’s mission, philosophy, and admission policies specifically welcome
individuals with co-occurring disorders, and create no barriers to admission
based solely on psychiatric history, diagnosis, or non-addictive prescribed
medication. Assessment of motivation
and functional capacity to participate in treatment are assessed for this
purpose, as they would be for anyone seeking admission. (Note that individuals with psychiatric
presentations or medication regimes that are more complex or controversial will
ordinarily require DDE-CD programs for addiction treatment.)
2.
Screening for Comorbidity: There
are specific screening procedures for the presence of psychiatric disorders and
symptoms, and evidence that such procedures or tools are followed and used
competently.
3.
Assessment: The
assessment process is ongoing, and incorporates routinely gathering information
about psychiatric history and current psychiatric status, including symptoms,
disability, current treatment supports, and psychotropic medication needed to
maintain stability. There is evidence
that this process, and the associated forms, are followed and used competently. In addition, proactive linkage is provided
to ensure access to mental health treatment for those individuals who need
mental health services beyond the capabilities of the program.
4.
Diagnosis and Treatment
Planning: Psychiatric diagnoses are identified in the
treatment record, and, where current treatment is required, listed as problems
on the treatment plan. Specific goals
and objectives are identified for each such problem.
Ex. Problem:
Major Depression, on meds, currently minimal symptoms
Goal: Maintain stability and prevent interference
with addiction rx.
Objective: Patient demonstrates competency in taking
meds as prescribed.
Patient identifies
techniques for addressing med issues in 12 Step meetings
5.
Documentation: Progress
notes document monitoring of the psychiatric disorder in relation to the
treatment plan.
6.
Programming: Treatment programming (at
least one group per week) addresses issues related to co-occurring mental
illness directly and openly, educating ALL clients about basic symptoms of
mental illness, the possibility of comorbidity, and the need for continued
medication compliance while working an addiction recovery program.
7.
Medication Policies: Program
policies address obtaining medication prescriptions, as well as medication
distribution and compliance, directly, and support medication compliance with
MD prescription as a program requirement, including staff’s responsibility to
support such compliance.
8.
Psychiatric Emergency
Policies: Program has specific procedures for dealing with
psychiatric emergencies.
9.
Mental Health Consultation: Program
has access to MH consultation for diagnostic assessment and treatment planning
assistance. (Ideally, an existing program supervisor has MH background and
training.)
10.
Collaboration with MH
Treaters: Program has defined policies and procedures for
integrating input from outside MH treaters into treatment plans, progress
notes, and discharge plans, including obtaining routine input from psychiatric
prescribers. (Psychiatrist on site is preferable, but not required.)
11.
Competencies: Human
resource policies and staff training and supervision policies incorporate
attention to specific competencies in co-occurring disorders related to program
function (eg, screening, running the group), and continuing education to
support and enhance those competencies.
12.
Discharge Planning: Discharge
or transition planning documents specific attention to continuity of care for
psychiatric disorder.
DDE-CD: DDE-CD programs are psychiatrically enhanced
programs at any level of care or type of treatment in the addiction system, in
which additional resources and capabilities are added to an existing addiction
program model in order to accommodate individuals with psychiatric disorders
who have moderate levels of acute symptomatology or psychiatric disability. This type of program may include individuals
who are motivated for addiction treatment, but also have active symptoms of
PTSD which may include intermittent flashbacks and/or suicidal ideas, or who
also have stable schizophrenia with persistent disability that may interfere
with usual functioning required in a DDC addiction program.
DDE-CD
programs are more costly than usual DDC addiction programs, and require
additional funding, often through braiding or blending MH funding into the
addiction program funding base. The ASAM
recommendation is that within each system of care, at each level of care in the
addiction system, there is a plan for DDE-CD capacity. This may involve distinct programs, or it
may involve a component of an existing DDC program.
The
specific characteristics of DDE programs are as follows:
1.
Meets all DDC criteria, plus:
2.
Increased staffing levels, with more staff with MH
training
3.
Direct availability of a licensed
prescriber with training in psychopharmacology
on site.
4.
On site availability of MH supervision/consultation
5.
Smaller group size, with more flexible expectations,
and more specific MH symptom management incorporated into program content.
6.
Documentation of active interventions to stabilize
mental health symptoms present in treatment plans and progress notes
7.
Continuing documentation of collaboration with
continuing care mental health treaters, and involvement of those treaters in
treatment planning meetings.
8.
Program materials, such as skills training modules
for substance reduction or relapse prevention, adapted to individuals with
psychiatric impairment who may have impediments to learning new skills, by
utilizing shorter, simpler, and more flexible assignments.
9.
Policies that support welcoming return for
individuals who lapse in treatment or who are unable to adhere to rules during
the current treatment episode. More
likelihood to accommodate more than one lapse before discharge.
10.
Increased availability of individualized counseling
and case management.
DDC-MH; The concept of DDC-MH was developed by
Minkoff (Minkoff, 2000) as an extension of conceptualizations developed in the
1998 CMHS Expert Consensus Panel Report on Standards of Care for individuals
with co-occurring disorders. Like
DDC-CD, DDC-MH is considered to be an expectation for ALL mental health
programs, and can be implemented with technical assistance and training
support, but without additional clinical operational resources.
DDC-MH
programs routinely welcome individuals with active co-occurring substance
disorders, and provide appropriate phase specific interventions to treat those
disorders. Capacity for
medically-monitored detoxification is dependent upon the availability of
medical and nursing care comparable to that found in an ASAM Level III detoxification
program, but intoxicated individuals who do not require medical detoxification
can be routinely stabilized in appropriately staffed settings.
Like
DDC-CD, DDC-MH is evaluated through routine program audit procedures, through
chart review of specific, measurable criteria.
Specific
characteristics of DDC-MH programs include:
1.
Mission and Philosophy: Mission
statement and philosophy clearly welcome individuals with active substance use,
and promote continued mental health treatment of such individuals even when
actively using.
2.
Screening for Comorbidity: Specific
screening for substance use disorders documented, with evidence that such
screening is performed competently.
3.
Assessment: For
individuals who are screened positively for past or present disorder, there is
documentation of substance assessment, incorporating types and amounts of use,
patterns of use, problems associated with use, specific substance diagnoses,
past successful interventions, characteristic mh symptoms during previous
sobriety periods, current treatment if any, and specific documentation of stage
of change. In addition, proactive
linkage is provided to ensure access to substance disorder treatment for those
individuals who need substance disorder services beyond the capabilities of the
program.
4.
Treatment Planning: Substance
diagnoses are routinely recorded in the clinical record, and identified as
problems in the treatment plan, with specific goals, objectives, and
interventions.
5.
Substance Disorder
Consultation: Documentation of access to consultation with CADAC
or another clinician with documented substance expertise, and integration of
this input into progress notes and treatment plans.
6.
Continuity: In
programs responsible for continuity of care, no denial of access or continuity based
on continuing substance use for individuals who require treatment for
continuing psychiatric disorders, and program policies specify that primary
clinicians provide integrated continuous treatment relationships.
7.
Stage-Specific Treatment: Availability
of stage-specific treatment interventions, including a range of group
interventions in programs that offer groups
8.
Competencies: Human resource policies
incorporate basic competencies in substance use disorders consistent with job
requirements, and supervision and training policies include continuing
education plans to support and enhance those competencies.
9.
Collaboration with CD
Treaters: Documentation of coordination of care with
collaborative substance providers integrated into treatment record.
10.
Discharge Planning: Discharge or transition
planning incorporates specific attention to continuity of phase-specific
treatment for co-occurring substance disorder.
DDE-MH: Dual diagnosis enhanced mental health
programs incorporate increased capacity to address co-occurring substance
disorders in a variety of mental health settings. In general, in any mental health system, at each level of care,
there needs to be a plan for appropriate availability of DDE-MH services. In almost every level of care in the MH system,
a DDE service is no more costly than a comparable DDC service; creation of
appropriate DDE services in a system with adequate baseline capacity often
involves designating some of those services as DDC, and the remainder as DDE,
in the planning process.
Characteristics
of DDE-MH programs vary according to the type of program. All programs meet DDC criteria, plus
additional criteria as follows.
1.
One type of program involves provision of an active
addiction treatment program in a mental health environment, such as an
inpatient psychiatric unit, partial hospitalization program, or mental health
group residential setting.
a.
The program staff have increased training in
addiction with available supervision by addiction credentialed staff.
b.
Program content includes substantial addiction focus
(approximately half time as a minimum.), with strong connections to standard
(e.g., 12-Step) and dual recovery programs.
c.
Program policies address abstinence expectations,
and make provisions for transfer to a setting with lower expectations if the
individual lapses.
2.
The second type of program emphasizes motivational
enhancement interventions for individuals with active substance disorders and
severe psychiatric illnesses that are very disengaged: e.g., continuous treatment teams, “wet”
housing programs.
a.
Program staff have increased training and experience
in working with actively using individuals with severe substance disorders.
b.
Programs incorporate motivational interventions,
along with contingency management (e.g., payeeships), and intensive case
management, maintaining continuity with clients who are very disengaged.
3.
The third type of program incorporates a range of
phase-specific treatment options into a comprehensive program setting that
emphasizes working with individuals with co-occurring disorders. Examples include: dual diagnosis specialized
continuing day treatment, dual diagnosis specialized damp housing, as well as
combinations of services in a comprehensive continuum.
a.
Program staff members have increased training and
access to supervision, as above.
b.
Programs have a full range of phase-specific
interventions, including connection to dual recovery programs
c.
Programs have substance use policies that clarify
consequences for various types of behavior in each phase of treatment, and
procedures for connecting program contingencies to motivational enhancement
strategies.
d.
Programs incorporate a combination of continuing
care strategies with interventions attached to increased expectation.
Housing Programs
In
addition, as described in the AACP Position Statement on Housing Options for
Individuals with SPMI, the
comprehensive system of care in each local service area must include a full
range of housing options for individuals with co-occurring disorders. In particular, psychiatric housing programs (which provide or support a place to
live for individuals with psychiatric disability, in order to prevent
homelessness) must be distinguished from addiction (or psychiatric) residential
treatment programs (which provide episodes of treatment in a residential
setting, usually with defined expectations or requirements). Both are important components of a
comprehensive system of care.
In most service areas, the addiction treatment system provides a range of addiction residential treatment programs (both DDC-CD and DDE-CD) and sober housing programs (e.g., Oxford House model programs), all of which need to be abstinence-expected programs in order to protect the integrity of the addiction recovery support provided. Individuals who enter these settings are seeking a sober recovery environment, not merely housing, and expect these requirements to be enforced. Ideally, all such individuals have a plan for housing in the event that they fail to meet program requirements and are prematurely discharged.
The mental health system, by contrast, provides mainly
housing support programs for individuals with SPMI. Many of these individuals have co-occurring substance use
disorders, but vary in their willingness to define substance use as a problem
and/or identify sobriety as a goal, even though they may desire assistance to
maintain stable housing. Some of these
individuals are simply unable or unwilling to limit substance use, even when
all housing supports available require such limits; these individuals
frequently become homeless as a result.
Consequently, the range of
housing supports and programs for individuals with SPMI (with or without
co-occurring disorder) who need housing assistance due to psychiatric disability,
and who are at risk of homelessness, MUST include the following choices:
a.
Abstinence-expected (“dry”) housing: This model (usually a DDE-MH program) is most appropriate for
individuals with comorbid substance disorders who choose abstinence, and who
want to live in a sober group setting to support their achievement of
abstinence. This model may also be
appropriate for individuals with no substance disorder who wish to live
in an abstinent environment. Such
models may range from typical staffed group homes to supported independent
group sober living. In all these
settings, any substance use is a program violation, but consequences are
usually focused and temporary, rather than “one strike and you’re out.”.
b.
Abstinence-encouraged (“damp”) housing. This model (which can be either DDC or DDE) is most appropriate
for individuals who recognize their need to limit use and are willing to live
in supported setting where uncontrolled use by themselves and others is
actively discouraged. However, they are
not ready or willing to be abstinent.
Interventions focus on dangerous behavior, rather than substance use per
se. Motivational enhancement interventions are usually built in to program
design.
c.
Consumer-choice (“wet”) housing. This
model of DDE-MH housing has had demonstrated effectiveness in preventing
homelessness among individuals with persistent homeless status and serious
psychiatric disability (cf. Tsemberis & Eisenberg, “Pathways to Housing
Program” in Psychiatric Services, April, 2000). The usual approach is to provide independent supported housing
with case management (or ACT) wrap-around, focused on housing retention. The consumer can use substances as he
chooses (though recommended otherwise) except to the extent that use related
behavior specifically interferes with housing retention. Pre-motivational and motivational
interventions are incorporated into the overall treatment approach.
Each
system needs to assess housing needs across all three options and provide an
appropriate balance of availability.
Consumers with psychiatric disabilities who need housing support,
including those who choose to enter dry housing but are unsuccessful in
remaining sober, should not be left homeless simply because of inability or
unwillingness to maintain abstinence.