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AMERICAN ASSOCIATION OF COMMUNITY PSYCHIATRISTS

Persons with co-occurring psychiatric and substance disorders experience persistent and recurrent difficulties which can interfere with every aspect of their lives. In addition, these persons have a high incidence of medical comorbidity, and their clinical course is associated with higher costs and poorer outcomes.

In almost all psychiatric and addiction settings, people with co-occurring disorders appear with sufficient frequency that their presence must be anticipated in every clinical encounter, regardless of level of care or location of service. In many settings, particularly those serving people with serious and persistent mental illness, the majority of people seeking care have co-occurring substance disorders. Nonetheless, these persons are often poorly served in the current service system, in which treatment for co-occurring psychiatric and substance disorders is commonly provided in separate settings, with lack of integration and continuity.

The American Association of Community Psychiatrists (AACP) is an organization of psychiatrists dedicated to the provision of highest quality services to persons in the behavioral health delivery system. As such, the AACP has agreed to the following set of principles for the care and management of persons with co-occurring disorders.

We recommend that these principles form the basis of a collaborative planning process, in which mental health and substance abuse agencies, payors, providers, consumers and family members work together in every system of care to perform the following functions:

1. Assume shared responsibility to design a comprehensive, continuous, integrated system of care for persons with co-occurring psychiatric and substance disorders;
2. Develop the system of care according to the principles contained in this document;
3. Plan collaboratively to utilize current resources in implementing the such a system;
4. Identify which components of the system cannot be implemented with current resources and;
5. Recommend collaborative strategies for funding all of the components of the system of care over time.
6. Evaluate the effectiveness of the system of care in achieving mutually desired outcomes for persons with co-occurring disorders

The following principles characterize an effective system of care for persons with co-occurring psychiatric and substance disorders. They will be further elaborated in the remainder of this document.

Pessimistic attitudes about people with co-occurring disorders represent a major barriers to successful system change and to effective treatment interventions. However, a growing evidence base suggests that persons with co-occurring disorders who receive care based on the principles outlined in this document have positive outcomes and make significant progress in achieving recovery.

Recovery is defined as a process by which a person with persistent, possibly disabling disorders, recovers self-esteem, self-worth, pride, dignity, and meaning, through increasing his or her ability to maintain stabilization of the disorders and maximizing functioning within the constraints of the disorders. As a general principle, every person, regardless of the severity and disability associated with each disorder, is entitled to experience the promise and hope of dual recovery, and is considered to have the potential to achieve dual recovery.

In a consumer/family oriented system, for persons with co-occurring disorders, the service goal is to ensure that each clinical contact is welcoming, empathic, hopeful, culturally sensitive, and consumer-centered. Special efforts should be made to engage persons who may be unwilling to accept or participate in recommended services, or who do not fit into available program models.

In an accessible system for persons with co-occurring disorders, 24 hour crisis services are available to provide welcoming and competent assessment and intervention for psychiatric and substance symptomatology in any combination. Arbitrary barriers to immediate evaluation (e.g. alcohol levels below legal intoxication) are eliminated.

In an accessible system, at each level of care (outpatient, intensive outpatient, acute care, residential, inpatient), there are available programs which:

• accept persons with co-occurring disorders without barriers or waiting lists; and
• do not require such patients to self-define (as either "psychiatric", "substance abuse" or "dual"); in order to be accepted for evaluation and treatment.

There must be an integrated conceptual framework for designing a comprehensive service system for persons with co-occurring disorders, through implementing the following procedures:

• Develop a common language for describing this population: Persons with co-occurring psychiatric and substance disorders.
• Develop a common methodology for describing categories of integrated services in the system of care, based on the respective severity or disability of psychiatric and substance disorder. One model would be:
  • Severe and persistent mental illness (SPMI) and substance dependence
  •  SPMI and substance abuse
  • Psychiatrically complicated substance dependence
  • Psychiatric symptomatology (non-SPMI) and substance abuse
• Develop integrated treatment approaches for persons with co-occurring disorders, in which:
  • Each person has a primary clinician who coordinates ongoing treatment interventions for both disorders.
  • Each disorder receives specific and appropriately intensive primary treatment which takes into account the complications resulting from the co-occurring disorders.
  • Ideally, each person can receive integrated and coordinated treatment for both disorders in a single setting or service system.
• Emphasize the commonality of treatment philosophy, in that a disease and recovery model can be applied to the treatment of both mental illness and substance disorders.
• Recommended treatment interventions for persons with co-occurring disorders should be individualized, and matched according to the specific diagnosis of each disorder, the phase of treatment and recovery for each disorder, and acuity, severity, disability, and motivation for treatment of each disorder at any point in time.

   

Psychiatric and substance disorders, regardless of severity, tend to be persistent and recurrent. Co-occurrence of these disorders occurs with sufficient frequency in both systems that a continuous and integrated approach to assessment and treatment is required, regardless of the location of initial clinical presentation. Persons with co-occurring disorders should be regarded as having two (or more) co-occurring primary disorders, each of which requires specific assessment and diagnosis, and appropriately intensive treatment.

For persons with more serious co-occurring disorders, continuity of integrated treatment is significantly associated with better outcome and reduction of more expensive service utilization. Consequently, the service system for persons with co-occurring disorders must develop mechanisms for identifying all such persons with serious symptomatology, and establish a collaborative system of continuous care management for those persons.

A goal of the service system is to provide persons with co-occurring disorders early access to continuous integrated treatment relationships which can be maintained over time, through multiple episodes of acute and subacute treatment, and which are independent of any particular setting or locus of care.

The co-occurring disorders treatment and recovery process can be divided into similar phases for each disorder. Models based on readiness for treatment and level of engagement exist. The following phasic model is based on treatment intervention:

1. Acute Stabilization – Short term focused intervention to stabilize the acute manifestation of the disorder.
2. Engagement and Motivational Enhancement – Interventions designed to establish a primary clinical relationship and to facilitate the person’s ability and motivation to initiate and maintain participation in a program of stabilizing treatment.
3. Active Treatment to Maintain Stabilization – Interventions of any type which are designed to stabilize the symptoms of the disorder, prevent relapse, and help persons to maintain a stable baseline and optimal level of functioning.
4. Rehabilitation and Recovery – Interventions designed to help persons to develop new skills, reacquire old skills, and achieve personal growth and serenity, once prolonged stabilization has been consistently established.

With all models, the phases of treatment are not necessarily linear or sequential. With various clients, phases of treatment for psychiatric and substance disorder often differ, and persons may move in either direction from one phase of treatment to another.

Any psychiatric disorder with any substance use disorder may co-occur in any person, regardless of age, gender, or socio-economic status. Effective responses must be tailored to individual need. The system must be responsive to the needs of the consumer, instead of consumers needing to fit the specifications of the program or system. Integrated continuous treatment relationships should strive to provide each consumer with a balance of 1) appropriate case management and care and 2) appropriate empathic detachment (and, at times, empathic confrontation). This balanced approach can provide opportunities for meaningful choice and empowerment at each point during the course of treatment.

The system should be created utilizing existing services and programs as much as possible, through identifying the role of each program in providing particular types of integrated services within the comprehensive service system, and in accordance with the principles of individualized treatment matching defined above. The design goal is for implementation of a system of care in which all persons with co-occurring disorders have access to integrated continuous treatment relationships, and to a range of programs which can provide individually matched services according to the above principles.

Person with co-occurring disorders have broad primary care and behavioral health treatment and social service needs. Therefore, the shared mission of the system must be the design of a comprehensive, integrated, continuous service system for persons with psychiatric disorders, substance disorders and co-occurring psychiatric and substance disorders.

In such a system of care, some programs will be fully integrated, some programs will be primarily psychiatric programs with substance disorder capability or enhancement, and some programs will be primarily substance disorder programs with psychiatric capability or enhancement. Implementation of basic co-occurring disorder capability in these programs may occur via any or all of the following mechanisms:

• direct training of existing staff;
• hiring of cross-trained staff to provide on-site services to clients, and consultation and training to existing staff; and/or
• collaboration with another service provider to create combined services that appear integrated to the client.

The system of care should be designed in accordance with established national standards for serving persons with co-occurring disorders, including the following:

• CMHS Managed Care Initiative: Report of the Panel of Co-Occurring Psychiatric Substance Disorders, Parts I, II, III, IV: Co-occurring Psychiatric and Substance Disorders in Managed Care Systems (standards of care, practice guidelines, workforce competencies, and training curricula). Center for Mental Health Services,1998
• National Association of State Mental Health Program Directors and National Association of State Alcohol and Drug Abuse Directors: Effective Intervention with Co-occurring Mental Health and Substance Abuse Disorders: Financing and Marketing a New Conceptual Framework. NASHMPD, Alexandria, VA, 1999

There must to be an implementation plan which identifies priorities for and obstacles to change, defines specific objectives and outcomes for change, and which recommends strategies to overcome obstacles to achieving these objectives. This will include the following target areas:

1. Identification of existing services for persons with co-occurring disorders, and specification of the role of those services in the system of care.
2. Identification of existing services which require enhancement in order to meet the requirements of the system of care, and development of plans for achieving that enhancement.
3. Identification of significant gaps in existing services, which require new services, programs and/or funding to address those gaps.
4. Creation of an infrastructure empowered to oversee and direct the implementation process
5. Identification of quality monitors (structure, process and outcome) as markers for successful implementation
6. Development of a process to modify policies, procedures, regulations and laws in order to facilitate implementation of the system of care
7. Development of a comprehensive strategy for implementation of flexible funding streams to support the system of care
8. Development of a specific plan for a comprehensive array of programs, with defined program competencies for treating delineated subgroups of persons with co-occurring disorders, incorporating a full range of service intensities, and including models for continuing integrated care management. This plan should be based primarily on enhancing the competencies of existing programs, within the constraints of existing resources.
9. Development of cultural competency in all programs addressing co-occurring disorders, as well as the creation of specific cultural and linguistic supports and services for persons unable to access general services
10. Development of models and instruments for routine integrated assessment of psychiatric and substance disorders in both ambulatory and emergency settings, including tools for integrated assessment of service intensity and/or level of care requirements
11. Development of a definition of required clinical competencies, and a comprehensive training and evaluation plan to support achievement of those competencies
12. Mechanisms for enhancing consumer and family involvement in dual recovery efforts that involve peer participation and leadership