1. Evidence Based Practice &Toolkits: Implementation of Integrated Dual Diagnosis Treatment (IDDT)
Karin Kalk, Project Manager
Marc Bono, PsyD, Trainer
California Institute for Mental Health
(Adapted from Presentation by Neal Adams, MD, MPH)
Karin to start

2. Dual or Co-Occurring Disorders - a Definition
Mental illness and substance use disorder occurring together in one person
substance use disorders are common in people with severe mental illness
mental illness is common in people with substance use disorders
Dual disorders lead to worse outcomes and higher costs than single disorders
Marc: In the U.S., the mental health and substance abuse administrative and treatment systems have traditionally been separate. However, people with mental illness commonly have substance use disorders, and likewise, people with substance use disorders commonly have mental illnesses.
People who experience both disorders have a worse course of illness and worse outcomes than people with single disorders.
People with dual disorders require costlier treatment than people with single disorders.

3. Co-Occurring Disorders
High SA
Low MI
High MI
Low SA
Substance Abuse
Mental Illness

4. Worse Outcomes Relapse of mental illness
Treatment problems and hospitalization
Violence, victimization, and suicidal behavior
Homelessness and Incarceration
Medical problems, HIV & Hepatitis risk behaviors and infection
Family problems
Increase service use and cost
Now we will start to get at why we are here. What do you know about what happens to people who have severe mental illness when they use substances?
(You may want to elicit suggestions from audience)
This slide lists some of the difficult problems people with dual disorders face more frequently than people with single disorders. We’ll go over some of these in more detail in the next slides.

5. Integrated Dual Diagnosis Treatment - a Definition
Treatment of substance use disorder and mental illness together
same team
same location
same time
other characteristics to be described later
Emerging evidence based practice
toolkits as a strategy for dissemination and implementation
Developed for use in Mental Health Systems

6. Philosophic Underpinnings
Comprehensive
Recovery-Oriented
Person-Centered
Individualized

7. Interventions Motivational interviewing
Cognitive behavioral counseling
Group Interventions
Social skills training
Self-help groups
Working with families
Housing, employment, Psychopharmacology

8. Advantages of IDDT Comprehensive
all aspects of treatment from screening to relapse prevention
Substantial consensus of many experts that it is a useful approach.
It incorporates many of the currently accepted techniques of substance abuse treatment
including motivational interviewing
stages of treatment,
family psycho-education
pharmacological advances

9. IDDT Advantages cont Provides guidelines
reduce the wide variability of clinical practices
Focuses attention on an important and very difficult population
offers hope and assistance to stressed staff and clients
Clinicians and administrators find it of immediate practical value

10. IDDT Advantages cont Virtually no practical alternative models
parallel treatment in the substance abuse system has generally not been found to be feasible in California, although work continues on trying to overcome these barriers
dual disorder adapted therapeutic community model is also supported by evidence but is not appropriate for all clients or those not willing to participate

11. Clinician Knowledge & Skills
Knowledge about substances
Knowledge and skills for stage-wise treatment
outreach, practical help
motivational counseling
substance abuse counseling
skills training
self help referral
family work
infectious disease prevention and treatment
Rehabilitation training skills

12. California IDDT Training & Evaluation Grant
California Department of Mental Health has been awarded a SAMHSA grant to provide training for and evaluation of the implementation of integrated dual diagnosis treatment in four counties (eight sites) throughout the state.
Neal Adams, MD, MPH, DMH Medical Director,
PI: IDDT Toolkit Grant
Karin’s slide

13. SAMHSA Toolkits Information about the EBP
Individualized information for stakeholders, including consumers, family members and practitioners, administrators and pubic mental health authorities
Implementation tips
Basic curriculum
Fidelity scales

14. Toolkit Issues: California Grant
3 general questions California project hopes to answer:
Can the IDDT model be implemented with high fidelity in a variety of California sites typical of public mental health programs serving persons with severe mental illness?
Is the Toolkit helpful? What else is important in making implementation work?
Will client outcomes in our programs correlate with the fidelity of implementation of the IDDT model?

15. Counties
Alameda
Los Angeles
Ventura
Stanislaus

16. Organizational Change
Changes at 5 levels
health authority
program leadership
clinician/supervisor
family
consumer
Each level has its own training and TA needs
Because there is a history of separation of mental health and substance abuse services in the U.S., a significant amount of effort is required to make changes that allow integrated treatment to occur. There are 3 stages that systems go through to support a change to integrated treatment that we will go through in detail in a minutes. All the stakeholders involved in integrated treatment should be involved in making the change, including the state health authorities, program leaders, clinical leaders, families and consumers of services.

17. Tools for Design & Evaluation
Fidelity Scale
General Organizational Index
Client Outcomes

18. Fidelity Scale Defines the IDDT program and its elements
Operationalizes the principles of IDDT
complex model cannot be tested component by component
would require hundreds of studies
fidelity scale based on expert consensus opinion
“validated” fidelity scale should
discriminate low from high fidelity programs
correlate with outcomes
……..…see detailed Fidelity Scale
The extent to which the IDDT fidelity scale is based on expert opinion can be seen by comparing the scale published in the Mueser et al book with the one currently being used as part of the SAMHSA project. Ohio has also made some significant changes in the version they are using.

19. Chart of Work Flow Flow of Client from system entry to recovery
A ‘bird’s eye view’
Over generalized
Clarify what IDDT elements apply when
Eventually clinic will have its own chart of the IDDT Work Flow
………..see separate Work Flow Chart.

20. General Organizational Index
General Organizational Index (OI)
Similar to fidelity scale
applies to all of the SAMHSA evidence-based practices
Measures adherence to organizational practices
believed to further successful organizational change and high quality treatment
……….see detailed General Organizational Index

21. GOI Items Program philosophy Eligibility/Client identification
EBP commitment
Eligibility/Client identification
standardized screening
Penetration
% receiving EBP
Assessment
standardized assessment

22. GOI Items cont Individualized treatment plan Individualized treatment
Training
EBP for all practioners
Supervision
structured, weekly
Process monitoring
EBP implementation

23. GOI Items cont Outcome monitoring Quality Assurance
substance use for IDDT
Quality Assurance
semi-annual review of EBP
Client choice regarding service provision

24. Outcome Measures Alcohol Use Scale (AUS-R) Drug Use Scale (DUS-R)
Measures alcohol use from abstinence – institutionalized dependence
Drug Use Scale (DUS-R)
Measures drug use from abstinence – institutionalized dependence
Substance Abuse Treatment Scale (SATS)
Assigns client to a level of treatment used in designing appropriate interventions
Multnomah Community Abilities Scale (MCAS)
17 item validated level of functioning scale

25. Grant Activities Staff Training Implementation Activities Evaluation
Monthly
Education credits
Syllabus
Implementation Activities
Sequenced with training topics
Development of multi-disciplinary team
Selection of clients for project
Evaluation
Initial, baseline fidelity evaluation – August
Training on clinical evaluation tools – September
Re-evaluation every six months

26. Perspective
Developing a culture of learning, inquiry, quality and transformation
multiple levels
system
administration
clinicians
Organizational focus
not evaluation of staff performance
3 year vision

27. On to the fidelity scale…

28. IDDT Fidelity Items Multidisciplinary teams
Integration of dual diagnosis specialist
Stage-wise interventions
Access to comprehensive services
Time unlimited service
Outreach
Motivational Interviewing
Substance abuse counseling
Group dual diagnosis treatment
Family psycho-education in dual diagnosis
Participation in alcohol and drug self help groups
Pharmacological treatment
Interventions to promote health
Secondary interventions for substance abuse treatment non-responders

29. Multidisciplinary Teams
All clients targeted for IDDT receive care from a multidisciplinary team (MDT).
An MDT consists of two or more of the following: a physician, a nurse, a case manager, or providers of ancillary rehabilitation services described in Item 3. 1 2 3 4 5
Traditional
outpatient or
brokered CM
model; no team
Minimal
implementation
of Multi
discipline team
(2 or three
disciplines, low
frequency of
meeting, little
integration)
Partial
Implementation
of Multi discipline
team (all three
criteria are better
than in “2” or one
criterion done
very well but
others not)
Nearly full
of Multi-
Discipline team
(all three
criteria met to
Large degree)
Full implementation
team with Case
managers, psychiatrist,
nurses, residential staff,
and vocational specialists
work collaboratively on
mental health; treatment
team meetings daily; highly
integrated.

30. Integration of Dual Diagnosis Specialist
A DD specialist with at least 2 years of experience
Works collaboratively with treatment team
Experience can be in a variety of settings, preferably working with clients with a dual disorder 1 2 3 4 5
IDDT clients
are referred to
a separate
substance
abuse
department
within or
outside the
agency (e.g.,
referred to
drug and
alcohol staff)
A substance
specialist
serves as a
consultant to
treatment team;
does not attend
meetings; is not
involved in
treatment
Planning
A substance abuse
or DD specialist is a
fully integrated
member of the
attends all team
meetings; involved
in treatment
planning for IDDT
clients; models IDDT
skills and trains
other staff in IDDT
A DD specialist is
a fully integrated
clients; models
IDDT skills and
trains other staff in
IDDT
The team consists of
multiple DD
specialists with 2
years experience,
fully integrated. They
attend all team
meetings; are
involved in treatment
clients; model IDDT
skills and train other
staff in IDDT

31. Stage-Wise Interventions
All interventions (including ancillary rehabilitation services) are consistent with and determined by the client's stage of treatment or recovery.
Concept of stages of treatment (or stages of change) include: Engagement, Motivation, Action, Relapse Prevention 1 2 3 4 5
Program does not use stages of treatment at all
Minimal use of stages (no ratings, or not up to date, truncated or fuzzy stages, lack of interventions for each stage)
Moderate use of stages (at least one element well implemented but not all three); or some staff use and others do not
Consistent use of stages but at least one of the criteria not implemented fully
A full range of interventions is available for all four stages and each client has a written up-to-date rating of current stage in treatment plan and is consistently reflected in progress notes

32. Stages of Change &Treatment
Precontemplation -- Engagement
outreach, practical help, crisis intervention
Contemplation & Preparation -- Persuasion
provide education, set goals, build awareness
Action -- Active Treatment
substance abuse counseling, medications, skills training, family and self-help groups
Maintenance -- Relapse prevention
relapse prevention plan, skills training, expand recovery to other areas of life

33. Access to Comprehensive Services
To address a range of needs of clients targeted for IDDT, agency offers the following 5 rehab services:
Residential service
Supported employment
Family psychoeducation
Illness management and recovery
Assertive community tx (ACT) or intensive case mgmt (ICM)

34. Access to Comprehensive Services cont1 2 3 4 5
Access to
related
services
identified in
the client
treatment
plan
None of the
charts reviewed
showed
consideration of
need for related
services such
as employment,
illness mgmt
or intensive
case mgmt
Some mention
of related
services in
individual
plan, but few
services were
actually
accessed by
the clients
More related
the treatment
plan and they
were usually
Multiple
identified. All
were
accessed,
but not
necessarily
within 2 mos
Multiple related
related services
treatment plan
were accessed
within 2 months
residential/
housing
services for
DD clients
-Housing
specialist(s)
-Wet-damp-
dry housing
No housing
specialist
available in
county or
program; limited
or inadequate
wet, damp, dry
housing for DD
clients
Housing
in county but
not program;
limited or
inadequate
wet, damp,
for DD clients
in program;
full range of
for DD
specialist(s) in
program; full
range of wet,
damp, dry
clients; residential
program affiliated
with program

35. Time Unlimited Service
Clients with DD are treated on a long-term basis with intensity modified according to need and degree of recovery.
The following services are available on a time-unlimited basis:
Substance abuse counseling
Residential service
Supported employment
Family psychoeducation
Illness management and recovery
ACT or ICM

36. Time Unlimited Service cont
Clients with DD are treated on a long-term basis with intensity modified according to need and degree of recovery.
Services available on a time-unlimited basis:
Substance abuse counseling
Residential service
Supported employment
Family psychoeducation
Illness management and recovery
ACT or ICM 1 2 3 4 5
Overall
program
has a time
limit.
Program as a whole
has no time limit but
some of the services,
such as particular
groups are time
limited.
Neither program nor
individual services have
time limits or utilization
limits per se, but some
services are only offered
some of the time.
No time limits;
services available
at any time; but
waiting lists exist.
services
available at any
time; no waiting
lists.

37. Outreach
For all IDDT clients, but especially those in the engagement stage, IDDT program provides assertive outreach
Characterized by some combination of meetings and practical assistance (e.g., housing assistance, medical care, crisis management, legal aid, etc.) in their natural living environments as a means of developing trust and a working alliance.
Other clients continue to receive outreach as needed.

38. Outreach cont 1 2 3 4 5 Outreach:
In situ aid for housing, medical, court and legal
Outreach to engage clients initially and re-engage if stop attending
Program is passive in recruitment and re-engagement; almost never uses in situ outreach mechanisms.
Program makes initial attempts to engage but generally focuses efforts on most motivated clients; little or no in situ engagement
Program staff frequently attempt in situ OR engagement outreach, but not both.
Program staff frequently attempt BOTH in situ and engagement outreach (but it is not formally supported in policy, supervision and charting requirements).
Policy, supervision, and charting requirements encourage in situ and engagement outreach. Over half the charts show evidence it has occurred when appropriate (e.g. when attendance is poor or a client has dropped out or if a client has court appearances).

39. Motivational Interviewing
All interactions with DD clients are based on motivational interviewing that includes:
Expressing empathy
Developing discrepancy between goals and continued use
Avoiding argumentation
Rolling with resistance
Instilling self-efficacy and hope

40. Motivational Interviewing cont1 2 3 4 5
Motivational
Interventions:
Quantity
Clinicians who
treat IDDT
clients use
strategies.
≤20% of client
charts reflect
motivational
interviewing
approach (ie
goals
discrepancies,
pay-off matrix);
21%- 40% of
client charts
reflect
41%- 60% of
pay-off matrix)
61%- 79% of
>80% of client
Interviewing
Qualitative
No record of
training on MI
within past
year
Training on MI
year but not all
staff have
attended
Training for
all staff on MI
Year
Training for all
staff on MI
year and staff
interviews
reflect use of MI
Multiple
trainings for all

41. Substance Abuse Counseling
Clients who are in the action stage or relapse prevention stage receive substance abuse counseling aimed at:
Teaching how to manage cues to use and consequences of use
Teaching relapse prevention strategies
Teaching drug and alcohol refusal skills
Problem-solving skills training to avoid high-risk situations
Challenging clients’ beliefs about substance use; and
Coping skills and social skills training to deal with symptoms or negative mood states related to substance abuse

42. Substance Abuse Counseling cont1 2 3 4 5
DDX counseling is not routinely provide
Mental Health or Substance Abuse Counseling is provided by referral in a parallel or sequential model
Mental Health or Substance Abuse Counseling is provide by the agency in specialized SA and or MH individual and/or group services
Mental Health and Substance Abuse Counseling is provide by the agency in specialized integrated individual and/or group services
Mental Health and Substance Abuse Counseling is provide by the agency in an integrated fashion throughout all aspects of programming as well as in specialized integrated individual and/or group

43. Group Dual Diagnosis Treatment
All clients targeted for IDDT are offered a group treatment specifically designed to address both mental health and substance abuse problems, and approximately two-thirds are engaged regularly (e.g., at least weekly) in some type of group treatment.
Groups could be family, persuasion, dual recovery, etc.

44. Group Dual Diagnosis Treatment cont1 2 3 4 5
Group DD Treatment:
DD clients are offered
group treatment
specifically designed to
address both mental
health and substance
abuse problems
<20% of DD
clients
regularly
attend a DD
group
20% - 34%
of DD
35% - 49%
of DD clients
50% - 65%
>65% of DD
Integrated group
treatment for DD:
health and substance abuse problems
No groups
are offered for DD clients
Groups are
offered for
only one of
the two
disorders
Separate
groups are
offered but
not
integration of
the disorders
in the groups
groups for
each
disorder,
but some
integration
occurs in
the groups
Integrated
groups
where both
disorders are
the focus of
treatment

45. Family Psychoeducation in Dual Diagnosis
Where available and if the client is willing, clinicians always attempt to involve family members (or long-term social network members) to give psychoeducation about DD and coping skills to reduce stress in the family, and to promote collaboration with the treatment team. 1 2 3 4 5
No identification of families or significant others for each client; or no outreach to families provided
Minimum outreach to families provided:
Materials on DD offered or sent
Consultation with families around treatment decisions
Moderate outreach: materials, consultation, some specific intervention, i.e. support group, coping skills training group.
Partial implementation of an evidence-based family intervention for DD. Reviewers will look for evidence program is using an explicit evidence-based model
Full implementation of an evidence-based family intervention for DD. Reviewers will look for evidence program is using an explicit evidence-based model.

46. Participation In Alcohol And Drug Self Help Groups
Clinicians connect clients in the action stage or relapse prevention stage with substance abuse self-help programs in the community, such as:
Alcoholics Anonymous (AA)
Narcotics Anonymous (NA)
Rational Recovery
Double Trouble or Dual Recovery
Proactive Self Help Groups & Liaison
Staff have a working knowledge of the Self Help Groups they refer to
Staff attend self help groups with clients
Staff help clients to prepare and/or adjust to self help groups

47. Participation In Alcohol And Drug Self Help Groups cont1 2 3 4 5
<20% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community
20% - 34% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community
35% - 49% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community
50% - 65% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community
>65% of clients in the active treatment stage or relapse prevention stage attend self-help programs in the community
No referral of dual-disorder clients in action or relapse prevention stages to self-help in community or at agency
Occasional referral of dual-disorder clients in action or relapse prevention stages to self-help in community or at agency
Routine referral but staff do not have a working knowledge of the self help programs
Routine referral and staff has a working knowledge of the self help programs
Routine referral and staff has a working knowledge of the self help programs and take proactive steps to assist clients in utilizing this resource including such things as mock groups or attending with the client

48. Pharmacological Treatment
Physicians or nurses prescribing medications are trained in DD treatment and work with the client and the IDDT team to
increase medication adherence;
decrease the use of potentially addictive medications such as benzodiazepines; and
offer medications such as clozapine, disulfiram, or naltrexone that may help to reduce addictive behavior.
Five specific indicators are considered - do prescribers:
Prescribe psychiatric medications despite active substance use
Work closely with team/client
Focus on increasing adherence
Avoid benzodiazepines and other addictive substances
Use clozapine, naltrexone, disulfiram

49. Pharmacological Treatment cont1 2 3 4 5
All clients do
not have
ready access
to psychiatric
evaluation
and treatment
Clients have
access to
psychiatric
evaluation and
treatment but
medications may
be withheld for
those with
concurrent
substance
abuse; OR
prescription of
medications with
abuse potential
(e.g.enzodiazepines)
is not controlled
treatment,
medications are
not withheld, and
are controlled; but
prescribers have
virtually no contact
with treatment
team and make no
apparent efforts to
Increase
adherence
are controlled;
and prescribers
have extensive
contact with the
treatment team
and make
apparent efforts
to increase
In addition to
criteria in #4,
prescribers
actively consider
naltrexone,
disulfiram,
clozapine, & other
medications
having some
evidence base for
use with persons
with dual disorders

50. Interventions to Promote Health
Efforts are made to promote health through encouraging clients to
practice proper diet and exercise,
find safe housing, and
avoid high-risk behaviors and situations.
Intent is to directly reduce the negative consequences of substance abuse using methods other than substance use reduction itself
Typical negative consequences of substance abuse that are the focus of intervention include:
physical effects
social effects
self-care and independent functioning, and
use of substances in unsafe situations

51. Interventions to Promote Health cont1 2 3 4 5
No explicit
programmatic
support for
promoting health
or reducing
negative
consequences of DD
Program support
for general health
interventions
such as diet and
exercise but not
for reducing the
interventions and
for reducing
DD but
interventions not
used consistently
(as documented in
charts, protocols,
and staff
interviews)
for general
health
DD but only
individually (no
such as trauma
groups, smoking
cessation
groups, and
needle
exchange)
Program supports
reduction of
DD and
interventions are
including
interventions such
as trauma groups,
smoking cessation
needle exchange)

52. Secondary Interventions for SA Treatment Non-responders
Secondary interventions are more intensive (and expensive) interventions that are reserved for people who do not respond to basic outpatient IDDT.
Program has a specific plan to
identify treatment non-responders;
evaluate them for secondary (i.e., more intensive) interventions; and
link them with appropriate secondary interventions.
Potential secondary interventions might include
special medications that require monitoring;
more intensive psychosocial interventions; or
intensive monitoring, which is usually imposed by the legal system.

53. Secondary Interventions for SA Treatment Non-responders cont1 2 3 4 5
Secondary interventions for non-responders.
Diagnosis based (including trauma)
Residential program
Criminal-justice liaison
Money management or payeeship
Contingency management
Outreach harm reduction approach for pre-contemplation clients
Medications such as clozapine that require close monitoring
Others if specified in tx plan
No formal way of identifying non-responders
Formal way of identifying non-responders but no specific interventions are in treatment plans for these clients
Formal way of identifying and one to or two interventions are specified in treatment plans for these clients
Formal way of identifying and three or four interventions are specified in treatment plans for these clients
Formal way of identifying and five or more interventions are specified in treatment plans for these clients

54. Knowing is not enough; we must apply.
Goethe