Elements of the Evidence Based Practice Integrated Dual Disorder Treatment

Since integrated treatment is associated with positive outcomes, programs that are carried out according to the integrated dual disorder treatment (IDDT) model are predicted to produce better outcomes for the consumers they serve. To determine how faithful or how well a program resembles the IDDT model, the IDDT Fidelity Scale was developed. (This scale can be downloaded from the Substance Abuse and Mental Health Services Administration website at http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits.) Some of the items on the IDDT Fidelity Scale include the following:

1. Concurrent treatment of both conditions by the same clinicians: As described earlier, having the same clinicians simultaneously address both conditions is the core element of this EBP. This requires clinicians to have extensive training in both conditions as well as how the conditions may interact with one another. As you might imagine, the clinical picture presented by the individual with co-occurring conditions is more complicated than the clinical picture presented by someone with either condition alone.

2. Assertive outreach: Actively seeking out clients in their own environments, assertive outreach is an element of many of the EBPs. Given the propensity of individuals with either mental illness or substance abuse disorders to drop out of treatment, assertive outreach is often necessary to maintain contact.

3. Motivation-based interventions: Strategies for engaging the dually diagnosed client will be more effective if they are based on the motivational interviewing strategies described by Miller and Rollnick (2002). This approach takes into account how the client feels about her condition and her readiness to address it. This also incorporates the concept of stages of change put forth by Prochaska and colleagues (1994). Agencies that do not apply this approach tend to find that only a segment of their client population is responsive to their services.

4. Reduction in negative consequences (harm reduction): In general, the idea is that the focus should be on reducing the harm or negative consequences of substance use rather than insisting on abstinence. In short, if a client can be helped, for example, to drink less or less frequently the harm caused may be reduced. This is a controversial issue in the substance abuse community where abstinence has been considered the "gold standard" for some time. Still, based on Prochaska and colleagues' work (1994) it seems likely that many individuals in early treatment stages with respect to readiness for change are more likely to respond to a harm reduction approach than a request for abstinence.

The substance abuse concept that some people need to "hit bottom" before they get serious about dealing with their addiction is tacit recognition that readiness for change is an important factor in dealing with these conditions. In addition, "hitting bottom" in the sense of using substances in a destructive fashion can be very dangerous (e.g., contracting an HIV infection). Finally, someone who begins treatment based on an initial approach emphasizing harm reduction may, in time, arrive at the understanding that total abstinence is preferable to any substance use for achieving recovery.

5. Comprehensiveness: This is the idea that all of the related issues in a client's life need to be dealt with simultaneously. Clients often need to make fundamental changes in many aspects of their lives as they move through the recovery process. For example, it has long been recognized that a recovering substance abuser may need to change his habits including the places he frequents, the friends he hangs around with, and how he spends his time. Successfully addressing the addiction may require changes in all of these areas. To assist consumers in making such global changes, a wide array of services must be available such as residential programs, supported employment, and social skills training.

6. Cultural sensitivity and competence: This element of the EBP should be present in all services. Whenever persons of different cultures work together, there is the possibility of miscommunication of meaning. When co-occurring conditions are present this danger is greatly increased and needs to receive special attention.

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