Adaptation and Implementation of the Integrated Dual Diagnosis Treatment Model Into a Psychiatric Inpatient Facility: A 12-Year Perspective
As early as the 1970s, researchers and practitioners became increasingly aware of the necessity for services that would address the varied needs and treatment implications for consumers with the co-occurring disorders of substance abuse and mental illness. High percentages of consumers in substance abuse treatment centers were identified with mental illness disorders, and consumers admitted to psychiatric facilities often were identified as having additional substance use disorders.
The authors are affiliated with Twin Valley Behavioral Healthcare, Columbus, Ohio, an inpatient treatment facility of the Ohio Department of Mental Health for approximately 200 civil, forensic, and maximum-security forensic patients.
This article describes the components of the integrated dual diagnosis treatment (IDDT) outpatient services model and discusses how the IDDT outpatient service components and strategies were successfully adapted and implemented in a psychiatric hospital inpatient program. The adaptation and implementation was a small investment because it primarily used existing resources and personnel. However, it yielded a large change in the organizational inpatient structure and improved the treatment culture with co-occurring disorder treatment provisions. It therefore had a significant impact on the patient population and the quality of services overall.
Overview
As early as the 1970s, researchers and practitioners became increasingly aware of the necessity for services that would address the varied needs and treatment implications for consumers with the co-occurring disorders of substance abuse and mental illness.1 High percentages of consumers in substance abuse treatment centers were identified with mental illness disorders, and consumers admitted to psychiatric facilities often were identified as having additional substance use disorders.2,3 These findings prompted collaboration, particularly at the national level to consider treatment programs, which would jointly address the co-occurring disorders of substance abuse and mental illness directly.4,5 The New Hampshire–Dartmouth Psychiatric Research Center pioneered an outpatient co-occurring disorders treatment design that integrated multiple components according to the principles of evidence-based mental health practices.6 The resultant design was the IDDT model, which has become widely accepted as an evidence-based best practice.7,8
The IDDT model seeks to improve the quality of life for people with co-occurring severe mental and substance use disorders by integrating substance abuse services with mental health services. This model addresses both disorders at the same time, in the same service organization, and by the same team of treatment providers. The implementation of IDDT facilitates continuous and coordinated service and system adjustments to ensure clinical continuity of care for each consumer.
Research shows that treatment organizations that maintain fidelity to the original design of IDDT achieve and sustain the best outcomes. Successful IDDT programs include 13 defined service components and strategies (discussed below) in order to maintain fidelity to the IDDT model and to produce the positive outcomes that research has shown will occur.9-11 The realization of these IDDT outcomes motivates consumers, family members, service providers, and community stakeholders to maintain a long-term commitment to the model.
The successful establishments of outpatient substance abuse and mental illness co-occurring disorder (COD) treatment programs during the years 2000-2005 resulted in a change of treatment philosophy in the direction of the integration of these co-occurring disorder services into a program of substance abuse mentally ill services, abbreviated as “SAMI” services. There was a substantial increase in co-occurring disorder community-based programs nationwide.12 In 1999, Twin Valley Behavioral Healthcare (TVBH, formerly named Twin Valley Psychiatric Services) was one of the first US inpatient psychiatric facilities to adapt the New Hampshire–Dartmouth Psychiatric Research Center’s outpatient IDDT model to an inpatient environment. TVBH administration was motivated to adopt the IDDT model as a means to manage risk, to decrease recidivism, and to promote cost-effective co-occurring disorder treatment. The TVBH leadership felt that their organization was ready for the shift in perspective, possessed the need for treatment improvements and, therefore, began to adapt the IDDT model.
TVBH is one of 7 Joint Commission Accredited Ohio Department of Mental Health (ODMH) psychiatric hospitals. TVBH’s daily census approximates 100 acute care patients and 130 forensic patients; half of the forensic patients are treated in a separate statewide maximum-security facility. In 2000 the Ohio SAMI Coordinating Center of Excellence (CCOE) was created through an ODMH grant to assist in the statewide implementation of the IDDT model in an outpatient setting and later at all ODMH state psychiatric hospitals.6,11 Since the introduction of the IDDT model to Ohio, the inpatient psychiatric SAMI services at Twin Valley Behavioral Healthcare have consistently been on the forefront of COD treatment developments working closely with various statewide and federal resources in the establishment of high fidelity programs.
The initial TVBH IDDT implementation team recognized that this model would not be effective if put into practice on a single designated dual disorder unit, given the wide scope of services needed. Instead, it was clear that the IDDT model would be best integrated throughout the entire hospital treatment milieu including the acute and long-term forensic maximum-security settings. The TVBH IDDT implementation team recruited and organized clinical leadership and staff from each of the hospital disciplines that had an interest in assessing and treating CODs. These COD treatment leaders, in turn, helped develop the guidelines for the TVBH SAMI integrated services by applying the principles of the IDDT program to an inpatient setting. Each of the IDDT outpatient service components was adapted to meet the needs of the TVBH inpatient setting; these are presented below with a discussion of how these outpatient service components were successfully modified to maintain IDDT fidelity in the TVBH SAMI inpatient program.
Guidelines for the Inpatient Adaptation of the Outpatient IDDT Service Components
1. The “Multidisciplinary Team” Component: Maintain an overall multidisciplinary treatment culture that embraces and incorporates IDDT concepts for all patients
The IDDT model views the treatment of all activities of life as part of the recovery process. Therefore, a variety of service providers, in the form of a multidisciplinary treatment team, is required in order to help each consumer work on each of the multifaceted aspects of his or her life. The multidisciplinary treatment team meets regularly with the patient to discuss the consumer’s progress in all areas of life, and to provide insights and advice to one another for any needed adjustments to the patient’s treatment plan.9
TVBH’s adaptation of the IDDT multidisciplinary team component to an inpatient population included the necessity of reshaping existing hospital and unit-specific treatment teams to operate within a redesigned model. This involved a considerable culture shift for the staff from a belief system of “we are not substance abuse providers” to “we do have a large number of patients with co-occurring disorders and we need to treat both disorders.” This shift in culture change was successfully accomplished by the leadership in the hospital after they established key staff on each unit, and on each multidisciplinary treatment team, who understood the IDDT model and who were able to introduce, guide and reinforce the IDDT components in the treatment planning team meetings with the attending patients, hospital staff, community support staff, and significant others. These key staff members were chosen representatives from all the disciplines within the hospital including psychiatry, psychology, social work, nursing, adjunctive therapists, direct care staff, and substance abuse counselors. This core group of multidisciplinary IDDT providers developed of necessity, in many ways. TVBH sought grant funding to develop IDDT services, but when this request for funding was rejected, clinical leadership and line clinical staff collaborated effectively to meet the expanding need for dual diagnosis treatment using existing resources. This promoted long-term program stability and connectedness of providers that has led to overall program success.
2. The “Stage-Wise Intervention” Component: Plan and provide for IDDT inpatient services by structuring and coordinating them with existing recovery treatment model concepts
IDDT research suggests that individuals with CODs gain the most confidence with their abilities to recover, to develop independent living skills, and to meet daily living needs when they experience incremental successes through sequential and progressive stages of personal change. With an understanding of these stages, service providers and significant others are best equipped to help persons with CODs recover and maintain their self-confidence and independence.9