One Day at a Time: Implementing Integrated Treatment at a Large Behavioral Health Agency
Potter, Paul, Schorr, Mark, Addiction Professional
Fifteen years ago, our treatment agency first brought in a speaker to talk about the importance of dual diagnosis. MICA (Mentally Ill, Chemically Abusing) clients were more common than clinicians realized, the speaker said. Dual diagnosis was an important new trend.
Yet even to this day we find charts with behavioral assessments showing daily marijuana smoking and depression, with Axis I diagnoses that don't even include a rule out of marijuana abuse. Or charts with only an alcohol dependence diagnosis, even though the history includes symptoms of post-traumatic stress disorder (PTSD). Or clients said definitively to have bipolar disorder, though they admit to taking methamphetamine and drinking.
The research, and our own experience, shows that roughly two-thirds of community behavioral healthcare clients have both addictions and mental health problems. Despite a strong commitment from leadership, many years, and tens of thousands of dollars spent on trainings, supervision and consultation, we still struggle to convince some of those inside and outside the agency of the ethical and effective benefits of integrated treatment.
Cascadia Behavioral Healthcare, with offices in three Oregon counties and serving more than 16,000 clients every year, is recognized as a regional leader in integrated treatment. But providing good treatment for comorbid addictions and mental health is a "one day at a time" process.
When I (Paul Potter) attended social work school, addictions issues were not part of the curriculum. When the subject came up, faculty would frequently rely on me--knowing that I was a person in recovery--to provide answers.
When I (Mark Schorr) attended graduate school in counseling a half dozen or so years later, a couple of the faculty would occasionally mention exploring an addictions problem, but it was less discussed than were unusual diagnoses such as body dysmorphic disorder or trichotillomania. Schools that offered addictions-oriented degrees were equally provincial.
One of our agency's first effective strategies has been accepting interns and educating them on dual diagnosis, while they are most open to new approaches.
"The topic of integrated treatment is indeed beginning to make its way into formal training programs--finally. Its entry has been slow," says Vikki L. Vandiver, Dr.P.H., who is an associate professor at Portland State University's Graduate School of Social Work and is on the clinical faculty in the Department of Psychiatry at Oregon Health and Sciences University's School of Medicine.
"Teaching faculty are often slow on the uptake for integrating this perspective into course work--partially because of lag time between their own training and ability to upgrade course materials. While critics would say that higher education is not doing enough to prepare the upcoming workforce with the skills to provide assessment, treatment and support for dual diagnosis populations (and they are correct in many ways), all fields (psychiatry, social work, counseling, nursing) are trying to get up to speed."
But it is not only the clinicians who require education about the importance of integrated treatment. For clients as well, ignoring one concern often reflects an ingrained personal bias.
"I'm not crazy; I'm just an alcoholic" or "I'm not a drunk; I just have a chemical imbalance in my brain" are not uncommon responses when first talking to a dually diagnosed client.
Clinicians who may be comfortable discussing someone hearing voices might ask questions such as, "You don't drink too much, do you?" On the other hand, an A & D counselor who is skilled at nailing down how much liquor someone consumes may skirt questions about suicidal thoughts.
There are differences in language and approach that divide behavioral healthcare. For example, among those receiving mental health treatment, the preferred term has gone from "patient" to "client" to "consumer. …