Adaptation and Implementation of the Integrated Dual Diagnosis Treatment Model Into a Psychiatric Inpatient Facility: A 12-Year Perspective

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

TVBH’s IDDT adaptation of the stage-wise intervention component to an inpatient population was facilitated by building on the hospital’s already-established “recovery model” treatment environment. The stages of the recovery treatment model correspond well to the IDDT stages of change. Table 1 illustrates and compares the chronological and progressive recovery treatment model steps and IDDT stages.

In the course of adapting the IDDT model to the TVBH inpatient setting, the staff learned that the event or crisis leading to hospitalization could often be viewed and used as a “change motivator.” Therefore, it can be a key factor in moving a patient through the stages of change from the engagement stage to the persuasion stage and into active treatment. Inpatient hospitalization represents an opportunity for more rapid progression through the IDDT stages of change because the patient is separated from opportunities for substance use, their mental illness is being stabilized with medication, their emotional and cognitive functioning is improving, they have better nutrition and physical health care, and they receive 24-hour staff support (Table 1).

3. The “Access to Comprehensive Services” Component: Include IDDT provisions in all interagency continuity-of-care service agreements with community service providers
Successful IDDT programs offer comprehensive services because the recovery process occurs in the context of the multifaceted parameters of daily living. Services must be available to meet the daily ongoing needs of consumers during all stages of their treatment, which includes case management, family services, integrated substance abuse and mental health counseling, medical services, housing and residential services, supported employment, and assertive community treatment (ACT) or intensive case management.⁹

TVBH’s IDDT access to comprehensive services adaptation to an inpatient population is reinforced by the treatment philosophy that the inpatient IDDT SAMI program is not occurring in isolation but rather as an extension of outpatient or community treatment. For this reason, communication with the patient’s outpatient service providers, including case managers, is essential. TVBH has formal interagency service agreements with community service providers, which defines and assures this continuity of comprehensive care and collaboration. For patients who are hospitalized beyond the acute care/stabilization period (an average 14-day length of stay), a wide range of accessible, comprehensive services exists within the hospital structure. These include, but are not limited to a patient work program, community trips that allow for visiting of other community treatment facilities, consultation with the peer support programs, educational services, and spiritual life services.

4. The “Time-Unlimited Services” Component: Prepare and link each patient’s outpatient services with community providers prior to discharge and during the active inpatient treatment process
IDDT research suggests that consumers with co-occurring disorders experience cycles of relapse and recovery throughout their lives and those consumers will achieve the highest quality of life when they have access to services all of the time. Therefore, the IDDT model encourages organizations to provide services to consumers throughout their lifespan, even when the symptoms are mild or infrequent.⁹

TVBH’s IDDT time-unlimited services component adaptation to an inpatient milieu includes a complete medical, psychiatric, nutritional, and social work assessment for each person admitted to the hospital. These assessments contain an update of treatment occurring prior to the first admission and since any previous admissions. This evaluation process provides an opportunity for the treatment team and the patient to meet and to assess current functioning and current stage of change as well as an opportunity to look for change motivators. While inpatient IDDT SAMI services may be restricted by the hospital’s limited length of stay, patients are offered time-unlimited continuity of services on an outpatient basis before and after discharge. During hospitalization, a post hospital plan is developed with the input from aftercare IDDT service providers, and patients are then unified with outpatient service providers. Therefore, inpatient and outpatient IDDT are time-unlimited service extensions of each other. The post hospital plan assures that patients have access to the same services they received during hospitalization (eg, SAMI counseling, medication education, and group therapy with peers). In addition, discharged patients who attended the open AA and Drug Recovery Anonymous (DRA) 12-step groups and meetings held on hospital grounds are welcomed back to TVBH after discharge so they could continue to attend these meetings.

5. The “Assertive Outreach” Component: Engage each patient in IDDT services throughout the course of inpatient care utilizing an assured and respectful approach
Successful IDDT programs use assertive outreach to keep clients engaged in relationships with service providers, family members, and friends. Service providers involved in assertive outreach often find it necessary to meet with consumers in community locations familiar to consumers, such as in their homes or at their favorite coffee shops or restaurants.⁹

TVBH’s IDDT assertive outreach adaptation to an inpatient treatment milieu includes the concept of reaching out to the patient during all phases of treatment to provide SAMI services in a way that meets his individual and current needs, as designated on the patient’s personally signed treatment plan. This reaching out, or engagement, is not provided in a forceful manner but in an assured and respectful manner. Engagement can occur on admission during the initial assessments, during the first treatment planning meeting, or at any time and place during the inpatient stay. For example, when a patient is isolating himself in his hospital bedroom, staff should reach out to the patient in his room as an essential way to engage the patient. This strategy includes “meeting and engaging the patients where they are,” both literally and figuratively.

6. The “Motivational Interviewing” Component: Maintain an extensive motivational interviewing educational program and use motivational interviewing techniques during all assessments and treatment
Motivational interviewing is a technique that service providers use routinely while interacting with clients. Motivational interviewing helps consumers identify their personal goals for daily living, as well as strategies (activities) for achieving those goals. It also helps consumers examine any ambivalence about their goals and strategies. This process enables consumers to identify discrepancies between their stated goals and behaviors in order to help them better understand the relationship between what they want in life and what keeps them from achieving their goals.⁹

TVBH’s IDDT motivational interviewing adaptation to an inpatient population included the extensive training of all key staff in the motivational interviewing techniques described by Miller and Rollnick.¹³ An open work group was formed to educate the staff on the appropriate use of the various motivational interviewing techniques during the assessment process and throughout the progressive treatment stages. The Ohio SAMI CCOE continually offers motivational interviewing,” educational conferences and specialized training events, addressing beginning to advanced level skills, which staff attend according to their progressing skill development.

7. The “Substance Abuse Counseling” Component: Include specific substance abuse counseling as a treatment intervention
Consumers who are motivated to manage their illness(es) are ready to develop skills to control symptoms and to pursue an abstinent lifestyle. Successful IDDT programs support motivated consumers by providing specific counseling that helps them recognize and adopt recovery skills.⁹

TVBH’s adaptation of the IDDT practice of substance abuse counseling for an inpatient population included working with the original TVBH staff of substance abuse counselors to become proficient with IDDT specific substance abuse counseling skills, and then engaging them as leaders of a SAMI implementation team to teach these skills to all the staff. The implementation team initially became aware of the staff’s tendency to mismatch a patient’s SAMI stage with the type of treatment needed and being offered. For example, the implementation team learned that while the majority of TVBH’s patients were still in the engagement or persuasion treatment stages of change, there was the tendency for some staff to provide the patients with active skills stage treatment. Therefore, initial changes in the culture transformation included the appropriate matching of SAMI services with the IDDT stage of the patient’s impairment.

8. The “Group Treatment” Component: Provide regular and ongoing interdisciplinary group therapies which address issues such as recovery management, relapse prevention, symptom management, medication management, physical health and mental fitness and internal coping skills
IDDT research indicates that individuals with CODs achieve better outcomes when they engage in progressively staged group treatments that address both disorders simultaneously. Group treatment is also an ideal setting for consumers to develop peer supports. In groups, consumers share their experiences and learn to differentiate between effective and ineffective coping strategies. Service organizations using the IDDT model should offer a menu of group treatment options to all consumers who experience CODs. Consumers should be involved with group interventions at least weekly.⁹

Initial SAMI assessments identify the individual’s current stage of change and indicate the individual’s appropriate group level. During the initial part of the hospitalization, stabilization of both psychiatric symptoms and medical problems are facilitated by a focused, active therapy treatment stabilization protocol. Ninety percent of the patients admitted to TVBH are in the engagement or persuasion treatment stages of change, so a SAMI persuasion level group is provided on each of the 11 patient units at least once a week. These “SAMI Basics” groups are principally psychoeducational and provide information about the impact and effect of various drugs and alcohol on mental illness. Those individuals in the engagement or persuasion stages of change have the opportunity for individualized services, and are encouraged to use psycho-educational SAMI Basics groups and the 12-step groups to facilitate commitment and affiliation with the IDDT model and SAMI services. When the IDDT services were first offered at TVBH, the SAMI Basics groups were provided in an area away from the patient care unit and were poorly attended. Staff reviewed the outpatient IDDT model and decided to hold these groups directly on the patient units to “meet the patients where they are.” Attendance and outcomes improved markedly.

The remaining 10% of the TVBH patient population are in the IDDT active treatment stage and thus are motivated to manage their illnesses and ready to develop skills to control symptoms. In addition to individual therapy, these individuals are offered an active treatment program called Recovery Skills, which utilizes components from the Substance Abuse Management Model,¹⁴ emphasizing skill acquisition related to their independent/aware recovery level of change (see Table 1). For individuals in the IDDT active treatment phase, Recovery Skills groups are offered in an off-unit location that includes a collection of individuals from all the patient units. Recovery Skills groups focus on the practice and acquisition of strategies necessary to maintain abstinence and avoid high-risk situations that lead to relapse. Individuals in the active stage of change have the opportunity to provide leadership role in the 12-step meetings.

In addition to these IDDT specific groups, the hospital offers 34 weekly interdisciplinary group therapies that address issues such as Recovery Management, Relapse Prevention, Symptom Management, Medication Management, Physical Health and Mental Fitness, and Internal Coping Skills, which also integrate SAMI information and education.

9. The “Family Psychoeducation” Component: Include all persons involved in the consumer’s recovery in the patient’s psychoeducation processes
Family psychoeducation fosters social support. Psychoeducational programs educate all persons involved in the consumer’s recovery about the symptoms and effects of mental illness, the effects of substance use and abuse, the medicines used in treatment, and the challenges that the consumer faces.⁹

TVBH’s family psychoeducation adaptation focuses on the inclusion of consumers, family members, significant others, friends, and service providers in the treatment process. This includes their attendance at the patient’s treatment team meetings, and/or separate meetings with members of the patient’s treatment team, and participation in the monthly TVBH family night informational sessions. Family and support members are encouraged to attend the onsite afternoon and evening 12-step meetings with the patient. Family members are educated on the availability of community resources, and they are provided with reference manuals to assist them in contacting and utilizing resources, such as the many local Al-Anon support groups and the local NAMI chapter family group.

10. The “Participation in Alcohol and Drug Self-help Groups” Component: Provide onsite AA and DRA self-help group meetings and a peer support program
IDDT research shows that social support plays an important role in reducing relapse for persons with CODs. Self-help groups are excellent sources of social support for individuals who are motivated to achieve and maintain abstinence. They provide consumers with opportunities to share and learn from others who experience dual disorders and they help consumers feel fellowship and know that they are not alone.⁹

TVBH’s adaptation of the “self-help groups” component to an inpatient population includes the provision of the AA and DRA self-help group meetings on hospital grounds 4 times per week. The hospital has a Peer Support Program, consisting of former patients, who work with current patients by providing support services on the civil and forensic units, facilitating off-grounds excursions, and conducting patient satisfaction assessments for the hospital administration. Before TVBH’s implementation of IDDT, AA 12-step groups were a well-accepted TVBH therapy protocol for patients. With the advent of the IDDT program, these self-help group offerings were expanded to include DRA. There are averages of 100 patients per week who participate in these self-help groups. All 12-step groups are open to patients and others from the community to attend: spouses, significant others, adult children, community case managers and sponsors are encouraged to attend all evening meetings.

11. The “Pharmacological Treatment” Component: Provide pharmacological treatment that corresponds to the patient’s unique IDDT characteristics in the different and various stages of change
IDDT research shows that medications are effective in the treatment of persons with severe mental illness and CODs. Medications generally include antipsychotics, mood stabilizers and antidepressants. Although medications are powerful allies in the treatment process, research shows that medications are most effective when accompanied by comprehensive integrated services and treatments that address the biological, psychological, and social conditions and needs of consumers.⁹

TVBH’s pharmacological treatment adaptation to an inpatient population is inherent in the inpatient psychiatric treatment milieu because admitted patients typically receive medication to treat their mental disorder. The strong emphasis on COD treatment, in both the Recovery and IDDT models, aids in the education of patients in terms of teaching them strategies to manage their dual disorders. Psychiatrists and nurses provide medication education groups on the units and emphasize that medications to treat substance disorders specifically are evaluated and used on a case-by-case basis.

12. The “Interventions to Promote Health” Component: Focus on mental and physical wellness at all treatment planning and implementation stages
IDDT research indicates that individuals with CODs are at increased risk for poor health, including the need for hospitalization and emergency department visits, especially for infectious diseases (eg, HIV, hepatitis, and sexually transmitted diseases). They suffer complications resulting from chronic illnesses (e.g., diabetes and cancer), exposure to violence as witnesses and victims of assault, physical abuse, and sexual abuse, and are at risk for suicide.⁹

TVBH’s interventions to promote health adaptation is assisted by an emphasis on “wellness” during the treatment planning with all patients and the implementation of both the Recovery and IDDT models for the SAMI patients. TVBH supports the promotion of physical as well as mental health by providing physical evaluations on admission, regular medical and dental clinic visits, dietary assessments with specialized diets through the nutrition department, vaccines for illnesses, and opportunities physical exercise on the grounds or in the patient gym and workout rooms. The hospital’s medical clinic monitors and treats most physical problems, transfers patients to a general community hospital as needed, and arranges follow-up medical care in the community after discharge. TVBH’s peer supporters present information on topics of physical and mental wellness and personal and environmental safety at the daily unit community meetings. A wide range of therapy groups are offered in all disciplines and this treatment addresses various aspects of health and safety.

13. The “Secondary Interventions for Non-responders to Substance Abuse Treatment” Component: Provide a secondary intervention for patients who have not responded to outpatient care
Successful IDDT programs have a specific plan to identify individuals who are not responding to IDDT treatment (non-responders). Examples of secondary interventions include specialized treatment for anxiety disorders such as PTSD and specific trauma events, which may be causes for the non-response.⁹

TVBH’s adaptation of the IDDT secondary interventions for non-responders principle is inherent in the hospital’s inpatient programming because patients who are admitted to TVBH tend to be non-responders from other programs and/or have tended to be unsuccessful with outpatient treatment programs. Approximately 90% of TVBH’s dually diagnosed patients do not personally or psychologically comprehend and accept substance abuse as a major treatment issue for them; consequently, there are large numbers of patients who are in the earliest stages of change.

Over the 12 years of TVBH’s implementation of IDDT, the TVBH SAMI program has developed a greater awareness that the majority of our public health clients have been exposed to previous traumas, which are often linked to their psychiatric symptoms and/or substance use. Therefore, a patient’s history of trauma is assessed on admission, and appropriate trauma informed interventions are integrated into these patients’ treatment plans. TVBH has successfully implemented a detailed trauma informed care program in 2009 with the support of state and national leaders. The implementation of trauma informed care, as another shift in culture and perspective within the organization, was modeled after the successful implementation of the TVBH IDDT/SAMI program.

Conclusion
This article describes the successful adaptation of the IDDT outpatient model as a SAMI program in the TVBH inpatient psychiatric setting. The preservation of each of the basic 13 IDDT tenets, the assertive community treatment concept, and the provision of treatment in an integrated fashion by the same team consisting of cross-trained professionals was central to the adaptation and implementation.¹⁵ Inpatient SAMI treatment uses the IDDT stages-of-change approach with treatment interventions tailored to an individual’s level of SAMI insight and motivation. This adapted SAMI model has yielded results that are superior to the traditional divided non-SAMI treatment approach.¹⁰

One critical success factor for the IDDT inpatient adaptation is preservation of the concept of “community.” This involves conceptualizing the inpatient facility as a community with outreach to the patients on their units, provision of psychoeducational groups “close to home” on the units, with an assured, confident, and nonconfrontational approach. Cross training of all staff with patient contact is completed to maximize the staff’s ability to assess each patient at the accurate stage of change and then to correlate this stage with appropriate interventions. For the majority of patients this involves engaging them in their own recovery by instilling their hope that recovery from both mental illness and substance abuse is obtainable.

Although lifelong abstinence would be an unlikely outcome for patients who received only a 2-week hospitalization, patients in an extended period of stay could make important decisions in the change process, and thus be more receptive to interventions following a crisis than when residing in the community. The admission reasons for hospitalization may also be significant “change motivators” in an individual’s life, and if appropriately capitalized on during treatment, they could lead to an acceleration in the process of change for their CODs with enduring effects.

Check Points:

Although the original integrated dual disorder treatment (IDDT) model was designed for an outpatient setting, the same service components can be successfully adapted for an inpatient population with treatment provided an integrated fashion by the same team of cross-trained professionals.

With adaptation of the IDDT model to inpatient care in a psychiatric setting, there is a shift of ideology away from separate and specialized treatment approaches to substance abuse toward integrating substance abuse treatment into daily therapeutic activities across disciplines.

Most individuals in the inpatient setting fall within the engagement and persuasion stages of change for both their mental illness and substance use issues; therefore, the majority of treatment interventions should match these stages.

The crisis point necessitating inpatient care can itself be a change-motivator and can help move an individual into a more advanced stage of change.

Inpatient IDDT does not occur in isolation but rather it is an extension of outpatient mental and physical health care.

The adaptation and implementation of IDDT concepts to an inpatient setting can be a rather small investment because it primarily uses existing resources and personnel. However, it can yield a large change in the organizational structure, the treatment culture, and the co-occurring disorder treatment provisions, thereby having a significant impact on the patient population and the quality of services overall.

Consumer-Presented Case Vignette
At age 32, I am successfully recovering from mental health and substance abuse problems. This is a brief account of my 7-year journey to recovery, which was guided and supported by a mixture of inpatient and outpatient treatment services. Today I am employed at one of my past treating sources where I started my recovery, a psychiatric hospital, as a peer-support staff member helping other patients to understand, begin, or continue with their recovery.

At a very early age, my uncles allowed me to take sips from their cans of beer. This made me feel happy so when I had the chance at the age of 14, I decided to try marijuana. I really liked the way it made me feel and used it whenever I could. At 16, when I had my first job as a paperboy, I used that money to buy beer.

Between the ages of 16 and 17, I continued to use beer and pot, which was part of the scene of hanging out with the “wrong kids,” stealing cars, beating people up for fun, skipping school, getting suspended, and eventually dropping out of school. At 17, my mother kept telling me that I had a problem with drugs and I needed to get help. During this time, I assaulted my sister and found myself in jail for awhile.

At age 22, I was court-ordered to seek mental health treatment and was linked to a community mental health center. The staff told me that I had a problem with drugs and needed help; but I did not believe them because I was having too much fun. I did not seek treatment.

By age 25, I was again in jail for felonious assault, and assault and robbery after knocking down an old lady and taking her purse. She had no money so I just dropped the purse. Someone saw me and got a description and I was picked up by the police. I was in jail for 5 months, which means I was sober for the first time. After jail time, I was court-ordered to a State of Ohio maximum-security inpatient forensic treatment facility, Timothy B. Moritz Forensic Center (TBMFU), which is the maximum-security unit of TVBH.

When I first arrived at TBMFU, I thought I had hit rock-bottom with my drug and mental health problems. It was during SAMI group therapy in TBMFU when the discussion was on mental illness and substance abuse that I realized the relationship between my mental problems and substance abuse, and that I needed to make a change in my life. Listening to other patients in group therapy and reading materials from the staff helped me understand that while I was young I needed to commit to changing my behavior. It is as if a light-bulb went on, and I could see the mess created by my past substance use. With the medication, individual and group therapy, education, healthy food and the continued support of staff and my family, I was able to plan for a new future.

After 6 months in TBMFU unit, I was transferred to a civil hospital to continue my recovery for another 11 months. SAMI topics centered on the management of my substance abuse issues in combination with managing my mental illness once I was discharged. Through books, videos, and fun educational games, I developed lasting skills on how to deal with my issues of mental illness and substance abuse. I learned that mental illness and substance abuse had to be treated together, and it was not something that could be managed separately. I had to look at it all together as one problem.

After hospital discharge, I was linked with community supports such as Soaring Sober, AA, and an AA sponsor. My outpatient SAMI counselor helped me stay focused on my recovery while I identified my strengths, developed a plan to return to school, and found a recovery support group. The continued need for psychiatric medications, and how substance abuse can affect you both early in life and many years down the road, was a center to many interventions. I obtained a part-time job as a peer-support staff member helping other inpatients to understand, begin, or continue with their recovery.

In my role as a peer-support person who has been in 9 years of continuing recovery, I pass along to other patients the lessons that I have learned in my SAMI inpatient and community programs:

• To begin recovery, you have to acknowledge there is a problem that needs both mental and substance abuse treatment.
• For a while, you need to depend on others in order to become aware how to develop and use a treatment plan for recovery plan.
• To be successful with recovery, you must attend a range of interventions including medication, individual therapy, group sessions with peers, educational materials, and nutritional plans for healthy eating habits.
• Your family and friends must participate in your treatment and recovery so they can better understand you and help you recover.
• Eventually you will become more independent and secure in your recovery and you will be able to establish a life plan to prevent a relapse.
• Your relapse plan must include ongoing therapy, your family and friends as supports, and constructive social and work activities.
• During recovery, things will not always be easy. To keep up your recovery you may have to change things you do in life, which could include developing different relationships with new people and not associating with persons from your past who could be harmful to you.

References:

References

1.

Sacks S, Reis RK. Substance Abuse Treatment for Persons with Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMSHA). Center for Substance Abuse Treatment; 2005. DHHS Publication No. (SMA) 05-3992.

2.

Sacks S, De Leon G, Balistreri E, et al. A modified therapeutic community for homeless mentally ill chemical abusers: sociodemographic and psychological profiles.

J Subst Abuse Treatment

. 1998;15:545-554.

3.

Compton WM III, Cottler LB, Ben-Abdallah A, et al. Substance dependence and other psychiatric disorders among drug dependent subjects: race and gender correlates.

Am J Addict

. 2000;9:113-125.

4.

National Association of State Mental Health Program Directors and National Association of State Alcohol and Drug Abuse Directors. National Dialogue on Co-Occurring Mental Health And Substance Abuse Disorders. Washington, DC: NASADAD; 1999. http://www.nasadad.org

5.

National Association of State Mental Health Program Directors and National Association of State Alcohol and Drug Abuse Directors. Financing and Marketing the New Conceptual Framework for Co-Occurring Mental Health and Substance Abuse Disorders: A Blueprint for Systems Change. Alexandria, VA: NASADAD; 2000. http://www.nasadad.org.

6.

Boyle P, Delos Reyes CM, Kruszynski RA. Integrated dual-disorder treatment. In: Drake RE, Merrens MR, Lynde DW, eds. Evidence-Based Mental Health Practice. New York: WW Norton;2005:349-366.

7.

Mueser KT, Noordsy DL, Drake RE, Fox L. Integrated Treatment for Dual Disorders: A Guide to Effective Practice. New York: Guilford Press;2003.

8.

Ronis RJ. Best practices for co-occurring disorders.

J Dual Diagn

. 2005;1:83.

9.

Kubek P, Kruszynski R, Boyle PE. Integrated Dual Disorder Treatment:: An Overview of the Evidence-Based Practice. Cleveland: The Ohio Substance Abuse and Mental Illness Coordinating Center of Excellence (Ohio SAMI CCOE);2003. http://www.ohiosamiccoe.case.edu. Accessed June 10, 2010.

10.

McHugo GJ, Drake RE, Teague GB, Xie H. Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study.

Psychiatr Serv

. 1999;50:818-824.

11.

Wieder BL, Lutz WJ, Boyle P. Adapting Integrated Dual Disorders Treatment for inpatient settings.

J Dual Diagn

. 2006;2:101-107.

12.

Office of Applied Studies. National Survey of Substance Abuse Treatment Services (N-SSATS). Ann Arbor, MI: Substance Abuse and Mental Health Data Archive; 2002-2008; http://www.icpsr.umich.edu/cocoon/SAMHDA-SERIES/100058.xml. Accessed June 10, 2010.

13.

Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press;1991.

14.

Roberts L, Shaner A, Eckman T. Overcoming Addictions: Skills Training for People With Schizophrenia. New York: WW Norton; 1999.

15.

Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more Integrative model of change.

Psychother Theory Res Pract

. 1982;19:276-288.