An elephant-size challenge: implementing integrated services requires a "one bite at a time" mentality.

Overcoming difficult challenges has been compared to eating an elephant--you have to take one bite at a time if you intend to complete the task. In our field, integrating mental health and substance abuse treatments is certainly an enormous challenge. Yet Community Support and Treatment Services (CSTS) in Michigan has been able to provide cooccurring disorder services by taking a step-by-step implementation approach.

Background

CSTS is a department of the Washtenaw County, Michigan, government operating under a contract with the Washtenaw Community Health Organization (WCHO), which functions as both the local mental health authority and substance abuse coordinating agency. With an annual budget approaching $24 million, CSTS is responsible for delivering services to approximately 2,000 adult clients with severe and persistent Axis I and II mental illnesses and/or personality disorders, 900 adults with Axis II developmental disabilities, and 500 children with serious emotional disturbances and/or developmental disabilities. CSTS has been a long-standing provider of case management and clinical community mental healthcare services for county residents, but only in the past several years has our focus more intentionally included integrated treatment services for clients with co-occurring substance use disorders.

Before Integration

Participation in a three-year grant-funded dual-diagnosis project in the late 1990s sensitized the agency to the prevalence--and unique treatment needs--of clients with co-occurring disorders. The program response at the time, however, was to build a discrete dual-d iagnosis unit that accepted referrals from other units and teams within the agency, thereby providing services in a largely isolated fashion. Some progress was made during those years, but when grant funding fizzled, the majority of these services also did, with the exception of four weekly dual-diagnosis treatment groups that had "integrated" their way into the agency's mainstream programming.

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As evidence of which treatments worked best with the co-occurring population accumulated, integration of mental health and substance use disorder treatment services became CSTS's goal. However, compared to the relatively simple task of providing resources for a stand-alone team, agency-wide integration loomed as an overwhelming task touching on every level and aspect of service provision: from the administrative and policy level to service design and implementation to training and staffing decisions.

One "Bite" at a Time

In 2002, CSTS convened a work group to address the broad goal of implementing integrated co-occurring disorders treatment services. The larger workgroup soon divided into smaller groups vested with addressing both barriers and solutions at the administrative/policy, program services, clinical staff, and consumers and families levels. Feedback from months of meetings provided the beginning work plan. Early efforts were informed by consultation with Kenneth Minkoff, MD, a recognized expert on integrated systems, who stressed the system-wide and culture change aspects of our undertaking. Another consultant, Robert Drake, MD, stressed the importance of internally identified "champions" to carry out the plan, which could take up to five years to complete.

Administrative/Policy Challenges

The administrative leadership's buy-in and support were critical to the long-term success of the implementation. Other service systems in Michigan have floundered when attempting integration for lack of greater support from the top.

Although CSTS had been a community mental health organization for decades, the agency had not previously functioned as a state-licensed substance abuse treatment provider. Pursuing this licensure included reviewing all pertinent policies and making revisions (and additions) appropriate for the delivery of integrated treatment. This foundational work has proven valuable over the long haul.

Historically bifurcated funding streams were problematic in multiple ways, although WCHO's role as a dual mental health/substance abuse funding authority was a significant advantage to negotiating workable solutions affecting the screening, referral, and service authorization of dually diagnosed clients.

Program Services Challenges

Adjusting service models was critical, both philosophically and practically. Moving from a mental health model of lifelong "maintenance" care of chronic clients to a model embracing the possibilities of progressive recovery has been fundamental to supporting effective co-occurring treatment implementation.

CSTS initially needed to develop and staff new services with few new resources, although aggressive pursuit and use of grant funding have been helpful. Using the experience and expertise of CSTS's internal champions, consulting with outside experts (e.g., Dr. Minkoff and David Mee-Lee, MD), and relying on the increasingly well-developed professional literature in this area (such as materials provided by SAMHSA and Hazelden) proved vital to implementation success, including creating three specialized teams meeting high-fidelity standards of the SAMHSA Integrated Dual Disorders Treatment (IDDT) evidence-based practice model: the Project Outreach Team (PORT) serving the homeless population and two IDDT-enhanced Assertive Community Treatment (ACT) teams.

Clinical Staff Challenges

Frontline staff members' levels of experience, competence, comfort, and confidence with providing co-occurring disorder treatment services ran the gamut. Casting a convincing vision was key to increasing employees' willingness to engage in the significant training and clinical supervision necessary to support the implementation's success.

Using champions and other enthusiastic employees to facilitate groups helped get things moving immediately, as well as supported longer-term culture change by allowing these staff members to serve as change agents with their more reticent co-workers. Staff members willing to obtain an addictions counselor credential were rewarded with a mild salary grade promotion as an incentive for active participation. These employees regularly use therapeutic drug testing, contingency management strategies, motivational enhancement techniques, and dialectical behavior therapy with dually diagnosed consumers.

Consumer and Family Challenges

Clients with histories of failure in single-diagnosis substance abuse treatment episodes and their family members/natural supports needed to be reengaged and educated about the differences represented by co-occurring treatment approaches. CSTS's weekly co-occurring disorders education lecture series, open to clients, family members, students, staff, and the public, played a significant role.

Fifteen weekly staff-facilitated groups were tiered to match clients to their individual stage of readiness for treatment. The groups meet at various community settings and agency service sites. Also meeting at community-based locations (including the local Alano Club) are five weekly peer-led meetings of Dual Recovery Anonymous.

Conclusion

Space does not permit a more detailed description of the many lessons CSTS learned. As with many significant service initiatives, there always is room for ongoing quality improvement. We are tracking and evaluating service outcome data, processes greatly assisted by using electronic health records.

Sustaining effective co-occurring disorder treatment services is a challenge in and of itself, with corresponding needs for continuing education/training and the reinforcement that comes from capable clinical supervision. "Eating an elephant" is certainly not easy! However, CSTS's experience demonstrates that "eating the co-occurring treatment elephant" is possible. Given what is at stake for our clients and communities, it is absolutely worth the effort. Bon appetit!

Steve Wiland is a member of the Michigan Fidelity Assessment Team (MIFAST), which supports statewide implementation of SAMHSA's Integrated Dual Disorders Treatment evidence-based practice. To request a PDF with additional details of CSTS's co-occurring treatment services implementation, e-mail wilands@ewashtenaw.org.

ABOUT THE AUTHOR

Steve Wiland is the Clinical Practices Administrator at Washtenaw County (Michigan) Community Support and Treatment Services.

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