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Building integrated treatment for dually diagnosed youth: Sound Mental Health's team recounts lessons learned in developing a much-needed approach.

For adolescents, there's no shortage of turmoil in daily life: hormonal changes, peer pressure, the meandering path to adulthood. As if this isn't enough, youth must also cope with the dual threat of mental health and substance-use disorders. Statistics pointing to the link between the two simply cannot be ignored: A 2002 SAMHSA report noted that children with serious emotional disturbances are at greater risk for substance abuse, while young people who experience major depressive episodes are twice as likely to use alcohol or illegal drugs than kids who do not. According to a 2011 World Health Organization report, 45 percent of disability among adolescents and young adults is related to depression, bipolar disorder, schizophrenia, alcohol abuse, and other behavioral health disorders.


There's no arguing that addressing co-occurring mental health and substance use disorders among adolescents is a significant public health priority. Doing so effectively demands integrated mental health and substance abuse services, but, as we found in our own effort, developing and integrating the key components of such services is no simple task.

Integrated treatment for co-occurring disorders is more effective because both problems are treated at the same time, in an inclusive and holistic manner. This requires clinicians who are "dually credentialed" in both areas or, alternatively, a work environment that fosters a "side-by-side" treatment mentality, an environment that shares clinical and assessment information freely among all treatment team members and that develops and works from jointly developed consultation and care plans.

Our experience with integrated treatment for co-occurring disorders among young people indicates that overall client engagement is improved, care modifications are made faster--often in real time, care teams work more efficiently, and our young clients themselves typically have a more positive treatment experience.

Key components of an integrated approach

1. A shared vision. Agency leadership must develop and articulate a strong vision for an integrated practice and staff must buy in to it. Unless your professionals embrace and practice integrated programming, no program, despite best intentions, can succeed.

2. A strong foundation. A second critical component is determining the "orientation" of the program, or more accurately, the foundation on which that program will be built. At Sound Mental Health, we believe that integrated programs are most effective when built atop a recovery-oriented mental health foundation, with the SUD treatment component woven into it. There may be other models, but this approach has been highly effective.

3. Capable clinicians. Integrated treatment demands motivated professionals who are able to look beyond established interventions and modify their treatment approaches to fit the complex needs of dually diagnosed youth. Ideal candidates for additional chemical dependency training include Masters' level mental health clinicians, who must be proficient in conducting Global Assessment of Individual Needs (GAIN) assessments and other substance abuse interventions designed to treat dual diagnosed adolescents. With a Master's degree in Social Work, Psychology or other mental health fields, these professionals have the foundation to ensure integrated treatments that are in-depth and comprehensive.

4. Ongoing financial support Agencies committed to an integrated, recovery-based program should expect to invest in sustained support for clinical staff as they complete the additional training required for chemical dependency certification and licensure. This support should include not only the financial help needed to cover the costs of the additional training, but also financial incentives to attract and retain the most capable, dually credentialed staff.

5. Able supervisors and leaders. Addressing the complex needs of dually diagnosed young people requires more than dually qualified clinical professionals. A complete team requires skilled, and dually trained clinical supervisors, advanced nurse practitioners, and/or psychiatrists to address the myriad issues that will emerge for young people in recovery. Training and education, especially around new evidence-based practices or practice refinements, will remain a vital need.

Cultivating partners and referral sources

In addition to building a highly-trained and collaborative staff, identifying key partners and developing strategic relationships with other organizations and agencies that serve youth is another essential element in the success of a youth-focused dual diagnosis treatment program. Proactively building partnerships with such organizations as the Juvenile Rehabilitation Administration, the Department of Children and Family Services, local school districts, hospital emergency rooms and local/regional teen shelters is of great value, since these places are on the front lines of service to young people and are well placed to identify those having problems and those most in need of help.

But don't mistake effective collaboration with these youth-focused partners for effective integrated treatment, since these partners cannot replace the quality of care provided by an integrated team of mental health and chemical dependency professionals. The unique integration of such a team is essential to the kind of creative problem solving and discovery that, together with client input, can result in a level of effectiveness in care that is simply not possible in other supportive youth settings.




Overcoming challenges and barriers to dual-diagnosis treatment

Having a highly trained, dually credentialed professional team and a supportive environment are two necessary elements for success in an integrated program, but they alone aren't sufficient. Authentic program success depends on the resolve of both disciplines, together with agency leadership, to purposefully overcome historical biases and create a shared vision that values true integration. For example, agencies committed to integration must be willing to embrace changes in culture and workflow, invest in new and unfamiliar perspectives, rethink their practice areas, and persist patiently as new models of care emerge and demonstrate their effectiveness in helping young clients.

Until recently, mental health treatment has been based around diagnosing an underlying illness and reducing its symptoms, while chemical dependency treatment depended more on narrative, person-centered approaches. These differences made truly integrated treatment difficult. But the recent evolution of mental health treatment from the old "professional/client" model to a newer, more interactive "recovery" model in which clients became more directly involved in their treatment provided a significant opportunity for would-be integrated providers. Similarly, while reliance on the DSM is typically vital for mental health work, integrated treatment for dually diagnosed clients demands a wider view of the factors upon which successful treatment depends, including causality, family history, and individual life experiences, to name a few.

Because such evolution is not easy, agency leadership should be prepared for some challenging times. Developing new holistic treatment approaches, merging cultural and treatment differences, changing infrastructure and work processes, and retraining/retaining key staffdoesn't happen overnight. But it is our experience that the effort will be well worth the difficulty. Ultimately, the merging of practice areas will provide a better blueprint on which to build effective, responsive, and individualized care plans.

More programs needed

Among individuals with co-occurring disorders, the average age for onset of a mental health issue was 11 years of age, while substance abuse follows five to 10 years later. Countless other studies, too, show significant links between mental illness and substance abuse among youth.

Despite the prevalence of research that verifies the positive impact of integrated programs for dually diagnosed youth, such programs remain relatively rare. The potential to reduce the harm to young people who suffer from both a mental health and a substance-use disorder clearly justifies the substantial effort required to create more sophisticated and comprehensive integrated treatment approaches, approaches that can be achieved using methods that are readily available today.

RELATED ARTICLE: Starting points for integration

Our experience suggests that organizations focus initial integration efforts in a few key areas. This focus will help to develop a solid foundation for continuing the integration effort. We suggest these areas as starting points:

1. Intake and screening. The mental health intake assessment is the first substantive contact that an agency has with a client. This makes it an ideal point to gather youth substance-use information as well. King County (with whom Sound Mental Health collaborates), mandates the use of the GAIN SS assessment, which provides referral indications for mental health treatment, substance abuse treatment, or both. The GAIN I is a computer based assessment from Chestnut Health Systems that provides a comprehensive biopsychosocial assessment. Its results can be linked with those available at other agencies to ensure that the most current information about a young client is available, A component of the GAIN, the M90, offers a benchmark for progress reporting at intervals of 90 and 180 days.

2. Information exchange. Integrated programs that treat dually diagnosed clients must observe stringent confidentiality guidelines related to their clients' substance use treatment information. However, compliance with these requirements, necessary to realize the benefits of shared client information, must not be allowed to hamper effective care. Developing processes that allow the entire team to share critical client information enables the entire team to recommend levels of care and establish treatment plans with full--and shared--understanding of a client's mental health status, substance use status, and other vital health information. Members of the integrated treatment team also must work closely with other community partners, including schools and juvenile probation departments. These conversations must be inclusive, incorporate client input, and stay focused on the recovery model for long-term success,

3. Shared therapeutic approaches. In our service area, SMH collaborates closely with the King County Mental Health Chemical Abuse and Dependency Services (MHCADSD) division, which is a proponent of the Seven Challenges, a specialized therapy model developed by Dr. Robert Schwebel. This model, which strives to promote understanding among youth about the underlying causes of substance use, enables therapists and clients to see and approach mental health and chemical dependency issues holistically. Building on models preferred and used by key partners is another way to build a closer working relationship.

4. Case management. Without a coordinated case management system in place, there is truly no integrated care. Case management, as we know, provides a common "space" in which the various disciplines--mental health, chemical dependency, medication management and others--can assess, facilitate and collaborate around the best options for a client, then allow for continued tailoring and refinement of treatment plans for complex, dually diagnosed young clients.


Susie Winston, LICSW, is director of Sound Mental Health's Child & Family Services; Theresa Winther, LMFT, CDP, CMHS, is manager of Sound Mental Health's Child & Family Services; Cheri Smith, LMHD, CMHS, COPT, is coordinator at Sound Mental Health's Child & Family Services. To learn more, visit
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Title Annotation:TREATMENT
Author:Winston, Susie; Winther, Theresa; Smith, Cheri
Publication:Behavioral Healthcare
Date:Nov 1, 2012
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