Chapter 4 — Linkages For Mental Health and AOD Treatment Overview
Conventional boundaries between single-focus agencies have impeded the clinical progress of patients who have psychiatric disorders and alcohol and other drug (AOD) use disorders (Baker, 1991; Schorske and Bedard, 1988).
The treatment of patients with dual disorders is a clinical challenge, as well as a systems challenge, requiring innovation and coordination. The goal of this chapter is to help State and local administrators consider strategies for linkages across systems in order to improve service delivery and treatment outcomes. Profiles of patients with dual disorders demonstrate that they are more or differently disabled and require more services than patients with a single disorder. They have higher rates of homelessness and legal and medical problems. They have more frequent and longer hospitalizations and higher acute care utilization rates. For example, among patients with schizophrenia, episodes of violence and suicide are twice as likely to occur among those who abuse street drugs as among those who do not.
Treatment and social needs of patients with dual disorders differ depending on the type and severity of the disorders. Patients with dual disorders are generally less able to navigate between, engage in, and remain engaged in treatment services. Focusing on linkages highlights the fact that treatment providers, rather than patients and their families, have the responsibility for coordinating diverse and often conflicting treatment services.
Treatment must be suited to patients’ personal needs and characteristics, linking services across several different systems of care. Instead of blaming patients for poor treatment outcomes as they fall through the cracks of separate service systems, patients can be empowered and better treated when given effective options.
For the treatment of patients with dual disorders, the primary systems involved are AOD and mental health treatment. Programs that focus on dual disorders operate in both the mental health and AOD systems. Staff and administrative initiative is required to collaborate across systems. At a minimum, both systems should be involved when developing initiatives to improve linkages. This TIP is focused on the linkages between these systems.
In order to work effectively together, AOD treatment providers and mental health professionals need to understand and respect the different historical and philosophical underpinnings of both systems. As explained in the third chapter, the systems developed separately. There are inherent stresses and strengths among medical, psychoanalytic, psychosocial, and self-help care orientations, as well as between AOD treatment and mental health treatment.
These differences have frequently been a source of conflict and have caused problems for some patients. For example, if a patient with a dual disorder is told by his psychiatrist that he needs psychotropic medication to treat his psychiatric disorder, but members of his self-help AA group tell him to give up all mood-altering drugs to recover from his AOD abuse, to whom does he listen?
Patients with dual disorders challenge the treatment systems. Their involvement in treatment can become an opportunity for providers to examine the philosophical and practical aspects of treatment.
Providers should acknowledge that no single field has all the answers and that a need exists to integrate treatment by building upon and adapting from experience. Clinicians who work with dual disorder patients must add to their existing clinical skills. The development of a dual disorders program is an evolutionary process that requires agreed-upon outcome measures and program evaluation.
Providers should review admission criteria. These criteria should be inclusive, not exclusionary. Admission and placement criteria should be based on behaviors and skills required to participate in and benefit from a program rather than based solely on diagnosis.
Providers should find creative ways to bridge the differing funding streams, target populations, legal and regulatory mandates, and professional backgrounds and expertise.
Providers should accept the responsibility to provide integrated treatment — not parallel or concurrent treatment efforts that require the patient to integrate and adapt to different and sometimes conflicting treatment models.
In spite of the historical and philosophical differences that have separated the fields, the consensus panel identified several shared treatment concepts that administrators can use to help move toward integration.
To establish and maintain linkages among the various systems working with patients who have dual disorders, several primary administrative areas need to be examined.
It is beyond the scope of this document to provide detailed discussion of each area, but the following discussion of problems and solutions will help readers in their problem solving. The areas to be discussed in this chapter include:
Often there is little or no communication or collaboration among various departments and levels of government that have separate administrative structures, constituencies, mandates, and target groups. There are also different Federal, State, and local planning cycles within the AOD use and mental health treatment systems.
The Federal Government requires two separate planning processes for programs receiving Federal funds: A State mental health plan and a State substance abuse plan. The federally mandated State planning processes required under the Public Health Service Act for mental health treatment and AOD abuse treatment are separate and have no requirements for coordination.
Amendments are needed to the Public Health Service Act to encourage coordinated long-term planning between the State mental health and AOD abuse treatment systems for patients with dual disorders.
The development and use of long-term structural mechanisms (such as coordinating bodies, task forces, memoranda of understanding, and letters of agreement) can help improve planning for and integration of services for patients who have dual disorders.
To accomplish this goal, States might create a joint planning mechanism — an officially organized planning group — that would: 1) have diverse composition, 2) carry out specific types of tasks, and 3) maintain specific foci.
Because of diminishing fiscal resources and competition among many interest groups for particular types of treatment, those who seek funds for the treatment of patients with dual disorders have an increasingly difficult task. In many areas, patients with dual disorders may not be recognized as a priority group for funding. No specific monies are set aside for patients with dual disorders under the block grants. The amount of funds that the Federal Government allocates to States for the AOD and mental health block grant programs changes from year to year and often includes mandated set-asides for specific groups (for example, needle users, women, etc.). Set-asides tend to be different for mental health and AOD abuse treatment and limit the amount available for special groups not specifically targeted.
States often do not take advantage of Federal monies that can be used for patients with dual disorders. It is difficult to identify Federal grants that can be used for dual disorders, since grants and announcements are scattered across many agencies such as the Substance Abuse and Mental Health Services Administration (SAMHSA), CSAT, the Center for Substance Abuse Prevention (CSAP), the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute of Mental Health (NIMH), and the Center for Mental Health Services (CMHS), to name a few.
Current reimbursement practices inhibit integration of services and effective treatment, and there are several problems related to reimbursement from both public and private third-party payers. These problems include the following:
Only limited treatment and research data are available, and those that are available are not in a standardized format. Existing data also tend to be general and not useful to local planners for developing a continuum of care. Data collection systems are mandated to be separate from each other. It is difficult to gather prevalence data on patients with dual disorders because many of them interact with several treatment agencies or systems, while others do not interact with any.
There are systemic disincentives to gathering data on patients with dual disorders. For example, Medicaid may cover a patient who makes a suicide attempt as a result of major depression, but may not cover a patient who makes a drug-induced suicide attempt.
At least on the State level, common identifiers in data collection should exist for both AOD abuse and mental health treatment systems. Research should be in a form that allows for evaluation of cost-effectiveness and outcome. Outcomes should be measured across several categories encompassing biopsychosocial issues. Examples might be 1) severity of AOD and psychiatric symptomatology, 2) housing, 3) service involvement and utilization, and 4) vocational involvement. Collaboration with local colleges and universities to conduct such research should be encouraged.
State planning bodies should encourage or require local needs and resource assessment and data collection. Local planners should collect data from various systems, examining and comparing data from different groups, programs, and locations. The State could gather all the data and compile them for use in improved planning and in evaluating outcomes.
Confidentiality laws must protect the patient, but also must allow for inclusion of anonymous case number data in pools to promote better assessment and treatment outcome studies.
There should be aggressive efforts to examine cost-effectiveness and outcomes of specific models of treatment services for patients with dual disorders. These research efforts can be incorporated into State and local initiatives, perhaps involving local colleges and universities.
The screening process amplifies the tendency to look for a single diagnosis. Staff in single-focus screening services are not trained to assess patients for dual disorders.
There is no “gold standard” instrument to diagnose dual disorders. Some of the instruments that are used often yield false positive results.
Screeners are not adequately trained to make effective referrals across systems, which can result in denial of treatment services.
Screening for dual disorders may take longer than screening for a single disorder. For example, psychiatric symptoms can appear or disappear as the AOD-induced symptoms clear.
There frequently is no single person or agency responsible for following up on referrals and ensuring that patients are linked to treatment and that services are coordinated. People with dual disorders need others to help them obtain the services that they require, which are often fragmented.
The Public Health Service Act requires that State mental health agencies that receive Federal funds provide case management services to patients with severe mental illness. However, a comparable requirement is not built into the Federal mandate for AOD abuse treatment services. AOD abuse treatment agencies usually do not have enough social service staff to handle the case management functions of linkage or followup for many dual disorder patients.
All too often, treatment staff are knowledgeable about either mental health or AOD treatment. They lack thorough training and education about dual disorder patients.
There is often insufficient staff time available for the level of case management required for dual disorder patients.
Staff selection is often driven more by clinicians’ academic degree and their ability to provide reimbursable services than by clinicians’ expertise in dual disorders.
Clinicians in AOD abuse treatment and mental health treatment usually are not trained in the other discipline. The availability of staff trained in both fields is limited. Agencies frequently lack the resources to recruit and retain staff who have sufficient education and experience. There is both a shortage of qualified staff and an inability to financially compensate qualified staff for their specialized abilities.
The diagnosis and treatment of dual disorders are not generally understood by staff, administrators, and legislators, let alone the general public. Agency directors and supervisors often assign whom they believe to be the most appropriate staff member to work with dual disorder patients without a clear idea of the knowledge and skills required.
Professionals in AOD abuse and mental health treatment have accumulated biases against the other discipline, as well as negative stereotypes of both patients and staff.
There are no structured incentives for individuals or programs to develop or take part in training, such as pay differentials and career opportunities specific to dual disorders. Opportunities and incentives for cross-training are lacking.
Consumers are not adequately involved in the training process.
Relatively few academic programs involve training or research in this field.
Cross-training is one of the most effective tools administrators have for bridging gaps between clinicians and services from different fields. Training programs that provide knowledge about local networking can greatly improve linkages for patients with dual disorders.
A large proportion of patients with dual disorders require social services. The scope of social services is extremely broad, encompassing public and private multisystems.
Federally mandated income support programs are notoriously complex, each with its own set of regulations. Some, such as the Social Security Income (SSI) maintenance program, are administered by the Federal Government, while others are administered by the State and vary from State to State.
Income support programs include SSI, Medicaid, Medicare, welfare, Aid to Families With Dependent Children (AFDC), and food stamps.
Regulations for each program are often not understood by professionals and others who provide services to potential recipients. This makes it even more difficult for the potential recipient to get and retain benefits.
Some programs, such as SSI, require proof of a permanent and total disability. Mental health problems often do not neatly fit into categories, making it difficult to obtain this support.
Income support programs for single individuals have been cut drastically in recent years.
Applications for these income support programs are often taken at a site other than where either mental health or AOD services are provided for the patient.
The complexity of the application and appeal process adds to the stress of a person with a dual disorder.
Overburdened staff who are processing income support applications often do not understand dual disorders.
Federally mandated services for children, youth, and families include services that fall under the child welfare system (for example, child protective services and foster care placement).
Child welfare system staff are overburdened and understaffed. A large percentage of caseloads involve family AOD use problems.
Most child welfare staff are not trained in recognizing or treating dual disorder problems. Mental health and AOD abuse staff are not trained in child welfare. There is a lack of knowledge of each other’s systems and resources.
Other social service programs serve a wide range of special needs populations, including the homeless and victims of domestic violence or sexual abuse, who require a broad array of support services. Although many users of these services have mental health and AOD abuse problems, these services are often not available on site. Social service staff often lack knowledge of how to refer people with such problems into these systems.
The medical system is vast, covering a wide range of public and private programs including primary, secondary, and tertiary care.
Public primary care clinics are often overburdened, understaffed, and underfinanced. They are often oriented to treating presenting physical problems, and staff may not be trained in screening for either AOD abuse or mental health problems. The same problems often exist in nonprofit primary care facilities. Staff are often not knowledgeable about how and where to refer patients.
Historically, physicians have not received any education about AOD treatment and little education about mental health problems in medical school. Primary care physicians are often unaware of the signs and symptoms of AOD use disorders, and may have only a basic understanding of a few psychiatric problems such as depression and anxiety. For example, persons who experience physical trauma, such as burn injuries or falls, often have AOD use disorders. Yet, when presented with injured patients, primary care physicians may not screen for AOD use disorders.
At hospital discharge, personnel often have difficulty dealing with AOD abuse and mental health concerns. Patients are sometimes discharged inappropriately with inadequate discharge planning and linkage with aftercare services.
Staff in mental health and AOD abuse treatment systems often do not know how to gain access to medical systems and therefore are ineffective in providing information and ongoing education.
The criminal justice is a top-down system. There is often no mandated joint planning.
The mental health system has no formal responsibility for inmates with dual disorders.
Incarceration is often a substitute for AOD abuse and mental health treatment. Treatment may not begin until shortly prior to release.
Medical services for the incarcerated are not reimbursable under Medicaid or any third-party payer. There is often an interagency debate regarding who should pay for care.
Offenders who should be committed are often released. Prerelease assessments are often inadequate. There usually is no coordinated plan for release. No systemic funding incentives to provide care exist. There is a range of custody status.
Criminal justice staff often have AOD abuse or mental health problems. There are many inadequate employee assistance programs within the criminal justice system.
The criminal justice system and community AOD abuse and mental health treatment agencies may compete for the same AOD abuse and mental health treatment dollars.