Tackling Co-Occurring Substance Abuse and Mental Illness

An individual arrives in the emergency department with a broken leg. Immediately, the emergency department team begins asking questions. Do we assess the other leg to see if it is also broken? If it is, do we ask which one broke first to obtain a primary diagnosis? Do we wait for one to heal before treating the other? Do we send them to another hospital to treat the second broken leg after the first is healed?

For years, similar kinds of treatment questions have been asked regarding individuals who experience both mental health and substance abuse issues.

The statistics are everywhere. Substance abuse is the most common co-occurring disorder in people with mental illness, and these individuals experience more negative outcomes: Relapses, demoralization, repeated hospitalization, victimization and violent behaviors. They die 25 years earlier due to complications from smoking and the adverse effects of medications, and they have a higher rate of suicide. We know that both substance abuse and mental illness are brain disorders.

Robert Drake, MD, PhD, and his team from Dartmouth Psychiatric Research Center in New Hampshire completed research in the 1990s and later wrote the manual on Integrated Dual Disorders Treatment (IDDT).¹ Drake chose the Program of Assertive Community Treatment (PACT), developed in 1972 by Arnold Marx, Leonard Stein and Mary Ann Test, as a foundation for understanding how to best help people with dual disorders.  

An IDDT Assertive Community Treatment (ACT) Team is based on the following principles: The team is the primary provider of services with a fixed point of responsibility; services are provided out of office 75% of the time; services are highly individualized to the person; and an assertive approach is used with the team doing “whatever it takes” to help meet the individual’s needs and goals. WestBridge, the treatment center focused on tackling mental illness and substance abuse together where I work, has two IDDT ACT Teams.

The ACT Team is comprised of psychiatrists, social workers, nurses, mental health staff, substance abuse staff and support staff. Each member has knowledge of vocational rehabilitation, mental illness, sexual abuse issues, substance abuse, trauma informed care and interventions. They provide coverage around the clock, 365 days a year with the use of an on-call system.

The key to success is the supportive relationship between the individual and the team. The team carries and inspires hope for people served through its resourcefulness and innovation in service provision. It is not a typical case-management model that refers and links out. Treating mental health and substance abuse within the ACT Team at the same time supports positive outcomes. The team assists the individual in developing the motivation for treatment and the establishment of goals that are meaningful to that individual.

IDDT is a recovery-based model of care. The patient is a partner in the treatment process, and the team is a guide with knowledge and experience to share and assist. The team expects the individual will improve and recover, and the team celebrates successes, uses positive language, values empowerment by offering choices and clarifying that individuals have the power to make choices. The team understands that they are offering tools, and the person can choose to use them or not.