The integrated treatment model is the gold-standard, evidence-based approach to treating people with co-occurring disorders. Integrated treatment is part of a broader movement in healthcare, as elucidated by the World Health Organization (WHO):
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
With regards to substance use and mental health, that means health is more than the absence of substance use or the absence of mental health symptoms. The Centers for Disease Control (CDC) concurs with this definition, and indicates their goals for all people in the U.S.:
- Help people live fulfilling lives, free from preventable disease, disability, injury, and premature death
- Establish health equity, eliminate disparities and barriers to care, and improve the health of all groups
- Promote quality of life, healthy development, and healthy behavior in all areas of life
Integrated treatment acknowledges these definitions and goals for overall health and includes them in treatment for co-occurring disorders. The general idea is that treatment should address not only the SUD or mental health disorders themselves, but all the factors in the life of an individual that may contribute to the SUD or mental health disorder. Addressing and resolving symptoms is important, but the absence of symptoms is not necessarily synonymous with overall health and wellbeing.
That’s the goal of integrated treatment: total health.
We’ll describe how integrated treatment can help patients achieve total health in a moment. Firsts, we’ll take a moment to define what we mean by co-occurring disorders.
What are Co-Occurring Disorders?
When a person receives a diagnosis for one or more substance use disorders and one or more mental health disorders at the same time, they receive a dual diagnosis and have co-occurring disorders. In the context of SUD treatment, this is always what these terms mean. In other areas of healthcare, dual diagnosis may refer to the presence of two conditions or diseases at the same time, but the more appropriate phrase is comorbidity, while co-occurring disorders or dual diagnosis is the preferred term in mental health and SUD treatment.
Co-occurring disorders are far more prevalent than most people realize. In fact, in the introduction to the 2020 Substance Abuse and Mental Health Services Administration (SAMHSA) publication “SAMHSA TIP 42: Substance Use Disorder Treatment for People With Co-Occurring Disorders,” a leading expert on SUD and mental health treatment observes:
“Comorbidity is important because it is the rule rather than the exception with mental health disorders.”
Two years later, the data still supports this observation. The 2022 National Survey on Drug Use and Health (2022 NSDUH) shows:
- 84 million adults in the U.S. had either SUD or any mental health illness (AMI)
- 25 million adults had SUD but not AMI
- 59.3 million adults had AMI
- 37.7 million adults had AMI but not SUD
21.5 million adults had SUD and AMI
- 3 million adults in the U.S. had either SUD or a serious mental health disorder (SMI)
- 39.1 million adults had SUD but not SMI
- 15.4 million adults had SMI
- 8.0 million adults had SMI but not SUD
7.4 million adults had SUD and SMI
Those are the big-picture facts about co-occurring disorders. Millions of people nationwide have co-occurring disorders, and need effective, evidence-based treatment to achieve the best possible outcome.
Let’s look at how integrated treatment can help people with co-occurring substance use disorder and mental illness.
Integrated Treatment for Co-Occurring Disorders: An Overview
Here are the primary elements of the integrated treatment model, as defined by SAMHSA.
Integrated Treatment: Six Core Components
To meet the criteria established by SAMHSA for a fully integrated SUD/Co-Occurring Disorders treatment program, a treatment center:
1. Provides Access
- Access means the process by which an individual first encounters the treatment experience. There are four main types of access:
- Routine: individuals who are not in crisis seek treatment independently
- Emergency: individuals who initiate treatment because of a crisis
- Outreach: individuals in need but do not seek treatment independently
- Involuntary: individuals who initiate treatment as mandated by an employer, the criminal justice system, or the child welfare system
- No Wrong Door
- This concept it crucial: it means that an individual should receive access to treatment no matter how they arrive at, initiate, or encounter the opportunity to engage in treatment. If an individual asks for help, help them.
- Providers can create the right door through outreach
2. Performs a Comprehensive Assessment
- Providers must screen for SUD and mental health disorders immediately
- Type of SUD/mental health disorder
- Severity of SUD/mental health disorder
- Providers must assess background:
- Family history
- Trauma history
- Medical history
- Work history
- SUD treatment history
- Providers must assess psychosocial factors:
- Employment status
- Housing status
- Food access status
- Assessments must be followed by treatment evaluations during the treatment process:
- Determine treatment progress
- Make changes to treatment plan if necessary
3. Determines an Appropriate Level of Care
- Providers use the Level of Care Utilization System (LOCUS) or similar metric to refer an individual to the appropriate level of care. The LOCUS matrix uses six factors to hep clinicians determine a level of care:
- Risk of Harm: Is the individual a risk to themselves or others?
- Functional Status: Is the individual impaired with regards to family, work, and school?
- Medical or Psychiatric Factors: Are there additional conditions or disorders that will impact treatment?
- Home Environment: Does the individual have a safe, recovery friendly home or family situation?
- Treatment History: Has the individual been in treatment before?
- Engagement/Recovery Status: Does the individual understand their disorder? Is the individual committed to treatment?
4. Achieves Integration of Treatment
- Providers address SUDs and mental health disorders concurrently, based on symptoms and need
- Clinicians receive training in treating individuals with SUD and mental health disorders
- Treatment occurs in phases that match individual readiness for treatment and engagement
- Providers use motivational strategies such as motivational interviewing (MI) to facilitate readiness and engagement
- Providers offer substance use and alcohol counseling services
- Providers offer:
- Individual therapy
- Group therapy
- Family therapy
- Peer support, such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA)
- Medication-assisted treatment when appropriate
5. Provides Comprehensive Services
- In this context, comprehensive means everything not mentioned above. Comprehensive services for people in treatment for co-occurring disorders may include:
- Vocational support/access to vocational services
- Housing support/ access to housing services
- Food support/access to food support services
- Language support for non-native English speakers
6. Ensures Continuity of Care
- Continuity of care refers to two things:
- Transitions between levels of care during formal treatment
- Ongoing care after the completion of a formal treatment program, which is often called aftercare or alumni support
- The goal of continuity of care between levels of care is to facilitate a smooth transition, capitalize on treatment progress, and communicate all relevant details about treatment from one treatment team to the next
- The goals of an aftercare plan – i.e. a plan an individual receives upon completion of a formal treatment program – include, but are not limited to:
- Sustaining sobriety
- Continuing recovery
- Living independently
- Resolving relationship and family issues
- Finding employment
- Continuing healthy, recovery friendly habits, such as health eating and exercising
- Ongoing engagement with a peer support/recovery community such as AA or NA
The intentional combination of the treatment components above increases the chance of successful recovery for a person diagnosed with co-occurring substance use and mental health disorders. The idea is to treat both disorders simultaneously, and, while doing so, begin to address the psychosocial factors at play that can either promote or impair the recovery process. When a person receives evidence-based treatment for all the disorders for which they receive a diagnosis, and receives support in all the areas of life that impact recovery, then their chances of achieving sustainable, long-term recovery improve.
Treating the Whole Person
The movement toward integrated treatment often involves components which we never would have considered twenty years ago. Lifestyle changes, exercise, diet, meditation, yoga, and stress management – just 20 years ago – may have been considered radical or woo woo or simply ineffective treatments with no evidence to support them.
There is now evidence to support those complementary approaches, and high-quality treatment centers around the country incorporate these components into treatment programs every day.
In addition, treating substance use and mental health disorders at the same time was not common: that’s a new approach, based on evidence – see our SAMSHA link above – that shows treating one without treating the other can impair treatment progress for both.
The final piece of the puzzle, with regards to integrated treatment, is the widespread recognition of the importance of the psychosocial components of recovery, which align with the WHO definition of health and the CDC goals for a healthy society that we list earlier in this article. Health is more than the absence of disease: health is when a person thrives in all areas of life.
The same is true for recovery from SUD and mental health disorders. Health is not simply abstinence from substances or the absence of mental health symptoms, although those are critical elements of health for a person with SUD and a co-occurring disorder. Health is when a person thrives in recovery, maintains positive relationships, meets personal responsibilities, and achieves overall wellbeing and life satisfaction.
That’s what integrated treatment can do for an individual in recovery: create a foundation for long-term health and happiness. It takes work and commitment – and for people new to treatment, those goals can seem a long way off – but it’s important for anyone in treatment to understand this fact:
Those goals are achievable.
Right now, across the country, millions of people are finding hope in treatment, belief in themselves, and creating a positive vision of a better tomorrow.