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Running Head: Literature Review


Integrated Treatment for Co-occurring Disorders

December 8, 2010

Candace Mills

Temple University – Harrisburg

Integrated Treatment for Co-occurring Disorders


This literature review looks at the integrated service models for treatment of co-occurring and

dual diagnosed individuals, and how to offer a more cost effective and efficient way to meet the

service needs of the community. This paper will compare the current models of integrated

treatment with the effectiveness of cross training mental health and substance abuse

professionals and teaching them to recognize DSM-IV personality disorder categories, in order

to provide effective services to dual diagnosed clients and clients with severe mental illness in an

effort to reducing mental health recidivism.

Integrated Treatment for Co-occurring Disorders

Integrated Treatment for Co-occurring Disorders

The National Alliance on Mental Illness states that even though there is research

supporting the success of integrated services, it is not offered consistently to consumers. Dual

diagnosed consumers face numerous problems. Most mental health providers are not able to help

consumers suffering from co-occurring disorders because they are not trained to identify co-

occurring problems; if they do recognize a dual diagnosed consumer, the consumer is sent back

and forth between providers or may be refused treatment. This causes gaps in service, which

leads to higher recidivism rates (

Consumers who receive effective integrated treatment with the same provider, in the

same setting, and receive treatment for both mental health and substance abuse, receive the most

effective services in a coordinated fashion. Interventions are bundled together and consumers

receive consistent mental health and substance abuse assistance treatment. There is no need to

consult with separate teams or programs.


Community-based case management offers two different models of integrated treatment

for treating co-occurring disorders; assertive community treatment and standard clinical case

management. The assertive community treatment model is for individuals with severe mental

illness who tend to not use outpatient services locally, have frequent relapses and

rehospitalizations, and have severe psychosocial impairment. The standard clinical case

management treatment model is for individuals with serious mental illness to be treated in an

outpatient setting with a case manager coordinating all necessary medical and mental health care

and supportive services. Adding cross training or education for mental health workers in dual
Integrated Treatment for Co-occurring Disorders

diagnosis treatment and/or integrated treatment for drug and alcohol addictions would aid in the

recovery process for many consumers.

Essocks and collogues studied the comparison between the two different models of

integrated treatment to ascertain if clients with co-occurring severe mental and substance use

disorders were at a higher risk of institutionalization and other adverse outcomes. The study also

compared the effectiveness of the two treatment methods and was conducted in a predominately

rural area of New Hampshire and an urban area of Connecticut; the baseline data from the

Connecticut group was compared to baseline data from the New Hampshire group.

Demographics of the participants indicated that this particular study was dominated by male

participants, most were unemployed, and 90 percent were from a racial or ethnic minority group

(African Americans 55 %, Hispanics 14 %, and 7% were from another minority group). Only

half of this group graduated from high school (Essocks, et al).

The participants in this study suffered from severe mental illnesses, such as

schizophrenia, bipolar disorder, and alcohol abuse. Some participants had lifetime substance use

disorders and some were current substance abusers. Because of the clients circumstances, they

had an increased risk of relapse, re-hospitalization, homelessness, incarceration, being a burden

to their family, economic hardship, and infectious diseases. Clients in both the rural New

Hampshire and urban Connecticut groups improved using the assertive community treatment

over the standard clinical case management, but also showed that clients in urban areas had

higher rates of drug use, housing instability, and more legal situations. It was thought that these

urban areas would benefit more from assertive community treatment than from the standard

clinical case management (Essocks, et al).

Integrated Treatment for Co-occurring Disorders

Essocks and colleagues concluded that integrated treatment for both of these groups can

be successfully delivered, although in areas where there is a lower rate of institutionalization

there may be a greater positive effect on the lives of the clients by just using integrated treatment

for co-occurring disorders (Essocks, Mueser, Drake, Covell, McHugo, Frisman, Kontos, Jackson,

Townsend, & Swain, 2006).

Although there is a high prevalence of personality disorder among consumers that abuse

substance abuse, there is limited literature available on the co-occurring condition. Substance

abuse disorder and personality disorder are among the most common co-occurring mental health

diagnoses. They report 14.8 percent of adults with one personality disorder, 28.6 percent with a

personality disorder and alcohol abuse disorder, and 47.7 percent with a personality disorder,

alcohol abuse disorder, and substance abuse disorder (Ashenberg Straussner & Nemenzik, 2007).

A national epidemiological study done by Grant, Stinson, Dawson, Chou, Ruan, & Pickering

(2004) verifies this.

Ashenberg and collogues report that 15% of the population that meets the DSM-IV

criteria for the 11 personality disorders is divided into three clusters. The first cluster includes

Paranoid personality type, Schizoid personality type, and the Schizotypal personality type. The

second cluster includes the dramatic, emotional, and erratic personalities, better known as the

Antisocial, Borderline, Histrionic, and Narcissistic personalities. The third cluster includes

anxious and fearful personalities, such as are found in individuals with Avoidant, Dependent, and

Obsessive-Compulsive personalities (Ashenberg, Straussner & Nemenzik, 2007).

Ashenberg et al., (2007) state that understanding the different clusters and types of DSM-

IV diagnostic criteria is also important for the treatment of co-occurring disorders. More often

than not patients that have personality disorder or are borderline type are excluded from clinical
Integrated Treatment for Co-occurring Disorders

trials and treatment for substance abuse diagnoses and patients that have substance abuse

disorders are excluded from treatment for personality disorders.

The lack of cross training between substance abuse professionals and mental health

professionals is also a barrier to those facing co-occurring diagnoses. Substance abuse and

personality disorders are common to co-occurring dysfunctional clients and they can be lifelong

problems as they represent separate and complicated disease processes. Receiving appropriate

treatment of both disorders can be successful and lessen mental health recidivism in correctional

facilities and help society to provide services for person with mental illnesses (Ashenberg

Straussner & Nemenzik, 2007).

Roskes &Feldman (1999) report on a study done in Baltimore City based on the

community mental health model. Participants were each assigned a psychiatrist, therapist, and

would continue working with a probation officer. At the start of the study this group of offenders

had a violation rate of 56% before their current release. The programs intervention may have

had an impact in decreasing from 56 % to 19 %. With the consumer working with the

community supervision system and the correctional system together, the co-occurring mental and

addictive disorders can be dealt with in a more integrated fashion and thereby help to reduce

recidivism (1999).


Based on the above information identifying if cross training of mental health and

substance abuse professional is a more effective and cost efficient way to offer integrated

services and help to reduce recidivism will be answered. It is also noted above that the lack of

cross training between substance abuse professionals and mental health professionals is a barrier
Integrated Treatment for Co-occurring Disorders

to those facing co-occurring diagnoses and receiving appropriate treatment for disorders can be

successful and lessen mental health recidivism.

The purpose of this study is to ascertain the effectiveness of cross training case managers

and intensive case managers in substance abuse, addictions, and DSM-IV codes, will better

enable them to work with dual diagnosed and co-occurring individuals in the community. The

study will focus on self direct learning and attending company paid trainings.

The participants will be case managers for NHS Human Services. The case management

unit, consisting of intensive case managers and resource coordinators, will participate in a pretest

and post-test to find out how knowledgeable they were about integrated services for dual

diagnosed and co-occurring disorders, if they would they be willing to attend training for dual

diagnosis and co-occurring disorders, and how often they would be willing to attend training.

The survey will be created using Survey Monkey, a free online survey website (Appendix

A), and training will be offered through Drexel University. This will be cost effective also

because of the partnership between Drexel University and NHS Human Services. The case

management unit will be resurveyed after three months. The data collected in the second survey

will be measured against the data collected in the first survey to determine if the training has

impacted attitudes toward tracking clients with dual disorders.


Mental health workers, working with consumers that are already dual diagnosed need to

know what type of behaviors are normal in substance abuse and mental illness consumers, so that

the consumers receive effective treatment. Implementing integrated services for clients with co-

occurring or dual diagnoses can initially be costly, but training staff in understanding the

relationships between substance use and personality disorder, understanding that even a single
Integrated Treatment for Co-occurring Disorders

diagnosis may be part of a co-occurring disorder, and recognizing the DSM-IV personality

disorder categories and clusters, is one way to ensure that clients with a co-occurring disorder

receive effective treatment. Offering integrated training to mental health professionals using

models such as the community treatment model, to more effectively work with consumers with

both a substance abuse diagnosis and a mental health diagnosis would better serve the consumer

by treating each condition in one setting.

The community mental health model shows how progress can be made when all services

are provided by a single agency through coordinated services in a cost effective/efficient manner.

The lack of cross training between substance abuse professionals and mental health professionals

is a constant barrier to those with co-occurring diagnoses. Training would build communication

and trust with the dual diagnosed consumer, and help providers understand the consumer’s needs

from both sides.


This study will be conducted in two parts, beginning in February 2011 and ending in

April 2011.


This study will be cost free because the survey will be produced from a free online survey

website (Appendix A), the researcher will perform the work of administering the survey and the

training for case managers will be provided by NHS human services.


Attached please find Appendix B, a letter from NHS Human services, dated December 9,

2010, giving permission to conduct this research project at this work site.
Integrated Treatment for Co-occurring Disorders


Ashenberg Straussner, S.L., & Nemenzik, J. M. (2007). Co-occurring substance use and

personality disorder: current thinking on etiology, diagnosis, and treatment. Journal of

Social Work Practice in the Addictions, 7 (1/2), 5-23.

Essocks, S. M., Mueser, K. T., Drake, R. E., Covell, N. H., McHugo, G. J., Frisman, L.K.,

Kontos, N. J., Jackson, C. T., Townsend, F., & Swain, K. (2006). Comparison of act and

standard case management for delivering integrated treatment for co-occurring disorders.

Psychiatric Services, 57 (2), 185-196.

Grant, B. F., Stinson, F.S., Dawson, D., Chou, S.P., Ruan, W. J., & Pickering R. P., (2004). Co-

occurrence of 12 month alcohol and drug use disorders in the United States: Results from the

national epidemiologic survey on alcohol and related conditions. Archives of General

Psychiatry, 61, 361-368.

National Alliance on Mental Illness. Dual diagnosis and integrated treatment of mental illness

and substance abuse disorder. 05/2003. Retrieved December 7, 2010 from


Roskes, E. & Feldman, R. (1999). A collaborative community-based treatment program for

offenders with mental illness. Psychiatric Services, 50 (12), 1614-1619.

Integrated Treatment for Co-occurring Disorders


Appendix A
Integrated Treatment for Co-occurring Disorders


Appendix B
Integrated Treatment for Co-occurring Disorders


Appendix C