Implementing Integrated Dual Disorders Treatment IDDT into Everyday Practice

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Implementing Integrated Dual Disorders Treatment
(IDDT) into Everyday Practice

• Melanie Kinley, BA, CADC (provisional)
• Jerry Wiczek, PRCP, MHP
• Tim Devitt, Psy.D., CADC
• Thresholds, Chicago, IL
• September 19, 2007

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Objectives

• Become acquainted with the IDDT implementation
  tools the Integrated Dual Disorders Treatment
  (IDDT) Fidelity Scale and the General
  Organizational Index (GOI)
• Learn specific ways in which IDDT implementation
  can steer recovery-focused services while
  honoring consumer choice
• Learn the difference between motivational
  stage-wise service provision and business as
  usual.
• Recognize the organizational and clinical
  practice challenges typical of organizations
  striving to implement IDDT.

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Does Sobriety Lead to a More Satisfying Life or
Does a More Satisfying Life Lead to Sobriety?

• Studies show that people with dual disorders
  regularly relapse on substances as they work
  toward attaining sobriety
• The attainment of sobriety occurs over months and
  years and is enhanced by successful engagement in
  the positive life factors
• Alverson et al. (2000)

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Co-occurring Disorders Have Severe Adverse
Consequences

• More and more severe psychiatric hospitalizations
• Psychiatric symptom exacerbation
• Homelessness
• Violence, victimization and suicidality
• Incarceration
• Serious medical infections such as HIV and
  hepatitis
• Family problems
• Drake et al. 2001

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Disorder Severity Matrix
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IDDT

• The IDDT model is an Evidence Based Practice
  (EBP) derived from over 25 years of research
  conducted with programs and treatments
  specifically designed for people with dual
  disorders.
• IDDTs central premise is the integration of MI
  and SA interventions into one coherent package.

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IDDT Core Components

• Integrated Care
• Assertive Outreach
• Access to a full array of services
• Stage-wise Interventions
• Motivational Counseling
• Self-help Liaison
• Multidisciplinary Team Approach
• Time Unlimited Approach
• ACT Center of Indiana website
• http//psych.iupui.edu/ACTCenter/IDDTposter.pdf

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Overview of IDDT implementation tools

• IDDT Fidelity Scale
• GOI Fidelity Scale
• SAMHSA website
• http//mentalhealth.samhsa.gov/cmhs/communitysuppo
  rt/toolkits/cooccurring/dualdisorders/default.asp
• http//mentalhealth.samhsa.gov/cmhs/communitysuppo
  rt/toolkits/cooccurring/goi/default.asp

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Fidelity Assessments

• The IDDT Fidelity Scale is a fourteen item scale
  that evaluates how closely the clinical and
  administrative components of IDDT approximate the
  original model
• The General Organizational Index(GOI) is a
  twelve item index that rates the organizations
  commitment and focus to each EBP (i.e., IDDT).
• Together, both assessments can provide useful
  feedback to programs. These assessments identify
  and prioritize specific elements of service
  delivery or program design that will enable
  organizations to achieve greater fidelity.

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Recovery and IDDT

• Recovery is.
• a process of reclaiming ones life after the
  catastrophe of mental illness
• William Anthony

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Thresholds Mission Is Recovery

• Thresholds assists and inspires people with
  severe mental illnesses to reclaim their lives by
  providing the supports, skills, and the
  respectful encouragement that they need to
  achieve hopeful and successful futures.
• We strive to be the provider of choice,
  employer of choice, and a world leader in the
  development and evaluation of rehabilitation and
  recovery services.

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Thresholds Goals

• A good home
• A good job
• Educational success
• Good friends loving families
• Optimal health
• Staying out of crisis the hospital

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How IDDT implementation can help steer
recovery-focused service delivery

• Emphasis on integration of substance abuse and
  psychiatric rehabilitation interventions
• Individualized focus with emphasis on consumer
  choice regarding what goals to work on in each
  stage of treatment
• Application of motivational stage-wise
  interventions
• Creation of partnerships between consumers and
  staff in setting programmatic policy

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Emphasis on integration of substance abuse and
psychiatric rehabilitation interventions

• Sequential and/or parallel treatment approaches
  dont work for many persons with co-occurring
  disorders
• Consumers served by treatment programs that fail
  to treat both disorders at the same time tend to
  experience
• Higher dropout rates
• Non-adherence to interventions
• Service extrusion
• Poor communication with providers
• Poor outcomes
• Drake, Mueser, Brunette, McHugo (2004)

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Rationale for re-evaluating relapse policy

• Followed people after they left (due to extrusion
  for relapse/continued A/SA use) and observed
  worse outcomes
• Realization that zero-tolerance runs counter to
  the therapeutic interventions people needed most
  time-unlimited, flexible, motivational stage-wise
  services
• Dawning awareness that people were being extruded
  for showing the behavior that suggested they most
  needed the supports offered at the program

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Organizational and clinical practice challenges
related to implementing IDDT

• Staff and practitioner issues
• Attitudes and perception of direct service staff
• Staff recruitment
• Clinical supervision
• Organizational and infrastructure issues
• Executive level buy-in
• Proper dedication of agency resources to
  implementation efforts
• Training and technical support directed towards
  fidelity to the model
• Sustainability issues

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Organizational and Infrastructure Issues

• Transforming infrastructure requires time, money
  and a well-articulated vision supported by
  executive level staff
• The GOI can assist agencies in identifying and
  focusing their efforts towards modifying
  organizational systems and program design
• Minimally, QA, Research, IS and Training staff
  must collaborate to disseminate consistent
  information regarding changes in procedures and
  measures that will support the practice

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Implementation results(national)

• In the 2007 fidelity outcomes for the National
  Implementation of Evidence-Based Practices
  Project
• IDDT had the lowest 2-year mean fidelity score
  (3.42)
• SE (4.45) and ACT (4.17) had the highest fidelity
  scores
• IDDT requires extensive training and supervision
  to operationalize clinical interventions
• IDDT is one of the hardest EBPs to implement
• McHugo et al. submitted, 2007

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Lessons learned

• Use the SAMHSA Implementation Tool Kit and
  fidelity assessments to structure feedback, set
  implementation goals, and monitor progress
• Use external expertise and existing IDDT
  implementation networks committed to ongoing
  research and TA
• Dartmouth PRC
• Ohio SAMI CCOE
• ACT Center of Indiana
• SAMHSA

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Lessons learned

• Staff fit is critical - clinical and
  philosophical compatibility with the model is
  paramount
• Consistent, quality IDDT supervision is critical
  to staff proficiency with the model and the
  accompanying skills
• Educate consumers about IDDT, elicit their
  involvement in the implementation process, and
  partner with them to work on IDDT teams and
  provide training and TA to others.
• Pay attention to organizational and staff stage
  of readiness to implement the model, and work
  from there.

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Lessons learned

• Organizational change takes time (a parallel
  process to the time it takes for our consumers to
  change) and money.
• First focus on achieving fidelity at a limited
  number of pilot sites, and then replicate to
  other sites.
• Focus on one or two core clinical skills and set
  reasonable, achievable six-month goals, so as not
  to overwhelm staff and leaders.
• Training, research and quality improvement
  advances implementation efforts but is no
  substitute for executive-level management,
  support, and buy-in.

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And finally.

• The work of sustaining IDDT practices is never
  done.
• Our understanding of IDDT, like the model,
  itself, is constantly evolving.