Service Integration: Inhibiting and Promoting Forces

A review of the histories of the addictions and mental health fields provides three clues on why past service integration efforts might have failed.

First, efforts to integrate have failed when they focused on discussions of the etiology or nature of these disorders or on treatment philosophies and techniques. Historically, common ground for behavioral health integration does not lie in these arenas, although advances in neurobiology may yet establish such common ground.

Second, practitioners from both fields have been unprepared, and often unwilling, to treat clients from their sister field. The relationships between addiction treatment providers and clients with severe mental illness, and the relationships between mental health service providers and those with severe alcohol and other drug problems, have been characterized by institutionalized counter-transference (e.g., lack of empathy, disrespect, contempt, exclusion, and extrusion). Service integration efforts often have failed to address these attitudinal barriers.

Third, the historical conflict between these two fields is embedded in prolonged competition for scarce resources, fears regarding the loss of institutional and professional legitimacy and integrity, and structural issues at the national level that drive segregated policies, funding streams, and regulatory oversight. Without a strong and shared conceptual foundation, the processes involved in service integration experiments have occurred largely by administration fiat, and often were experienced at the front lines as one field attempting to colonize the resources of the other.

What is surprising in light of this history is the continued discussion regarding the potential advantages of an integrated behavioral health system. The forces pushing integration appear to be just as significant as those inhibiting it. People experiencing addictions and those with severe mental illness often have been considered hopeless and been the target of intense social stigma, manifested in their sequestration in almshouses, decaying asylums, jails, and prisons, or abandoned on the nation's streets. In this shared history is a sense that the fate of individuals and families affected by mental illness and addiction may be somehow linked, and that joint efforts might lead to more progress than isolated efforts.

Adding to the weight of this history is the growing confluence of these problems. Epidemiologic and service utilization data reveal that these problems are as likely to co-occur in the same individuals and families as to exist independently of one another.

Over the past two decades, an extensive body of literature has illuminated the poor quality of care individuals and families with multiple problems receive within the current system of categorically segregated services. That body of research is confirming the superior outcomes achieved within integrated models of care.

All of these factors add momentum to service integration initiatives, but we suspect the primary spark for such integration will come from another source. The individuals and families experiencing these problems and the lived solutions they are discovering suggest new rationales and strategies for service integration that have hitherto escaped policy makers, managers, and practitioners.

The Recovery Revolution

There is a shift within the broad arena of behavioral health from pathology and treatment paradigms to one of recovery.4 This shift is indicated by:

• The growth and diversification of recovery mutual aid structures (e.g., support groups, clubhouses, recovery support centers, recovery housing, recovery educational programs, and recovery job co-ops)

• The growth in grassroots recovery advocacy organizations in both fields that are addressing the problem of co-occurring disorders at both clinical and organizational levels

• Major policy reports, including the President's New Freedom Commission on Mental Health 2003 final report, SAMHSA's Transforming Mental Health Care in America (2005), and the National Institute of Medicine's Improving the Quality of Health Care for Mental and Substance-use Conditions (2005)

• New pilot initiatives at the federal level (the Center for Substance Abuse Treatment's Recovery Community Services Program and Access to Recovery program), and state and city initiatives (e.g., those in Connecticut and Philadelphia) to integrate behavioral healthcare within a recovery-focused system transformation

• Significant increases in the number and quality of scientific studies on the pathways and processes of long-term recovery from addiction and from mental illness

“Recovery-oriented system transformation” is becoming an umbrella concept for integrating behavioral healthcare and creating systems of care that are culturally competent, trauma-informed, evidence-based, inclusive of families, based on strengths, and connected to communities (as indigenous sources of recovery support). Leading the call for such system transformation are new recovery advocacy movements in both the addictions and mental health fields. These movements, led by people in recovery, their families, and visionary professionals, are demanding that care be focused on the processes of long-term recovery and anchored within natural supports and local communities.

Core Ideas

Recovery refers to the ways in which persons with or affected by a mental illness and/or addiction tap resources within and beyond the self to move beyond experiencing these disorders to actively managing them and their residual effects to build full, meaningful lives in the community. Recovery is more than the elimination of symptoms from an otherwise unchanged life. It is about regaining wholeness, connection to community, and a purpose-filled life. A number of overarching ideas are at the core of these new recovery advocacy movements:

• Recovery is a reality in the lives of millions of individuals and families.

• There are many pathways and styles of recovery.

• Recovery is a voluntary process.

• Recovery flourishes in supportive communities.

• Recovery gives back (to individuals, families, and communities) what addiction and mental illness have taken away.

• Behavioral healthcare must move beyond emergency and palliative care to care oriented to promoting long-term recovery.

Recovery-oriented care is what psychiatric and addiction treatment and rehabilitation practitioners offer in long-term support of the person's/family's own recovery efforts. Recovery-oriented care shifts the design of the addiction treatment system from an acute care model, focused on serial episodes of biopsychosocial stabilization, to a model of sustained recovery management.

That same recovery orientation in the mental health field shifts the service design beyond cyclical crisis intervention and “sustaining care,” aimed at symptom suppression and reduced hospitalizations, to one of recovery enhancement. Recovery-oriented care focuses on the acquisition and maintenance of recovery capital (internal and external assets required for recovery initiation and self-maintenance), global health (physical, emotional, relational, and spiritual), and community integration (meaningful roles, relationships, and activities).

Editor's note: In part two of this series, the authors will examine how integrated systems are evolving.

Acknowledgment

Work on this article was supported in part by the Philadelphia Department of Behavioral Health and Mental Retardation Services.