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An elephant-size challenge

January 1, 2008
by Steve Wiland
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Implementing integrated services requires a “one bite at a time” mentality

Overcoming difficult challenges has been compared to eating an elephant—you have to take one bite at a time if you intend to complete the task. In our field, integrating mental health and substance abuse treatments is certainly an enormous challenge. Yet Community Support and Treatment Services (CSTS) in Michigan has been able to provide co-occurring disorder services by taking a step-by-step implementation approach.


CSTS is a department of the Washtenaw County, Michigan, government operating under a contract with the Washtenaw Community Health Organization (WCHO), which functions as both the local mental health authority and substance abuse coordinating agency. With an annual budget approaching $24 million, CSTS is responsible for delivering services to approximately 2,000 adult clients with severe and persistent Axis I and II mental illnesses and/or personality disorders, 900 adults with Axis II developmental disabilities, and 500 children with serious emotional disturbances and/or developmental disabilities. CSTS has been a long-standing provider of case management and clinical community mental healthcare services for county residents, but only in the past several years has our focus more intentionally included integrated treatment services for clients with co-occurring substance use disorders.

Before Integration

Participation in a three-year grant-funded dual-diagnosis project in the late 1990s sensitized the agency to the prevalence—and unique treatment needs—of clients with co-occurring disorders. The program response at the time, however, was to build a discrete dual-diagnosis unit that accepted referrals from other units and teams within the agency, thereby providing services in a largely isolated fashion. Some progress was made during those years, but when grant funding fizzled, the majority of these services also did, with the exception of four weekly dual-diagnosis treatment groups that had “integrated” their way into the agency's mainstream programming.

As evidence of which treatments worked best with the co-occurring population accumulated, integration of mental health and substance use disorder treatment services became CSTS's goal. However, compared to the relatively simple task of providing resources for a stand-alone team, agency-wide integration loomed as an overwhelming task touching on every level and aspect of service provision: from the administrative and policy level to service design and implementation to training and staffing decisions.

One “Bite” at a Time

In 2002, CSTS convened a work group to address the broad goal of implementing integrated co-occurring disorders treatment services. The larger workgroup soon divided into smaller groups vested with addressing both barriers and solutions at the administrative/policy, program services, clinical staff, and consumers and families levels. Feedback from months of meetings provided the beginning work plan. Early efforts were informed by consultation with Kenneth Minkoff, MD, a recognized expert on integrated systems, who stressed the system-wide and culture change aspects of our undertaking. Another consultant, Robert Drake, MD, stressed the importance of internally identified “champions” to carry out the plan, which could take up to five years to complete.

Administrative/Policy Challenges

The administrative leadership's buy-in and support were critical to the long-term success of the implementation. Other service systems in Michigan have floundered when attempting integration for lack of greater support from the top.

Although CSTS had been a community mental health organization for decades, the agency had not previously functioned as a state-licensed substance abuse treatment provider. Pursuing this licensure included reviewing all pertinent policies and making revisions (and additions) appropriate for the delivery of integrated treatment. This foundational work has proven valuable over the long haul.

Historically bifurcated funding streams were problematic in multiple ways, although WCHO's role as a dual mental health/substance abuse funding authority was a significant advantage to negotiating workable solutions affecting the screening, referral, and service authorization of dually diagnosed clients.

Program Services Challenges

Adjusting service models was critical, both philosophically and practically. Moving from a mental health model of lifelong “maintenance” care of chronic clients to a model embracing the possibilities of progressive recovery has been fundamental to supporting effective co-occurring treatment implementation.

CSTS initially needed to develop and staff new services with few new resources, although aggressive pursuit and use of grant funding have been helpful. Using the experience and expertise of CSTS's internal champions, consulting with outside experts (e.g., Dr. Minkoff and David Mee-Lee, MD), and relying on the increasingly well-developed professional literature in this area (such as materials provided by SAMHSA and Hazelden) proved vital to implementation success, including creating three specialized teams meeting high-fidelity standards of the SAMHSA Integrated Dual Disorders Treatment (IDDT) evidence-based practice model: the Project Outreach Team (PORT) serving the homeless population and two IDDT-enhanced Assertive Community Treatment (ACT) teams.

Clinical Staff Challenges

Frontline staff members’ levels of experience, competence, comfort, and confidence with providing co-occurring disorder treatment services ran the gamut. Casting a convincing vision was key to increasing employees’ willingness to engage in the significant training and clinical supervision necessary to support the implementation's success.