During the late 19th century, conflict flourished between leaders of the Association of Medical Superintendents of American Institutions for the Insane and leaders of the American Association for the Study and Cure of Inebriety. Members of both groups represented institutions and practitioners plagued by the confluence of addiction and mental illness. Chicken or egg arguments on the relationship between the two types of disorders abounded, as did debates about cultural/professional ownership of the most intractable clients and their appropriate diagnosis and treatment.1,2
From this inauspicious beginning, an uneasy relationship between the addictions and mental health fields has evolved, marred by sustained conflict, competition, mutual antipathy, and failed service integration efforts followed by resegregation of the fields. Pockets of successful behavioral health service integration at the local level within this history have been obscured by the overall bifurcation of behavioral health into separate addictions and mental health fields.
A recovery revolution now is occurring within and across the addictions and mental illness problem arenas that challenge practices within both of these fields, as well as their historical segregation. This paradigmatic shift will fuel debate over whether this recovery revolution is a long-awaited and desperately needed opportunity to revitalize, or a cataclysm that will deprofessionalize, and then destroy, both fields.
The purpose of this two-part series is to explore whether the concept of recovery could serve as a conceptual bridge through which the treatments of addiction and mental illness could be integrated within one recovery-oriented system of care. The authors speak as long-tenured insiders within these fields, whose writings and presentations advocate embracing this revolution in thinking and practice.3—10
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)