Case Management

Case management is crucial when patients are receiving simultaneous AOD and psychiatric care at separate settings (parallel treatment). There must be good linkages between the two treatment programs or providers. For example, patients might see their mental health counselor three times a week, go to both AOD self-help group meetings and mental health support group meetings, and receive AOD counseling. This level and mix of treatment can be overwhelming and confusing for the patient. An effective case manager can help with planning sensible treatment. Case managers can also facilitate the use of self-help groups. (See the discussion on the use of 12-step programs and other self-help groups in Chapter 6).

The separate disorders, their distinct treatment needs, and the divergent treatment approaches can cause staff splitting and turf problems that exacerbate the patient’s denial and can cause other treatment problems. These problems can be avoided in almost all cases by effective communication and coordinated treatment planning. Good psychiatric and addiction treatment efforts are rarely truly conflicting.

Counseling and Psychotherapy For Depression

It is beyond the scope of this TIP to provide comprehensive details on the use of psychotherapeutic treatment. However, there are numerous resources regarding counseling and psychotherapy and depression. Recent publications written for both counselors and patients include The Good News About Depression by M.S. Gold and When Self-Help Fails by P. Quinnet.

Levels of Care

Once psychiatric and addiction severity has been determined, the treatment intensity, structure, and level of care required must be decided. From the least to the greatest intensity, the levels of care are:

  1. Individual treatment with a psychotherapist or counselor. This is the least intensive level of care and includes few, if any, additional treatment services such as education.
  2. Outpatient treatment. Within this level of care are services that vary greatly in structure and intensity. They include weekly to daily individual or group counseling, often in combination with additional treatment services such as detoxification, education, medical services, and specially focused groups. A multidisciplinary treatment team that includes assertive and intensive case management services may be needed for patients with severe and persistent mood disorders coexisting with AOD disorders.
  3. Intensive outpatient treatment. This level of care includes treatment models such as partial hospitalization (which includes day treatment, evening, and weekend programs). For example, patients in day treatment generally participate in a full day of treatment for 5 or more days per week. Intensive outpatient treatment represents a range of treatment intensities. The level of intensity of a given program is based primarily on the number of treatment services offered. Generally, intensive outpatient treatment programs offer several treatment components such as group therapy, educational sessions, and social support services.
  4. Halfway houses. These are settings that serve as safe AOD-free homes for people who can manage independent daily activities and can benefit from a structured and recovery-oriented group living arrangement. They vary widely in style and purpose.
  5. Residential rehabilitation setting. Participation can vary from 30 days to 3 months or more, with patients removed from familiar surroundings and separated from AODs. In residential settings, patients receive education about dual disorders and learn important recovery skills such as utilizing groups, building trust, and talking about feelings. Therapy and support groups provide socialization and support and are the core of treatment. They prepare the patient for increased reliance on group support systems after discharge.
  6. Therapeutic communities. Long-term therapeutic communities often require patient participation lasting from 6 months to 2 years. They are generally considered to be appropriate for patients with severe AOD disorders who have significant social and vocational deficits and who require long-term and intensive support, skill building, interpersonal abilities refinement, and trauma resolution.
  7. Hospitals. Psychiatric or AOD hospitalization may be required for acute and subacute stabilization. In this age of managed care, hospitalization episodes have become much shorter and more acute than a few years ago. This puts more responsibility and risk on outpatient treatment providers.

Patients with severe and persistent mood and AOD disorders frequently require intensive and assertive treatment approaches as outlined in Chapter 8 on psychotic disorders. These patients will benefit from programs that can provide concurrent, integrated dually focused treatment. Also, these patients may require assertive case management to encourage medication compliance and to help them secure all psychiatric, addiction, and social services that they may need.

While some programs for dual disorders exist at all levels of care and in several program models, few AOD or mental health residential programs are dually focused, and many AOD programs refuse to accept patients who have histories of psychiatric disorders or who currently are prescribed medication for psychiatric disorders.

Traditional biases in the addiction field against psychiatric medication should be shed in light of the evidence that medicating existing disorders is humane, can be provided safely, and is necessary for some patients to engage in treatment. It is helpful to use psychiatrists who are skilled and are perhaps specialists in the treatment of coexisting psychiatric and AOD disorders.

Similarly, traditional psychiatric biases regarding rapid medication intervention and some clinicians’ emphases on “getting in touch with feelings” can impede or reverse the AOD recovery process. Encouraging emotional expression without regard for the patient’s stage of AOD recovery and stability can aggravate AOD disorders. Many residential facilities in the mental health system are inadequately controlled for the presence of AODs, are not abstinence based, and are not safe environments for AOD users.