Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

DDCAT

Dual Diagnosis Capability

inAddiction Treatment

(DDCAT) Toolkit

Version 4.0

Dual Diagnosis Capability in Addiction Treatment Toolkit

Acknowledgements

This document was produced for the Substance Abuse and Mental Health Services Administration

(SAMHSA) by Westat under the Co-Occurring Mental Health and Substance Abuse Disorder (COD)

Knowledge Synthesis, Product Development, and Technical Assistance (CODI) contract (reference number

283-07-0610). Charlene E. Le Fauve, PhD, Tison Thomas, MSW, Jayme S. Marshall, MS, and Deborah

Stone, PhD served as the Government Project Ofcers. At Westat, Mary Anne Myers, PhD served as the

CODI Project Director and Nina Hamburg, MBA served as the CODI Project Manager. Other Westat project

staff included Tina Marshall, PhD, Chandria Jones, MPH and Shoma Ghose, PhD. Michelle Steinley-

Bumgarner developed the DDCAT Excel Scoring Spreadsheet, which was adapted by Kathryn Kulbicki

forthe DDCMHT and DDCHCS. Jason Davis produced the layout and design.

Disclaimer

The views, opinions, and content of this publication are those of the authors and contributors

and do not necessarily reect the views, opinions, or policies of SAMHSA or HHS.

Public Domain Notice

All material appearing in this publication is in the public domain and may be reproduced or copied

without permission from SAMHSA. Citation of the source is appreciated. However, this publication

may not be reproduced or distributed for a fee without specic, written authorization from the Ofce

ofCommunications, SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication may be downloaded or ordered at http://store.samhsa.gov.

Or call SAMHSA at1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

Recommended Citation

Substance Abuse and Mental Health Services Administration, Dual Diagnosis Capability in Addiction

Treatment Toolkit Version 4.0. HHS Publication No. SMA-XX-XXXX, Rockville, MD: Substance Abuse

andMental Health Services Administration, 2011.

Originating Ofce

XXXXXXXX

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, MD 20857

HHS Publication No. SMA-XX-XXXX. Printed 2011

Dual Diagnosis Capability

inAddiction Treatment

(DDCAT) Toolkit

Version 4.0

September 2011

iv Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

Julienne Giard, MSW

Consultant

Afliated with the Connecticut

Department of Mental Health &

Addiction Services

Hartford, CT

Rhonda Kincaid, MEd

Consultant

Afliated with the Connecticut

Department of Mental Health &

Addiction Services

Hartford, CT

Heather J. Gotham, PhD

Associate Research Professor

Mid-America ATTC

Kansas City, MO

Ron Claus, PhD

Senior Study Director

Westat

Rockville, MD

Chantal Lambert-Harris, MA

Research Associate

Dartmouth Medical School

Concord, NH

Mark P. McGovern, PhD

Product Development Workgroup

Chair

Associate Professor of Psychiatry

Dartmouth Medical School

Lebanon, New Hampshire

Joseph E. Comaty, PhD, MP

Director, Division of Quality

Management

Ofce of Behavioral Health

Louisiana Department of Health and

Hospitals

Baton Rouge, LA

Jessica L. Brown PhD

Director of Policy and Planning

Ofce of Behavioral Health

Louisiana Department of Health

&Hospitals

Baton Rouge, Louisiana

Janet Bardossi, LCSW

President

Bardossi and Associates, Inc.

Portland, Oregon

Ron Claus, PhD

Measurement Renement Workgroup

Chair

Senior Study Director

Westat

Rockville, MD

Joseph E. Comaty, PhD, MP

Director, Division of Quality

Management

Ofce of Behavioral Health

Louisiana Department of Health and

Hospitals

Baton Rouge, LA

Alysa Fornarotto-Regenye, MSW,

LCADC, DRCC, CPS

COD / Best Practice Specialist

New Jersey Department of Human

Services, Division of Mental Health &

Addiction Services

Trenton, NJ

Heather J. Gotham, PhD

Associate Research Professor

Mid-America ATTC

Kansas City, MO

Rhonda Kincaid, MEd

Regional Manager

Community Services Division

Ofce of the Commissioner

CT Department of Mental Health and

Addiction Services

Hartford, CT

Chantal Lambert-Harris, MA

Research Associate

Dartmouth Medical School

Concord, NH

Mark P. McGovern, PhD

Associate Professor of Psychiatry

Dartmouth Medical School

Lebanon, New Hampshire

Deborah K. Nieri, MS

Project Coordinator II, Co-occurring

State Incentive Grant

South Carolina Department of Mental

Health

Columbia, South Carolina

Randi Tolliver, PhD, CADC

Heartland Center for Systems Change

Heartland Health Outreach

Chicago, IL

Phil Welches, PhD, Clinical

Psychologist

Clinical Director

Gateway Foundation

Chicago, Illinois

DDCAT Toolkit Authors

Measurement Renement WorkgroupMembers

Table of Contents

Acknowledgements

Table of Contents

I. Introduction ......................................................................................................................... 1

A. Introduction to Co-occurring Disorders (COD) and IntegratedServices ................................... 3

1. Literature Support and Report toCongress ...................................................................... 3

2. Fidelity and Patient Outcomes ....................................................................................... 4

3. Benchmark Measures ................................................................................................... 4

4. Terminology and Acronyms ............................................................................................ 5

B. Description of the Index .................................................................................................... 5

C. Development and PsychometricStudies.............................................................................. 6

1. Reliability .................................................................................................................... 6

2. Convergent and Discriminant Validity ............................................................................. 7

3. Criterion Related Validity .............................................................................................. 7

4. Sensitivity to Change .................................................................................................... 8

D. Toolkit Organization .......................................................................................................... 8

II. Applications ........................................................................................................................ 9

A. System and Regulatory Agencies ........................................................................................ 9

B. Treatment Providers ........................................................................................................ 10

C. Health Services Researchers ............................................................................................ 11

D. Families and Individuals SeekingServices ........................................................................ 11

III. Methodology .................................................................................................................... 13

A. Observational Approach andDataSources ........................................................................ 13

B. The Site Visit ................................................................................................................. 13

C. Cautions Regarding Self-Evaluation .................................................................................. 14

D. Training Program Quality Assurance Staff ......................................................................... 15

E. Training Individuals to Conduct the Program Assessment.................................................... 15

1. Didactic Training ........................................................................................................ 15

2. Shadowing ................................................................................................................ 16

3. DDCAT Vignette/Case Study ......................................................................................... 16

IV. Scoring and Prole Interpretation ....................................................................................... 17

A. Scoring Each DDCAT Item ............................................................................................... 17

B. Scoring the DDCAT Index ................................................................................................ 18

C. Creating Scoring Proles ................................................................................................. 18

D. Feedback to Programs .................................................................................................... 19

vi Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

V. The DDCAT Index: Scoring and Program Enhancement .......................................................... 21

VI. Epilogue .......................................................................................................................... 97

VII. Appendices ..................................................................................................................... 99

A. Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index Version 4.0 ..................... 101

B. Frequently Asked Questions (FAQ) ................................................................................. 115

C. No or Low Cost Enhancements toIncrease Co-Occurring Capability ................................... 117

D. The Site Visit ............................................................................................................... 119

DDCAT — Multiple Chart Review Form .......................................................................... 119

DDCAT — Agency Director/Program Director/Clinical Director Questions ........................... 120

DDCAT — Clinician Interviews ...................................................................................... 123

DDCAT — Consumer Interview Questions ....................................................................... 125

E. Training Raters to Conduct DDCATAssessments .............................................................. 127

DDCAT — Scoring Scenario .......................................................................................... 127

DDCAT — Case Study Scoring Key ................................................................................ 131

F. Sample Memorandum of Understanding ......................................................................... 135

G. Screening for Mental Health andSubstance Use Disorders ............................................... 137

Modied MINI Screen (MMS) ........................................................................................ 139

Mental Health Screening Form III (MHSF-III) ................................................................. 143

CAGE-Adapted to Include Drugs (CAGE-AID) .................................................................. 145

Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD) ................................ 147

Traumatic Life Events Inventory and Post-Traumatic Stress Disorder Checklist ................... 149

Social Interaction Anxiety Scale ..................................................................................... 153

H. Measuring Motivation for Change andMotivation for Treatment ....................................... 155

URICA (Long Form) ...................................................................................................... 157

SOCRATES 8A ............................................................................................................. 159

SATS .......................................................................................................................... 160

I. Tracking Changes in Substance Use andMental Health .................................................... 161

J. References .................................................................................................................. 163

K. Recommended Readings .............................................................................................. 167

Table of Contents

1Introduction

I. Introduction

Addiction treatment providers are continually challenged

to improve services. Often, these challenges occur in

a scal growth environment that is not only at, but

in most instances, declining. Over the past 15 years,

there has been an increased awareness of the common

presentation of persons with co-occurring mental health

disorders in routine addiction treatment settings.

Research results suggest that sequential treatment

(treating one disorder rst, then the other) and purely

parallel treatment (treatment for both disorders provided

by separate clinicians or teams who do not coordinate

services) are not as effective as integrated treatment

(Drake, O’Neal, &Wallach, 2008). National and state

initiatives related toco-occurring disorders have been

signicant, stimulating considerable interest in providing

better services for people with these challenges. Although

clearly interested in improving existing services, addiction

treatment providers have lacked pragmatic guidance on

how to change. In 2005, the Substance Abuse and Mental

Health Services Administration’s (SAMHSA) Center for

Substance Abuse Treatment (CSAT) published Treatment

Improvement Protocol 42 (or TIP 42) to respond to this

need. However, providers continue to identify the need for

specic benchmarks and related practical direction with

which to plan and developservices.

In 2003 the Dual Diagnosis Capability in Addiction

Treatment (DDCAT) index was created and eld tested.

Since 2004, we have been developing and implementing

the index. The DDCAT, based on the American Society

of Addiction Medicine’s (ASAM) taxonomy of program

dual diagnosis capability, has been subjected to a

series of psychometric studies. The map below reects

the widespread implementation in various stages of

the DDCAT as well as two parallel instruments, the

Dual Diagnosis Capability in Mental Health Treatment

(DDCMHT) and Dual Diagnosis Capability in Health Care

Settings (DDCHCS). The DDCAT, dened more fully below,

guides both programs and system authorities in assessing

and developing the dual diagnosis capacity of addiction

treatment services (McGovern, Matzkin, & Giard, 2007).

Dual Diagnosis Capability

inAddiction Treatment

(DDCAT) Toolkit

Version 4.0

2 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

This toolkit emerges from these efforts. It is a response

to numerous requests by community treatment providers

for more specic guidance on how to enhance services

based upon their current status. For programs that the

DDCAT determines to offer services at an Addiction

Only Services (AOS) level, this toolkit provides specic

suggestions and examples from the eld on how to reach

Dual Diagnosis Capable (DDC) level services. Likewise,

programs already assessed at the DDC level have asked

for specic guidance on how to attain the Dual Diagnosis

Enhanced (DDE) level. This toolkit responds to that

request as well.

The motivation among addiction treatment providers to

improve the quality of care offered to their patients is

impressive if not inspirational. This toolkit was developed

in direct response to addiction treatment programs at the

“action” stage of readiness. The toolkit is designed to

immediately offer practical tools and useable materials

that will rapidly improve services to those programs with

co-occurring disorders entrusted to their care.

States

States using DDCAT/DDCMHT/DDCHCS

in 2011 (32 states, District of Columbia,

and Navajo Nation)

States Utilizing the DDCAT/DDCMHT/DDCHCS Measure as of April 2011

Navajo

Nation

3Introduction

A. Introduction to Co-occurring

Disorders (COD) and

IntegratedServices

1. Literature Support and Report

toCongress

Co-occurring mental health and substance use disorders

are prevalent and difcult to treat. Although rates vary

by disorder combinations and somewhat by study,

epidemiological research has shown that a signicant

portion of the population experiences co-occurring

disorders (Grant et al., 2004; Kessler et al., 1994,

1997; Regier et al., 1990). Moreover, the prevalence

ofco-occurring disorders is even higher in populations

of individuals seeking mental health or substance abuse

treatment (Grant et al., 2004; McGovern et al., 2006;

Watkins et al., 2004). Furthermore, individuals with

co-occurring mental health and substance use disorders

have poorer outcomes, including higher rates of relapse,

suicide, homelessness, incarceration, hospitalization,

and lower quality of life (Compton et al., 2003; Wright,

Gournay, Glorney, & Thornicroft, 2000; Xie, McHugo,

Helmstetter, & Drake, 2005). Compounding the problem

has been that, traditionally, mental health and addiction

treatment have been separate systems with separate

practitioners, and little crossover. Treatment was

provided sequentially for the two types of disorders, and

individuals were often told that they must deal with one

disorder prior to entering treatment for the other. Care

was not coordinated.

During the past 15 years, increasing attention has been

given to the problem of co-occurring substance use

and mental health disorders. In 2002, an important

milestone in changing treatment for individuals with

co-occurring disorders occurred with the release of

the Substance Abuse and Mental Health Services

Administration’s Report to Congress on the Prevention

and Treatment of Co-Occurring Substance Abuse

Disorders and Mental Disorders. Not only did the report

highlight the signicant portion of individuals in the

United States with co-occurring disorders and the poor

treatment outcomes for these individuals, the report

also discussed the lack of effective care available at

the time. The report noted an increasing research

base suggesting that coordinated and integrated care

was effective, and that evidence-based treatment

practices were being developed. Treatment research

from both the mental health and substance abuse elds

has shown that treatments aimed at addressing both

disorders simultaneously are generally more effective

than dealing with one disorder at a time (Drake et al.,

2001; Mangrum, Spence, & Lopez, 2006; SAMHSA,

2002). In2005, SAMHSA’s Center for Substance

Abuse Treatment (CSAT) released the Substance

Abuse Treatment for Persons With Co-Occurring

Disorders, Treatment Improvement Protocol 42 (CSAT,

2005), which summarizes consensus and evidence-

based practices for co-occurring disorders, including

integrated psychiatric and addiction medication

services, psychoeducation, counseling, andspecialized

peer recovery support groups for persons with

co-occurringdisorders.

The Report to Congress was also a call for treatment

programs to develop increased capability to serve

patients with co-occurring disorders, including increasing

access to treatment and initial screening/assessment,

stating “any door is the right door” (SAMHSA, 2002).

Although not all addiction treatment programs need

to have fully integrated services for co-occurring

disorders, as suggested by the report, all programs

may be expected to have some level of capability

toaddressCOD.

To classify the dual diagnosis capability of addiction

treatment programs, the American Society of Addiction

Medicine (ASAM) developed a taxonomy (ASAM Patient

Placement Criteria 2

Revision [ASAM-PPC-2R];

Mee-Lee et al., 2001). The taxonomy includes three

categories of capability: Addiction Only Services (AOS),

Dual Diagnosis Capable (DDC), and Dual Diagnosis

Enhanced (DDE).

4 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

Generally, AOS programs do not accommodate

individuals with mental health disorders; DDC programs

accommodate individuals with mental health disorders

that are relatively stable, and the programs address COD

to some extent in policies, procedures, assessment, and

programming. DDE programs accommodate individuals

with even acute and unstable mental health disorders.

The taxonomy provides a useful classication for

capability, but needed a benchmark or delity measure

to place addiction treatment programs within it.

2. Fidelity and Patient Outcomes

It was assumed that if shown new evidence about

treatments that improve patient outcomes, treatment

providers would rapidly implement such therapies. In

reality, it is less than a straightforward process to use

new information to shift routine practice and treatment

services. The new eld of implementation science

focuses on the challenges of implementing evidence-

based or expert consensus-based treatments. One

component that supports implementation success is the

observation by those who implement new treatments that

their patients’ outcomes are improved. Ironically, most

implementation efforts do not include patient outcome

tracking, meaning treatment providers do not see that

the new treatment or services really do work better.

Another aspect of implementation pertains to delity

or the adherence to the new practice guidelines or

techniques. Simply saying that the new practice is being

implemented is not adequate, so systematic observations

of the implementation are often used to evaluate whether

the practice is being implemented as designed. The

research upon which the evidence for any practice has

been established typically includes quality monitoring

(i.e., integrity of the practice is veried). Therefore, the

assumption is that to maximize the outcomes found in

the research, real world providers should deliver the new

therapy with delity.

In medical care, it has been demonstrated that if a new

technique is not implemented with delity, the expected

gain in improved patient outcomes is non-existent (Woolf

and Johnson, 2005). This also seems to be the case with

behavioral treatments (Durlak and DuPre, 2008).

In reality, some adaptations will likely be needed

toassimilate a new service or practice approach

intoany particular setting, culture, patient population

andprovider group. Nonetheless, delity or adherence

to the original model is important. This nding has been

established across a variety of interventions, including

medical procedures, psychotherapy, addiction treatments,

and behavioral therapies (McHugo et al., 1999;

Schoenwald, Sheidow, & Letourneau, 2004).

3. Benchmark Measures

Several benchmark instruments have been developed

to assess co-occurring capability or delity to specic

co-occurring disorders treatments in mental health

treatment programs. The Integrated Dual Disorders

Treatment (IDDT) Fidelity Scale assesses delity to a

specic evidence-based practice (Mueser et al., 2003;

SAMHSA, 2003). Several more general agency self-

assessment tools have been developed by Minkoff and

Cline (2004) and Timko, Dixon, and Moos (2005).

What had been lacking in this area was an objective

instrument for measuring co-occurring disorders

capability within addiction treatment programs. Research

has shown signicant over-reporting of capability with

self-assessments (e.g., Adams, Soumerai, Lomas, &

Ross-Degnan, 1999). For example, McGovern et al.

(2006) found that when asked to categorize their

addiction treatment programs using the ASAM taxonomy

(Mee-Lee et al., 2001), program directors and clinical

staff showed less than 50 percent agreement, with

program managers rating the program at a higher level of

capability. Similarly, in a study of Australian treatment

programs, Lee and Cameron (2009) found that programs

over-rated their co-occurring services capability

compared to presumably more objective external raters.

The DDCAT is a valid and reliable, objectively rated

benchmark measure to assess capability of addiction

treatment programs to provide services to individuals

with co-occurring disorders.

5Introduction

4. Terminology and Acronyms

Co-occurring disorders is used to denote the status of having a substance use disorder and a psychiatric/mental

health disorder.

Dual diagnosis (DD) refers to the same status dened by co-occurring disorders. Dual diagnosis is used

inthismanual to retain the language initially established by ASAM and the DDCAT Index.

Substance use disorders is used specically to denote the broad range of substance use disorders within

theDSM-IV that include the broad categories of substance use and substance-induced disorders.

Mental health disorders or psychiatric disorders are used to refer to other major psychiatric disorders besides

the substance use disorders. Generally, this term refers to the mood disorders, anxiety disorders, thought

disorders, adjustment disorders, and other disorders not substance related or induced by substances.

Addiction Only Services (AOS) is an ASAM-PPC-2R category referring to addiction treatment programs

thatdonot accommodate individuals with mental health disorders.

Dual Diagnosis Capable (DDC) is an ASAM-PPC-2R category referring to addiction treatment programs

thataccommodate individuals with mental health disorders that are relatively stable. These programs address

COD to some extent in policies, procedures, assessment, and programming.

Dual Diagnosis Enhanced (DDE) is an ASAM-PPC-2R category referring to addiction treatment programs

thataccommodate individuals with acute and unstable mental health disorders.

B. Description of the Index

The Dual Diagnosis Capability in Addiction Treatment

Index—referred to as the DDCAT—is a benchmark

instrument for measuring addiction treatment program

services for persons with co-occurring mental health and

substance use disorders (see the appendix for a copy of

the instrument).

The DDCAT has been in development since 2003, and it

is based upon a delity assessment methodology. Fidelity

scale methods have been used to ascertain adherence

to and competence in the delivery of evidence-based

practices. This methodology has been used to assess

mental health program implementation of the Integrated

Dual Disorder Treatment (IDDT) model. IDDT is an

evidence-based practice for persons with co-occurring

disorders in mental health settings, and who suffer

from severe and persistent mental illnesses (Mueser et

al., 2003). The DDCAT utilizes a similar methodology

as the IDDT Fidelity Scale, but has been specically

developed for addiction treatment service settings. Until

the DDCAT, addiction treatment services for co-occurring

disorders were guided by an amalgam of evidence-based

practices and consensus clinical guidelines.

The DDCAT evaluates 35 program elements that are

subdivided into seven dimensions.

n

The rst dimension is Program Structure.

Thisdimension focuses on general organizational

factors that foster or inhibit the development

ofintegrated treatment.

n

Program Milieu is the second dimension, and

it focuses on the culture of the program and

whether the staff and physical environment

6 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

are receptive and welcoming to persons with

co-occurringdisorders.

n

The third and fourth dimensions are referred to

as the Clinical Process dimensions (Assessment

and Treatment). These examine whether specic

clinical activities achieve specic benchmarks

forintegrated assessment and treatment.

n

The fth dimension is Continuity of Care,

which examines the long-term treatment

issues and external supportive care issues

commonly associated with persons who have

co-occurringdisorders.

n

The sixth dimension is Stafng, which examines

stafng patterns and operations that support

integrated assessment and treatment.

n

The seventh dimension is Training, which

measures the appropriateness of training and

supports that facilitate the capacity of staff

totreatpersons with co-occurring disorders.

The DDCAT draws heavily on the taxonomy of addiction

treatment services outlined by the American Society

of Addiction Medicine (ASAM) in the ASAM Patient

Placement Criteria Second Edition Revised (ASAM-PPC-

2R, 2001). This taxonomy provided brief denitions of

Addiction Only Services (AOS), Dual Diagnosis Capable

(DDC) and Dual Diagnosis Enhanced (DDE). The ASAM-

PPC-2R provided brief descriptions of these services

but did not advance operational denitions or pragmatic

ways to assess program services. The DDCAT utilizes

these categories and developed observational methods

(delity assessment methodology) and objective metrics

to ascertain the dual diagnosis capability of addiction

treatment services for persons with co-occurring

disorders: AOS, DDC, or DDE.

C. Development and

PsychometricStudies

Development of the DDCAT began in 2003 by Dr.

Mark McGovern, Associate Professor of Psychiatry

at Dartmouth Medical School and member of The

Dartmouth Psychiatric Research Center. The index

wasinitially eld-tested in Connecticut, Louisiana,

andNew Hampshire before widespread implementation

in a number of states, Native American tribes, and

internationally. DDCAT items and scoring anchors

wererevised in 2006 and 2011.

Investigations by the developers of the DDCAT and

DDCMHT have found initial support for the psychometric

properties of the measures. Studies assessing the DDCAT

and DDCMHT indices’ inter-rater reliability, internal

consistency, convergent and discriminant validity,

preliminary criterion validity, and sensitivity to change

are summarized in the sections below.

1. Reliability

In terms of inter-rater reliability, in a study of seven

programs and rater pairs in Missouri, Gotham, Haden,

and Owens (2004) found a correlation coefcient of .76

(p < .01) and median kappa coefcient of .67 (p<.05)

across all scales. Brown & Comaty (2007) reported

an intra-class correlation coefcient of .84 (p<.001)

across 35 program sites and ve raters in Louisiana.

With respect to internal consistency, Gotham, Claus,

Selig, and Homer (2010) found the median dimension

alpha coefcient to be .73, with a range across all 7

dimensions from .61 to .81.

7Introduction

2. Convergent and Discriminant Validity

Two studies of the DDCMHT’s convergent and

discriminant validity have been reported. The DDCMHT

was compared with the IDDT Fidelity Scale, the

latter designed for use in assessing implementation

of IDDT for patients with severe mental illnesses and

substance abuse-level disorders in community mental

health settings. The DDCMHT total score was found

positively correlated with the IDDT total score (.75;

p<.01). Therelationship between the IDDT total score

and the DDCMHT dimension scores ranged from .53 to

.68. Four (57 percent) of the 7 DDCMHT dimensions

were signicantly correlated with the IDDT total score

(at p<.05), whereas 3 (43 percent) were not. Since

the IDDT delity scale measures adherence to the

IDDT approach, designed for different patients and

settings, some correspondence, but not complete

overlap with the DDCMHT was expected (Gotham

et al., 2004). Gotham et al. (2008) also compared

DDCMHT total scores (n=7) with the Organizational

Readiness for Change Scale (Lehman et al., 2002).

Using Cohen’s (1987) classications (correlation of

.10= small, .30 = medium, and .50 = large), 11 of the

18 Pearson correlation coefcients were large, and the

remaining 9were small or insignicant, suggesting that

program dual diagnosis capability shares common but

independent characteristics with organizational factors

such as resources, staff, organizational climate, and

overall needs and pressures. Both of these studies by

Gotham et al. (2004; 2008) support the convergent

anddiscriminant validity of the DDCMHT.

3. Criterion Related Validity

Two studies have shown that programs of differential

dual diagnosis capacity (DDCAT assessed) have different

types of patients accessing their services, as determined

by standardized screening measures at admission and

more severe and complex problems as measured at

admission using the Addiction Severity Index (ASI).

McGovern & Giard (2007) found that of 15 programs

using the Mental Health Screening Form-III (MHSF-III)

with new admissions, AOS programs (550 admissions)

had signicantly fewer co-occurring disorder positive

(COD+)(69.1 percent) than DDC programs (n=36

admissions)(94.4 percent). These differences were also

reected in signicant differences in average MHSF-

III total scores (AOS Mean=3.39; SD=3.69) (DDC

Mean=7.06; SD=3.86) (p<.001).

This nding was conrmed in data from 15 different

addiction treatment programs that used the Modied

MINI Screen (MMS) at admission. AOS programs (452

admissions) had fewer MMS identied COD+ patients

(46.9 percent) vs. DDC programs (743 admissions)

(52.5 percent). These differences were also found

to be signicant (AOS Mean=5.39; SD=5.13) (DDC

Mean=6.57; SD=5.87) (p<.001). In a study of 391

admissions across 3 AOS programs and 112 admissions

across 2 DDC programs, Mangrum (2007) found a similar

trend. On the MINI Neuropsychiatric Interview (MINI),

DDC patients were more likely diagnosed with bipolar,

psychotic, dysthymia, and PTSD, whereas AOS patients

were more likely positive for depression, obsessive-

compulsive, and generalized anxiety disorders. DDC

patients had signicantly more problem days (p<.05)

than AOS patients on the ASI scales of psychiatric, drug,

alcohol, social, medical and employment domains. Both

of these investigations nd preliminary criterion validity

for the DDCAT and also suggest the feasibility of using

the MMS and MINI, based on patient screening and

assessments within one week of admission, and by routine

communitycounselors.

8 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

4. Sensitivity to Change

In a study of 16 addiction treatment programs assessed

using the DDCAT at baseline and 9 months later,

McGovern, Matzkin, et al. (2007) found the DDCAT

sensitive to change. The programs received one of three

“dual diagnosis enhancement strategies”:

1) DDCAT assessment + feedback only (8 programs);

2) DDCAT assessment + feedback + training (4

programs); and

3) DDCAT assessment + feedback + training +

implementation support (4 programs).

All three groups increased dual diagnosis capability

over the 9 months, but the DDCAT assessment +

feedback + training + implementation support group

hadsignicantly greater change overall (Kruskal-Wallis

tests, p <.01).

Although programs were not randomized and were

signicantly different at baseline, this small study

supports the application of the DDCAT to measure

change. Other studies have also found effective program

improvement efforts, as measured by the DDCAT,

moderately predict baseline program organizational

factors as assessed by the Organizational Readiness

forChange scales (Gotham, Brown, Comaty, &

McGovern, 2008) and leadership styles (Claus, Gotham,

Harper-Chang, Selig, & Homer, 2007; Claus, 2008).

These ndings underscore the importance of gathering

information about the implementation or change

strategies used when conducting a repeated measures

study using the DDCAT, and obtaining information

about more generic organizational factors as potential

correlates of baseline capacity or moderators of change

over time. These ndings were replicated and further

enhanced by tracking implementation strategies in more

recent research (McGovern, Lambert-Harris, McHugo,

Giard & Mangrum, 2010).

D. Toolkit Organization

This toolkit is intrinsic to administering and scoring the

DDCAT. Accordingly, toolkit suggestions are embedded

within the context of each item’s scoring. Each of the

seven dimensions of the DDCAT is described and then

each item is listed and the scoring procedure articulated.

Each item includes a section entitled “Item Response

Coding,” which provides descriptive anchors to assist

scoring this scale item using the DDCAT rankings of

1-AOS, 3-DDC, and 5-DDE. In some cases descriptive

anchors are available for scores of 2 and 4, when

observations fall within intermediate ranges between

the 1, 3, and 5 ratings. A section titled “Source” lists

sources of the data to be considered in determining

thescore.

Corresponding to each item, the toolkit offers specic

enhancement suggestions for AOS and DDC programs.

Many of the suggestions throughout the toolkit are

examples from actual treatment providers. A complete

listing of the no and low cost suggestions is available

below, as an appendix. Sample instruments, forms, and

other resources that are mentioned in the discussions

ofeach item are also available in the appendix section.

9Applications

II. Applications

The widespread use of the DDCAT and DDCMHT

measures speaks to their appeal to the behavioral

health community. The measures are pragmatic and

relatively easy to use. A range of constituencies nd

themeasure useful and a variety of implementations

have occurred by system and regulatory agencies as

wellas treatmentproviders.

The sections below summarize examples of how the

DDCAT and DDCMHT have been used to assess and

guide quality improvement in program co-occurring

capacity. In addition, descriptions are provided for

applications in health services research and how

familiesand individuals seeking services have used

DDCAT summaries to make informed treatment choices.

A. System and Regulatory Agencies

As of 2010, over 30 state regulatory authorities,

several large county governments, private treatment

programs, and several nations are in various stages of

implementation using the DDCAT and DDCMHT indices.

Systems seek to obtain objective information about

dual diagnosis capacity among the providers with whom

they contract for services. In the absence of objective

measures, the regulatory agency has only provider self-

report or anecdote upon which to base their appraisal.

Research has consistently shown that provider self-

assessment of dual diagnosis capability is of dubious

validity, and often inated (McGovern, Xie, et al., 2007;

Lee & Cameron, 2009). For this reason, a standardized

yardstick, such as the DDCAT or DDCMHT, enables

the state or county authority to obtain an accurate

and multi-dimensional picture of services within their

jurisdiction. System agencies have found multiple uses

for thisinformation:

1) Developing a map of types of treatment agencies

based upon dual diagnosis capability;

2) Examining variation in funded services by region,

level of care, or type of agency;

3) Using the data to plan and implement standards

for differential funding;

4) Using the data to plan and offer targeted training

and technical assistance;

5) Assessing baseline capacity and then repeating

assessments to measure the effectiveness of

quality improvement efforts;

6) Featuring the information in grant applications

tofederal agencies;

7) Using the data to present to legislators; and

8) Linking the DDCAT and DDCMHT indicators

topatient level outcomes.

Dual Diagnosis Capability

inAddiction Treatment

(DDCAT) Toolkit

Version 4.0

10 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

B. Treatment Providers

The experience of treatment providers who have been

assessed with the DDCAT is near universally positive.

Concrete and practical guidance about policy, practice,

and workforce development in the arena of co-occurring

disorders has been lacking. For at least the past

decade, treatment providers have been well aware of

federal recommendations, such as SAMHSA’s Report

toCongress, the President’s New Freedom Commission,

and SAMHSA’s TIP 42. Community treatment providers

have also been highly motivated to address the issue and

improve services for persons with co-occurring disorders

already under their care. What have been missing are

the concrete guidelines and benchmarks with which

todoso.

Treatment providers have used the DDCAT and DDCMHT

to assess their status on co-occurring capacity relative

to established benchmarks on policy, practice, and

workforce. Using this guide, many providers have

identied target scores they wished to achieve on

specic benchmarks, and then planned quality

improvements in the intended direction. More generally,

providers often want to operate at a certain level of

overall capacity, such as DDC or DDE. Providers utilize

the information from the DDCAT and DDCMHT to

achieve concrete change to score at these levels. In

some instances, having a DDE level program has been

associated with increased reimbursement rates, whereas

in the private sector, operating an objectively veried

DDE program is used to negotiate with private payers

and for marketing purposes.

Another application for treatment providers is the use

of the measures to articulate specic training goals for

programs and clinical staff members. Rather than a more

global or vague approach to agency endorsed or funded

training, specic clinical goals (e.g., facilitating a co-

occurring disorders stage-wise group session) can lead

to training exposure that staff members need. In fact,

DDCAT and DDCMHT items pertain to the recommended

basic co-occurring training for all staff (item VIIA)

and specialized training for clinical staff (VIIB). These

benchmarks sharpen the focus and create clarity for staff

professional development plans.

Specics on Implementing Change

The two sections above discuss how the DDCAT and

DDCMHT may be used by system/regulatory agencies

and treatment providers and in both instances those

applications involve making changes at the system,

agency, or program levels. The developing eld of

implementation science can contribute to the use of

the DDCAT and DDCMHT. While a complete review of

implementation science ndings are beyond the scope

of this toolkit, some general recommendations can

bemade.

Many programs and systems have obtained initial

DDCAT assessments. Using these data as a “baseline”

measure of co-occurring capability, the programs go on

to develop co-occurring implementation plans akin to

treatment plans. Such plans have similar ingredients

totreatment plans in that they include goals, objectives,

interventions, responsible persons, and projected target

dates. Programs have used the DDCAT dimensions or

domains at baseline to organize the list of goals, and

then used the specic items in the DDCAT to dene

specic objectives. Interventions and the specic targets

of change can be extracted directly from this toolkit.

Thus the DDCAT can provide an addiction treatment

program with a practical blueprint and tools to achieve

increased capacity for co-occurring disorders. Since the

measure can be re-administered, it can also be used to

assess the success (or sustainability) of these changes.

In addition to a written implementation plan, other

components of a change process that programs often

nd helpful include:

1) Identify a program “champion” or change agent;

2) Develop a steering committee;

3) Obtain training and technical assistance;

11Applications

4) Ensure that clinical supervisors in the program

are competent in the new skills being expected

of clinicians/counselors and lead routine clinical

supervision sessions (individual and group)

topractice the new skills with staff;

5) Connect with other programs that have or are

currently implementing the same kinds of

changes, either individually or through a learning

collaborative;

5) Track certain data elements that inform whether

the service changes are happening and if they are

improving patient outcomes; and

6) Conduct ongoing DDCAT assessments every 3 to

6 months during the rst year of implementation,

with annual reviews thereafter.

This change process, including a written implementation

plan, is meant to be used in an ongoing iterative

fashion; as initial goals and tasks are achieved, other

goals and tasks can be added to the plan. For more

information on implementation science, please see

theReferencessection.

C. Health Services Researchers

The availability of a program level measure of co-

occurring capability has a variety of implications for

organizational and clinical research. Descriptive research

studies are now possible, such as in assessing variation

in co-occurring capability across a specic region, or in

comparing capacity in urban and rural areas, in mental

health to addiction treatment programs, or hospital

programs and free-standing clinics. Researchers are

often interested in categorizing the characteristics or

types of organizations within which multi-site clinical

trials take place. This enables the researchers to either

understand the potential study confounds due to site

differences or to a priori use sites that have similar levels

of co-occurring capacity to minimize this inuence.

Researchers also are interested in the effectiveness of

quality improvement or process improvement strategies.

Such strategies may range from training in specic

evidence-based practices, increased funding for

certain services, Network for Improvement of Addiction

Treatment (NIATx) approaches, or Plan-Do-Study-Act

cycles. Using the DDCAT or DDCMHT as a pre-post

implementation measure identies changes in co-

occurring capability over time.

A burning question remains for health services

researchers: What is the relationship between program

level measures of capability, such as the DDCAT or

DDCMHT, and patient level outcomes, such as mental

health symptom reduction, decreased substance

use, medication compliance, or improved quality of

life? Studies conducted under controlled conditions

and of sufcient sample size are needed to address

thesequestions.

D. Families and Individuals

SeekingServices

Classifying programs as AOS, DDC, or DDE can help

families and individuals seeking care for a co-occurring

disorder. Since no current directory sorts programs by co-

occurring capability, consumers may be misled by self-

appraisals or marketing statements which lack objective

or independent validation. A regional, statewide, or

national directory would enable consumers to make

informed treatment decisions based on preferences.

Many patients and families with co-occurring disorders

have had negative treatment experiences, in part due to

the fact that they did not receive adequate or integrated

care. Being able to condently identify a program

providing DDC or DDE services based on objective

standards established by the DDCAT and DDCMHT would

support persons and families struggling with co-occurring

disorders as they make a courageous step towards

professional help.

13Methodology

III. Methodology

A. Observational Approach

andDataSources

The DDCAT uses observational methods to gather

information about a program and rate its co-occurring

capability. External raters make a site visit to an

addiction provider, collecting data about the program

from a variety of sources:

1) Ethnographic observations of the milieu

andphysical settings;

2) Focused but open-ended interviews of agency

directors, clinical supervisors, clinicians,

medication prescribers, support personnel,

andpatients; and

3) Review of documentation such as medical

records, program policy and procedure manual,

brochures, daily patient schedules, telephone

intake screening forms, and other materials that

mayseem relevant.

Information from these sources is used to rate the 35

DDCAT Index items.

B. e Site Visit

The scheduling of the site visit is done in advance.

Generally the site visit will take up to a half day or a

full day. The time period is contingent on the number

of programs within an agency that are being assessed,

the number of assessors, and their experience with

the DDCAT tool. Since the DDCAT is used to assess

aprogram, rather than an entire agency, the raters

pre-arrange what program or programs within the agency

are to be assessed. Experience suggests that it may be

possible to fully assess one program in approximately

ahalf day. In a full day it may be possible to assess two

to three programs within one agency, depending upon

how closely their operations are related. It is important

to allocate sufcient time to do the DDCAT assessment.

This process typically becomes more efcient as the

assessor gains experience, and when multiple assessors

can share the site visit tasks.

The DDCAT process begins with identifying the

appropriate contact person, usually the agency director

or a designee. In a preliminary conversation, raters

can dene the scope of the assessment and clarify the

time allocation requirements. At this time it is also

be important to convey the purpose of the assessment

and relay any implications of the data being collected.

Thisprocess has been found to be most effective if

Dual Diagnosis Capability

inAddiction Treatment

(DDCAT) Toolkit

Version 4.0

14 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

offered as a service to the agency—that is, to help

the agency learn about its services to persons with

co-occurring disorders, and to suggest practical

strategies to enhance services if warranted. This sets

an expectation of collaboration rather than evaluation

and judgment, which will help theassessor elicit more

accurateinformation.

Scheduling should include both an initial meeting and

an “exit” feedback meeting with the agency director,

and time for separate group interviews with the program

clinical leaders and supervisors, select clinicians,

and patient(s). Conducting separate interviews allows

the assessor to identify different perspectives on

the program’s practices and procedures, and any

discrepancies between what one group perceives and

another experiences. Selected persons in these roles

canbe interviewed (i.e., not every supervisor, staff

member or patient must be interviewed). More is always

better, but reasonableness and representativeness should

be the overarching goal.

This initial contact with the agency director is also a

good opportunity to gather descriptive information about

the program as listed on the DDCAT rating scale cover

sheet. While this information is not necessary to score

the DDCAT, it can be useful in tabulating or making

comparisons of DDCAT scores, such as across regions

or states, or by level of care, size, or funding source.

The cover sheet offers the assessor an easy format

fororganizing basic information as well as providing

aprogram with information about the data sources used

and the assessment process

During the visit a tour of the program’s physical site is

essential. Agencies have experience doing this for other

purposes, and it often serves not only as a way to observe

the milieu, but also affords the assessor the opportunity

to meet additional staff and have conversations along

the way. There should also be some time allocated

to review documents, such as brochures, policy and

procedure manuals, patient activity schedules, and other

pertinent materials. When possible, obtaining a copy of

any of these materials to review ahead of time will help

save time at the visit. Lastly, enough time should be

scheduled to review eight to 10 medical records, all for

individuals identied as having co-occurring disorders.

Ideally records should be for recently discharged

patients, and representative of different clinicians.

It is important to allow time for the assessor to process

and formulate the ndings from the DDCAT assessment

at the end of the visit. This may be a period of 15 to 30

minutes. During this time, the assessor considers DDCAT

items that have not yet been addressed. He or she also

considers how to provide preliminary feedback to the

agency about the ndings of the assessment. Missing

information can most likely be gathered within the nal

meeting with the director or staff. If necessary, a follow-

up call can be made after the visit if the assessor nds

any data was overlooked.

The preliminary feedback or debrieng at the end of the

DDCAT assessment is typically positive and afrming,

and it emphasizes program strengths and themes

from the assessment. The assessor is encouraged to

consider the program’s readiness to change and focus

onaddressing issues that have already been raised as

areas of concern or desired change.

C. Cautions Regarding

Self-Evaluation

The accuracy and usefulness of a DDCAT assessment

is directly proportional to the objectivity of the assessor

and her or his familiarity with the underpinning of each

DDCAT item response coding. Experience has shown

that self-assessors generally view their programs as more

capable than they actually are (McGovern, Xie, et al.,

2007), and that there is a high likelihood self-assessors

will score their programs higher in all dimensions (often

by a full point or more) than will an objective assessor

(Lee and Cameron, 2009). This is not to say that self-

assessment should not be attempted and cannot be

doneeffectively.

15Methodology

The self-assessor’s foremost task is to look with “fresh

eyes” and ask all the questions necessary to base a score

on facts, rather than on assumptions based on prior

information or impressions. Agencies that choose toself-

assess are encouraged to use their quality assurance

staff, which due to the nature of their work can typically

be more objective, and/or staff from a program other

than the one being assessed. A team of two or more

self-assessors is recommended in order to increase

the opportunity to identify, discuss, and mitigate any

inherent biases by scoring independently and coming to

consensus when initial scores don’t agree. Agencies may

also want to explore reciprocal arrangements with other

agencies to further minimize bias. The Louisiana Ofce

of Behavioral Health conducted DDCAT assessments

using a team that included their expert raters as well

as staff from providers to be assessed; this meant

that staff raters participated in assessing their own

programs. Program staff’s consistency with the expert

raters was demonstrated by the fourth visit (i.e., the

quality of assessment increases with practice) (Brown

&Comaty,2007).

A thorough understanding of the denition and item

response coding for each DDCAT element is equally

as important as objectivity. Louisiana found that the

development of manuals enhanced ratings consistency.

A recent study of dual diagnosis capability of residential

substance abuse programs in Australia found that the

self-assessors consistently did not read the DDCAT

instructions, resulting in incorrect scores (Matthews,

Kelly, & Deane 2011). Basing scores on the DDCAT

tool’s anchors alone often results in inaccurate ratings;

the anchors serve only as a prompt for scoring, and they

are not intended to be all-encompassing descriptors.

This toolkit contains expanded denitions for many of

the scores. It describes the essence and nuances of each

element. Additionally, the guidance for programs wishing

to increase their capability offers examples that can

provide further clarity.

D. Training Program Quality

Assurance Sta

It is recommended that programs intending to improve

their co-occurring capability use both process and

outcome measures to monitor and improve program

quality over time. DDCAT baseline and follow-up

assessments can be an integral element of such quality

assurance efforts. Quality assurance staff not only may

be more objective, but also are likely to have interviewing

and chart review skills that will help ensure a competent

assessment. Quality assurance staff who are trained to

conduct DDCAT assessments can use them to measure

progress toward implementation plan goals. The quality

assurance staff can also assess and compare different

programs within the agency.

E. Training Individuals to Conduct

the Program Assessment

1. Didactic Training

Individuals who wish to conduct a DDCAT assessment

can attain some prociency through familiarizing

themselves with the information in this toolkit. Some

state agencies have offered workshops on the DDCAT.

Other resources are listed in the References section.

Prior to a visit, some assessors have found it helpful to

note on the scoring sheet the various sources for each

item to cue them throughout the visit. They also develop

separate lists of questions for each interview group that

will elicit information necessary to score each item,

in some cases organizing them by topic rather than by

assessment dimension and element. Some have found

it helpful to develop a brief checklist form to use as a

guide when reviewing medical records. Samples of these

are included as appendices to the Toolkit.

16 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

2. Shadowing

One of the best training methods is to shadow an

experienced DDCAT assessor on a visit, preferably

more than once. As mentioned above, practice has

been shown to improve the quality of the assessment.

Observing how the visit is organized, what the

assessor looks for on the tour, the assessor’s interview

questions and techniques, how the assessor manages

discrepancies in information, and the preliminary

feedback session provides a model for the new assessor

to emulate. Reviewing medical records, policies and

procedure manuals, and other materials together offers

an opportunity to learn how to obtain the desired

information in a limited period of time. Individuals

who train in this fashion are encouraged to score the

assessment independently of the experienced assessor,

and then compare and discuss the basis for each score,

not just those that were scored differently.

3. DDCAT Vignette/Case Study

A vignette has been developed to help individuals

practice evaluating information gathered at a DDCAT

visit and scoring the assessment. The vignette briey

describes a DDCAT visit to a ctional addiction

treatment program and the information gleaned from

tour observations, staff and patient interviews, policy

and procedures review, and medical record reviews.

Itis a composite of actual DDCAT visit interactions and

observations, intended to give “the feel” of a visit, as

well as a demonstration of how a visit might elicit some

conicting information. The vignette and scoring guide

are included as appendices.

17Scoring and Prole Interpretation

IV. Scoring and Prole Interpretation

A. Scoring Each DDCAT Item

Each program element of the DDCAT is rated on a

1-to-5scale.

n

A score of 1 is commensurate with a program that

is focused on providing services to persons with

substance use disorders. This level, using ASAM

language, is referred to on the DDCAT as Addiction

Only Services (AOS).

n

A score of 3 indicates a program that is capable

of providing services to some individuals with

co-occurring substance use and mental health

disorders, but has greater capacity to serve

individuals with substance use disorders.

Thislevelis referred to as being Dual Diagnosis

Capable (DDC) by ASAM and on the DDCAT.

n

A score of 5 designates a program that is capable

of providing services to any individual with co-

occurring substance use and mental health

disorders, and the program can address both types

of disorders fully and equally. This level is referred

to as being Dual Diagnosis Enhanced (DDE) on the

DDCAT.

n

Scores of 2 and 4 are reective of intermediary

levels between the standards established at the

1-AOS, 3-DDC, and 5-DDE levels.

Dual Diagnosis Capability

inAddiction Treatment

(DDCAT) Toolkit

Version 4.0

When rating a program on the DDCAT, it is helpful to

understand that the objective anchors on the scale for

each program element are based on the followingfactors:

1) The presence or absence of specic hierarchical

or ordinal benchmarks: 1-AOS sets the most basic

mark; a 3-DDC sets the mid-level mark; a 5-DDE

sets the most advanced benchmark to meet. For

example, the rst Index element regarding the

program’s mission statement requires specic

standards to be met in order to meet the minimum

requirements for scoring at each of the benchmark

levels (AOS, DDC, or DDE).

-or-

2) The relative frequency of an element in the

program, such as in the last Index element

regarding clinical staff that have advanced training

in integrated services. The rating 1-AOS sets a

lower percentage of staff with required training,

3-DDC requires a moderate percentage, and 5-DDE

requires the maximum percentage. Another way

frequency may be determined is the degree to

which the process under assessment is clinician-

driven and variable or systematic and standardized.

When processes are clinician-driven they are

less likely to occur on a consistent basis and be

incorporated into a program’s routine practices.

-or-

18 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

3) A combination of a presence of a hierarchical

standard and the frequency at which these

standards occur. In other words, in order to meet

the criterion of 3 or 5 on a DDCAT item, a program

must meet a specic qualifying standard. Also, the

program must consistently maintain this standard

for the majority of their patients (set at an 80

percent basis). For example, the program element

regarding integrated assessment sets a qualifying

standard for the type of assessment used and

species the frequency with which the standard

isroutinely applied.

B. Scoring the DDCAT Index

Scoring the DDCAT will produce ratings on the seven

dimensions and categorize the program as AOS, DDC or

DDE. This is a simple way to indicate the co-occurring

capacity of an agency’s program.

The total score for the DDCAT and rank of the program

overall is arrived at by:

1. Tallying the number of 1’s, 2’s, 3’s, 4’s, and 5’s

that a program obtained.

2. Calculating the following percentages:

a) Percentage of 5’s (DDE) obtained

b) Percentage of 3’s, 4’s, and 5’s (scores of 3 or

greater) obtained

c) Percentage of 1’s and 2’s obtained

3. Applying the following cutoffs to determine the

program’s DDCAT category:

a) Programs are DDE if at least 80 percent

ofscores (i.e., 28 of the 35) are 5’s

b) Programs are DDC if at least 80 percent

ofscores are 3’s or greater

c) Programs are AOS if less than 80 percent

ofscores are 3’s or greater

C. Creating Scoring Proles

The dimension scores are the average scores of the

items within each dimension. Dimension scores can

be examined for relative highs and lows and may be

connected with the agency’s own readiness to address

specic, if not all, areas. These averages can also be

depicted on a chart (line graph) and presented as the

program’s prole. Horizontal lines can indicate points

above or below the benchmark criteria (e.g., DDC) and

this can serve as a visual aid in focusing the assessor

and program leadership on both those dimensions that

are strengths and areas for potential development. This

bar graph can be very useful to guide feedback and for

targeting program enhancement efforts. Lastly, the visual

depiction can be enlightening if DDCAT assessments are

conducted at two or more points in time. As a process

or continuous quality improvement measure, the prole

depicts change or stabilization by dimension.

19Scoring and Prole Interpretation

D. Feedback to Programs

Feedback to programs based on their assessment

istypically provided in two formats: verbal feedback

andawritten report.

First, at the end of the DDCAT site visit, agency directors

and leadership may receive some preliminary verbal

feedback. A suggestion is to focus on the strengths of

the program and, where possible, join with those issues

that have already been identied as quality improvement

issues by the agency/program staff members themselves.

This could be seen as a parallel to motivational

interviewing techniques.

The second format is via written report, which can be

structured in several different ways. The report may be

inthe form of a summary letter to the agency director

or a more formal structured report. Regardless of the

format, the feedback letter or report should include:

n

a communication of appreciation;

n

a review of what programs and sources of data

were assessed;

n

a summary of their scores, including their

categorical rating of AOS, DDC, or DDE, and a

graph from the Excel workbook that shows the

seven dimension scores;

n

an acknowledgment of relative strengths in existing

services; and

n

empathic and realistic suggestions of potential

areas that can be targeted for enhancement.

Additional components that could be included in the

report include:

n

a graphical display of the program’s overall and

dimension scores compared to their region/county/

state’s overall averages;

n

a discussion and graph showing the changes since

baseline if the assessment is a follow-up.

Conversation and written summaries about dimensions,

as well as themes across dimensions, are often the

most useful ways for providers to consider where they

are and where they want to go. The report may include

specic recommendations (e.g., listing and describing

specic screening measures to systematize screening

forco-occurring disorders) or may mention only thematic

areas of potential improvements.

21DDCAT Index: Scoring and Program Enhancements

V. The DDCAT Index:

Scoring and Program Enhancement

n

Dual Diagnosis Capable = (SCORE-3): Primary

focus is addiction, co-occurring disorders are

treated. The program has a mission statement that

identies a primary target population as being

individuals with substance use disorders, but

the statement also indicates an expectation and

willingness to admit individuals with a co-occurring

mental health disorder and to address that

disorder, at least within the context of addiction

treatment. The term “co-occurring disorders”

does not need to be used specically in the

missionstatement.

An example of a mission statement that meets the DDC

level would be one similar to the following. Note that a

specic population is identied, but it also incorporates

a willingness to treat the person comprehensively and

provide the necessary arrays of services.

“e mission of the Addiction Board is to improve the

quality of life for adults and adolescent with addictive

disorders. is is accomplished by ensuring access to an

integrated network of eective and culturally competent

behavioral health services that are matched to persons’

needs and preferences; thus promoting consumer rights,

responsibilities, rehabilitation, and recovery.”

Dual Diagnosis Capability

inAddiction Treatment

(DDCAT) Toolkit

Version 4.0

I. Program Structure

IA. Primary focus of agency as

stated in the mission statement.

(Ifprogram has mission, consider

programmission.)

Denition: Programs that offer treatment for individuals

with co-occurring disorders should have this philosophy

reected in their mission statements.

Source: Agency or program brochure or in frames

onwalls of ofces or waiting areas.

Item Response Coding: Coding of this item requires

an understanding and review of the program’s mission

statement, specically as it reects a co-occurring

disorders orientation.

n

Addiction Only Services = (SCORE-1): Addiction

only. The program has a mission statement that

outlines its mission to be the treatment of a

primary target population who are dened as

individuals with substance use disorders only.

22 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

AOS PROGRAMS

Enhancing IA. Primary focus of agency as stated in the mission statement.

(If program has mission, consider program mission.)

Programs scoring a 1 for this item likely have a more

traditional mission statement, such as: “The North

Side Alcohol and Drug Treatment Center is dedicated

to assisting persons with alcohol and drug problems

regain control over their lives.”

Revising a mission statement is emblematic of

a “seachange” in leadership philosophy and

commitment even though the new mission statement

may not directly or immediately affect the clinical

practices at a program. Consider this subtle shift in

the last phrase of the mission statement: “The North

Side Alcohol and Drug Treatment Center is dedicated

to assisting persons initiate a process of recovery from

substance use and its associated problems.”

A DDC mission statement is characterized by a clear

willingness to treat individuals with COD. Often this

is communicated in overarching terminology, such as

“behavioral health” or “recovery.” Here is an example:

“The City Clinic is committed to offering a full range

of behavioral health services to promote well-being

andlifelong recovery.”

DDC PROGRAMS

Enhancing IA. Primary focus of agency as stated in the mission statement.

(If program has mission, consider program mission.)

DDC programs have scored a 3 on this item. It is

likely that the mission statement reects a program

philosophy that recognizes comorbid mental health

disorders as secondary to substance use disorders.

A DDE program mission statement is characterized

by an equivalent focus on substance use and mental

health disorders. It will include the term “co-occurring

disorders” or clearly encompass both mental health

and addiction treatmentservices.

Some providers take issue with the “behavioral”

terminology, arguing that it may connote a less

than holistic (or perhaps mechanistic) approach to

health care. Alternative terminology that embraces

co-existing mental health and substance use disorders

isalsotting.

n

Dual Diagnosis Enhanced = (SCORE-5): Primary

focus on persons with co-occurring disorders.

Theprogram has a mission statement that

identies the program as being one that is

designed to treat individuals with co-occurring

disorders. The statement notes that the program

has the combined capacity to treat both mental

health andsubstance use disorders equally.

“e Behavioral Health Unit is a private, non-prot

organization dedicated to providing services that support

the recovery of families and individuals who experience

co-occurring mental health and substance use disorders.”

23DDCAT Index: Scoring and Program Enhancements

IB. Organizational certication

andlicensure.

Denition: Organizations that provide integrated

treatment are able to provide unrestricted services

to individuals with co-occurring disorders. These

organizations do so without barriers that have

traditionally divided the services for mental health

disorders from the services for substance use disorders.

The primary examples of organizational barriers include

licenses or certications of clinics or programs that

restrict the types of services that can be delivered.

Source: Interview with agency or program director

orprior knowledge of applicable rules and regulations.

Item Response Coding: Coding of this item requires

anunderstanding and review of the program’s

license orcertication permit and specically how

this document might selectively restrict the delivery

ofservices on adisorder-specic basis.

n

Addiction Only Services = (SCORE-1):

Permitsonlyaddiction treatment. The program’s

certication, licensure agreement or state permit

restricts services to individuals with substance use

disorders only.

n

(SCORE-2): Has no actual barrier, but staff report

there to be certication or licensure barriers.

Theprogram’s certication, licensure agreement

orstate permit is the same as described at the

DDClevel in that there are no restrictions in serving

individuals with mental health disorders that co-

occur with substance use disorders. But the staff

and administrators report and perceive barriers in

providing mental health services; thus the program

operates in a manner consistent withAOS.

n

Dual Diagnosis Capable = (SCORE-3): Has no

barrier to providing mental health treatment or

treating co-occurring disorders within the context

of addiction treatment. The program’s certication,

licensure agreement or state permit identies

the target population to be individuals with

substance use disorders but does not restrict the

program from serving individuals with co-occurring

mental health disorders. The program provides

services in the context of addiction treatment

licensure. It targets mental health problems in

ageneral approach, for example, in the context

ofrelapseprevention.

n

Dual Diagnosis Enhanced = (SCORE-5): Is certied

and/or licensed to provide both. The program’s

certication, licensure agreement(s) or state

permit(s) identies the program as providing

services for both mental health and substance

usedisorders.

24 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

AOS PROGRAMS

Enhancing IB. Organizational certication and licensure.

Programs at the AOS level often face legitimate

certication or licensure restrictions. This restriction

encumbers a program to provide treatment solely to

persons who meet criteria for a substance use disorder.

Even though many patients will have an active co-

occurring mental health disorder, the program must

declare the substance use disorder as primary if

notsingular.

Several practical strategies are possible to elevate a

program to the DDC level. Some programs cite long-

standing agency traditions to assert their inability to

treat persons with co-occurring disorders. Regional,

state, and funder policies must be veried so that

restrictions, if they do exist, can be clearly determined.

Some state authorities have made special allocations

for persons with co-occurring disorders (i.e., substance

use disorders with complications). Other programs have

sought joint mental health licensure or hired licensed

staff to bill for unbundled services. Finally, it is common

and realistic for a program to provide services that

generically target mental health problems within the

context and scope of addiction treatment licensure.

DDC PROGRAMS

Enhancing IB. Organizational certication and licensure.

Programs at the DDC level with intentions to attain

DDE on this item will likely need to acquire secondary

or additional licensure or certication to provide

mental health treatment services.

25DDCAT Index: Scoring and Program Enhancements

Minimal coordination, consultation, collaboration, and

integration are not discrete points, but bands along a

continuum of contact and coordination among service

providers. “Minimal coordination” is the lowest band

along the continuum, and integration the highest

band. Please note that these bands refer to behavior,

not to organizational structure or location. “Minimal

coordination” may characterize provision of services by

two persons in the same agency working in the same

building; “integration” may exist even if providers are

in separate agencies in separate buildings.

Minimal coordination: “Minimal coordination”

treatment exists if a service provider meets any of the

following: (1) is aware of the condition or treatment

but has no contact with other providers, or (2) has

referred a person with a co-occurring condition to

another provider with no or negligible follow-up.

Consultation: Consultation is a relatively informal

process for treating persons with co-occurring

disorders, involving two or more service providers.

Interaction between or among providers is informal,

episodic, and limited. Consultation may involve

transmission of medical/clinical information, or

occasional exchange of information about the person’s

status and progress. The threshold for “consultation”

relative to “minimal coordination” is the occurrence

of any interaction between providers after the initial

referral, including active steps by the referring

party to ensure that the referred person enters the

recommended treatment service.

Collaboration: Collaboration is a more formal process

of sharing responsibility for treating a person with

co-occurring conditions, involving regular and

planned communication, sharing of progress reports,

or memoranda of agreement. In a collaborative

relationship, different disorders are treated by

different providers, the roles and responsibilities of

the providers are clear, and the responsibilities of all

providers include formal and planned communication

with other providers. The threshold for “collaboration”

relative to “consultation” is the existence of formal

agreements and/or expectations for continuing contact

between providers.

Integration: Integration requires the participation

of substance abuse and mental health services

providers in the development of a single treatment

plan addressing both sets of conditions, and the

continuing formal interaction and cooperation of these

providers in the ongoing reassessment and treatment

of the client. The threshold for “integration” relative

to “collaboration” is the shared responsibility for the

development and implementation of a treatment plan

that addresses the co-occurring disorder. Although

integrated services may often be provided within

a single program in a single location, this is not a

requirement for an integrated system. Integration

might be provided by a single individual, if s/he is

qualied to provide services that are intended to

address both co-occurring conditions.

IC. Coordination and collaboration

withmental healthservices.

Denition: Programs that transform themselves from

ones that only provide services for substance use

disorders into ones that can provide integrated services

typically follow a pattern of staged advances in their

service systems. The steps indicate the degree of

communication and shared responsibility between

providers who offer services for mental health and

substance use disorders. The following terms are used

to denote the stepwise advances and originate from

SAMHSA’s Co-Occurring Measure (2007).

26 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

Source: Interviews with agency director, program clinical

leaders, and clinicians. Some documentation may also

exist (e.g., a memorandum of understanding).

Item Response Coding: Coding of this item requires

anunderstanding of the service system and structure

ofthe program, specically with regard to the provision

of mental health as well as addiction treatment services.

An understanding of the SAMHSA terms dened

above isalso necessary. The DDCAT scoring directly

corresponds to those denitions.

n

Addiction Only Services = (SCORE-1): No

document of formal coordination or collaboration.

Meets the SAMHSA denition of Minimal

Coordination.

n

(SCORE-2): Vague, undocumented, or informal

relationship with mental health agencies, or

consulting with a staff member from that agency.

Meets the SAMHSA denition of Consultation.

n

Dual Diagnosis Capable = (SCORE-3): Formalized

and documented collaboration or collaboration

with mental health agency. Meets the SAMHSA

denition of Collaboration.

n

(SCORE-4): Formalized coordination and

collaboration, and the availability of case

management staff, or staff exchange programs

(variably used). Meets the SAMHSA denition of

Collaboration and has some informal components

consistent with Integration. These programs

have a system of care that meets the denition

of collaboration and demonstrate an increased

frequency of integrated elements. However, these

elements are informal and not part of the dened

program structure. Typical examples of activities

that occur at this level would be informal staff

exchange processes or case management on an

as-needed basis to coordinate services.

n

Dual Diagnosis Enhanced = (SCORE-5): Most

services are integrated within the existing program,

or routine use of case management staff or staff

exchange programs. Meets the SAMHSA denition

of Integration.

AOS PROGRAMS

Enhancing IC. Coordination and collaboration with mental health services.

AOS level programs either have no existing relationship

or an informal one with the local mental health

provider. Programs intending to achieve DDC status

must develop more formalized procedures and

protocols to coordinate services for persons with

co-occurring disorders.

Staff at the North Shore Alcohol and Drug Treatment

Center (NSADTC) often referred patients to the

Lakeland Mental Health agency for psychiatric

emergencies or for a medication evaluation if deemed

appropriate. Psychiatric emergencies would occur

one to two times per year, and would usually be dealt

with by calling 911. A social worker at NSADTC

who formerly worked at Lakeland was often asked

tocontact his former colleagues so that patients might

be evaluated within a more expedient time frame.

To become DDC, NSADTC initiated a series of

meetings with Lakeland and the agencies composed

amemorandum of understanding (MOU) that addressed

admission, transfer and referral procedures (see the

appendix for a sample MOU). Monthly meetings

between program coordinators and designated intake

clinicians were also initiated to review the protocol

anddiscuss plans for common patients.

An AOS program moves from a loose and clinician-

driven consultation model to a more formalized and

collaborative one in order to become DDC.

27DDCAT Index: Scoring and Program Enhancements

DDC PROGRAMS

Enhancing IC. Coordination and collaboration with mental health services.

Programs at the DDC level will need to develop more

integrated services in order to score at the DDE level.

Integration can be accomplished at the program

level by providing all services “in house” so patients

may obtain one-stop services. Integration can also

be accomplished at the system level where programs

are so closely connected either by common policies,

electronic medical record systems, or other lines so

that integration occurs across agencies. Coordination

or consultation between programs is not sufcient

for integration. Integration is characterized by mental

health and addiction treatment provision by one or

more providers that is seamless from the patient’s

perspective. Integration within a program can exist

forboth outpatient and residential levels ofcare.

ID. Financial incentives.

Denition: Programs that are able to merge funding for

the treatment of substance use disorders with funding

for the treatment of mental health disorders have a

greater capacity to provide integrated services for

individuals with co-occurring disorders.

Source: Interview with agency director, knowledge

ofregional rules and regulations.

Item Response Coding: Coding of this item requires an

understanding of the program’s current funding streams

and the capacity to receive reimbursement for providing

services for substance use and mental health disorders.

n

Addiction Only Services = (SCORE-1): Can only

bill for addiction treatments or bill for persons with

substance use disorders. Programs can only get

reimbursement for services provided to individuals

with a primary substance use disorder. There is

no mechanism for programs to be reimbursed for

services provided to treat mental health disorders.

n

(SCORE-2): Could bill for either service type if

substance use disorder is primary, but staff report

there to be barriers. OR: Partial reimbursement

formental health services available. The program’s

reimbursement codes allow for reimbursement

as described in the DDC category, but the staff

and administrators report and perceive barriers

in getting reimbursed for mental health services;

thus the program operates in a manner consistent

withAOS.

n

Dual Diagnosis Capable = (SCORE-3): Can bill

for either service type, however a substance

use disorder must be primary. Programs can be

reimbursed for services provided to treat mental

health and substance use disorders as long as the

person being treated has a substance use disorder

that is listed as primary.

n

Dual Diagnosis Enhanced = (SCORE-5): Can bill

for addiction or mental health treatments, or

their combination and/or integration. Programs

can be reimbursed for services provided to treat

both mental health and substance use disorders

equally. There are no specic requirements for

theindividual to have a substance use disorder.

28 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

AOS PROGRAMS

Enhancing ID. Financial incentives.

Programs scoring at the AOS level typically cannot

bill or receive reimbursement for any mental health

services. AOS programs that have shifted to enhanced

mental health services have been able to locate

physicians or prescribers on whose behalf they can

billfor unbundled services.

Another mechanism is to obtain contract or grant

funding to provide adjunctive pharmacological

orpsychosocial services. An innovative methadone

maintenance program secured additional county grant

funding to provide psychiatric and mental health

counseling for methadone patients with mental health

problems. This additional funding from the county

covered the human resources of a psychiatrist

(.1 FTE) and a clinical social worker (.5 FTE).

DDC PROGRAMS

Enhancing ID. Financial incentives.

Programs scoring at the DDE level can bill or receive

reimbursement for mental health services. This may

include mechanisms for billing Medicaid, Medicare,

third party insurance, or via state contracts or

voucherprograms.

The Good Neighbor Clinic, an outpatient addiction

treatment program, arranged for their onsite consulting

psychologist, Dr. Heinrich, to be able to bill Medicaid

and Medicare as well as receive payment for services

to indigent patients (via state funding) and for

diagnostic and couples therapy services.

29DDCAT Index: Scoring and Program Enhancements

II. Program Milieu

IIA. Routine expectation of and welcome

to treatment for both disorders.

Denition: Persons with co-occurring disorders are

welcomed by the program or facility, and this concept

iscommunicated in supporting documents. Persons who

present with co-occurring mental health disorders are not

rejected from the program because of the presence of

this disorder.

Source: Observation of milieu and physical environment,

including posters on walls in waiting rooms and group

rooms, as well as interviews with clinical staff, support

staff, and patients.

Item Response Coding: Coding of this item requires

areview of staff attitudes and behaviors, as well as

theprogram’s philosophy reected in the organization’s

mission statement and values.

n

Addiction Only Services = (SCORE-1): Program

expects substance use disorders only, refers or

deects persons with mental health disorders

orsymptoms. The program focuses on individuals

with substance use disorders only and deects

individuals who present with any type of mental

health problem.

n

(SCORE-2): Documented to expect substance

use disorders only (e.g., admission criteria, target

population), but has informal procedure to allow

some persons with mental health disorders to

be admitted. The program generally expects to

manage only individuals with substance use

disorders, but does not strictly enforce the

refusal or deection of persons with mental

health problems. The acceptance of persons with

mental health disorders likely varies according

to the individual clinician’s competency or

preferences. There is no formalized documentation

indicating acceptance of persons with mental

healthdisorders.

n

Dual Diagnosis Capable = (SCORE-3): Focus

is on substance use disorders, but expects and

accepts mental health disorders by routine and if

mild and relatively stable as reected in program

documentation. The program tends to primarily

focus on individuals with substance use disorders,

but routinely expects and accepts persons with

mild or stable forms of co-occurring mental

health disorders. This is reected in the program’s

documentation and surroundings, (e.g., on walls

and brochure racks).

n

(SCORE-4): Program formally dened like DDC,

but clinicians and program informally expect and

treat co-occurring disorders regardless of severity;

not well documented. The program expects and

accepts individuals with co-occurring disorders

regardless of severity, but this program has evolved

to this level informally and does not have the

supporting documentation to reect this.

n

Dual Diagnosis Enhanced = (SCORE-5): Clinicians

and program expect and treat co-occurring

disorders regardless of severity; well documented.

The program routinely accepts individuals with

co-occurring disorders regardless of severity and

has formally mandated this through its mission

statement, philosophy, welcoming policy, and

appropriate protocols.

30 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

AOS PROGRAMS

Enhancing IIA. Routine expectation of and welcome to treatment for both disorders.

AOS programs typically foster a more traditional

ambiance and environment. This cultural

“atmosphere” is focused on substance-related issues

and recovery from addiction only. Often this focus

hampers a dialogue or openness about mental health

problems or concerns. This milieu may not enable

apatient to inquire about the potential for recovery

from co-occurring mental health disorders.

AOS programs seeking to become DDC must

document, for example, in their admission criteria,

that the program accepts individuals with mild or

stable co-occurring mental health disorders. Programs

can decrease the stigma and elevate the status of

mental health disorders by providing in waiting areas

brochures that describe mental health problems

(e.g., depression) and recovery (e.g., Dual Recovery

Anonymous brochures). These subjects can also be

routinely raised in orientation sessions, community

meetings, or family visits. These practices explicitly

convey a welcoming and acceptance of persons with

mental health disorders.

The cultural undercurrent to a DDC program enables

persons with co-occurring mental health problems

tofeel “normal.”

DDC PROGRAMS

Enhancing IIA. Routine expectation of and welcome to treatment for both disorders.

In order to become a DDE level program, DDC

programs make a milieu or cultural shift to an

equivalent focus on addiction and mental health

disorders. Programs must document, for example,

mission or philosophy statements, and admission

criteria, their acceptance of individuals with

co-occurring disorders regardless of severity. Patients

in DDC programs will report that they are in treatment

to get “clean and sober” but they can also readily

talk about mental health problems and ask questions

about emotional difculties. Whereas patients in DDE

programs are able to articulate that they have two

(or more) co-occurring disorders and they are getting

treatment for both (or all). They may contrast this with

previous treatment experiences, and remark this is

the rst program that has addressed both at the same

time. Patients also report no stigma or differential

status associated with having a co-occurring disorder.

31DDCAT Index: Scoring and Program Enhancements

IIB. Display and distribution of literature

and patient educational materials.

Denition: Programs that treat persons with co-occurring

disorders create an environment which displays,

distributes, and provides literature and educational

materials that address both mental health and substance

use disorders.

Source: Observation of milieu and physical settings,

review of documentation of patient handouts, videos,

brochures, posters and materials for patients and

families that are available and/or used in groups. Patient

interviews are also completed.

Item Response Coding: Coding this item depends on

examination of the clinic environment and waiting

areas. Specically, the different types and displays of

educational materials and public notices are considered.

n

Addiction Only Services = (SCORE-1): Addiction or

peer support (e.g., AA) only. Materials that address

substance use disorders are the only type that is

routinely available.

n

(SCORE 2): Available for both disorders, but not

routinely offered or formally available. Materials

are available for both substance use and mental

health disorders, but they are not routinely

accessible or displayed equally. The majority of

materials and literature are focused on substance

use disorders.

n

Dual Diagnosis Capable = (SCORE-3): Routinely

available for both mental health and substance

use disorders in waiting areas, patient orientation

materials and family visits, but distribution is less

for mental health disorders. Materials are routinely

available for both substance use and mental

disorders, and they are equally displayed. However,

materials for mental health disorders are not

equitably distributed by staff or the program.

n

(SCORE 4): Routinely available for both mental

health and substance use disorders with equivalent

distribution.

n

Dual Diagnosis Enhanced = (SCORE-5): Routinely

and equivalently available for both disorders and

for the interaction between both mental health

and substance use disorders. Materials and

literature address both substance use and mental

disorders and also attend to concerns specic

to co-occurring disorders, such as interactions

of co-occurring disorders and the effects on

psychological function, health, ability to nd and

keep a job, etc.

32 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

AOS PROGRAMS

Enhancing IIB. Display and distribution of literature and patient educational materials.

AOS programs display materials related to drug and

alcohol problems. In some instances, AOS programs

may display brochures and have handouts about

sexually transmitted diseases, substance use during

pregnancy, or transportation entitlements. To become

DDC, a program must provide materials about co-

occurring disorders, or specic common disorders

such as depression, anxiety, and PTSD. These

materials should be visible in waiting areas, in patient

orientation packets or binders, and distributed during

family visits.

Such materials are readily available from SAMHSA

(www.samhsa.gov) and the National Institute of

Mental Health (www.nimh.nih.gov). Many professional

organizations (e.g., the American Psychiatric

Association and American Psychological Association)

and pharmaceutical companies also provide excellent

materials specic to certain co-occurring disorders.

Specic examples include:

A description of co-occurring disorders and guide

to recovery suitable for the general public can be

obtained from SAMHSA’s National Clearinghouse for

Alcohol and Drug Information: http://store.samhsa.

gov/product/Overcoming-Substance-Use-and-Mental-

Disorders/PHD1078.

Some states have a clearinghouse of materials.

Forexample, the Connecticut Department of Mental

Health and Addiction Services funds theConnecticut

Clearinghouse that includes many audiovisual

materials, books, curricula, andpamphlets on co-

occurring disorders, available for providers to borrow

orkeep. Visitwww.ctclearinghouse.org.

DDC PROGRAMS

Enhancing IIB. Display and distribution of literature and patient educational materials.

DDE level programs display and equivalently distribute

materials related to substance use and mental health

problems, and their interaction. These programs

emphasize the common co-occurrence of the

disorders and suggest a plan for recovery from both.

In orientations to the program, psychoeducational

sessions, and family sessions, materials about co-

occurring disorders are routinely distributed.

North Shore Behavioral Health introduces the concept

of mental health disorders to all patients in their

addiction treatment intensive outpatient program.

Theydistribute pamphlets and fact sheets that

describe the expected occurrence rates for depression,

bipolar disorder, anxiety disorders, and PTSD as well

as signs, symptoms and treatments so that patients

and families have realistic ideas about their prospects.

They also present information distinguishing drugs

from medications, and discuss the challenges of co-

occurring disorders in society and in attempting to

afliate with mutual self-help meetings.

DVDs that describe the causes and course of co-

occurring disorders are available from a variety of

publishers. Hazelden Publishing (www.hazelden.org)

offers DVDs on adults with co-occurring disorders and

adolescents with co-occurring disorders. These DVDs

are brief (about 30 minutes) and targeted to patients

and family members. These can serve to systematically

raise awareness and promote discussion during

treatment groups, family education or visit programs

and result in educated consumers of addiction

treatment services.

33DDCAT Index: Scoring and Program Enhancements

III. Clinical Process: Assessment

IIIA. Routine screening methods

formental health symptoms.

Denition: Programs that provide services to individuals

with co-occurring disorders routinely and systematically

screen for both substance use and mental health

disorders. The following text box provides a standard

denition of “screening” and originates from SAMHSA’s

Co-Occurring Measure (2007).

Screening: The purpose of screening is to

determine the likelihood that a person has a

co-occurring substance use or mental disorder.

The purpose is not to establish the presence or

specic type of such a disorder, but to establish

the need for an in-depth assessment. Screening

is a formal process that typically is brief and

occurs soon after the patient presents for

services. There are three essential elements that

characterize screening: intent, formal process,

and early implementation.

n

Intent: Screening is intended to determine the

possibility of a co-occurring disorder, not to

establish denitively the presence, or absence,

orspecic type of such a disorder.

n

Formal process: The information gathered

during screening is substantially the same no

matter who collects it. Although a standardized

scale or test need not be used, the same

information must be gathered in a consistently

applied process and interpreted or used in

essentially the same way foreveryone screened.

n

Early implementation: Screening is conducted

early in a person’s treatment episode. For

the purpose of this questionnaire, screening

would routinely be conducted within the rst

four visits or within the rst month following

admission totreatment.

Source: Interviews with program leadership and staff,

observations of medical record (or electronic medical

record system) or intake screening form packets.

Item Response Coding: Coding of this item requires

the evaluation of screening methods routinely used

intheprogram.

n

Addiction Only Services = (SCORE-1): Pre-

admission screening based on patient self-

report. Decision based on clinician inference

from patient presentation or by history. The

program has essentially no screening for mental

health disorders. On occasion, a program

at this level offers a minimal screening for

mental health disorders, which is based

on the clinician’s initial observations and/

orimpressions.

n

(SCORE-2): Pre-admission screening for symptom

and treatment history, current medications,

suicide/homicide history prior to admission. The

program conducts a basic screening for mental

health problems prior to admission, but it is

not a routine or standardized component of the

evaluation procedures (occurs less than 80 percent

of the time). At this level, the screen might include

some symptom review, treatment history, current

medications, and/or suicide/homicide history.

Considerable variability across clinicians occurs

atthis level.

n

Dual Diagnosis Capable = (SCORE-3): Routine

set of standard interview questions for mental

health using generic framework, e.g., ASAM-

PPC (Dimension III) or “biopsychosocial” data

collection. The program conducts a screening

process with interview questions for mental

health problems; it is incorporated into a more

comprehensive evaluation procedure and it

occurs routinely (at least 80 percent of the

time). This screening is standardized in that

itconsists of a standard set of questions or items

and a routine mental health status screening,

including questions to assess risk of harm to self

34 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

or others. The format of the screening questions

may be open-ended or discrete, but they are

usedconsistently.

n

(SCORE-4): Screen for mental health symptoms

using standardized or formal instruments with

established psychometric properties. The program

conducts a systematic screening process that uses

standardized, reliable and valid instrument(s) for

screening mental health symptoms. This screening

process is routinely used (at least 80 percent of

the time).

n

Dual Diagnosis Enhanced = (SCORE-5): Screen

using standardized or formal instruments for both

mental health and substance use disorders with

established psychometric properties. The program

conducts a systematic screening process which uses

standardized, reliable, and validated instrument(s)

for screening both substance use andmental

health disorders. This screening process is routinely

(atleast 80 percent of the time) incorporated into

the comprehensive evaluation procedures, and it

is considered an essential component in directing

theindividual’scare.

AOS PROGRAMS

Enhancing IIIA. Routine screening methods for mental health symptoms.

AOS programs typically attempt to capture or detect

mental health problems via an initial phone interview.

This interview typically asks about current and past

medications, prior psychiatric hospitalizations, and

ifthe caller ever received a mental health diagnosis.

The responses may be used to refer a patient to a

mental health treatment center and may not routinely

trigger a mental health assessment.

In order to become DDC, AOS programs must extend

this procedure to routinely screen for current and

past mental health problems using a standard set

of interview questions (such as to screen for mood,

PTSD, or trauma symptoms), and a routine mental

health status screening, including questions to assess

risk of harm to self or others.

For more information on screening, an overview of

screening and assessment produced by SAMHSA’s

Co-Occurring Center for Excellence is available.

Screening, Assessment, and Treatment Planning

forPersons with Co-Occurring Disorders is online at

www.samhsa.gov/co-occurring/topics/screening-and-

assessment/samsha-overview.aspx.

35DDCAT Index: Scoring and Program Enhancements

DDC PROGRAMS

Enhancing IIIA. Routine screening methods for mental health symptoms.

In order to achieve the DDE level, DDC programs

institute standardized screening measures for both

mental health and substance use disorders, and the

measures are used routinely (with at least 80 percent

of patients). Measures can screen for more general

mental health symptoms and/or substance use, and

some are sensitive to identifying specic mental health

problems. Examples of some general measures include

the Modied MINI Screen (MMS), Mental Health

Screening Form-III , CAGE-AID, Simple Screening

Instrument for Alcohol and Other Drugs (SSI-AOD),

and the Global Appraisal of Individual Need (GAIN)

Short Screener (GAIN-SS). Measures with greater

specicity to screen for the most prevalent mental

health disorders are also recommended. These may

include measures for depression (e.g., the Beck

Depression Inventory), anxiety (e.g., the Beck Anxiety

Inventory), PTSD (e.g., the Posttraumatic Stress

Disorder Checklist), and social phobia (e.g., Social

Interaction Anxiety Scale). Key to operating at the DDE

level is the implementation and systematic application

of a standardized (and psychometrically sound)

screening measure(s). Examples of screening measures

are included in the appendices.

36 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

IIIB. Routine assessment if screened

positive for mental health symptoms.

Denition: Programs that provide services to persons

with co-occurring disorders should routinely and

systematically assess for mental health problems

as indicated by a positive screen. The following text

box provides a standard denition of “assessment”

and originates from SAMHSA’s Co-Occurring

Measure(2007).

Assessment: An assessment consists of gathering

information and engaging in a process with the

patient that enables the provider to establish the

presence or absence of a co-occurring disorder;

determine the patient’s readiness for change; identify

patient strengths or problem areas that may affect

the processes of treatment and recovery; and engage

a person in the development of an appropriate

treatment relationship. The purpose of the

assessment is to establish (or rule out) the existence

of a clinical disorder or service need and to work

with the patient to develop a treatment and service

plan. Although a diagnosis is often an outcome of

an assessment, a formal diagnosis is not required

to meet the denition of assessment, as long as the

assessment establishes (or rules out) the existence

ofsome mental health or substance use disorder.

Assessment is a formal process that may involve

clinical interviews, administration of standardized

instruments, and/or review of existing information.

Forinstance, ifreasonably current and credible

assessment information is available at the time

of program entry, the (full) process need not be

repeated. There are twoessential elements for the

denition of assessment: establish or rule-out a co-

occurring disorder (diagnosis) and use results of the

assessment in the treatment plan.

Establish (rule-out) co-occurring disorder: The

assessment must establish justication for services

and yield sufcient information to determine or

rule-out the existence of co-occurring mental health

and substance use disorders. (A specic diagnosis

isnotrequired.)

Use results in the treatment plan: The assessment

results must routinely be included in the

development ofa treatment plan.

Source: Interview with program leadership and staff,

policy and procedure manual, and medical record.

Item Response Coding: Coding of this item requires the

evaluation of the assessment methodology routinely used

in the program or facility.

n

Addiction Only Services = (SCORE-1): Assessment

for mental health disorders is not recorded in

records. There is no formal or standardized process

that assesses for mental health disorders when

such disorders are suspected within the program.

At most, a program offers ongoing monitoring

for mental health disorders when mental health

disorders are suspected. In most cases, the

ongoing monitoring is to determine appropriateness

or exclusion from care.

n

(SCORE-2): Assessment for mental health

disorders occurs for some patients, but is not

routine or is variable by clinician. This may include

a more detailed biopsychosocial assessment or

mental status exam, but it is clinician-driven.

Theprogram does not offer a standardized process

to assess for mental health disorders, but there

are variable arrangements for a mental health

assessment that are provided based upon clinician

preference and expertise.

37DDCAT Index: Scoring and Program Enhancements

n

Dual Diagnosis Capable = (SCORE-3): Assessment

for mental health disorders is present, formal,

standardized and documented in 50 to 69 percent

of the records. Formal mental health assessment,

if necessary, typically occurs if there is a positive

screen for mental health symptoms. The program

has a formal policy and a regular mechanism

for providing a formal mental health assessment

as is necessary based on a positive screen.

Aformal mental health assessment is dened

as a standardized set of elements or interview

questions that assesses mental health concerns

(current symptoms and chief complaints, past

mental health history and typical course and

effectiveness of previous treatment, mental health

risk, etc.) in a comprehensive fashion. This level

of mental health assessment requires the expertise

ofan individual who is capable of conducting

such anevaluation, either by education, training,

licensure, certication, or supervised experience.

This could be done on site or off site with a formal

relationship as documented in a memorandum

ofunderstanding, forexample.

n

(SCORE-4): Assessment for mental health

disorders is present, formal, standardized, and

documented in 70 to 89 percent of the records.

This includes having a policy and capacity for

formal mental health assessments, as dened

above, following all positive mental health screens.

n

Dual Diagnosis Enhanced = (SCORE-5):

Assessment for mental health disorders

isformal, standardized and integrated with

assessment for substance use symptoms,

anddocumented in at least 90 percent of the

records. The program provides standardized or

formal integrated assessment to all individuals

following all positive mental health screens per

formal policy. Anintegrated assessment entails

comprehensive assessment for both substance use

and mental health disorders, which is conducted

in a systematic, integrated, and routine manner

byacompetent provider.

AOS PROGRAMS

Enhancing IIIB. Routine assessment if screened positive for mental health symptoms.

DDC programs offer a mental health assessment to

persons who are identied via screening, by history,

or by observable behaviors. Such assessments are

guided by the belief that there is a potential benet

for a mental health treatment (e.g., medication). DDC

programs offer such assessments on site or off site

with a formal relationship as documented in a MOU,

for example, and these can be conducted on a routine,

timely, and consistent basis.

The City Clinic provides a mental health assessment

to patients who are identied by self-reports of mental

health symptoms. This evaluation is performed by the

consultant nurse practitioner who is at the program

one day per week.

38 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

IIIC. Mental health and substanceuse

diagnoses madeanddocumented.

Denition: Programs serving persons with co-

occurring disorders have the capacity to routinely and

systematically diagnose both mental health disorders

and substance use disorders.

Source: Interviews with staff, medical record/chart.

Item Response Coding: Coding of this item requires the

review of diagnostic practices within the program.

n

Addiction Only Services = (SCORE-1): Mental

health diagnoses are neither made nor recorded

inrecords. The program does not provide

diagnoses for mental health disorders. In some

cases, diagnoses of mental health disorders may

be discouraged or not recorded.

n

(SCORE-2): Mental health diagnostic impressions

or past treatment records are present in records,

but the program does not have a routine process

for making and documenting mental health

diagnoses. The program has a limited capacity to

provide mental health diagnoses in an inconsistent

capacity. At most, this service is provided

occasionally or on an as needed basis.

n

Dual Diagnosis Capable = (SCORE-3): The program

has a mechanism for providing diagnostic services

in a timely manner. Mental health diagnoses are

documented in 50 to 69 percent of the records.

The program has established a formal mechanism

for mental health diagnoses to be provided and

documented. There is some variability in the

program’s capacity to do this, but these diagnostic

services are provided with enough regularity to

meet the needs of individuals with severe or acute

mental health disorders.

n

(SCORE-4): The program has a mechanism for

providing routine, timely diagnostic services.

Mental health diagnoses are documented in 70 to

89 percent of the records. Mental health diagnoses

are more frequently recorded, but inconsistently; it

is done if issues are identied in the assessment.

n

Dual Diagnosis Enhanced = (SCORE-5):

Comprehensive diagnostic services are provided

in a timely manner. Mental health diagnoses are

documented in at least 90 percent of the records.

Standard and routine mental health diagnoses

are consistently made. The program has a formal

mechanism to ensure a comprehensive diagnostic

assessment for each individual, which ensures

that mental health diagnoses, when warranted

are consistently made and documented. Evidence

supports that the full range of mental health

diagnoses are provided.

DDC PROGRAMS

Enhancing IIIB. Routine assessment if screened positive for mental health symptoms.

To achieve a DDE level, DDC programs must

institute asystematic mental health assessment for

all individuals who screen positive. This is based

on the clear expectation that all patients entering

the treatment will have a co-occurring mental

health disorder. ADDE program will conduct these

assessments in a consistent manner across clinicians.

This can either be accomplished by an electronic

clinical decision support tool, or a semi-structured

clinical interview (GAIN), Addiction Severity Index

(ASI), Structured Clinical Interview for DSM-IV-TR

(SCID), or another well-dened and thorough protocol

developed by the program.

39DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing IIIC. Mental health and substance use diagnoses made and documented.

AOS programs register only substance use disorder

diagnoses in their medical record or patient chart.

There are numerous reasons for this exclusive focus.

To become DDC, however, AOS programs must

follow the process from screening to assessment to

a formal diagnosis minimally in relation to screening

results/presenting problems. In those cases, this

diagnosis must be regularly included in the program’s

documentation or electronic record. Including a

problem (e.g., depression problem) or a rule out

diagnosis (e.g., R/O dysthymia) is not acceptable

atthe DDC level.

DDC PROGRAMS

Enhancing IIIC. Mental health and substance use diagnoses made and documented.

DDC programs routinely provide comprehensive

diagnostic services in a timely manner, with mental

health diagnoses. These diagnoses are routinely

reected in medical records. To attain DDE level

services, these diagnoses, when present, are more

systematically and routinely ascertained. Further,

they are observable in a sample of all records and all

patients being treated. The diagnoses are specic,

and include all ve of the axes on the DSM-IV multi-

axialsystem.

40 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

IIID. Mental health and substance use

history reected in medical record.

Denition: Biopsychosocial and other clinical assessment

and evaluative processes routinely assess and describe

past history and the chronological or sequential

relationship between substance use and mental health

disorders or problems.

Source: Medical record.

Item Response Coding: Coding of this item requires the

review of documentation, specically the protocols or

standards in the collection of the individual’s substance

use and mental health history.

n

Addiction Only Services = (SCORE-1):

Collection ofsubstance use disorder history

only. The program does not utilize or promote

standardized collection of mental health history

and only collects substance use history on a

routine basis.

n

(SCORE-2): Standard form collects substance

use disorder history only. Mental health

history collected inconsistently. In addition

to the routine collection of substance use

history, the program encourages the collection

of mental health history, but this history is

neither structured nor incorporated into the

standardized assessment process. The degree

and variability in collection methods varies

considerably by clinician preference and

competency. If the program provides a means of

collecting a formal mental health history (as set

by the standard in DDC), the program does so

only variably (less than 80 percent of the time).

n

Dual Diagnosis Capable = (SCORE-3): Routine

documentation of both mental health and

substance use disorder history in record in

narrative section. In the course of routine

collection of substance use history, there is

a routine narrative section in the record that

discusses mental health history and this

documentation occurs at least 80 percent of the

time. This is evident in the records of the majority

of individuals assessed, which document and

discuss mental health histories. When applicable

for an individual’s history, narrative sections note

even the absence of mental health related history.

n

(SCORE-4): Specic section in record dedicated

tohistory and chronology of both disorders.

n

Dual Diagnosis Enhanced = (SCORE-5): Specic

section in record devoted to history and chronology

of course of both disorders and the interaction

between them is examined temporally. The

program has established a specic standardized

section of the assessment that is devoted to both

mental health and substance use histories, and

this section also provides historical information

regarding the interactions between these two

disorders. The mental health history section

is more structured and has specic content or

elements that are to be covered in this section

of the assessment, and this documentation is

completed at least 80 percent of the time.

41DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing IIID. Mental health and substance use history reected in medical record.

Although mental health and substance use disorders

commonly interact, AOS programs typically document

only a history of a patient’s mental health disorder.

However, assessing and diagnosing mental health

disorders in addiction treatment are complicated by

the effects of substances, from intoxication to craving

to withdrawal to protracted withdrawal. The DSM-

IV provides some guidelines in making differential

diagnosis (substance-induced vs. independent

disorders) and the Clinical Institute for Withdrawal

Assessment (CIWA) assists in identifying the type

andseverity of withdrawal symptoms.

Programs at the DDC level typically gather information

about a patient’s substance use and mental health

disorders in terms of ages of onset and course. This is

recorded in the patient chart and typically documented

as a narrative in a quasi-chronological format.

DDC PROGRAMS

Enhancing IIID. Mental health and substance use history reected in medical record.

DDE programs recognize the complexity of the

interaction of these disorders, and that only

by conducting a longitudinal and systematic

observation will the relationship between disorders

be comprehended. DDE programs have specic and

dedicated segments in their initial evaluation process

to record dates of onset, course of illness, and the

interaction between disorders during periods of

abstinence, treatment, institutionalization, etc.

DDE programs recognize that the criteria in the

DSM-IV necessitates a chronological and sequential

review of symptoms in order to distinguish between

substance-induced disorders (e.g., substance-

induced mood disorder; substance-induced anxiety

disorder, orsubstance-induced psychotic disorder) vs.

independent mental health disorders (e.g., dysthymic

disorder, panic disorder, or schizophrenia).

DDE programs do not rely on individual clinicians

to probe these chronologies, but ensure consistency

by formats within the medical record or electronic

medical record. Time line follow-back (TLFB) calendars

are a helpful tool to assess and document histories of

substance use and mental health symptoms (see the

appendix section). This temporal display illustrates

the interplay between disorders, which may facilitate

an appropriate treatment plan and effective relapse

prevention strategies.

42 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

IIIE. Program acceptance based on

mental health symptom acuity:

low,moderate, high.

Denition: Programs offering services to individuals with

co-occurring disorders use mental health symptom acuity

or instability within the current presentation to assist

with the determination of the individual’s needs and

appropriateness, and whether the program is capable

ofeffectively addressing these needs.

Source: Interview with program leadership and staff,

policy and procedure manual, and initial contact and/or

referral form.

Item Response Coding: Coding of this item requires

anunderstanding of clinical protocol for individuals who

present with different levels of mental health symptom

acuity (e.g., suicidality, dangerousness, agitation, self-

regulatory capacity). The level of care capacities within

the program must be taken into account when rating

thisitem.

n

Addiction Only Services = (SCORE-1): Admits

persons with no to low acuity. The program cannot

care for individuals who present with any level of

mental health symptom acuity.

n

Dual Diagnosis Capable = (SCORE-3): Admits

persons in program with low to moderate acuity,

but who are primarily stable. The program is

capable of providing care to individuals who

present with low to medium acuity of mental

health symptoms; persons are primarily stable

atpresent (i.e., no active suicidality, homicidality,

and some capacity for self-regulation). These

programs are able to plan for (i.e., advanced

directives) and temporarily manage some crisis

stabilization interventions with higher acuity

mental health disorders, but tend to rely on

linkages/referrals to mental health programs.

n

Dual Diagnosis Enhanced = (SCORE-5): Admits

persons in program with moderate to high acuity,

including those unstable in their mental health

disorder. The program is capable of providing

services to individuals who present with all ranges

of mental health symptom acuity, including those

with high acuity, whose present mental status may

be severe or unstable. These programs have the

capacity to provide comprehensive treatment in an

integrated manner for these high-acuity individuals

and are not dependent on a referral system with

mental health services.

43DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing IIIE. Program acceptance based on mental health symptom acuity: low, moderate, high.

AOS programs routinely base admission decisions on

mental health history (e.g., prior hospitalizations), the

present diagnoses they carry (e.g., bipolar disorder),

or medications (e.g., olanzapine). Even if persons with

mental health disorders are presently stable, by virtue

of their history, the AOS program will decline or defer

admission. Determination of these patients’ entry may

be based upon clinical appropriateness (“We can’t get

their meds if they run out.”) or milieu driven (“We don’t

want other patients to be distracted.”) or staff driven

(“We only have one person at this residential program

here on nights and weekends.”).

To be DDC, AOS programs must be able, within the

capacity of their staff resources and level of care, to

accept patients regardless of their history of mental

health disorders, but more so based on their current

level of acuity or stability (e.g., suicidality, homicidality,

self-care, affective dysregulation, impulsivity). DDC

programs accept patients regardless of their history

ofimpairment, but who are primarily stable.

DDC PROGRAMS

Enhancing IIIE. Program acceptance based on mental health symptom acuity: low, moderate, high.

Within the constraints of clinical appropriateness

bylevel of care to manage risk (inpatient hospital

vs.outpatient), DDE programs will accept patients for

treatment regardless of present acuity. DDC programs

seeking to achieve this status should establish

appropriate staff members, protocols for patient

monitoring and observation, and clear crisis and

emergency procedures.

Mental health acuity must be assessed in the DDE

program using routine protocols and procedures (and

qualied staff to do so). The DDE program accepts

patients regardless of acuity (i.e., patients do not need

to be stable for admission). DDE programs that are

unable to offer a complete continuum of care have

established and can demonstrate strong collaborative

arrangements with mental health providers.

44 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

IIIF. Program acceptance based on

severity and persistence ofmental

health disability: low,moderate, high.

Denition: Programs offering services to individuals with

co-occurring disorders use the severity and persistence

of disability related to the mental health disorders:

n

As an indicator to assist with the determination

ofthe individual’s needs, and

n

As an indicator whether the program is capable

ofeffectively addressing these needs.

Source: Interviews with program leadership

and staff, policy and procedure documentation,

andmission statement.

Item Response Coding: Coding of this item requires

anunderstanding of clinical protocol for individuals who

present with different levels of severity and persistence

of mental health disorder.

n

Addiction Only Services = (SCORE-1): Admits

persons in program with no to low severity and

persistence of mental health disability. The

program can only provide care to individuals

whopresent with no to low levels of persistence

of mental health disability. These individuals are

dened as those who have no or a very limited

history of functional impairment (e.g., person’s

capacity to manage relationships, job, nances,

and social interactions) as a result of a mental

health disorder. Persons with a history of severe

and persistent mental illnesses, as well as persons

with histories of psychiatric hospitalization or

extended ambulatory treatments episodes, would

be deected from this type of program.

n

Dual Diagnosis Capable = (SCORE-3): Admits

persons in program with low to moderate severity

and persistence of mental health disability. The

program can only provide care to individuals

who present with low to moderate severity and

persistence of mental health disability. These

individuals are dened as those who have mild

to moderate histories of functional impairment

as a result of a mental health disorder. In this

case, there may be some substantial history of

recurrence in the mental health disorder, and/or

there has been evidence of continued impairment

in at least one functional area. Persons with Axis I

mood, anxiety or posttraumatic stress disorders, or

Axis II disorders might be more typically served by

this program. Individuals with higher severity and

persistence of mental health problems are directed

toward services in a mental health service program,

or they may be at risk for a premature discharge

from this program.

n

Dual Diagnosis Enhanced = (SCORE-5): Admits

persons in program with moderate to high severity

and persistence of mental health disability. The

program can provide care to individuals who present

with moderate to high severity and persistence

of mental health disability. These individuals are

often characterized as having chronic, potentially

lifelong, functional impairment as a result of a

mental health disorder, including persons with

severe and persistent mental illnesses. In this

case, there may be a signicant history of multiple

recurrences in the mental health disorder, and/or

there has been evidence ofcontinued impairment

in several functional areas. DDE programs are able

to comprehensively manage the complex treatment

needs of these individuals.

45DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing IIIF. Program acceptance based on severity and persistence of mental health disability:

low, moderate, high.

AOS programs intending to be at the DDC level will

need to accept patients for services who have histories

and/or current mental health diagnoses that may be

associated with moderate severity and impairment.

These diagnostic categories may include: mood,

anxiety, PTSD, Axis II disorders, as well as persons

with schizophrenia or bipolar disorders. DDC programs

will often accept persons who are stable with a non-

severe mental illness type. This may be commonly

known as a person from Quadrant III (see the Quadrant

Model of Co-occurring Disorders, SAMHSA’s Report to

Congress, 2002, which is online at http://www.samhsa.

gov/reports/congress2002/).

Programs clearly operating at the DDC level routinely

accept persons with bipolar disorder and less often

persons with psychotic spectrum disorders, even with

current stable clinical status.

DDC PROGRAMS

Enhancing IIIF. Program acceptance based on severity and persistence of mental health disability:

low, moderate, high.

DDC programs who seek DDE level on this item

will extend their program acceptance to patients in

both Quadrant III (mood, anxiety, PTSD, less severe

Axis II disorders) and Quadrant IV (schizophrenia,

bipolar disorder, schizoaffective disorder) on a more

routine basis. Integrated with Item IIIE, these liberal

program acceptance policies are based upon clinical

appropriateness and not just an unrealistic willingness

to accept all patients at admission. DDE programs

must have a clear capacity to effectively treat persons

of high levels of severity of mental health disability

and high levels of acuity.

46 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

IIIG. Stage-wise assessment.

Denition: For individuals with substance use and

mental health disorders, the assessment of readiness

forchange for both disorders is essential to the planning

of appropriate services. Although the stages of change

model has been more traditionally associated with

treatment for substance use disorders, assessment of

motivational stages across the individual’s identied

areas of need (including both substance use and mental

health) is a more comprehensive approach. Doing so

helps to more strategically and efciently match the

individual to appropriate levels of service intensities.

Source: Interviews with program staff, medical records.

Item Response Coding: Coding of this item requires

anunderstanding of the assessment procedures used

inthe determination of the stages of change or a similar

model to systematically determine treatment readiness

or motivation.

n

Addiction Only Services = (SCORE-1): Not

assessed or documented. The program does not

have an established protocol within the evaluative

procedures that assesses or documents motivation

(stage of change or stage of treatment).

n

(SCORE-2): Assessed and documented variably by

individual clinician. The program has an informal,

non-standardized process to assess motivation

(stage of change or stage of treatment) or the

program has encouraged the use of a protocol that

assesses motivation, but the process is irregularly

used (less than 80 percent of the time).

n

Dual Diagnosis Capable = (SCORE-3): Clinician

assessed and routinely documented, focused

on substance use motivation. The program

has a routinely used assessment protocol that

incorporates an assessment of motivation (stage

ofchange or stage of treatment) and documents

this consistently (at least 80 percent of the time).

n

(SCORE-4): Formal measure used and routinely

documented but focusing on substance use

motivation only.

n

Dual Diagnosis Enhanced = (SCORE-5):

Formalmeasure used and routinely documented,

focus on both substance use and mental health

motivation. The program has a routinely used

assessment protocol that incorporates standardized

instrument(s) to assess and document motivation

(stage of change or stage of treatment), for

substance use and for mental health.

AOS PROGRAMS

Enhancing IIIG. Stage-wise assessment.

Assessing stages of patient motivation has added

a new level of clinical sophistication to addiction

treatment in recent years. As evidence-based

practices, motivational interviewing (MI) and

motivational enhancement therapies (MET) depend

ona careful assessment of patient motivation.

A variety of models have been developed to

conceptualize motivation to change a specic problem

(e.g., cocaine dependence or panic attacks) or

motivation to attend treatment. For AOS programs

toachieve DDC, they must have identied a patient’s

level of motivation atthe initialassessment.

At a DDC program, clinicians routinely focus on and

document patient motivation related to substance use

disorders. Mental health disorders are not prioritized

or may be variably documented. This assessment may

focus on readiness to change or treatment motivation,

and they may use motivational assessment methods

or measures that are well established in the scientic

literature (see the appendix section for examples of

these instruments). A global rating in a medical record

(precontemplation, contemplation, preparation, action,

and maintenance) is also possible.

47DDCAT Index: Scoring and Program Enhancements

DDC PRGRAMS

Enhancing IIIG. Stage-wise assessment.

DDC programs intending to become DDE will have

made a transition from labeling motivation to a more

formal, systematic, and complete effort to assess

motivation. This can include the routine incorporation

of the well-established self-report measures (URICA,

SOCRATES) and/or clinician-completed measure

(SATS). It may also include training staff to develop

ratings on the ASAM-PPC-2R Treatment Acceptance/

Resistance Dimension (Dimension IV). Motivation to

change both mental health and addiction problems

isroutinely documented.

DDE programs can also use clinician ratings on

motivation to address any perceived self-efcacy

forboth substance use and mental health problems.

These are incorporated as general clinical ratings at

the end of the assessment protocol, or in some cases,

a presentation of a two-sided “motivational ruler”

to a patient for their own ratings of motivation and

efcacy. The specic wording can vary, but a simple

examplefollows:

Variants on this approach include an emphasis

on“want help” vs. the desire to change.

The stage of change model has been criticized for

its cognitive emphasis, so other approaches include

more of a behavioral focus (“What steps are you

willing to take?),” and incorporate clinician ratings

demonstrating evidence for the patient’s behavioral

commitment to change.

On a 10-point scale, how much do you want to change your substance use now?

Not at all 1----------------------------------------------------------------------10 Totally

On a 10-point scale, how sure are you that you will be able to make this change?

Not at all 1----------------------------------------------------------------------10 Totally

On a 10-point scale, how much to you want to change your mental health problem?

Not at all 1----------------------------------------------------------------------10 Totally

On a 10-point scale, how sure are you that you will be able to make this change?

Not at all 1----------------------------------------------------------------------10 Totally

48 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

IV. Clinical Process: Treatment

IVA. Treatment Plans.

Denition: In the treatment of individuals with co-

occurring disorders, the treatment plans indicate that

both the mental health disorder as well as the substance

use disorder will be addressed.

Source: Review of treatment plans.

Item Response Coding: Coding of this item requires

an understanding of the program’s treatment planning

process as well as any standardized procedures and

formats used in treatment planning.

n

Addiction Only Services = (SCORE-1): Address

addiction only (mental health not listed). Within

the program, the treatment plans focus exclusively

on substance use disorders.

n

(SCORE-2): Variable by individual clinician (i.e.,

plans vaguely or only sometimes address co-

occurring mental health disorders). Within the

program, the treatment plans for individuals with

co-occurring disorders do not often or specically

address the mental health disorders while the

substance use disorders are more comprehensively

targeted. The variability is likely due to individual

clinician preferences/competencies or resource/

time constraints.

n

Dual Diagnosis Capable = (SCORE-3): Plans

routinely address both disorders although

substance use disorders are addressed as

primary, mental health as secondary with generic

interventions. Within the program, the treatment

plans of individuals with co-occurring disorders

routinely (at least 80 percent of the time) address

both the substance use and mental health

disorders, although the treatment planning for

the substance use disorders tends to be more

specic and targeted. Mental health disorders

areregularly addressed, albeit in a somewhat non-

specic fashion and often within the framework

ofsubstance use relapse prevention.

n

(SCORE-4): Plans routinely address substance

use and mental health disorders; equivalent focus

on both disorders; some individualized detail

is variably observed. Within the program, the

treatment plans of individuals with co-occurring

disorders routinely consider both the substance use

and mental health disorders equivalently. However,

individualized objectives and interventions specic

to each disorder are notconsistently incorporated.

n

Dual Diagnosis Enhanced = (SCORE-5): Plans

routinely address both disorders equivalently

and in specic detail; interventions in addition

to medication are used to address mental health

disorders. Within the program, the treatment

plans of individuals with co-occurring disorders

consistently (at least 80 percent of the time)

and equivalently address both substance use

and mental health disorders with clear, specic,

measurable objectives and individualized

interventions that systematically target symptoms

of the specic disorders. Additionally, the

interventions used by the program include both

psychosocial and pharmacological treatments.

49DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing IVA. Treatment plans.

Treatment planning is the culmination of a process

ofassessment and the interaction between the program

and the patient. Goals agreed to by both, using a

shared decision-making approach, are generally agreed

to be most associated with success, as illustrated by

the research on therapeutic alliance inpsychotherapy.

AOS programs, whether by screening, assessment, or

even diagnosis, may identify mental health problems,

but routinely do not address the same mental health

problems in the treatment plan.

To score at the DDC level, these mental health

disorders need to be identied, targeted by at least

generic treatment interventions, and monitored

for treatment response. Interventions may include

feelings or anger management groups, or a referral to

an outside provider for medication and/or medication

management to manage psychiatric symptoms.

Although substance use problems may continue to be

the major focus of the treatment plan, mental health

problems and disorders are increasingly listed.

DDC PROGRAMS

Enhancing IVA. Treatment plans.

In order for DDC programs to transition to DDE on

thisitem, there must be a documented and equivalent

focus on treatment planning for both substance use

and mental health disorders. A review of records nds

this to be normative, and interventions are targeted,

generally “in house.” The objectives are clear,

measurable, and specic (vs. generic) for problems

related to each disorder. One dening characteristic of

the DDE program is the use of interventions in addition

to medications to address and leverage a mental

health disorder. These interventions are identied

andconnected with treatment plan goals. Interventions

may be associated with specic staff members who

will deliver them and monitor patient progress.

Joan T’s treatment plan identied her problems with

prescription narcotics and PTSD. In addition to a

series of goals and interventions associated with opioid

dependence disorder, the goal for her PTSD was also

specied and included reduction in re-experiencing

and avoidance symptoms as objectives, and cognitive

behavioral therapy as the intervention.

50 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

IVB. Assess and monitor interactive

courses of both disorders.

Denition: In the treatment of persons with co-occurring

disorders, the continued assessment and monitoring of

substance use and mental health disorders as well as the

interactive course of the disorders is necessary.

Source: Medical records.

Item Response Coding: Coding for this item requires an

understanding of the program’s process and procedures

for monitoring co-occurring disorders.

n

Addiction Only Services = (SCORE-1): No

attention or documentation of progress with mental

health problems. Within the program, treatment

monitoring and documentation reect a focus

onsubstance use disorders only.

n

(SCORE-2): Variable reports of progress on

mental health problems by individual clinicians.

Within the program, treatment monitoring of co-

occurring mental health problems is conducted

inconsistently, largely depending on clinician

preference/competence as well as staff resources.

n

Dual Diagnosis Capable = (SCORE-3): Routine

clinical focus in narrative (treatment plan review

or progress note) on mental health problem

change; description tends to be generic. Treatment

monitoring for individuals with co-occurring

disorders routinely (at least 80 percent of the time)

reects a clinical focus on changes in mental health

symptoms, but this monitoring tends to be a basic,

generic, or qualitative description within the record.

n

(SCORE-4): Treatment monitoring and

documentation reecting equivalent in-depth

focus on both disorders is available but variably

used. Treatment monitoring and documentation

sometimes reect a more systematic and equally

in-depth focus on changes in the symptoms of

both mental health and substance use disorders,

although this is done variably (less than 80

percent of the time).

n

Dual Diagnosis Enhanced = (SCORE-5): Treatment

monitoring and documentation routinely reects

clear, detailed, and systematic focus on change

inboth substance use and mental health disorders.

Treatment monitoring and documentation routinely

(at least 80 percent of the time) reect asystematic

and in-depth focus on changes in the symptoms

ofboth mental health and substance use disorders.

51DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing IVB. Assess and monitor interactive courses of both disorders.

Data obtained on this item ow from the assessment

process, in particular item IIID: Mental health and

substance use history reected in medical record.

In AOS level services, the chronologies of the disorders

are not well documented during the assessment, so

treatment is not likely to anticipate the exacerbation

ordiminution of psychiatric symptoms with abstinence.

DDC programs have attempted to record these

chronologies in the assessment, as well as monitor

mental health symptom change in early addiction

treatment experiences. They may assist patients in

preparing for changes (e.g., the return of social phobia

symptoms after benzodiazepine and alcohol use are

discontinued). DDC programs may also be prepared

to rapidly intervene by initiating pharmacotherapy.

The DDC record captures the ebbs and ows of both

substance use and mental health symptoms.

DDC PROGRAMS

Enhancing IVB. Assess and monitor interactive courses of both disorders.

DDE programs improve on DDC services by the use

ofmore systematic tracking and monitoring of patient

symptoms during treatment, and correlation with

abstinence or continued use. DDE programs have

amedical record structured so that these changes

can be regularly observed and recorded. DDE records

consistently have documentation of progress or

deterioration on both substance use and mental health

domains. For example, clinician and/or patient use

of time line follow-back (TLFB) calendars are likely

to be used by DDE programs (see the appendix for

anexample).

Many programs will admit and treat patients with less

than one month since their last substance use. Also,

many of these same patients will have never had a

period of one month of abstinence. Monitoring mental

health symptoms during the course of treatment will

provide essential diagnostic and treatment planning

data. Substance-induced disorders and independent

mental health disorders can be differentiated during

this assessment period. Programs can anticipate

different treatment approaches accordingly.

52 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

IVC. Procedures for mental health

emergencies and crisis management.

Denition: Programs that treat individuals with co-

occurring disorders use specic clinical guidelines to

manage crisis and mental health emergencies, according

to documented protocols.

Source: Interviews with clinicians, policy and procedure

manual.

Item Response Coding: Coding of this item requires an

understanding of a program’s specic clinical protocols

used to manage mental health crises or concerns.

Consider the program’s level of care when coding,

meaning that the criteria are met as could be expected

from the program’s level of care (e.g., programs do not

need to be residential/inpatient setting to score a 5).

n

Addiction Only Services = (SCORE-1): No

guidelines conveyed in any manner. The program

has no written clinical guidelines for mental

health emergencies, and the majority of staff

has no general understanding of any unwritten

crisis/emergency management procedures for

suchsituations.

n

(SCORE-2): Verbally conveyed in-house guidelines.

The program staff is able to communicate a good

general understanding of emergency procedures

for crisis situations associated with mental health

concerns, although there are no written guidelines.

Automatically calling 911 or emergency personnel

is not considered acceptable general internal

procedure for the management of such crises.

Ageneral understanding would include the concept

that there is a need to globally assess the risk/crisis

and a basic understanding of available options for

intervention based on the assessment.

n

Dual Diagnosis Capable = (SCORE-3): Documented

guidelines: referral or collaborations (to local mental

health agency or emergency department). The

program has some written guidelines for mental

health crisis/emergency management that include

a standard risk assessment that captures mental

health emergencies. The written guidelines also

dene the available intervention strategies that

are matched to the assessed risk. Most of these

strategies will include linkage with other providers

or entities. An essential aspect of intervention

strategies for this level is a formalized arrangement

with collaborative entities like mental health clinics

or the mental health unit of a hospital emergency

department to assist in the management of these

crisis situations. Staff is thoroughly familiar with

guidelines and collaboration agreements.

n

(SCORE-4): Variable use of documented guidelines,

formal risk assessment tools and advance directives

for mental health crisis and substance use relapse.

The program has detailed written guidelines for

in-house crisis/emergency management that are

designed to provide consistent risk assessment

andinterventions to maintain individuals within the

program when possible. However, these guidelines

are not routinely followed, as evidenced by variable

staff competency to use them. This inconsistency

is likely due to individual staff preferences/

competencies or training resource constraints.

n

Dual Diagnosis Enhanced = (SCORE-5): Routine

capability, or a process to ascertain risk with

ongoing use of substances and/or severity of mental

health symptoms; maintain in program unless

commitment is warranted. The program has explicit

and thoroughly written guidelines for comprehensive

mental health crisis/emergency management that

outline explicit in-house procedures, including

the completion of advance directives pertaining

to mental health crisis and substance use relapse

with every patient, use of a formal risk assessment

tool, and expected intervention strategies matched

to assessed risk. These guidelines are designed to

maintain individuals within the program, unless the

severity of the circumstance warrants alternative

placement. This means that the program is capable

of ongoing risk assessment and management

of persons with interacting and exacerbating

symptoms. Staff expects crisis/emergency

situations, and is thoroughly familiar with and

adheres to the guidelines.

53DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing IVC. Procedures for mental health emergencies and crisis management.

AOS programs often have undocumented, informal,

outdated, or loose arrangements for dealing with

mental health emergencies. Often, by deferring

admission of cases of even moderate risk, these events

are kept to a minimum. Calling 911 is often the only

plan given such an event.

DDC level programs have more formalized and

documented guidelines and staff can clearly articulate

the policy in place. Emergencies may be a more

common occurrence. The response to emergencies

and crises is typically characterized by a more

formalized relationship with the local mental health

agency or the mental health emergency service of

the nearby hospital. This is a signicant upgrade

incapability from an internal or familiar relationship

with paramedics or the local hospital emergency

department staff. Mental health advance directives

may be offered to patients to complete as an option

upon intake.

DDC PROGRAMS

Enhancing IVC. Procedures for mental health emergencies and crisis management.

DDC programs have more thorough and articulated

emergency and crisis intervention plans, expect events

to occur more regularly, and have protocols in place so

that the emergency or crisis does not result in referral

or linkage issues. DDE programs can and do evaluate

the nature and level of emergency they may be able

to handle in house, and have clearer documented

guidelines and a formal risk assessment tool, staff

training in risk management and assessment and, if

possible, a review of current stafng patterns. Mental

health advance directives are completed with every

patient upon intake to prepare for any mental health

crises and substance use relapse they may have during

their treatment episode.

Under no circumstances should the DDC program

overextend its clinical capability in this area solely for

the purposes of perceived enhancement of services.

Taking on more clinical risk must be carefully planned

and prepared for in protocol, stafng, and prudence.

54 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

IVD. Stage-wise treatment.

Denition: Within programs that treat individuals with

co-occurring disorders, ongoing assessment of readiness

to change contributes to the determination ofcontinued

services which appropriately t that stage in terms

of treatment content, intensity, and utilization of

outsideagencies.

Source: Interviews with clinicians, review of treatment

plans/reviews and progress notes.

Item Response Coding: Coding of this item requires

an understanding of the program’s protocol for the

continued assessment and monitoring of the individual

as well as whether the stages of change assessment is

part of this continued follow-up. Note: Programs that do

not routinely assess the stage of motivation in the initial

assessment will likely not consistently address this issue

during the course of treatment.

n

Addiction Only Services = (SCORE-1):

Notassessed or explicit in treatment plan.

Theprogram does not monitor motivational stages

in an ongoing fashion throughout treatment.

n

(SCORE-2): Stage of change or motivation

documented variably by individual clinician

in treatment plan. The program assesses and

documents stages of motivation/ change on an

inconsistent and informal basis throughout the

course of treatment. This is largely driven by

clinician preference or competence.

n

Dual Diagnosis Capable = (SCORE-3): Stage

of change or motivation for substance use

issues routinely incorporated into individualized

plan, butno specic stage-wise treatments.

The program has endorsed the concept of

ongoing stage of change assessment and has

inserted this into clinical procedures related to

substance use disorders. The program routinely

(at least 80 percent of the time) assesses and

documents stage of change related to substance

use issues throughout the treatment course, but

treatments do not reect these ongoing stage-

wise assessments. This mismatch is often due

to the generic application of core services or the

placement of individuals into service tracks as

opposed to an individualized approach.

n

(SCORE 4): Stage of change or motivation

routinely incorporated into individualized plan;

general awareness of adjusting treatments by

substance use stage or motivation only. There

is some evidence that the program considers

individual stage of change or motivation in

delivering treatments for substance use disorders

throughout the course of treatment, but this is

done variably (less than 80 percent of the time).

Stage of readiness related to mental health

disorders is typically not assessed and/or not

incorporated into treatment planning.

n

Dual Diagnosis Enhanced = (SCORE-5):

Stageof motivation routinely incorporated into

individualized plan, and formally prescribed and

delivered stage-wise treatments for both substance

use and mental health issues. Theprogram

regularly assesses and documents stage of

change or motivation for both substance use and

mental health disorders throughout the course

of treatment, and specic stage-wise treatments

for both disorders are routinely provided (at least

80 percent of the time) to individuals based on

thesere-assessments.

55DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing IVD. Stage-wise treatment.

Data obtained on this item ow from the assessment

process, in particular item IIIG: Stage-wise assessment.

AOS programs may not assess stage of motivation upon

admission, and are therefore even less likely to do so

during treatment. Individual clinicians may understand

the dynamic nature of motivation, in terms of its

non-linearity and difculty assessing its verbalized,

inferred, and behavioral components.

DDC programs routinely assess and document stages

of motivation for substance use issues on an ongoing

basis during the course of treatment, but do so in

a way that is fairly general, and which may not be

closely linked to intervention choice. DDC programs

are “stage aware” and sometimes modify treatments

accordingly if only informally. For example, instead

of working with a patient as if she is at the relapse

prevention stage, by recognizing she is at the

precontemplative/comtemplative stage interventions

may be more appropriate to the extent they are

motivational enhancement strategies, engagement

of signicant others in treatment planning, or even

psychoeducational in nature. DDC programs do

not routinely assess stage of readiness related to

mental health issues or deliver stage-wise mental

healthtreatments.

Free resources to assess and build motivational

interviewing skills are available. Clinical vignettes used

to train clinicians on MI principles are available at

http://adai.washington.edu/instruments/VASE-R.htm.

Implementing and maintaining this evidence-

based practice can be supported by strong clinical

supervision. Supervisory tools for enhancing MI

prociency are available at http://www.attcnetwork.

org/explore/priorityareas/science/blendinginitiative/

miastep/product_mate.rials.asp

56 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

DDC PROGRAMS

Enhancing IVD. Stage-wise treatment.

DDE programs extend beyond DDC by more routinely

and reliably assessing and using stage of motivation

for both substance use and mental health issues

during the course of treatment, and especially during

treatment or level of care transitions (see the appendix

for examples of stagewise assessment instruments).

Stage is directly correlated to the treatment plan

objectives and interventions, and drives the particular

approach used by clinicians in individual and group

sessions and even determines level of care. Differential

motivation to address substance use and mental health

disorders is addressed.

A residential program has operationalized the ASAM

Dimension IV (Treatment Acceptance or Resistance)

and reduces the length of stay based upon stage of

readiness assessed at two-week intervals. Ratings

of precontemplative or contemplative stages result

in earlier transitions to an intensive outpatient

level of care. This conserves a more expensive

resource (residential services) and enables patients

at preparation, action, or relapse prevention stages

moreaccess.

The Bay Park House implemented the following stage-

wise assessment and treatment protocol. Motivational

rulers for both mental health and substance use

problems were used: Motivation for Change, 1-10

scale: “How motivated are you to change?”; Efcacy,

1-10 scale: “How sure are you that you can make

the change?” Responses to these rulers were used

to determine the relative importance and risk of

substance use vs. mental health issues, and Bay Park

House uses these to assign clients to different groups.

57DDCAT Index: Scoring and Program Enhancements

IVE. Policies and procedures for

medication evaluation, management,

monitoring, and compliance.

Denition: Programs that treat individuals with co-

occurring disorders are capable of evaluating medication

needs, ensuring access to a prescriber when needed,

coordinating and managing medication regimens,

monitoring for adherence to regimens, and responding

to any challenges or difculties with medication

compliance, as documented in policy/procedure.

Source: Interviews (preferably with a prescriber), policy

and procedure manual, and medical records.

Item Response Coding: Coding of this item requires an

understanding of the program’s medication management

policies and procedures as well as an understanding of

the prescribers’ job description.

n

Addiction Only Services = (SCORE-1):

Patientsonmedication routinely not accepted. No

capacities tomonitor, guide prescribing, or provide

psychotropic medications during treatment.

Theprogram does not admit individuals who

have been prescribed medications. The program

has no capacity to manage, monitor, or prescribe

medications to individuals.

n

(SCORE-2): Certain types of medication are not

acceptable, or patient must have own supply

for entire treatment episode. Some capacity to

monitor psychotropic medications. The program

does not have the capacity to prescribe. The

program has a very limited capacity to accept

and monitor individuals who take medications.

Frequently, the program has restrictions on the type

of medications that it can manage, or the program

requires the individual to have a sufcient supply

of their medications in order to be accepted into

theprogram.

n

Dual Diagnosis Capable = (SCORE-3): Present,

coordinated medication policies. Some access

to prescriber for psychotropic medications and

policies to guide the prescribing within the

program is provided. Monitoring of the medication

is largely provided by the prescriber. The program

maintains written policies and guidelines for

prescribing medications for individuals with co-

occurring disorders in treatment. And: The program

has a formalized mechanism for accessing the

services of a prescriber, who is at least a consultant

to theprogram.

n

(SCORE-4): Clear standards and routine for

medication prescriber who is also a staff member.

Routine access to prescriber and guidelines

for prescribing in place. The prescriber may

periodically consult with other staff regarding

medication plan and recruit other staff to assist

with medication monitoring. The program maintains

written standards and guidelines for prescribing

and monitoring medications for individuals with

co-occurring disorders. And: The program retains a

staff person(s) who is a prescriber and is competent

in the pharmacotherapy of mental health disorders,

but the prescribing staff member(s) is not fully

integrated into the treatment team. This prescribing

staff member is frequently perceived as providing

an adjunctive service to the program and tends

tofunction in an independent fashion.

n

Dual Diagnosis Enhanced = (SCORE-5): Clear

standards and routine for medication prescriber

who is also a staff member. Full access to

prescriber and guidelines for prescribing in

place. The prescriber is on the treatment team

and the entire team can assist with monitoring.

Theprogram maintains standards and guidelines

for prescribing medications to individuals with

co-occurring disorders. And: The program retains

a staff person(s) who is a prescriber competent

inthe pharmacotherapy of mental health disorders

and is fully integrated into the program’s treatment

team. The prescriber does not provide services

in anisolated or independent manner or as an

external, add-on service. The prescriber is an active

member of the treatment program, involved in

treatment planning and administrative decisions.

58 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

AOS PROGRAMS

Enhancing IVE. Policies and procedures for medication evaluation, management, monitoring and compliance.

Data obtained on this item are related to the stafng

dimension, in particular item VIA: Psychiatrist or other

physician or prescriber of psychotropic medications.

Programs that do not have an onsite prescriber will

not have formal policies and procedures to guide

prescribing within the program.

AOS programs typically have no patients who are

on medication or have very informal undocumented

policies about what medications are appropriate.

AOS programs moving toward DDC will need to

have a prescriber, at least on a contractual basis,

develop clearer medication policies and protocols,

and likely will increase the range of acceptable

medications. Medications may be kept in a secure,

locked storage area, and be self-administered but

observed. Medications may be brought in by a patient,

and there is some access to the program’s prescriber

who can renew or give a new prescription during

treatment. Medications are monitored, primarily by

the prescriber, and necessary adjustments can be

made; such protocols are formalized. DDC programs

document the use of medications and the patient’s

compliance with them, and this is evident in the

patient medicalrecord.

DDC PROGRAMS

Enhancing IVE. Policies and procedures for medication evaluation, management, monitoring and compliance.

DDE programs generally are capable of accepting

patients on most psychotropic medications,

which may also extend to medications for other

problems: STDs, HIV, chronic pain, hepatitis

C, andhypertension. The program has policies

which address the use of benzodiazepines or other

potentiallyaddictivemedications.

The DDE program has the capacity to evaluate

existing, and initiate new, pharmacotherapies for either

or both the substance use and mental health disorders.

Further, the DDE level program may have the capacity

to aggressively treat patients who are actively using

substances or patients using medications for medical

or mental health problems with abuse liability

(e.g.,narcotics, anxiolytics), by more frequent contact,

stringent toxicological monitoring, and behavioral

contracting. These protocols are well developed,

and the medication response is consistently well

documented in the patient record. As a treatment

team member, the prescriber informs the team about

the medication plan and the entire team can assist

withmonitoring.

59DDCAT Index: Scoring and Program Enhancements

IVF. Specialized interventions with mental

health content.

Denition: Programs that treat individuals with

co-occurring disorders utilize specic therapeutic

interventions and practices that target specic

mental health symptoms and disorders. There is a

broad array ofsuch interventions and practices that

can be effectively integrated into treatment. Some

interventions can be generically applied by programs.

These interventions might include stress management,

relaxation training, anger management, coping skills,

assertiveness training, and problem solving. In some

cases, addiction treatment programs may already use

some of these techniques in the treatment of substance

use disorders. More advanced interventions that could

beapplied to persons with co-occurring disorders include

adaptations of evidence based addiction treatments

(e.g., brief motivational or cognitive behavioral therapies,

to target specic disorders such as PTSD, depression,

anxiety disorders, and Axis II disorders.

This DDCAT item pertains to psychosocial or behavioral

interventions for persons with co-occurring disorders

in addiction treatment settings. Frequently, providers

wish to focus on medications as the primary option for

treatment of the mental health disorder. Medications

can be FDA-approved medications for the most common

disorders in addiction treatment (mood, anxiety, PTSD,

bipolar disorder). However, these disorders are at

least if not more responsive to psychosocial/behavioral

interventions in terms of clinical efcacy and durability

of response. Accordingly, this is an opportunity for

addiction treatment providers, with and without

medication resources, to develop or enhance services

along these lines.

DDC programs will typically incorporate generic

interventions for co-occurring disorders in group,

individual and psycho-educational formats. However,

DDE programs will also routinely adapt psychological/

behavioral therapies for addiction disorders for use

withpatients with co-occurring mental health disorders,

delivering therapies in a targeted and systematic

(manual-guided) fashion. DDE programs also attempt

to implement the available integrated treatments for

persons with co-occurring disorders (e.g., Seeking Safety,

Dialectical Behavior Therapy—Substance Abuse, or other

integrated therapies for co-occurring disorders). There

are presently few such treatments, although many are

inthe development and testing stages.

Source: Interviews with clinicians and patients, review

of treatment plans, progress notes, group schedule

andgroup curriculum, and observation of group.

Item Response Coding: Coding of this item requires

an understanding of the program’s interventions for

individuals with co-occurring disorders that focus on

mental health concerns, symptoms, and disorders.

n

Addiction Only Services = (SCORE-1): Not

addressed in program content. The program

services do not include the incorporation of

therapeutic interventions intended to specically

address mental health concerns, symptoms,

ordisorders.

n

(SCORE-2): Based on judgment by individual

clinician; variable penetration into routine

services. The program inconsistently provides

generic interventions for mental health concerns.

The variability is secondary to the judgment or

expertise of the individual clinician.

60 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

n

Dual Diagnosis Capable = (SCORE-3): In program

format as generalized intervention, (e.g., stress

management) with penetration into routine

services. Routine clinician adaptation of an

evidence based addiction treatment (e.g., MI,

CBT,Twelve-Step Facilitation). The program is able

to routinely incorporate (at least 80 percent of the

time) mental health interventions for individuals

with co-occurring disorders. This is translated

to mean that the individuals with co-occurring

disorders who are treated within the program

almost always receive treatment interventions that

specically target mental health problems. And:

The type of interventions at this level is not usually

individualized but instead tends to be of a more

broadly applicable, generic, and less resource

intensive. Some clinicians may adapt evidence-

based addiction treatments to include some

general interventions for mental health disorders.

n

(SCORE-4): Some specialized interventions

by specically trained clinicians in addition to

routine generalized interventions. The program

meets the standards set at DDC, and the program

shows some movement toward the DDE level by

having some clinicians who offer components of

more specialized interventions for specic mental

healthdisorders.

n

Dual Diagnosis Enhanced = (SCORE-5): Routine

mental health symptom management groups;

individual therapies focused on specic disorders;

systematic adaptation of an evidence based

addiction treatment (e.g., MI, CBT, Twelve Step

Facilitation). The program routinely (at least 80

percent of the time) provides targeted mental

health interventions that are individualized to

the disorder. This is translated to mean that

individuals with co-occurring disorders almost

always receive skilled interventions specic to

their mental health problems. The mental health

interventions at this level are characterized as

being comprised of a full array of services types,

including integrated treatments for co-occurring

disorders or adaptations of evidence-based

addiction treatments.

61DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing IVF. Specialized interventions with mental health content.

As the previous item pertains to pharmacological

interventions for mental health disorders in addiction

treatment, this item pertains to psychosocial

interventions. These interventions do not necessarily

require a licensed or certied mental health professional

to deliver. However, they do require a trained clinician or

counselor, who may also have additional certications,

or has attended workshops and received supervision

in therapies with that particular co-occurring disorder

(e.g., borderline personality disorder) or has had good

training in cognitive behavioral therapy.

AOS programs tend to address the mental health

problem as a side effect of basic addiction treatment:

reviewing relapse triggers may touch on negative mood

associated with depression; bringing a patient to a

mutual peer support meeting may help with social

anxiety disorder; or “working the steps” may soften

the rough edges of a personality disorder. To be DDC

level, however, the program must address the mental

health disorder more intentionally, and explicitly. In

DDC programs, this may be accomplished through use

of generic interventions such as stress management

or coping skills groups, in addition to adaptation of

cognitive behavioral therapy (e.g., for substance use,

feelings or anger management groups, and individual

counseling). The application of these treatments to

patients is likely more clinician- vs. program-driven.

It is reasonable for DDC providers to make adaptations

to evidence-based practices for substance use

disorders in order to apply them to mental health

disorders. Although the terminology and denition

of “evidence-based” is not consistent or regulated

(McGovern & Carroll, 2003), the guide offers resources

for manualized approaches that at least have an

evidence-base. SAMHSA has been making some

strides in creating a National Registry of Evidence-

Based Programs and Practices. This effort is in its early

stages and far from the level of detail, protocol, and

sophistication needed for a comparison with the FDA-

approval process used for pharmacological agents.

Recommendations for evidence-based addiction

treatments that may be adapted for persons with

co-occurring disorders can be obtained for free from

thefollowing websites:

National Institute on Drug Abuse Therapy Manuals

(www.nida.nih.gov/DrugPages/Treatment.html)

1. Cognitive-Behavioral Approach

2. Community Reinforcement Approach

3. Individual Drug Counseling

4. Group Drug Counseling

5. Brief Strategic Family Therapy

National Institute on Alcohol Abuse and Alcoholism

Therapy Manuals

(http://pubs.niaaa.nih.gov/publications/match.htm)

1. Twelve Step Facilitation Therapy

2. Motivational Enhancement Therapy

3. Cognitive Behavioral Coping Skills Therapy

SAMHSA Youth Treatment Manuals

(http://kap.samhsa.gov/products/manuals/cyt/index.htm)

1. Motivational Enhancement Therapy/Cognitive

Behavioral Therapy – 5 Sessions

2. Motivational Enhancement Therapy/Cognitive

Behavioral Therapy – 7 Sessions

3. Family Support Network Therapy

4. Assertive Community Reinforcement Approach

5. Multidimensional Family Therapy

SAMHSA Specialized Manuals

(http://kap.samhsa.gov/products/manuals)

1. Therapeutic Community for Residential

Programs

2. Matrix Model for Intensive Outpatient Programs

3. Anger Management Groups

62 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

DDC PROGRAMS

Enhancing IVF. Specialized interventions with mental health content.

DDE programs will have specialized and targeted

interventions and psychosocial treatments for patients

with co-occurring disorders. Often, these approaches

are specic manual-guided treatments for diagnosed

disorders: Seeking Safety for PTSD, Dialectical Behavior

Therapy - Substance Abuse for borderline personality

disorder; Integrated Group Therapy for bipolar disorder

or Modied Therapeutic Community (MTC) for antisocial

personality disorders.

Training is widely available in the approaches noted

above, and in some regions certied trainers and

supervisors exist. Often DDE programs recognize the

need for specically targeted treatments for the most

prevalent disorders (those related to mood, anxiety,

PTSD) and address this within the context of individual

psychotherapy, or a well-delivered cognitive behavioral

therapy group that targets both the substance use

and the mental health disorder at the same time.

These latter approaches are most typical of DDE

programs, due to program size, staff resources, and

the unnecessary burden of multiple manuals specic

for each disorder. However, regardless of the approach

used, DDE programs ensure that clients with co-

occurring disorders receive treatments that specically

address their mental health disorder.

For the DDE programs, links are provided to resources

that either have been tested or documented for persons

with co-occurring disorders. A list of evidence-based

practices and empirically supported practices for

mental health disorders are beyond the scope of this

toolkit. A general principle seems to be emerging

from the research, however. Much like the nding that

the FDA-approved medication for the mental health

disorder is indicated for persons with co-existing

substance use disorders, it also seems apparent that

cognitive behavioral therapies for those conditions are

likewise routinely effective. More research is needed to

substantiate this nding. But studies with PTSD (Hien

et al., 2004), depression (Brown et al., 2001), social

phobia (Randall et al., 2001) and other diagnostically

heterogeneous groups (McEvoy & Nathan., 2007)

support CBT as a generically effective treatment.

The Toolkit references provide several specic citations

for studies and manuals related to the most common

disorders: mood, anxiety (including PTSD and social

phobia) and Axis II disorders. Presently, several

interventions are in the investigational stage, including

group therapy for co-occurring bipolar disorder and

substance use (Roger Weiss, Harvard-McLean Hospital),

and PTSD and substance use (Denise Hien, City

University of New York; Mark McGovern, Dartmouth

Medical School).

The following is an excellent reference for cognitive

behavioral therapy groups for depression, anxiety

disorders, and dual disorders, with additional chapters

on youth, elders, and Latino group approaches: White

JR, Freeman AS. Cognitive-behavioral group therapy

for specic problems and populations. Washington DC:

American Psychological Association, 2002).

SAMHSA’s National Registry of Evidence Based

Programs and Practices for Co-Occurring Disorders

(http://nrepp.samhsa.gov/)

1. Dialectical Behavioral Therapy

2. Multisystemic Family Therapy

3. Seeking Safety

4. Trauma Empowerment and Recovery Model

The Hazelden Co-Occurring Disorders Program

for adults with co-occurring disorders in addiction

treatment can be obtained at www.hazelden.org.

Itincludes a stage-based curriculum that combines

evidence-based motivational enhancement therapy,

cognitive behavioral therapy, and twelve-step

facilitation, as well as a cognitive behavioral therapy

curriculum specically adapted for individuals with co-

occurring disorders. Hazelden Publications also has a

series on adolescent co-occurring disorders, with group

curriculum on substance use and anxiety disorder, mood

disorder, attention decit/hyperactivity disorder, conduct

disorder, oppositional deant disorder, adjustment

disorder, and anger. There is no information about the

evidence base for these materials, but they are also

available at thislink.

63DDCAT Index: Scoring and Program Enhancements

IVG. Education about mental health

disorders, treatment, and interaction

with substance use disorders.

Denition: Programs that offer treatment to individuals

with co-occurring disorders provide education about

mental health and substance use disorders, including

treatment information and the characteristics, features,

and interactive course of both types of disorders.

Source: Interviews with staff and patients, review

of schedules of psycho-educational groups, group

curriculum, and progress notes.

Item Response Coding: Coding of this item requires an

understanding of the program’s educational components

that address mental health disorders.

n

Addiction Only Services = (SCORE-1): Not offered.

The program does not offer education about mental

health disorders and treatment, or the interaction

with substance use disorders.

n

(SCORE-2): Generic content, offered variably or by

clinician judgment. The program may occasionally

offer education about mental health disorders and

mental health treatment, but such programming

tends to focus on these issues as they relate to

substance use disorders and concerns (e.g., within

the context of substance use relapse prevention).

n

Dual Diagnosis Capable = (SCORE-3): Generic

content, routinely delivered in individual and/

or group formats. The program routinely (at least

80 percent of the time) provides to all patients

general education about mental health disorders,

mental health treatment, and its interaction with

substance use disorders and treatment. Examples

include a general orientation to co-occurring

disorders, educational lectures about mental

health disorders and symptoms, and educational

lectures about the connections between mental

health symptoms and substance use, as well as

the appropriate use of psychotropic medications

(medications are not drugs). These are lectures

designed to inform and are not designed to treat.

n

(SCORE-4): Specic content for specic co-

morbidities; variably offered in individual and/

or group formats. The program variably provides

information about a patient’s specic mental

health disorder(s), including symptoms, treatment,

and interaction with substance use disorders and

treatment. This is primarily driven by individual

clinician preference or competence.

n

Dual Diagnosis Enhanced = (SCORE-5): Specic

content for specic co-morbidities; routinely

offered in individual and/or group formats.

The program regularly offers a combination

ofgeneral education components to all patients

as described at the DDC level. The program also

has incorporated more individualized instruction

(at least 80 percent of the time) that addresses

specic issues within mental health disorders.

Instruction addresses mental health treatment

and its interaction with substance use disorders

and treatment and their relation to specic needs

of the persons in treatment. Examples might

include topics such as interaction between alcohol

and marijuana use and social anxiety. These

instructional sets tend to be more in-depth and

they are designed to address specic needs and

risks of individuals in treatment.

64 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

AOS PROGRAMS

Enhancing IVG. Education about mental health disorders, treatment, and interaction with substance use disorders.

It is widely believed in medical care that educating

patients about the nature and treatment of their

disease will improve compliance. It may also increase

the likelihood of positive outcomes. A longstanding

tradition in addiction treatment is the didactic

presentation of a variety of aspects to the disease of

addiction, the effect on the family, and the role of

mutual self-help groups in long-term recovery. AOS

programs may continue with this tradition without

much attention to prevalence and the importance of

mental health disorders among addicted persons, and

their inuence on outcomes.

DDC programs routinely offer all patients basic

information about mental health disorders through

general lectures, group therapy or community

meetings, family sessions, and/or through individual

sessions. These services are offered in a fairly generic

format that is systematically delivered as part of a

protocol. They include some effort to have individuals

verbalize their diagnosis, understand the current

treatments, express the risks in not following through

with treatments (in terms of their abstinence from

substance use), and have some understanding of the

role of the family (including inheritability issues) in

both the mental health and substance use disorders.

The program may offer a medication group where

the differences between drugs and medications are

discussed, and the role of medication in self-help

recovery traditions is explored. These efforts are a

substantial improvement over the lack of attention

paid to the common mental health disorders by

AOSprograms.

DDC PROGRAMS

Enhancing IVG. Education about mental health disorders, treatment, and interaction with substance use disorders.

DDE programs, in contrast to DDC programs, deliver

didactic and specic informational material to

patients about co-occurring disorders in a systematic,

individualized manner. These may be via informational

sessions about the specic disorder or the dynamics

of co-occurring disorders, or in individual counseling

sessions. These efforts are delivered routinely in the

program schedule, and a strong emphasis is placed on

the patient understanding that they have two disorders,

that these disorders interact, that there are treatments

for each (and both), that long term compliance is

essential, and that recovery with both is possible.

The materials available for these didactics are carefully

prepared, used by the program (not just one or two

clinicians) and are part of a protocol and treatment

plan. Materials are available online from SAMHSA, the

National Institute of Mental Health (NIMH), and the

Center for Mental Health Services. For example, NIMH

provides a detailed booklet on depression for clients.

It describes symptoms, causes, and treatments, with

information on getting help and coping (2000): http://

www.nimh.nih.gov/health/publications/depression/

index.shtml.

Hazelden offers free fact sheets and educational

handouts at www.cooccurring.org/public/handouts.

page. Hazelden Publications has also produced DVDs

for adults with co-occurring disorders and adolescents

with co-occurring disorders. Both are 30 minutes in

length and can be viewed by patients individually or

in groups. These can be used for educational purposes

and also to initiate a discussion specic to their co-

occurring disorder.

65DDCAT Index: Scoring and Program Enhancements

IVH. Family education and support.

Denition: Programs that offer treatment to individuals

with co-occurring disorders provide education and

support to family members regarding co-occurring

disorders. This includes treatment information and the

characteristics and features of both types of disorders.

This is offered to educate collaterals about realistic

expectations, the interactive course of the disorders,

andthe positive prospects for recovery. It is also

designed to provide a supportive environment for family

members to address specic concerns and be involved

inthe individual’s treatment planning as necessary.

Family education and support can occur in individual

orgroup formats. Family is broadly dened to include

any signicant others and members of support systems.

Source: Interviews with clinicians and patients, schedule

of group therapies and support groups, and review of

treatment plans and progress notes.

Item Response Coding: Coding of this item requires

an understanding of the program’s educational and

supportive components for the family or signicant

others that address co-occurring disorders.

n

Addiction Only Services = (SCORE-1): For

substance use disorders only, or no family

education at all. The program may provide

education and support to family members, but the

focus tends to be only on substance use disorders.

n

(SCORE-2): Variably or by clinician judgment.

Theprogram sometimes provides educational

groups or support to families regarding mental

health disorders and may at times address mental

health questions if raised. These services are

informally conducted and usually depend on the

competency and preference of the treating clinician.

n

Dual Diagnosis Capable = (SCORE-3): Mental

health issues routinely but informally, incorporated

into family education or support sessions.

Available as needed. The program offers a more

formalized mechanism that routinely offers

general educational groups and support to

families of individuals with co-occurring mental

health disorders. These groups tend to focus on

information and issues related to substance use

disorders. General information about co-occurring

mental health disorders, while not in any formal

curriculum, is consistently included. While this

service might be regularly accessed, it would not

be considered to be a standard part of the routine

program format.

n

(SCORE-4): Generic group on site for families

on substance use and mental health disorders,

variably offered. Structured group with more

routine accessibility. The program has established

family education and support groups that

intentionally address both substance use and

mental health disorders. And: The program makes

some effort to incorporate these family groups

more regularly into the treatment interventions

butthis occurs less than 80 percent of the time.

n

Dual Diagnosis Enhanced = (SCORE-5): Routine

and systematic co-occurring disorder family group

integrated into standard program format. Accessed

by families of the majority of patients with co-

occurring disorders. The program routinely provides

education and support groups to families of

individuals with co-occurring disorders on specic

disorder co-morbidities and their interactions.

And: the provision of this service is considered

astandard part of the treatment interventions, with

the majority of families and/or members of support

systems of individuals with co-occurring disorders

regularly participating in these activities.

66 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

AOS PROGRAMS

Enhancing IVH. Family education and support.

The AOS program seeking to attain DDC status on

this item will need to include many of the same

ingredients from item IVG (Education about substance

use disorders, treatment, and interaction with

mental health disorders), but directed towards family

members. Addiction treatment programs vary in the

inclusion of family members in services. “Family” has

been broadened to include any signicant others and

members of support systems, and it is understood to

be a major support or risk factor in ongoing recovery.

For this reason, in times past, family members were

excluded from treatment. Many evidence-based

practices for substance use disorders are family or

couples formats, and it is now widely believed that

including family members will augment outcomes.

AOS programs may educate families about addiction

and recovery, with a singular focus on substance

issues. Al-Anon may be introduced.

DDC programs take the time, either through individual

family sessions, or by using a segment in multi-family

groups (which are often required in order to visit the

identied patient) to present the co-morbid mental

health disorder as a complicating factor in recovery.

The importance of medications to manage the mental

health disorder may be emphasized. Advanced

DDC programs may begin to discuss familial and

genetic predispositions, medications vs. drugs and

mutual support organizations for family members.

These are not protocol driven and are more so driven

by individual clinicians, particularly ones with an

emphasis on family systems or therapies.

DDC PROGRAMS

Enhancing IVH. Family education and support.

DDE programs routinely offer services to family

members or signicant others of people with substance

use, mental health and co-occurring disorders.

Services in DDE programs involve systematic and

protocol driven didactics and materials, as well as an

individualized presentation of the interactive risks of

co-occurring disorders, in terms of etiology, course,

compliance and recovery. Educational materials are

routinely distributed to family members and signicant

others. They learn about both (or more) disorders that

their loved one is and will be dealing with. Careful

discussions about drugs vs. medications, chronic

vs. acute care models, and the importance of family

support are routinely conducted, and information is

routinely provided about mutual support resources for

family members.

SAMHSA’s Family Psychoeducation Toolkit may be

helpful in implementing family education and support

programming. You can nd it online at http://store.

samhsa.gov/product/Family-Psychoeducation-Evidence-

Based-Practices-EBP-KIT/SMA09-4423.

Hazelden Publications has also produced a DVD series

for adults with co-occurring disorders and adolescents

with co-occurring disorders. Both are 30 minutes in

length and can be viewed by families individually or in

multi-family groups. These can be used for educational

purposes and also to initiate a discussion specic

to the co-occurring disorder of their family member.

The Hazelden Co-Occurring Disorders Program

also includes educational resources and a family

curriculum. Hazelden is online at www.hazelden.org.

67DDCAT Index: Scoring and Program Enhancements

IVI. Specialized interventions to facilitate

use of peer support groups in

planning or during treatment.

Denition: Addiction treatment programs that offer

treatment to individuals with co-occurring disorders

provide assistance in developing a support system

through peer recovery support groups. Individuals

with mental health symptoms and disorders often face

additional barriers in linking with peer recovery support

groups. These individuals may require additional

assistance such as being referred/ accompanied/

introduced to peer recovery support groups by clinical

staff, designated liaisons, or mutual aid group peer

volunteers. Additional interventions may be required to

help individuals nd peer support groups with accepting

attitudes toward people with co-occurring disorders and

toward the use of psychotropic medication.

Source: Interviews with clinicians and patients, schedule

or calendar of available peer recovery support groups,

and review of treatment plans and progress notes.

Item Response Coding: Coding of this item requires

an understanding of the mechanism through which

individuals, specically those with co-occurring

disorders, are linked with peer recovery support groups.

n

Addiction Only Services = (SCORE-1): No

interventions used to facilitate use of either

addiction or mental health peer support. The

program does not encourage and does not offer

a mechanism to encourage or link individuals

with co-occurring mental health disorders to peer

support groups.

n

(SCORE-2): Used variably or infrequently by

individual clinicians for individual patients, mostly

for facilitation to addiction peer support groups.

The program sometimes offers assistance or

support to individuals with co-occurring mental

health disorders in linking with appropriate peer

support groups. This is usually the result of

clinician’s judgment or preference.

n

Dual Diagnosis Capable = (SCORE-3): Generic

format on site, but no specic or intentional

facilitation based on mental health disorders.

More routine facilitation to addiction peer support

groups (e.g., AA, NA). The program routinely

encourages the use of peer support groups for

patients with co-occurring disorders. While the

mechanisms tend to be general and not specic

to the individual, they are consistently used.

Examples of this include providing individuals

with a schedule of peer support groups or making

some initial contacts made on their behalf. This is

considered to be a standard aspect of the program

and occurs at least 80 percent of the time.

n

(SCORE-4): Variable facilitation targeting specic

co-occurring needs, intended to engage patients

in addiction peer support groups or groups specic

to both disorders (e.g., DRA, DTR). Individualized

facilitation, including to peer support groups

specically for patients with co-occurring disorders

occurs, but is only occasionally documented

incharts.

n

Dual Diagnosis Enhanced = (SCORE-5): Routine

facilitation targeting specic co-occurring needs,

intended to engage patients in addiction peer

support groups or groups specic to both disorders

(e.g., DRA, DTR). The program systematically

advocates for the use of peer support groups with

their patients who have co-occurring disorders.

Treatment plans and/or progress notes indicate

that linkage with self-help groups is regularly

discussed with patients. Specialized assistance

in making this linkage attempts to proactively

68 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

plan for potential barriers or difculties that the

patient might experience in the peer support

group environment. Examples of individualized

approaches to linking a patient with peer support

group include the following: (1) identifying a

liaison, who assists the individual in transitioning

to the group; (2) consultation with the peer

recovery support group on behalf of the individual

regarding specialized mental health needs of the

individual; (3) an onsite “transition group” with

specic mutual aid group members who have

some willingness to discuss co-occurring mental

health problems pertaining to use of the peer

support group in the community; and (4) assisting

individuals to identify specic strategies to help

them connect with peer support groups. This

specialized support to the individual is a standard

part of program activities.

AOS PROGRAMS

Enhancing IVI. Specialized interventions to facilitate use of peer support groups in planning or during treatment.

Involvement with mutual support groups, including

twelve-step groups, is associated with long-term

recovery and positive life change. These groups

typically embrace a chronic disease model that

understands addiction as a lifelong vulnerability, offer

a fellowship of non-using peers, provide an explanatory

model with suggested steps for change, and do not

collect dues or fees. There is some evidence to suggest

persons with co-occurring disorders have difculty

afliating and participating in addiction peer support

groups. Double Trouble in Recovery, Dual Recovery

Anonymous, and other groups have been developed to

address this challenge. These groups have had varying

degrees of success. Addiction twelve-step groups

may be optimal, since they have more members with

signicant periods of sobriety, have clearer guidelines

about operations (traditions), and there are more

available meetings in the community.

AOS programs typically do not offer special services

to bridge the person with a co-occurring disorder into

addiction peer support. DDC programs, by identifying

the mental health problem, will individualize the

referral to mutual peer recovery support groups. The

DDC program presents generic information through

individual sessions, group sessions, or in-house

meetings to help a person with a co-occurring disorder

learn how to join and participate (and presumably

benet) from these groups. At the DDC level, these

efforts are not systematic, but are more driven by

individual clinicians, many of whom have a personal

or working understanding of how certain groups in

the community tolerate persons with mental health

disorders, and to what degree.

There are two manualized evidence-based versions

of facilitation of the connection with peer group

support in the community. Although neither of these

approaches specically addresses co-occurring mental

health barriers, they can be adapted for this purpose:

National Institute on Drug Abuse (NIDA) Therapy

Manuals for Individual Drug Counseling and Group

Drug Counseling

(www.nida.nih.gov/DrugPages/Treatment.html)

National Institute on Alcohol Abuse and Alcoholism

(NIAAA) Therapy Manual for Twelve-Step Facilitation

Therapy

(http://pubs.niaaa.nih.gov/publications/match.htm)

Hazelden Publications has also produced a 30-minute

DVD (Introduction to Twelve Step Groups) and a

manual based on the NIAAA Twelve Step Facilitation

Outpatient Program. Hazelden products are available

for purchase at www.hazelden.org.

69DDCAT Index: Scoring and Program Enhancements

DDC PROGRAMS

Enhancing IVI. Specialized interventions to facilitate use of peer support groups in planning or during treatment.

In contrast to DDC programs, DDE programs may

have co-occurring recovery groups on site, and will

systematically address the possible difculties of

specic co-occurring disorders. These may include

helping a person with depression learn about the role

of medications in recovery and how to (or not) discuss

medicines in groups. Staff may help a person with

social phobia gradually approach a group, rst by

attending smaller groups, then by showing up earlier

and staying later to minimize public speaking anxiety

yet being able to meet others. Other assistance may

include helping a person with PTSD nd meetings

without members who may trigger her re-experiencing

symptoms. These interventions may be conducted

within the context of a co-occurring disorder group,

and may feature counselors attending meetings

with patients in order to facilitate afliation. DDE

programs document the various strategies used to

help people connect with peer support groups to share

across all staff and retain the knowledge when staff

turnoveroccurs.

Dual Recovery Anonymous groups (http://www.

draonline.org/) and Double Trouble in Recovery groups

(http://nrepp.samhsa.gov/ViewIntervention.aspx?id=13)

are the most common self-help groups designed

specically for people with co-occurring disorders.

In the absence of dual recovery groups, DDE programs

use intentional and routine facilitation approaches to

AA and NA groups for medication, anxiety, avoidance,

sponsorship, and speaking challenges common among

persons with co-occurring disorders.

70 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

IVJ. Availability of peer recovery

supportsfor patients with

co-occurring disorders.

Denition: Addiction programs that offer treatment to

individuals with a co-occurring mental health disorder

encourage and support the use of peer supports and role

models that include consumer liaisons, alumni groups,

etc. Assistance is provided to individuals in developing

a support system that includes the development of

relationships with individual peer supports (in addition

topeer support groups described in the previous item.)

For the purpose of this item, peer is dened as a person

with a co-occurring disorder.

Source: Interviews with clinicians and patients, review

of treatment plans, calendar of available peer recovery

supports, understanding of onsite peer recovery supports,

consumer liaisons, and alumni staff.

Item Response Coding: Coding of this item requires

an understanding of the availability of co-occurring

disorders-specic peer supports and role models.

n

Addiction Only Services = (SCORE-1): Not present,

or if present not recommended. The program does

not support or guide individuals with co-occurring

mental health disorders toward peer supports or

role models with co-occurring disorders.

n

(SCORE-2): Off site, recommended variably.

Theprogram may occasionally offer referrals to

offsite peer supports, primarily individuals with

substance use disorders. This is largely dependent

on the providers’ preferences and knowledge

oftheavailable individual supports in the area.

n

Dual Diagnosis Capable = (SCORE-3): Off site

and facilitated with contact persons or informal

matching with peer supports in the community,

some co-occurring focus. The program routinely

(at least 80 percent of the time) attempts to refer

and link individuals with co-occurring mental

health disorders to peer supports and role models

located off site, some of whom have co-occurring

disorders. This is considered a standard support

service that can be offered to individuals, but

itisnot incorporated into treatment planning.

n

(SCORE-4): Off site, integrated into plan, and

routinely documented with co-occurring focus.

The program routinely (at least 80 percent of the

time) integrates off site peer recovery supports

into the treatment plan for individuals with co-

occurring mental health disorders. Utilization

of recovery supports is considered a part of

standard programming, and treatment plans

consistently reect the utilization of these peer

recoverysupports.

n

Dual Diagnosis Enhanced = (SCORE-5): On

site, facilitated and formally integrated into

program (e.g., alumni groups); routinely used and

documented with co-occurring focus. The program

routinely supports the use of peer supports and

role models for individuals with co-occurring

disorders, developing these peer supports on

site. Treatment plans consistently document

theutilization of these recovery supports.

71DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing IVJ. Availability of peer recovery supports forpatients with CODs.

An AOS score on this item is highly associated with a

program’s score on the previous item (IVI. Specialized

interventions to facilitate use of peer support groups

in planning or during treatment.). AOS programs make

no specialized effort to link persons to support group

meetings, and likewise there is no effort to connect

current patients to persons with co-occurring disorders

who are in recovery.

DDC programs often have staff members who

make special introductions to individuals from the

community who are in recovery. DDC programs may

have staff members who are in personal recovery who

attempt to “match” patients with temporary sponsors

based upon aspects of mental health disorders

commonality. These efforts are typically clinician-

driven and not a routine aspect of a protocol designed

to link peers who may identify with one another on

common co-occurring disorder bases.

DDC programs intentionally and routinely encourage

the use of peer supports, but not in a particularly

formalized way.

DDC PROGRAMS

Enhancing IVJ. Availability of peer recovery supports for patients with CODs.

In order for DDC programs to achieve DDE status on this

item, they must develop clearer systems and protocols

for matching patients with peer mentors or supports.

These mentors or supports are matched based upon the

likelihood of identication on mental health disorders in

their background, and the need to learn how to live with

both disorders. This matching is protocol-driven rather

than clinician-instigated, with the use of volunteer

boards, program alumni, the twelve-step hospital

and institution committees, volunteer peer recovery

specialists, or bridging the gap groups.

The City Clinic has responded to this crucial issue

through the establishment of weekly “bridge”

groups, co-led by recovering volunteers and a staff

member. A segment of the group is dedicated to co-

occurring mental health issues with the goal being the

development of individual peer support relationships.

A key feature in the DDE program is creating peer

support connections on site and having a formal

protocol to insure the ongoing availability of

thesesupports.

72 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

V. Continuity of Care

VA. Co-occurring disorder addressed

indischarge planning process.

Denition: Programs that offer treatment to individuals

with a co-occurring mental health disorder develop

discharge plans that include an equivalent focus on

needed follow-up services for both mental health and

substance use disorders.

Source: Discharge plans, memoranda of understanding.

Item Response Coding: Coding of this item requires an

understanding of the key elements considered in the

documented discharge plan of individuals with co-

occurring mental health symptoms.

n

Addiction Only Services = (SCORE-1): Not

addressed. Within the program, the discharge

plans of individuals with co-occurring disorders

routinely focus on substance use disorders only

and do not address mental health concerns.

n

(SCORE-2): Variably addressed by individual

clinicians. Within the program, the discharge

plans of individuals with co-occurring disorders

occasionally address both the substance use and

mental health disorders, with the substance use

disorder taking priority. The variability is typically

due to individual clinician judgment or preference.

n

Dual Diagnosis Capable = (SCORE-3): Co-occurring

disorder systematically addressed as secondary

in planning process for offsite referral. Within

the program, the discharge plans of individuals

with co-occurring disorders routinely (at least 80

percent of the time) address both the substance

use and mental health disorders, but the substance

use disorder takes priority and is likely to continue

to be managed within the program’s overall system

of care or by the next addiction treatment provider.

Follow-up mental health services are managed

through an offsite linkage (e.g., for medication

management), and are often generically addressed

as part of the relapse (substance) prevention plan.

n

(SCORE-4): Some capacity (less than 80 percent

of the time), to plan for integrated follow-up (i.e.,

equivalently address both substance use and

mental health disorders as a priority). Discharge

plans occasionally include appropriate follow-up

services for both disorders equally. The variability

is secondary to the judgment or expertise of the

individual clinician.

n

Dual Diagnosis Enhanced = (SCORE-5): Both

disorders seen as primary with conrmed plans

made for onsite follow-up, or documented

arrangements for offsite follow-up; at least 80

percent of the time. Within the program, the

discharge plans of individuals with co-occurring

disorders routinely (at least 80 percent of the

time) address both the substance use and

mental health disorders. And: Both disorders are

considered a priority, with equivalent emphasis

placed on ensuring appropriate follow-up services

for each disorder. The program/agency may have

the capacity to continue management and support

of both disorders in-house or have a formalized

agreement with a mental health clinic to provide

the needed services. In the case of discharge,

appropriate services are identied to address

both disorders. Referrals are routinely made,

conrmed, and documented in the discharge plan.

The program has specic protocols that guide the

discharge process.

73DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing VA. Co-occurring disorder addressed in discharge planning process.

Since AOS programs often have not listed the co-

existing mental health disorder or problem on the

treatment plan, it may not be a subject for intentional

discharge planning. In order to achieve DDC status,

the AOS program must make a more deliberate plan

for post-discharge and consider the inuence of the

co-occurring disorders on one another. DDC programs

will conceptualize the substance use disorder

as primary, but will underscore the importance

of treatments for the mental health disorder

(pharmacological and psychosocial) and will make

discharge plans accordingly.

Consultative relationships (see Program Structure

items) at a minimum are particularly important here,

since successful linkage is predicated on a close

relationship and clear referral protocol shared by

providers. Programs that admit from and discharge

back to wide geographic areas may not have these

relationships with every provider, but every effort is

made to formally arrange services prior to discharge.

The discharge process, in considering both disorders,

retains a largely clinician-driven rather than protocol

driven format.

DDC PROGRAMS

Enhancing VA. Co-occurring disorder addressed in discharge planning process.

DDE programs have an equivalent focus on discharge

planning for both substance use and psychiatric

disorders. Treatment providers and interventions,

medications and dose, recovery supports, and

relapse risks for both disorders are well described

and documented. The DDE medical record has

a systematic approach to the discharge process,

resulting in a systematic rather than clinician-

drivendocument.

The Miracles detoxication program transfers men

from a clinically managed setting to an afliated

addiction treatment program that has a collaborative

agreement with a local mental health clinic. Miracles’

staff arranges for the initial appointment prior to

discharge, and a primary care giver accompanies the

patient to the rst appointment. Upon discharge from

detoxication services, a patient has already visited

the outpatient program (which offers addiction and

mental health treatment) and has met his counselor.

This has improved linkage to both programs and

appropriately addresses both substance use and

mental healthproblems.

74 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VB. Capacity to maintain treatment

continuity.

Denition: When programs address the continuum

of treatment needs for individuals with co-occurring

disorders, there should be a formal mechanism for

providing ongoing needed mental health follow-up.

Best practice indicates that mental health concerns are

followed-up and monitored in a manner that is integrated

with substance use follow-up. The program emphasizes

continuity of care within the program’s scope of practice

but if a linkage with another level of care is necessary

it sets forth the expectation that treatment continues

indenitely with a goal of illness management.

Source: Interview with clinicians, medical records,

andpolicy and procedure manual.

Item Response Coding: Coding of this item requires an

understanding of the continuity of care available for the

continued treatment and monitoring of mental health

disorders in conjunction with substance use disorders.

Outpatient programs, or programs in an agency with an

outpatient component, will have a greater capacity to

provide ongoing follow-up services, even if linkage with

another level of care is necessary. Inpatient or residential

programs that stand alone, or serve a large geographic

area, may not have this option.

n

Addiction Only Services = (SCORE-1): No

mechanism for managing ongoing care of mental

health needs when addiction treatment program

is completed. With regard to treatment continuity,

the program’s system of care may offer follow-up

care for substance use disorders only, and there

is no internal mechanism for providing any follow-

up care, support, or monitoring of mental health

disorders. Follow-up mental health treatment is

referred to an offsite provider without any formal

consultation or collaboration. Programs at this

level may discharge individuals for mental health

symptoms or relapse to substance use with

minimal expectation or preparation for returning

toservices.

n

(SCORE-2): No formal protocol to manage mental

health needs once program is completed, but

some individual clinicians may provide extended

care until appropriate linkage takes place;

variable documentation. With regard to treatment

continuity, the program’s system of care is similar

to that of an AOS system, but there are individual

clinicians who are competent and willing to

provide some increased follow-up care for co-

occurring mental health disorders.

n

Dual Diagnosis Capable = (SCORE-3): No formal

protocol to manage mental health needs once

program is completed, but when indicated,

most individual clinicians provide extended

care until appropriate linkage takes place;

routine documentation. With regard to treatment

continuity, the program’s system of care has the

capacity to provide continued monitoring/support

for mental health disorders in addition to any

regularly provided follow-up care for substance

use disorders until the patient is systematically

linked to mental health services off site through

collaborative efforts. The program does not

routinely discharge a patient for substance use

relapse or mental health symptoms, but instead

reviews on a case by case basis with the goal of

maintaining the individual in treatment when

possible; if referral to another level of care is

necessary, the program ensures a rapid return for

anew episode of program services when indicated.

n

(SCORE-4): Formal protocol to manage

mental health needs indenitely, but variable

documentation that this is routinely practiced,

typically within the same program or agency.

With regard to treatment continuity, the

program’s system of care has the capacity to

provide continued monitoring and treatment

for mental health disorders in addition to any

regularly provided follow-up care for substance

use disorders but use of this continuum is

inconsistentlydocumented.

75DDCAT Index: Scoring and Program Enhancements

n

Dual Diagnosis Enhanced = (SCORE-5): Formal

protocol to manage mental health needs

indenitely and consistent documentation that

this is routinely practiced, typically within the

same program or agency. With regard to treatment

continuity, the program’s system of care has

the capacity to monitor and treat both mental

health disorders and substance use disorders

over an extended or indenite period. Onsite

clinical recovery check-ups may be an annual

or more frequent option in this type of program.

The program, within its scope of practice, treats

substance use relapse and exacerbation of

mental health symptoms on an individualized

basis and maintains individuals in treatment

whenever possible. If referral to another level of

care is necessary, the program ensures a rapid

re-admission when indicated.

AOS PROGRAMS

Enhancing VB. Capacity to maintain treatment continuity.

AOS programs may discharge persons with co-

occurring disorders who exhibit mental health

symptoms, or who relapse or “slip” in substance

use. In order to achieve DDC status, AOS programs

will need to develop increased clinical exibility to

explore the exacerbation of mental health symptoms

(and deliver treatments) or relapse to substances (and

consider the potential for a “therapeutic” approach to

relapse). These shifts in protocol must not exceed the

program’s capability in level of care. DDC programs

will evaluate the mental health problem, and if it is

sufciently stable they will retain the patient in the

current program. If a referral is required (preferably

within the same agency or to a mental health agency

with which there is a memorandum of understanding),

they will accept the patient back once stabilized.

Likewise, within the constraints particular to level of

care and patient safety, relapse to substances may

be approached from the context of an exacerbation of

symptoms, potentially managed within the program, or

once stabilized, not a barrier to immediately accepting

the patient back.

Outpatient DDC programs have the capacity to treat

both disorders (substance use and psychiatric) for an

extended if not open-ended period of time. Residential

DDC programs strive to maintain patients with co-

occurring disorders within their agency (if they offer a

comprehensive array of services) or link to follow-up

services through a collaborative relationship with the

local mental health provider.

DDC PROGRAMS

Enhancing VB. Capacity to maintain treatment continuity.

DDE programs recognize the chronic nature of

addiction and the majority of co-existing mental

health disorders. DDE programs, in contrast to DDC,

are typically able to provide in-house or within-

agency services that promote a patient experience

of a seamless process. Patients understand and can

verbalize that this is a program that may be in position

to continue with them for the foreseeable future if not

indenitely. DDE programs do not see the addiction

as primary, but rather maintain continuity for both

disorders in an equivalent fashion.

76 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VC. Focus on ongoing recovery issues

forboth disorders.

Denition: Programs that offer services to individuals

with co-occurring disorders support the use of a recovery

philosophy (vs. symptom remission only) for both

substance use as well as mental health disorders.

Source: Interviews with clinicians and patients,

document review (mission statement, brochure, policy

and procedure manual), and review of treatment plans.

Item Response Coding: Coding of this item requires

an understanding the program’s philosophy and how

the concept of recovery (vs. remission) is used in the

treatment and planning of both substance use and

mental health disorders.

n

Addiction Only Services = (SCORE-1): Not

observed. The program embraces the philosophy

ofrecovery for substance use disorders only.

Mental health recovery is not incorporated.

n

(SCORE-2): Individual clinician determined.

Theprogram embraces the philosophy of recovery

for substance use disorders only, but there are

individual clinicians who use recovery philosophy

when planning services for mental health disorders

as well.

n

Dual Diagnosis Capable = (SCORE-3): Routine

focus is on recovery from addiction, mental health

issues are viewed as potential relapse issues

only. The program systematically embraces the

philosophy of recovery for substance use disorders

and also includes a recovery philosophy for co-

occurring mental health disorders, but primarily

as it impacts the recovery from the substance use

disorder. For example, a mental health disorder

is perceived as a recovery issue in terms of its

probability of leading to substance use relapse if

not appropriately treated. Medication compliance

may be conceptualized as part of generic wellness

and positive lifestyle change.

n

Dual Diagnosis Enhanced = (SCORE-5): Routine

focus on addiction recovery and mental health

illness management and recovery, both seen as

primary and ongoing. The program embraces the

philosophy of hope and recovery equivalently for

both substance use and mental health disorders,

and articulates specic goals for persons to

achieve and maintain recovery that include both

mental health and substance use objectives.

77DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing VC. Focus on ongoing recovery issues for both disorders.

AOS programs will typically focus on recovery from

alcohol or drug addiction. Emphasis will be placed

on those traditional approaches that have been

found to be effective: aftercare, twelve-step group

afliation, nding a sponsor, working the steps, and

remaining abstinent one day at a time. Although these

processes are in fact associated with long-term positive

outcomes, for the person with a co-occurring mental

health disorder, another disease and recovery process

will need to be embraced.

DDC programs add to the recovery path outlined above

with some emphasis on how mental health problems

complicate or are a risk factor to one’s recovery

from substances. This may include the importance

of medication compliance, attendance at therapy

sessions for cognitive behavioral therapy, or perhaps

staying connected to the community mental health

center’s case management staff members.

DDC PROGRAMS

Enhancing VC. Focus on ongoing recovery issues for both disorders.

Whereas the DDC level program recognizes recovery

from substance use as primary and mental health

disorders as complicating factors, the DDE level

program recognizes the process of recovery for both

disorders. The DDE program may utilize the concepts

of twelve-step recovery to advance the principles

necessary for lifelong illness management. The DDE

program will also augment these steps and concepts

with mental health recovery literature (from NAMI) or

by implementing the Illness Management and Recovery

strategy (from SAMHSA): http://store.samhsa.gov/

product/Illness-Management-and-Recovery-Evidence-

Based-Practices-EBP-KIT/SMA09-4463

The key is that recovery from both disorders is seen

as equivalent and interactive, and that the prospects

are positive. The similarity, in terms of the distinction

between symptom remission and recovery, is imparted

in the DDE program.

Recovery for both addiction and mental illness is

seen as a positive lifestyle change and personal

transformation. Recovery extends well beyond simple

symptom remission or the absence of something

negative. Instead, recovery embraces a new life lled

with hope, promise, and opportunity.

78 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VD. Specialized interventions to facilitate

use of community-based peer support

groups during discharge planning.

Denition: Programs that offer services to individuals

with co-occurring disorders anticipate difculties

that the individuals might experience when linking

or continuing with peer recovery support groups in

the community. Thus these programs provide the

needed assistance to support this transition beyond

activetreatment.

Source: Interviews with clinicians and patients, review

ofprogress notes, discharge procedures.

Item Response Coding: Coding of this item requires

an understanding of peer support groups within the

program’s continuum of services and the systems for

facilitating the connection with groups in the community.

Note: Some programs have difculty with specialized

interventions to facilitate the use of peer support groups

while the individual is in treatment. These programs

will likely have difculty meeting this goal when the

individual is discharged.

n

Addiction Only Services = (SCORE-1): No

interventions made to facilitate use of either

addiction or mental health peer support groups

upon discharge. The program does not advocate

or assist with linking individuals with co-

occurring disorders to peer support groups beyond

recommendations, assignments, meetings lists,

and suggestions to “work the steps” and/or “nd

atemporary sponsor.”

n

(SCORE-2): Used variably or infrequently by

individual clinicians for individual patients, mostly

for facilitation to addiction peer support groups

upon discharge. The program does not advocate

or generally assist with linking persons with co-

occurring disorders with peer support groups or

document any such attempts. However, there is

some indication that it may happen as a result

ofclinician judgment or preference. A connection

specic to co-occurring disorders may be

variablydeveloped.

n

Dual Diagnosis Capable = (SCORE-3): Generic,

but no specic or intentional facilitation based

onmental health disorders. More routine facilitation

toaddiction peer support groups (e.g., AA, NA)

upon discharge. The program facilitates the process

of linking individuals with co-occurring disorders

to peer support groups at discharge. This is not

a systematic part of standard discharge planning

butoccurs with some frequency. Interventions might

include providing a list of addiction peer support

meetings that are more tolerant of individuals with

co-occurring disorders, linking women with PTSD

towomen’s AA meetings, and thoroughly discussing

medications vs. drugs, including how to talk at

NA meetings about medications and how to nd

areceptive sponsor.

n

(SCORE-4): Assertive linkages and interventions

variably made targeting specic co-occurring needs

to facilitate use of addiction peer support groups or

groups specic to both disorders (e.g., DRA, DTR)

upon discharge. The program sometimes facilitates

the process of assertively matching individuals with

co-occurring disorders to peer support groups at

discharge. This is not a part of standard discharge

planning but occurs with increasing frequency (at

least 50 percent of the time).

n

Dual Diagnosis Enhanced = (SCORE-5): Assertive

linkages and interventions routinely made targeting

specic co-occurring needs to facilitate use of

addiction peer support groups or groups specic

toboth disorders (e.g., DRA, DTR) upon discharge.

The program routinely recognizes the difculties

of individuals with co-occurring disorders in

linking or continuing with peer recovery support

groups. It routinely (at least on a 80 percent basis)

facilitates this process of assertively matching

individuals to these groups at discharge. This may

be a component of the program’s continuity of care

policy, and it may include directed introductions

to recovering individuals from the community,

accompanying patients to meetings in the

community, or enabling patients to attend in-house

mutual aid meetings on site indenitely.

79DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing VD. Specialized interventions to facilitate

use of community-based peer support groups during discharge planning.

Item IVI. (Specialized interventions to facilitate use

ofpeer support groups in planning or during treatment)

describes the benets of specialized interventions to

facilitate the use of peer recovery support groups for

persons with co-occurring disorders during treatment.

This item is an extension of this line of clinical

reasoning through the discharge and future of the

patient. AOS programs have not made specialized

interventions up to this point. Nonetheless, many

patients will have successfully linked with mutual

aid groups. Many patients will have only linked to

thedegree it satises program requirements, and once

these are lifted the patient may no longer attend or

benet. Other patients will attend, but not participate.

This may be helpful in fostering remission, but not

in the possible lifestyle and psychological changes

(transformations) that a person who participates fully

can more likely expect.

DDC programs have made efforts to match the patient

with community support groups, with a plan to foster

the connection and deepen the patient’s relationships

with other non-using people. Further, these social

connections serve as mentors or role models, who

can guide the newcomer on a course of recovery. DDC

programs note this in the discharge planning process,

and perhaps offer the patient the opportunity to return

for alumni events.

DDC PROGRAMS

Enhancing VD. Specialized interventions to facilitate

use of community-based peer support groups during discharge planning.

The DDE program expands on the usual practices

of the DDC program on this item by an increase

in systematization and a more protocol-driven (vs.

clinician-driven) process. DDE programs ensure the

introductions of current patients to peer recovery

support group members with an eye toward matching.

Peers will have accompanied patients to meetings in

the community until sufcient linkage and comfort

has been veried, and they may offer in-house Dual

Recovery Anonymous or twelve-step meetings that

patients can attend as alumni indenitely.

Since co-occurring recovery peer support groups are

less available in some areas, DDE programs insure

smooth linkage and integration with more traditional

and readily available community peer support

groups, such as Alcoholics Anonymous and Narcotics

Anonymous where appropriate.

80 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VE. Sufcient supply and compliance plan

for medications is documented.

Denition: Programs that serve individuals with a co-

occurring mental health disorder have the capacity to

assist these individuals with psychotropic medication

planning, prescription and medication access and

monitoring, and prescribing sufcient supplies of

medications at discharge.

Source: Interviews with clinicians and prescriber,

discharge procedures, and review of discharge plans.

Item Response Coding: Coding of this item requires an

understanding of the program’s prescribing guidelines

for individuals with co-occurring disorders atdischarge.

Note: Programs that have difculty providing

pharmacotherapy for co-occurring mental health

disorders while the individual is in treatment will likely

have difculty providing this service at discharge.

n

Addiction Only Services = (SCORE-1):

Nomedications in plan. When an individual

with aco-occurring mental health disorder

isdischarged, the program does not offer any

accommodations with regard to medication

planning or supplies other than recommending

theindividual consult with a prescriber or making

an appointment on her/hisbehalf.

n

(SCORE-2): Variable or undocumented availability

of 30-day supply to next appointment off

site. When an individual with a co-occurring

mental health disorder is discharged, the

program may prescribe a 30-day supply of

medication to “bridge” the individual until his/

her next appointment. This is not a consistent

ordocumented program practice.

n

Dual Diagnosis Capable = (SCORE-3): Routine

30-day or supply to next appointment off

site. Prescription and conrmed appointment

documented. When an individual with a co-

occurring mental health disorder is discharged,

theprogram has the capacity to provide for

medication planning and prescribes a 30 day or

short-term supply until the individual can be linked

for follow-up prescriptions at an external site. The

follow-up appointment is arranged and conrmed

by the program with some exchange of information

to the referral site, and the appointment and

bridge prescription are documented in the chart.

n

(SCORE- 4): Maintains medication management

in program/agency until admission to next level

of care at different provider (e.g., 45 to 90

days). Prescription and conrmed admission

documented. The program meets the standards

setat DDC and has the capacity to prescribe a

longer-term “bridge” supply of medication.

n

Dual Diagnosis Enhanced = (SCORE-5): Maintains

medication management in program with provider.

When an individual with a co-occurring mental

health disorder is discharged, the program/agency

has the capacity to provide continued medication

management including prescribing within the

program/agency structure for an indenite period.

81DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing VE. Sufcient supply and compliance plan for medications is documented.

AOS programs are likely not in position to prescribe a

supply of medication, but they do encourage linkage,

collaboration or consultation with the local mental

health provider. DDC programs may have continued

or initiated psychotropic medication and a sufcient

short-term supply of medication—necessary until

the next level of care or provider is reached—is

prescribed at discharge. This procedure is documented

and a collaborative arrangement with the next level

of care provider ensures acknowledgement and

successfullinkage.

DDC PROGRAMS

Enhancing VE. Sufcient supply and compliance plan for medications is documented.

In contrast to DDC programs, DDE programs will

maintain prescribing relationships with patients for

the foreseeable future. Inpatient or residential DDE

programs that are time-limited will be more closely

integrated with the next level of care, often within the

same agency, than are DDC providers. Medication is

seen to be one key part of an overall strategy of dual

recovery and illness management.

82 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VI. Stang

VIA. Psychiatrist or other physician

or prescriber of psychotropic

medications.

Denition: Programs that offer treatment to individuals

with co-occurring disorders offer pharmacotherapy

for both mental health and substance use disorders

through the services of prescribing professionals.

These programs may have a formal relationship with

a psychiatrist, physician, or nurse practitioner (or

other licensed prescriber) who works with the clinical

team to increase medication compliance, to decrease

the use of potentially addictive medications such as

benzodiazepines, and to offer medications such as

disulram, naltrexone, or acamprosate that may help

toreduce addictive behavior.

Source: Interviews with program director and clinical

staff (and prescriber if possible)

Item Response Coding: Coding of this item requires

an understanding of the specic competencies of

the prescribing professional and his or her level of

involvement with the clinical treatment team.

n

Addiction Only Services = (SCORE-1): No formal

relationship with a prescriber for this program.

The program has no formal relationship with

a prescriber and cannot prescribe or provide

medication services to individuals.

n

(SCORE-2): Consultant or contractor off site.

Theprogram has an arrangement with a prescriber

as a consultant or as an offsite provider.

n

Dual Diagnosis Capable = (SCORE-3): Consultant

or contractor on site. The program has an

arrangement with a prescriber who is experienced

and competent to prescribe medications for

mental health disorders, as either a consultant

or contractor who provides prescribing services

on site but who is not a member of the program’s

clinical staff (i.e., is only available for direct

patient care).

n

(SCORE-4): Staff member, present on site for

clinical matters only. The program has a prescriber

who is experienced and competent to prescribe

medications for mental health disorders as an

onsite staff member to provide specic clinical

duties, but who does not routinely participate in

the organized activities of a clinical team. At this

level, this prescriber may be accessed by staff on

alimited basis, but this is not routine.

n

Dual Diagnosis Enhanced = (SCORE-5): Staff

member, present on site for clinical, supervision,

treatment team, and/or administration.

Theprogram has a prescriber, who is experienced

andcompetent to prescribe medications for mental

health disorders, as an onsite staff member.

And:This prescribing staff member is also an

active participant in the full range of the program’s

clinical activities, is an integral member of the

clinical team, and may serve in a key clinical

decision-making or supervisory role.

83DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing VIA. Psychiatrist or other physician or prescriber of psychotropic medications.

Many addiction treatment providers consider this

item to be pivotal. Having access to a psychiatrist,

physician, or other prescriber can leverage a program

from AOS to DDC, and is associated with many

other items on the DDCAT. Yet, many programs do

have physician coverage, and based upon the role

of the physician within the agency, policies for

clinical practice, traditions, and patient admission

criteria, a program may still be AOS, even with

physiciancoverage.

AOS programs typically do not have a formal

relationship with a prescriber. They must refer patients

in need of medication or medication evaluations to a

prescriber outside the program. DDC programs have

contracted with a consultant prescriber who can

evaluate and treat patients on site. These contracted

arrangements may be inadequate to cover the needs

of all patients, but most patients can be initiated

on medication when indicated. The DDC program

consultant prescriber is typically available for

circumscribed clinical duties only.

DDC PROGRAMS

Enhancing VIA. Psychiatrist or other physician or prescriber of psychotropic medications.

Whereas the DDC program prescriber is focused on

clinical and patient management responsibilities, the

DDE prescriber has taken on a more expanded role.

Thetime allocated for patient care, either during no

shows or by arrangement, can be augmented if the

prescriber can meet with staff, either individually or

inteam meetings. To the extent the prescriber can

act in a clinical leadership capacity, a teaching and

supervision role, the program may enhance its dual

diagnosis capability. These relationships are best

if formalized and recognized. We have also seen

prescribers who are unofcial leaders and do so

byexample.

In order to become DDE, Deerpath Associates decided

to ask their nurse practitioner to attend their weekly

clinical team meetings. These meetings occurred

every Wednesday morning from 9:00 to 10:30. The

nurse practitioner agreed to attend the meetings

which cut down on the amount of time staff needed

to contact her by e-mail or phone to discuss shared

patient issues, but also created an opportunity for her

to educate staff, supervise and lead. Staff appreciated

this new relationship and the nurse practitioner

became more of a leader in the program.

84 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VIB. Onsite clinical staff members with

mental health licensure (doctoral

or masters level), competency or

substantive experience.

Denition: Addiction treatment programs that offer

treatment to individuals with co-occurring disorders

employ clinical staff with expertise in mental health

to enhance their capacity to treat the complexities

ofmental health disorders that co-occur with substance

use disorders.

Source: Interview with leadership and clinicians, review

of staff composition.

Item Response Coding: Coding of this item requires

an understanding of the program’s clinical staff

composition, particularly the number of licensed,

certied and/or competent mental health staff

(e.g.,LCSW, LPC, LMFT, licensed psychologist,

psychiatrist, APRN, or others with education and

experience equivalent to a master’s degree). In addition,

professionals need at least two years of supervised

experience in assessing and treating patients with

co-occurring disorders, to the point where certication

or autonomy has been achieved and competence

established. Competence is dened as a demonstrated

capability to assess and diagnose mental health

disorders, determine treatment needs including

appropriate level of care, prevent and manage mental

health crises, and deliver mental health treatments.

Clinical staff are so dened if they carry a caseload,

conduct individual or group sessions, or provide clinical

supervision or medication management.

n

Addiction Only Services = (SCORE-1): Program

has no staff who is licensed as mental health

professionals or has had substantial experience

sufcient to establish competence in mental

health treatment. The program has no staff

members with specic expertise or competencies

in the provision of services to individuals with

mental health disorders.

n

(SCORE-2): 1to 24 percent of clinical staff have

either a license in a mental health profession

or substantial experience sufcient to establish

competence in mental health treatment. The

program has less than 25 percent of clinical staff

with specic expertise or competencies in the

provision of services to individuals with mental

health disorders.

n

Dual Diagnosis Capable = (SCORE-3): 25 to 33

percent of clinical staff has either a license in a

mental health profession or substantial experience

sufcient to establish competence in mental

health treatment. The program has at least 25

percent of clinical staff with specic expertise

or competencies in the provision of services to

individuals with mental health disorders.

n

(SCORE-4): 34 to 49 percent of clinical staff

has either a license in a mental health profession

or substantial experience sufcient to establish

competence in mental health treatment. The

program has at least 34 percent of staff with

specic expertise or competencies in the

provision of services to individuals with mental

healthdisorders.

n

Dual Diagnosis Enhanced = (SCORE-5): 50

percent or more of clinical staff have either a

license in a mental health profession or substantial

experience sufcient to establish competence in

mental health treatment. The program has at least

50 percent of clinical staff with specic expertise

or competencies in the provision of services to

individuals with mental health disorders.

85DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing VIB. Onsite clinical staff with mental health licensure (doctoral or masters level),

competency or substantive experience.

The AOS program intending to become DDC is

challenged to provide an increasing array of services

in-house. Some addiction clinicians can and will

obtain additional training and certication to be able

to deliver psychosocial treatments and assessments

to persons with co-occurring disorders in addiction

settings. DDC programs have sought to increase

the number of mental health educated and trained

(if not licensed and certied) clinicians who have

demonstrated competence in assessing and treating

mental health disorders. A DDC program may have

about 25 percent of staff in this category. The DDC

program moving in this direction must be careful not

to reduce its capability to effectively treat substance

use disorders by enhancing its capacity to treat mental

health problems. Thus in hiring mental health trained

clinicians, those with complementary addiction

treatment education and/or experience should

bethetop priority.

DDC PROGRAMS

Enhancing VIB. Onsite clinical staff with mental health licensure (doctoral or masters level),

competency or substantive experience.

DDC programs wishing to achieve DDE status will

make a more denitive practice of hiring and stafng

the program with personnel who can deliver mental

health treatments and who are capable of assessing

mental health disorders. Reaching DDE status on

this criterion may also involve the inclusion of staff

members who are educated in mental health-related

elds (e.g., social work, psychology, counseling)

upon which addiction treatment expertise will be

built in apprenticeship learning models. In DDE

programs at least half of the clinical staff has mental

healthexpertise.

86 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VIC. Access to mental health clinical

supervision or consultation.

Denition: Programs that offer treatment to individuals

with a co-occurring mental health disorder provide

formal mental health supervision by a licensed

professional (i.e., LCSW, LPC, LMFT, licensed

psychologist, psychiatrist, APRN) for both trained

providers of mental health services who are unlicensed

or who have insufcient competence or experience in

the treatment setting, and licensed providers who are

developing delity to evidence-based practices.

Source: Interview with clinical supervisors, staff

composition.

Item Response Coding: Coding of this item requires

anunderstanding of the program’s supervision structure,

e.g., frequency, duration, supervision “tree,”etc.,

specically the credentials/qualications of those

individuals who provide supervision for mental

healthservices.

n

Addiction Only Services = (SCORE-1): No access.

The program does not have the capacity to provide

supervision for mental health services.

n

(SCORE-2): Consultant or contractor off site,

variably provided. The program provides a very

limited form of mental health supervision that

isinformal, irregular, and largely undocumented.

This service is typically offered through an offsite

consultant or only in emergent situations on site.

n

Dual Diagnosis Capable = (SCORE-3): Provided

as needed or variably on site by consultant,

contractor or staff member. Informal process.

Theprogram has the capacity to offer mental

health supervision on site to staff on a semi-

structured basis. Supervision at this level tends

tobe focused primarily on case disposition or crisis

managementissues.

n

(SCORE-4): Routinely provided on site by staff

member. The program offers regular supervision

for mental health services through an onsite

supervisor, which includes some in-depth learning

of assessment and treatment skill development

and may include activities such as rating

forms, review of audiotape sessions, or group

observation, but this supervision is not formally

orconsistentlydocumented.

n

Dual Diagnosis Enhanced = (SCORE-5): Routinely

provided on site by staff member and focuses on

in-depth learning. The program has the capacity

to offer a structured and regular supervision

for mental health services on site and there is

evidence that the supervision is focused on in-

depth learning of assessment and treatment skill

development, which includes use of at least one

of the following activities: delity rating forms,

review of audiotape sessions, or group observation,

and documentation is available that demonstrates

these activities and regularly scheduled supervision

periods occur.

87DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing VIC. Access to mental health clinical supervision or consultation.

AOS programs may not have access to mental health

consultation or supervision by a licensed professional.

In order to become DDC on this item, mental health

supervision must be provided. This supervision is

typically scheduled either on an individual or group

basis, and mental health treatments are encouraged

and reviewed. Often the focus in this supervision is

on diagnosis, appropriate referral to the prescriber

for medication, development of empathy, and

the management of countertransference issues.

Thesupervision, although present in DDC programs,

may tend to take on a crisis management or

disposition “laundry list” vs. in-depth quality.

DDC PROGRAMS

Enhancing VIC. Access to mental health clinical supervision or consultation.

DDE programs have recognized the value of clinical

supervision in promoting staff satisfaction, ensuring

quality care, and in promoting the installation

ofevidence-based practices. DDE programs offer

regular individual and/or group supervision (no more

time allocated than DDC) but deliberately focus the

supervision on in-depth learning of clinical practices.

These practices may include manual-guided therapies

in which the agency has just received training

(e.g.,Integrated Cognitive Behavioral Therapy [ICBT],

Seeking Safety, or DBT-S). Supervision is not confused

with caseload review or with discussing administrative

issues. The focus is dedicated to clinical process.

An LCSW attended a series of local workshops on

cognitive behavioral therapy for mood and anxiety

disorders. Through the regional Addiction Technology

Transfer Center the professional was able to arrange to

be supervised by phone over the course of a year. The

agency supported his efforts to acquire this skill since

they conceptualized it as an evidence-based practice

for which their state agency was beginning torequire

implementation. He then found that he could use it

in his supervision of the addiction counseling staff

members, as well as in his individual and group

supervision sessions with them. He used both therapy

rating forms (he obtained in the workshop) and

audiotape recordings of sessions to help the counselors

learn how to do cognitive behavioral therapy.

Research on the supervision process is underway,

including motivational interviewing approaches

tothe process itself. A suggested resource for

clinical supervision is SAMHA’s Technical Assistance

Publication 21-A: Competencies for Substance

Abuse Treatment Clinical Supervisors, which is

online at http://store.samhsa.gov/product/TAP-21A-

Competencies-for-Substance-Abuse-Treatment-Clinical-

Supervisors/SMA08-4243.

88 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VID. Case review, stafng or utilization

review procedures emphasize and

support co-occurring disorder

treatment.

Denition: Programs that offer treatment to individuals

with a co-occurring mental health disorder conduct co-

occurring disorder-specic case reviews or engage in a

formal utilization review process of co-occurring disorder

cases in order to continually monitor the appropriateness

and effectiveness of services for this population.

Source: Interview with clinicians, agency documents.

Item Response Coding: Coding of this item requires

an understanding of the program’s formal process for

reviewing mental health issues, specically the cases

ofindividuals with co-occurring disorders.

n

Addiction Only Services = (SCORE-1): Not

conducted. The program has no protocols to

review the cases of individuals with co-occurring

mental health disorders through a formal case

orutilization review process.

n

(SCORE-2): Consultant or contractor off site,

variably provided. The program has an offsite

consultant who occasionally conducts reviews

of the cases of individuals with co-occurring

mental health disorders. It appears to be

alargely unstructured and informal process,

anddocumentation may not be available.

n

Dual Diagnosis Capable = (SCORE-3):

Documented, on site, and as needed coverage

ofco-occurring issues. The program has a regular

procedure for reviewing the cases of individuals

with co-occurring mental health disorders through

a case or utilization review process by an onsite

supervisor. This process is a regular procedure

within the program that allows for a general review

of patient progress on mental health problems.

Documentation supports the consideration of co-

occurring disorders services within this process

(e.g., weekly stafngs).

n

(SCORE-4): Documented, routine, but not

systematic coverage of co-occurring issues.

The program routinely conducts case reviews

of individuals with co-occurring mental health

disorders. Reviews are documented, and the

program may use a standard format that includes

general categories related to co-occurring mental

health issues. However, there is no systematic

orin-depth evaluation of specic interventions

forco-occurring disorders.

n

Dual Diagnosis Enhanced = (SCORE-5):

Documented, routine and systematic coverage

ofco-occurring issues. The program has a routine,

formalized protocol that ensures the cases of all

patients are comprehensively reviewed in aprocess

that consistently reviews and focuses on co-

occurring mental health disorders. This process

takes a patient-centered approach that allows

for a systematic and critical review of targeted

interventions for co-occurring disorders in order

todetermine appropriateness or effectiveness, and

the process may include the patient. Documentation

of this formalized process isavailable.

89DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing VID. Case review, stafng or utilization review procedures

emphasize and support co-occurring disorder treatment.

While AOS programs may focus on the achievement of

recovery-oriented goals or in compliance with policy,

DDC programs attend to the status and progress with

the co-occurring disorder in case review, stafng

disposition or team meetings. DDC programs review

the patient’s progress with medications, ability to talk

about his/her mental health issues in group, progress

with signicant others, and the status of these issues

in mutual support group afliation and ongoing

recovery. The DDC program tends to review these

issues in a general way and on as an as-needed basis.

DDC PROGRAMS

Enhancing VID. Case review, stafng or utilization review procedures

emphasize and support co-occurring disorder treatment.

DDC programs review patient progress on mental

health problems in a general and variable way.

DDEprograms do so consistently and in a systematic

way. This is accomplished by standard case review

forms that a transcriber completes during team or

utilization review meetings. In addition to drug related

issues and addiction recovery progress, mental health

disorders are evaluated with precision and reliability.

One program uses Beck Depression Inventory and

Posttraumatic Stress Disorder Checklist scores to

ascertain patient status upon admission and at

two-week reviews. Another residential program lists

mental health disorders and designates clinically

responsible parties. These clinicians then report on

patient progress (per treatment plan) at each weekly

team meeting. The DDE program is characterized by

routine, systematic, and protocol-driven case review

ofco-occurring problems.

One indicator of Alphabet Clinic’s DDE level of

service is their staff familiarity with the scores of the

screening measures used to describe initial mental

health problem symptom severity. All staff members

know the scales on the MINI and the Beck Depression

Inventory, and they know how to interpret the clinical

importance of scores at the mild, moderate, or severe

level. In another program, clinicians in case review

meetings call out the latest screening measure scores

and stage of change for both mental health and

substance use for every patient discussed, not just

those they are concerned about.

90 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VIE. Peer/Alumni supports are available

with co-occurring disorders.

Denition: Programs that offer treatment to individuals

with co-occurring mental health disorders maintain staff

or a formalized relationship with volunteers who can

serve as co-occurring disorders peer/alumnisupports.

Source: Interviews with clinicians and patients, staff

andvolunteer composition.

Item Response Coding: Coding of this item requires an

understanding of the program’s staff composition and

the availability of staff or volunteers as peer/alumni

supports, specically the presence of individuals in

recovery from co-occurring disorders.

n

Addiction Only Services = (SCORE-1):

Notavailable. The program offers neither onsite

staff volunteers nor offsite linkages with either

alumni orpeer recovery supports with co-occurring

disorders.

n

(SCORE-2): Available, with co-occurring disorders,

but as part of the community. Variably referred by

individual clinician. Referrals are made secondary

to clinician knowledge and judgment.

n

Dual Diagnosis Capable = (SCORE-3): Available,

with co-occurring disorders, but as part of

community. Routine referrals made through

clinician relationships or more formal connections

such as peer support service groups (e.g., AA

Hospital and Institutional Committees or NAMI).

The program provides offsite linkages with peer/

alumni supports on a consistent basis.

n

(SCORE-4): Available on site, with co-occurring

disorders, either as paid staff, volunteers,

or program alumni. Variable referrals made.

Theprogram has developed onsite peer recovery

supports, although referrals are not routinely made.

n

Dual Diagnosis Enhanced = (SCORE-5): Available

on site, with co-occurring disorders, either as

paid staff, volunteers, or program alumni. Routine

referrals made. The program maintains a network

of staff or volunteers on site who can provide peer/

alumni support. Referrals are routinely made, and

clinicians have developed relationships with the

peer supports that facilitate strategic matching

of patients and peers. The program has a formal

protocol to ensure the ongoing availability of

thesesupports.

91DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing VIE. Peer/Alumni supports are available with co-occurring disorders.

This item closely corresponds to item IVJ: Availability

of peer recovery supports for patients with co-occurring

disorders. AOS programs approach this issue in a less

intentional and less individualized fashion. In order to

become DDC, the AOS program must consider being

more targeted in trying to match persons with specic

co-morbidities with peer role models. The use of alumni,

volunteers, or even carefully supervised recovering staff

members may be one way to accomplish this. The key

is to enable the patient with a co-occurring disorder to

recognize that he or she is not alone in having a co-

occurring disorder, and that someone who has been

successful can assist them in navigating and connecting

with mutual peer support groups in the community.

DDC programs typically will build upon these peer

support connections off site and within the community.

The Pottsville Hospital was approached by the three

members of the district AA Hospital and Institution

Committee. They wanted to “put on” meetings for the

patients at the hospital with alcohol problems and

hold the meetings in the hospital cafeteria on Friday

evenings. The Pottsville Hospital evening intensive

outpatient program director felt that adding this

component to his Monday through Thursday treatment

services would be an excellent new feature to his

program. Informally, he has gotten to know some of

the “regulars” at the meeting, so he has mentioned

to patients he knows have mental health problems to

look for specic regulars at the Friday night meetings.

He bases these “matches” on his awareness of their

empathy for certain types of people based on their

ownexperience.

DDC PROGRAMS

Enhancing VIE. Peer/Alumni supports are available with co-occurring disorders.

DDE programs capitalize on a network of community

volunteers, alumni, recovering staff and others, both

to serve as onsite recovery supports with co-occurring

disorders, and to strategically and routinely connect

persons with co-occurring disorders with identiable

others who can facilitate the afliation with mutual self-

help groups. DDE programs utilize traditional twelve-

step group mechanisms, peer led Illness Management

and Recovery groups, staff and volunteer co-led Bridge

groups, and open alumni and Dual Recovery meetings

held on site. Programs have wrestled with HIPAA,

condentiality, patient safety, and integrity of milieu

challenges. All have agreed these challenges were worth

the benets in facilitating patients’ connections to

recovering peers.

City Center methadone maintenance clinic has

developed an onsite peer program. Selected patients

with more than two years of successful treatment in the

clinic are included in new staff orientation trainings on

substance use and mental health disorders. These Peer

Recovery Specialists have an ofce, meet individually

with other patients referred by staff, and participate in

weekly staff meetings. Theprogram has intentionally

recruited individuals with co-occurring disorders to be

Peer Recovery Specialists.

The key difference in the DDE program is that this

occurs on site, and the program clinicians are more

closely connected with the peer group volunteers,

alumni, or members of the community. This connection

is often reinforced by monthly meetings to talk about

issues from clinical to administrative.

92 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VII. Training

VIIA. All staff members have basic

training in attitudes, prevalence,

common signs and symptoms,

detection and triage for co-

occurring disorders.

Denition: Programs that provide treatment to

individuals with co-occurring mental health disorders

ensure all staff who have contact with patients have

basic training in co-occurring disorders. For the

purpose of this item, basic training minimally includes

understanding one’s own attitudes, the prevalence of co-

occurring disorders and their screening and assessment,

common signs and symptoms of these disorders, and

triage/brief interventions and treatment decision-making.

Staff includes positions such as outpatient receptionists

and intake workers, as well as residential third shift and

weekend staff.

Source: Interviews with clinical leadership and

clinicians, review of strategic training plan and staff

training records

Item Response Coding: Coding of this item requires an

understanding of the program’s requirements for basic

skills and training with regard to co-occurring disorders,

and knowledge of the number of staff who have

completed this training.

n

Addiction Only Services = (SCORE-1): No staff

have basic training (0 percent trained). The

program’s staff has no training and is not required

to be trained in basic co-occurring issues.

n

(SCORE-2): Variably trained, no systematic

agency training plan or individual staff member

election (1 to 24 percent of staff trained). The

program encourages basic co-occurring disorders

training but has not made this a part of their

strategic training plan. A portion of the program’s

staff are trained as a result of management’s

encouragement or individual staff interest.

n

Dual Diagnosis Capable = (SCORE-3): Certain

staff trained, encouraged by management and

with systematic training plan (25 to 50 percent

of staff trained). The program’s strategic training

plan requires basic training in co-occurring

disorders for certain staff. And: Atleast 25

percent of all program staff is trained in

attitudes, prevalence, screening and assessment,

common signs and symptoms, and triage/brief

interventions and treatment decision-making for

co-occurringdisorders.

n

(SCORE-4): Many staff trained and monitored by

agency strategic training plan (51 to 79 percent of

staff trained). The program’s strategic training plan

requires the majority of staff to have basic training

in co-occurring disorders. And: The majority of

staff is trained. The program uses the plan to

monitor the number of staff who is trained and to

ensure they receive ongoing co-occurring disorders

training, typically at least annually.

n

Dual Diagnosis Enhanced = (SCORE-5): Most

staff trained and periodically monitored by agency

strategic training plan (80 percent or more of staff

trained). The program’s strategic training plan

requires all staff to have basic training in co-

occurring disorders. And: At least 80 percent of all

staff is trained in attitudes, prevalence, screening

and assessment, common signs and symptoms,

and triage and treatment decision-making for

co-occurring disorders. The program periodically

monitors the number of staff members who are

trained and uses the strategic training plan to

ensure that this number is maintained despite

staff turnover.

93DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing VIIA. All staff has basic training in attitudes, prevalence,

common signs and symptoms, detection and triage for co-occurring disorders.

Research into the successful adoption of new

technologies has generally found that training alone

is of limited value in sustaining change in practice

or behavior. Training is the principal mechanism to

impart new information, and a necessary step toward

practice change. AOS program staff members have

variable exposure to information about co-occurring

disorders, and about the prevalence of mental health

disorders already under their auspices.

DDC programs have made commitments to have

certain staff trained in basic issues pertaining to co-

occurring disorders: attitudes, prevalence, screening

and assessment, common signs and symptoms, triage/

brief interventions, and treatment decision making.

These trainings might be strategically directed using

existing training budgets or release time, and are

incorporated into a training plan. The need for this

basic training is not just for designated clinical staff,

but benecial for all persons who come in professional

contact with patients. Residential program aides

are often neglected in training programs, and these

individuals provide hours of direct service. As an

example of how to incorporate this into existing

structures, one program provides nine in-service

training sessions a year and has committed 1/3 of

these to co-occurring disorders. They include all staff

from clinical supervisors to residential aides to front

ofce administrative support staff.

DDC level programs, as part of a strategic

training plan, have an increasing number of staff

members who are trained in understanding their

attitudes, the prevalence, screening, assessment,

common signs and symptoms, and triage/brief

interventions and therapeutic needs of persons

withco-occurringdisorders.

An excellent introduction to the topic of workforce

development can be found in the SAMHSA

Co-Occurring Center for Excellence (COCE)

Workforce Development and Training: Technical

Assistance (TA) Report for the Co-Occurring State

Incentive Grants (COSIGS) September 9, 2005,

Updated June 2008, available at http://homeless.

samhsa.gov/(S(mizsnr455dukej55bgx342z4))/

ResourceFiles/4xcn5gxr.pdf.

DDC PROGRAMS

Enhancing VIIA. All staff members have basic training in attitudes, prevalence,

common signs and symptoms, screening and assessment for psychiatric symptoms and disorders.

Whereas DDC programs have focused on training

certain staff on basic issues pertaining to co-occurring

disorders, the DDE program has all or almost all

staff trained in basic issues as a result of a regularly

monitored implementation of its strategic training

plan. Much like a DDC level program, administrators

strategically direct staff training and incorporate

the cost of doing so into existing allocations

whereverpossible.

In contrast to the DDC program, the DDE program

intentionally plans and ensures that at all times at

least 80 percent of staff are trained in basic issues

related to co-occurring disorders.

94 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VIIB. Clinical staff members have

advanced specialized training

in integrated psychosocial

orpharmacological treatment of

persons with co-occurringdisorders.

Denition: Programs that offer treatment to individuals

with co-occurring disorders ensure clinical staff has

advanced specialized training to increase the needed

capacity to provide co-occurring disorders treatment

within the program and create a “no wrong door”

experience for patients. This aspect of training is

incorporated into the program’s strategic training plan.

For the purpose of this item, advanced specialized

training in integrated treatment minimally includes

knowledge of specic therapies and treatment

interventions for individuals with co-occurring disorders,

assessment and diagnosis, and basic knowledge of

pharmacological interventions for co-occurring disorders.

Clinical staff is dened as those staff who carry a

caseload, conduct individual or group sessions, or

provides clinical supervision or medication management.

Source: Interviews with executive director, clinical

leadership and clinicians, review of strategic training

plan and staff training records

Item Response Coding: Coding of this item requires

an understanding of the program’s requirements for

advanced specialized training in co-occurring disorders,

and knowledge of the numbers of staff who have

completed this training.

n

Addiction Only Services = (SCORE-1): Noclinical

staff have advanced training (0 percent trained).

The program has no staff with advanced

specialized training in integrated treatment

ofco-occurring disorders and does not require

thistraining.

n

(SCORE-2): Variably trained, no systematic agency

training plan, or individual staff member election

(1 to 24 percent of clinical staff trained). A portion

of the program’s clinical staff have advanced

specialized training in integrated treatment of

co-occurring disorders. This is either encouraged

by management or the result of individual staff

interest, but this is not a part of the program’s

strategic training plan.

n

Dual Diagnosis Capable = (SCORE-3): Certain

staff trained, encouraged by management and

with systematic training plan (25 to 50 percent

of clinical staff trained). The program’s strategic

training plan requires advanced specialized

training in integrated treatment of co-occurring

disorders for certain staff. And: At least 25 percent

of clinical staff is trained in specic therapies

and treatment interventions, assessment and

diagnosis, and pharmacological interventions

forco-occurringdisorders.

n

(SCORE-4): Many staff trained and monitored by

agency strategic training plan (51 to 79 percent

of clinical staff trained). The program’s strategic

training plan requires the majority of clinical

staff to have advanced specialized training in co-

occurring disorders. And: The majority of staff is

trained. The program uses the plan to monitor the

number of staff who is trained.

n

Dual Diagnosis Enhanced = (SCORE-5): Most

staff trained and periodically monitored by agency

strategic training plan (80 percent or more of

clinical staff trained). The program’s strategic

training plan requires advanced specialized

training in integrated treatment for co-occurring

disorders for all clinical staff. And: At least 80

percent of all clinical staff is trained in specic

therapies and treatment interventions, assessment

and diagnosis, and pharmacological interventions

for co-occurring disorders. The program periodically

monitors the number of staff who is trained and

uses the strategic training plan to ensure that

this number of trained staff ismaintained despite

staffturnover.

95DDCAT Index: Scoring and Program Enhancements

AOS PROGRAMS

Enhancing VIIB. Clinical staff members have advanced specialized training in integrated psychosocial

orpharmacological treatment of persons with co-occurring disorders.

This item reviews the overall training prole of the

staff working within a program. AOS programs may not

have an overall training strategy and have developed no

particular mechanism to track or direct staff needs for

training or training actually received. The DDC program

has made some effort to organize this critically

important and common competency support. DDC

programs aim to have 25 to 50 percent of staff with

advanced specialized training in integrated treatment

for individuals with co-occurring disorders, including

knowledge of specic therapies and treatment

interventions, assessment and diagnosis, and basic

knowledge of pharmacological interventions. This item

does not have to be cost-intensive but can require

anorganization to be more intentional and strategic

inthe use of its training dollars and time allocations.

An excellent introduction to the topic of workforce

development can be found in the SAMHSA

Co-Occurring Center for Excellence (COCE)

Workforce Development and Training: Technical

Assistance (TA) Report for the Co-Occurring State

Incentive Grants (COSIGS) September 9, 2005,

Updated June 2008, available at http://homeless.

samhsa.gov/(S(mizsnr455dukej55bgx342z4))/

ResourceFiles/4xcn5gxr.pdf

DDC PROGRAMS

Enhancing VIIB. Clinical staff members have advanced specialized training in integrated psychosocial

orpharmacological treatment of persons with co-occurring disorders.

DDE programs make a substantial investment in

creating a “no wrong door” experience for patients.

They do this at the program level, and with respect to

staff competency, attempt to do this at the individual

clinician level. Thus any clinician in a DDE program

will respond to a patient with a co-occurring disorder

with a similarly open framework. In the DDE program,

at least 80 percent of staff will have advanced

specialized training if not expertise in integrated

treatment of co-occurring disorders. An agency

strategic training plan allows program administrators

to coordinate the delivery of needed training and

may undergird the delivery and delity of specic

integrated services.

97Epilogue

VI. Epilogue

Both the DDCAT and DDCMHT are designed to be

practical measures of program level capacity to address

co-occurring substance use and mental health disorders.

The intent is for them to be used to improve services for

persons and families who suffer from these disorders.

These individuals and families are beleaguered by

the challenges confronting them with the severity

of symptoms associated with these disorders. They

should not have to confront barriers and confusion

in accessing care. The DDCAT and DDCMHT provide

objective, standardized and comparable benchmarks and

categorizations of addiction and mental health treatment

services and programs. This information can go far

to provide consumers with a guide to make informed

choices about where to seek treatment.

Dual Diagnosis Capability

inAddiction Treatment

(DDCAT) Toolkit

Version 4.0

The DDCAT and DDCMHT are relatively straightforward

measures to use. With this toolkit, and the indexes,

you can probably proceed with reasonable skill and

condence in assessing services. On the one hand,

we support your initiative in doing so. On the other

hand, we appreciate the benets of consultation with

others with experience in the administration, scoring,

interpretation of ndings, and the use of the data for

quality improvement efforts. The choice is yours.

Our mission is to improve the chances for recovery

among persons with co-occurring substance use and

mental health disorders. Their chances are less than

average. With the encouragement and pragmatic

guidance that the DDCAT and DDCMHT measures

provide those who deliver treatment, we hope their

chances improve.

Appendices 99

VII. Appendices

Dual Diagnosis Capability

inAddiction Treatment

(DDCAT) Toolkit

Version 4.0

Measures 101

A. Dual Diagnosis Capability in Addiction

Treatment (DDCAT) Index Version 4.0

Measures 103

DDCAT — Rating Scale Cover Sheet

Program Identication

Date __________________________ Rater(s)

_______________________________________________

Time Spent (Hours)

__________

Agency Name

_______________________________________________________________________________________________________

Program Name

_____________________________________________________________________________________________________

Address

_______________________________________________________________________________

Zip Code

____________________

Contact Person 1)

_____________________________________________________________________

_________________________

Telephone

______________________

FAX

____________________

______________________________________________________

State

___________________________

Region

_________________

Program ID

____________________

Time Period _______________

1= Baseline; 2 = 1st-follow-up;

3= 2nd follow-up; 4= 3rd follow-up; etc

Program Characteristics

Payments received (program)

____Self-pay

____Private health insurance

____Medicaid

____Medicare

____State nanced insurance

____Military insurance

Other funding sources

____Other public funds

____Other funds

Primary focus of agency

____Addiction treatment services

____Mental health (MH) services

____Mix of addiction & MH services

____General health services

____Hospital

Size of program

____# of admissions/last scal year

____Capacity (highest # serviceable)

____Average length of stay (in days)

____Planned length of stay (in days)

____# of unduplicated clients/year

Agency type

____Private

____Public

____Non-Prot

____Government operated

____Veterans Health Administration

Level of care

ASAM-PPC-2R (Addiction)

____I. Outpatient

____II. IOP/Partial Hospital

____III. Residential/Inpatient

____IV. Medically Managed Intensive

Inpatient (Hospital)

____OMT: Opioid Maintenance

____D: Detoxication

Mental Health

____Outpatient

____Partial hospital/Day program

____Inpatient

Exclusive program/

Admission criteria requirement

____Adolescents

____Co-occurring MH

& SU disorders

____HIV/AIDs

____Gay & lesbian

____Seniors/Elders

____Pregnant/post-partum

____Women

____Residential setting for patients

and their children

____Men

____DUI/DWI

____Criminal justice clients

____Adult General

104 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

Table Header Key

1-AOS Addiction Only Services

3-DDC Dual Diagnosis Capable

5-DDE Dual Diagnosis Enhanced

1 – AOS 2 3 – DDC 4 5 – DDE

I. Program Structure

IA. Primary focus

of agency as

stated in the

mission statement

(If program has

mission, consider

program mission).

Addiction only. Primary focus

is addiction,

co-occurring

disorders are

treated.

Primary focus on

persons with co-

occurring disorders.

IB. Organizational

certication

and licensure.

Permits only

addiction

treatment.

Has no actual

barrier, but staff

report there to be

certication or

licensure barriers.

Has no barrier to

providing mental

health treatment

or treating co-

occurring disorders

within the context

of addiction

treatment.

Is certied

and/or licensed

to provide both.

IC. Coordination

and collaboration

with mental

health services.

No document

of formal

coordination or

collaboration.

Meets the

SAMHSA denition

of minimal

Coordination.

Vague,

undocumented,

or informal

relationship

with mental

health agency, or

consulting with

a staff member

from that agency.

Meets the SAMHSA

denition of

Consultation.

Formalized and

documented

coordination or

collaboration with

mental health

agency. Meets the

SAMHSA denition

of Collaboration.

Formalized

coordination and

collaboration, and

the availability of

case management

staff, or staff

exchange programs

(variably used).

Meets the SAMHSA

denition of

Collaboration and

has some informal

components

consistent with

Integration.

Most services

are integrated

within the existing

program, or

routine use of case

management staff

or staff exchange

programs. Meets

the SAMHSA

denition of

Integration.

ID. Financial

incentives.

Can only bill

for addiction

treatments or bill

for persons with

substance use

disorders.

Could bill for

either service type

if substance use

disorder is primary,

but staff report

there to be barriers.

–OR– Partial

reimbursement

for mental health

services available.

Can bill for

either service

type; however, a

substance use

disorder must

be primary.

Can bill for

addiction or

mental health

treatments, or their

combination and/or

integration.

DDCAT — Rating Scale

Measures 105

1 – AOS 2 3 – DDC 4 5 – DDE

II. Program Milieu

IIA. Routine

expectation of

and welcome to

treatment for both

disorders.

Program expects

substance use

disorders only;

refers or deects

persons with mental

health disorders or

symptoms.

Documented to

expect substance

use disorders only

(e.g., admission

criteria, target

population), but

has informal

procedure to allow

some persons with

mental health

disorders to be

admitted.

Focus is on

substance use

disorders, but

accepts mental

health disorders

by routine and if

mild and relatively

stable as reected

in program

documentation.

Program formally

dened like DDC

but clinicians and

program informally

expect and treat co-

occurring disorders

regardless of severity,

not well documented.

Clinicians and

program expect and

treat co-occurring

disorders regardless

of severity, well

documented.

IIB. Display and

distribution

of literature

and patient

educational

materials.

Addiction or

peer support

(e.g., AA) only.

Available for both

disorders but not

routinely offered or

formally available.

Routinely

available for both

mental health

and substance

use disorders in

waiting areas,

patient orientation

materials and

family visits,

but distribution

is less for mental

health disorders.

Routinely available

for both mental

health and substance

use disorders

with equivalent

distribution.

Routinely and

equivalently

available for both

disorders and for

the interaction

between mental

health and

substance use

disorders.

III. Clinical Process: Assessment

IIIA. Routine

screening

methods for

mental health

symptoms.

Pre-admission

screening based on

patient self-report.

Decision based on

clinician inference

from patient

presentation or by

history.

Pre-admission

screening for

symptom and

treatment

history, current

medications,

suicide/homicide

history prior to

admission.

Routine set of

standard interview

questions for

mental health

using a generic

framework, e.g.,

ASAM-PPC

(Dimension III) or

“Biopsychosocial”

data collection.

Screen for mental

health symptoms

using standardized or

formal instruments

with established

psychometric

properties.

Screen using

standardized or

formal instruments

for both mental

health and

substance use

disorders with

established

psychometric

properties.

IIIB. Routine

assessment if

screened positive

for mental health

symptoms.

Assessment for

mental health

disorders is not

recorded in records.

Assessment for

mental health

disorders occurs

for some patients,

but is not routine

or is variable by

clinician.

Assessment for

mental health

disorders is

present, formal,

standardized, and

documented in 50-

69% of the records.

Assessment for

mental health

disorders is present,

formal, standardized,

and documented

in 70-89% of the

records.

Assessment for

mental health

disorders is formal,

standardized, and

integrated with

assessment for

substance use

symptoms, and

documented in at

least 90% of the

records.

DDCAT — Rating Scale

106 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

1 – AOS 2 3 – DDC 4 5 – DDE

IIIC. Mental health

and substance

use diagnoses

made and

documented.

Mental health

diagnoses are

neither made nor

recorded in records.

Mental health

diagnostic

impressions or

past treatment

records are present

in records but the

program does not

have a routine

process for making

and documenting

mental health

diagnoses.

The program has

a mechanism for

providing diagnostic

services in a timely

manner. Mental

health diagnoses

are documented

in 50-69% of the

records.

The program has

a mechanism for

providing routine,

timely diagnostic

services. Mental

health diagnoses are

documented in 70-

89% of the records.

Comprehensive

diagnostic services

are provided in a

timely manner.

Mental health

diagnoses are

documented in at

least 90% of the

records.

IIID. Mental health

and substance

use history

reected in

medical record.

Collection of

substance use

disorder history

only.

Standard form

collects substance

use disorder history

only. Mental health

history collected

inconsistently.

Routine

documentation of

both mental health

and substance use

disorder history in

record in narrative

section.

Specic section in

record dedicated

to history and

chronology of both

disorders.

Specic section

in record devoted

to history and

chronology of both

disorders and the

interaction between

them is examined

temporally.

IIIE. Program

acceptance

based on mental

health symptom

acuity: low,

moderate, high.

Admits persons

with no to low

acuity.

Admits persons

in program with

low to moderate

acuity, but who are

primarily stable.

Admits persons

in program with

moderate to high

acuity, including

those unstable in

their mental health

disorder.

IIIF. Program

acceptance based

on severity and

persistence of

mental health

disability: low,

moderate, high.

Admits persons

in program with

no to low severity

and persistence

of mental health

disability.

Admits persons in

program with low to

moderate severity

and persistence

of mental health

disability.

Admits persons

in program with

moderate to

high severity and

persistence of

mental health

disability.

IIIG. Stage-wise

assessment.

Not assessed or

documented.

Assessed and

documented

variably by

individual clinician.

Clinician assessed

and routinely

documented,

focused on

substance use

motivation.

Formal measure

used and routinely

documented

but focusing on

substance use

motivation only.

Formal measure

used and routinely

documented, focus

on both substance

use and mental

health motivation.

DDCAT — Rating Scale

Measures 107

1 – AOS 2 3 – DDC 4 5 – DDE

IV. Clinical Process: Treatment

IVA. Treatment plans. Address addiction

only (mental health

not listed).

Variable by

individual clinician,

i.e., plans vaguely

or only sometimes

address co-

occurring mental

health disorders.

Plans routinely

address both

disorders although

substance use

disorders addressed

as primary, mental

health as secondary

with generic

interventions.

Plans routinely

address substance

use and mental

health disorders;

equivalent focus on

both disorders; some

individualized detail

is variably observed.

Plans routinely

address both

disorders

equivalently and

in specic detail;

interventions

in addition to

medication are

used to address

mental health

disorders.

IVB. Assess and

monitor

interactive

courses of

both disorders.

No documentation

of progress with

mental health

disorders.

Variable reports of

progress on mental

health disorder

by individual

clinicians.

Routine clinical

focus in narrative

(treatment plan

review or progress

note) on mental

health disorder

change; description

tends to be generic.

Treatment monitoring

and documentation

reecting equivalent

in-depth focus on

both disorders is

available but variably

used.

Treatment

monitoring and

documentation

routinely reects

clear, detailed, and

systematic focus

on change in both

substance use

and mental health

disorders.

IVC. Procedures for

mental health

emergencies

and crisis

management.

No guidelines

conveyed in any

manner.

Verbally conveyed

in-house guidelines.

Documented

guidelines: Referral

or collaborations

(to local mental

health agency

or emergency

department).

Variable use of

documented

guidelines, formal

risk assessment

tools, and advance

directives for mental

health crisis and

substance use

relapse.

Routine capability,

or a process to

ascertain risk with

ongoing use of

substances and/or

severity of mental

health symptoms;

maintain in

program unless

commitment is

warranted.

IVD. Stage-wise

treatment.

Not assessed

or explicit in

treatment plan.

Stage of change

or motivation

documented

variably by

individual clinician

intreatment plan.

Stage of change or

motivation routinely

incorporated into

individualized

plan, but no

specic stage-wise

treatments.

Stage of change or

motivation routinely

incorporated into

individualized plan;

general awareness

of adjusting

treatments by

substance use stage

or motivation only.

Stage of change or

motivation routinely

incorporated into

individualized

plan; formally

prescribed and

delivered stage-

wise treatments for

both substance use

and mental health

disorders.

DDCAT — Rating Scale

108 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

1 – AOS 2 3 – DDC 4 5 – DDE

IVE. Policies and

procedures for

medication

evaluation,

management,

monitoring, and

compliance.

Patients on

medication

routinely not

accepted. No

capacities to

monitor, guide

prescribing

or provide

psychotropic

medications during

treatment.

Certain types of

medication are

not acceptable, or

patient must have

own supply for

entire treatment

episode. Some

capacity to monitor

psychotropic

medications.

Present,

coordinated

medication

policies. Some

access to prescriber

for psychotropic

medications

and policies to

guide prescribing

are provided.

Monitoring of the

medication is

largely provided by

the prescriber.

Clear standards

and routine for

medication prescriber

who is also a staff

member. Routine

access to prescriber

and guidelines for

prescribing in place.

The prescriber may

periodically consult

with other staff

regarding medication

plan and recruit

other staff to assist

with medication

monitoring.

Clear standards

and routine

for medication

prescriber who

is also a staff

member. Full

access to prescriber

and guidelines

for prescribing

in place. The

prescriber is on

the treatment team

and the entire team

can assist with

monitoring.

IVF. Specialized

interventions with

mental health

content.

Not addressed in

program content.

Based on judgment

by individual

clinician; variable

penetration into

routine services.

In program format

as generalized

intervention (e.g.,

stress management)

with penetration

into routine

services. Routine

clinician adaptation

of an evidence-

based addiction

treatment (e.g., MI,

CBT, Twelve-Step

Facilitation).

Some specialized

interventions by

specically trained

clinicians in addition

to routine generalized

interventions.

Routine mental

health symptom

management

groups; individual

therapies focused

on specic

disorders;

systematic

adaptation of an

evidence-based

addiction treatment

(e.g., MI, CBT,

Twelve-Step

Facilitation).

IVG. Education

about mental

health disorders,

treatment, and

interaction with

substance use

disorders.

Not offered. Generic content,

offered variably

or by clinician

judgment.

Generic content,

routinely delivered

in individual and/or

group formats.

Specic content

for specic co-

morbidities; variably

offered in individual

and/or group formats.

Specic content

for specic

co-morbidities;

routinely offered in

individual and/or

group formats.

IVH. Family education

and support.

For substance use

disorders only, or

no family education

at all.

Variably or by

clinician judgment.

Mental health

disorders routinely,

but informally

incorporated into

family education or

support sessions.

Available as

needed.

Generic family group

on site on substance

use and mental

health disorders,

variably offered.

Structured group

with more routine

accessibility.

Routine and

systematic

co-occurring

disorders family

group integrated

into standard

program format.

Accessed by

families of the

majority of patients

with co-occurring

disorders.

DDCAT — Rating Scale

Measures 109

1 – AOS 2 3 – DDC 4 5 – DDE

IVI. Specialized

interventions to

facilitate use

of peer support

groups in

planning or during

treatment.

No interventions

used to facilitate

use of either

addiction or

mental health peer

support.

Used variably or

infrequently by

individual clinicians

for individual

patients, mostly

for facilitation to

addiction peer

support groups.

Generic format on

site, but no specic

or intentional

facilitation based

on mental health

disorders. More

routine facilitation

to addiction peer

support groups

(e.g., AA, NA).

Variable facilitation

targeting specic

co-occurring needs,

intended to engage

patients in addiction

peer support groups

or groups specic to

both disorders (e.g.,

DRA, DTR).

Routine facilitation

targeting specic

co-occurring

needs, intended

to engage patients

in addiction peer

support groups or

groups specic

to both disorders

(e.g., DRA, DTR).

IVJ. Availability of

peer recovery

supports for

patients with

co-occurring

disorders.

Not present, or

if present not

recommended.

Off site,

recommended

variably.

Off site and

facilitated with

contact persons or

informal matching

with peer supports

in the community,

some co-occurring

focus.

Off site, integrated

into plan,

and routinely

documented with

co-occurring focus.

On site, facilitated

and integrated

into program (e.g.,

alumni groups);

routinely used and

documented with

co-occurring focus.

V. Continuity of Care

VA. Co-occurring

disorders

addressed

in discharge

planning process.

Not addressed. Variably addressed

by individual

clinicians.

Co-occurring

disorders

systematically

addressed as

secondary in

planning process

for off site referral.

Some capacity

(less than 80%

of the time) to

plan for integrated

follow-up, i.e.,

equivalently address

both substance use

and mental health

disorders as a

priority.

Both disorders seen

as primary, with

conrmed plans

for on-site follow-

up, or documented

arrangements for

off-site follow-up;

at least 80% of

the time.

VB. Capacity to

maintain

treatment

continuity.

No mechanism for

managing ongoing

care of mental

health needs

when addiction

treatment program

is completed.

No formal protocol

to manage mental

health needs

once program is

completed, but

some individual

clinicians

may provide

extended care

until appropriate

linkage takes

place. Variable

documentation.

No formal protocol

to manage mental

health needs

once program is

completed, but

when indicated,

most individual

clinicians provide

extended care

until appropriate

linkage takes

place. Routine

documentation.

Formal protocol

to manage mental

health needs

indenitely,

but variable

documentation that

this is routinely

practiced, typically

within the same

program or agency.

Formal protocol

to manage mental

health needs

indenitely

and consistent

documentation that

this is routinely

practiced, typically

within the same

program or agency.

VC. Focus on ongoing

recovery issues for

both disorders.

Not observed. Individual clinician

determined.

Routine focus is

on recovery from

addiction; mental

health symptoms

are viewed as

potential relapse

issues only.

Routine focus on

addiction recovery

and mental health

management and

recovery; both seen

as primary and

ongoing.

DDCAT — Rating Scale

110 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

1 – AOS 2 3 – DDC 4 5 – DDE

VD. Specialized

interventions to

facilitate use

of community-

based peer

support groups

during discharge

planning.

No interventions

made to facilitate

use of either

addiction or mental

health peer support

groups upon

discharge.

Used variably or

infrequently by

individual clinicians

for individual

patients, mostly

for facilitation to

addiction peer

support groups

upon discharge.

Generic, but

no specic

or intentional

facilitation based

on mental health

disorders. More

routine facilitation

to addiction peer

support groups

(e.g., AA, NA)

upon discharge.

Assertive linkages

and interventions

variably made

targeting specic

co-occurring needs

to facilitate use

of addiction peer

support groups or

groups specic to

both disorders (e.g.,

DRA, DTR) upon

discharge.

Assertive linkages

and interventions

routinely made

targeting specic

co-occurring needs

to facilitate use

of addiction peer

support groups or

groups specic to

both disorders

(e.g., DRA, DTR)

upon discharge.

VE. Sufcient supply

and compliance

plan for

medications

is documented.

No medications in

plan.

Variable or

undocumented

availability of 30-

day or supply to

next appointment

off-site.

Routine 30-day

or supply to next

appointment off-

site. Prescription

and conrmed

appointment

documented.

Maintains medication

management in

program/agency

until admission to

next level of care at

different provider

(e.g., 45-90 days).

Prescription and

conrmed admission

documented.

Maintains

medication

management in

program with

provider.

VI. Stang

VIA. Psychiatrist or

other physician

or prescriber of

psychotropic

medications.

No formal

relationship with

aprescriber for

thisprogram.

Consultant or

contractor off site.

Consultant or

contractor on site.

Staff member,

present on site for

clinical matters only.

Staff member,

present on site

for clinical,

supervision,

treatment

team, and/or

administration.

VIB. On-site clinical

staff members

with mental

health licensure

(doctoral or

masters level),

or competency

or substantive

experience.

Program has no

staff who are

licensed as mental

health professionals

or have had

substantial

experience

sufcient

to establish

competence in

mental health

treatment.

1-24% of clinical

staff have either a

license in a mental

health profession

or substantial

experience

sufcient

to establish

competence in

mental health

treatment.

25-33% of clinical

staff have either a

license in a mental

health profession

or substantial

experience

sufcient

to establish

competence in

mental health

treatment.

34-49% of clinical

staff have either a

license in a mental

health profession

or substantial

experience sufcient

to establish

competence in

mental health

treatment.

50% or more of

clinical staff have

either a license

in a mental

health profession

or substantial

experience

sufcient

to establish

competence in

mental health

treatment.

VIC . Access to mental

health clinical

supervision or

consultation.

No access. Consultant or

contractor off site,

variably provided.

Provided as needed

or variably on site

by consultant,

contractor or staff

member.

Routinely provided

on site by staff

member.

Routinely provided

on site by staff

member and

focuses on in-depth

learning.

DDCAT — Rating Scale

Measures 111

1 – AOS 2 3 – DDC 4 5 – DDE

VID. Case review,

stafng or

utilization review

procedures

emphasize

and support

co-occurring

disorder

treatment.

Not conducted. Variable, by off

site consultant,

undocumented.

Documented, on

site, and as needed

coverage of co-

occurring issues.

Documented,

routine, but not

systematic coverage

of co-occurring

issues.

Documented,

routine, and

systematic

coverage of

co-occurring issues.

VIE. Peer/Alumni

supports are

available with

co-occurring

disorders.

Not available. Available, with

co-occurring

disorders, but

as part of the

community.

Variably referred

by individual

clinicians.

Available, with

co-occurring

disorders, but

as part of the

community. Routine

referrals made

through clinician

relationships

or more formal

connections such

as peer support

service groups

(e.g., AA Hospital

and Institutional

committees

or NAMI).

Available on

site, with co-

occurring disorders,

either as paid

staff, volunteers,

or program alumni.

Variable referrals

made.

Available on site,

with co-occurring

disorders, either

as paid staff,

volunteers, or

program alumni.

Routine referrals

made.

VII. Training

VIIA. All staff

members have

basic training

in attitudes,

prevalence,

common signs

and symptoms,

detection

and triage for

co-occurring

disorders.

No staff have

basic training (0%

trained).

Variably trained, no

systematic agency

training plan or

individual staff

member election

(1-24% of staff

trained).

Certain staff

trained, encouraged

by management

and with systematic

training plan

(25-50% of staff

trained).

Many staff trained

and monitored by

agency strategic

training plan

(51-79% of staff

trained).

Most staff trained

and periodically

monitored by

agency strategic

training plan (80%

or more of staff

trained).

VIIB. Clinical staff

members have

advanced

specialized

training in

integrated

psychosocial or

pharmacological

treatment of

persons with

co-occurring

disorders.

No clinical staff

have advanced

training (0%

trained).

Variably trained, no

systematic agency

training plan or

individual staff

member election

(1-24% of clinical

staff trained).

Certain staff

trained, encouraged

by management

and with systematic

training plan (25-

50% of clinical

staff trained).

Many staff trained

and monitored by

agency strategic

training plan (51-

79% of clinical staff

trained).

Most staff trained

and periodically

monitored by

agency strategic

training plan (80%

or more of clinical

staff trained).

DDCAT — Rating Scale

112 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

____________________________________________________________________________________________________________

Site Visit Notes

Measures 113

DDCAT — Scoring Summary

I. Program Structure

A. _________

B. _________

C. _________

D. _________

Sum Total = ______________

/4 = SCORE ______________

II. Program Milieu

A. _________

B. _________

Sum Total = ______________

/2 = SCORE ______________

III. Clinical Process: Assessment

A. _________

B. _________

C. _________

D. _________

E. _________

F. _________

G. _________

Sum Total = ______________

/7 = SCORE ______________

IV. Clinical Process: Treatment

A. _________

B. _________

C. _________

D. _________

E. _________

F. _________

G. _________

H. _________

I. _________

J. _________

Sum Total = ______________

/10 = SCORE _____________

V. Continuity of Care

A. _________

B. _________

C. _________

D. _________

E. _________

Sum Total = ______________

/5 = SCORE ______________

VI. Stafng

A. _________

B. _________

C. _________

D. _________

E. _________

Sum Total = ______________

/5 = SCORE ______________

VII. Training

A. _________

B. _________

Sum Total = ______________

/2 = SCORE _____________

DDCAT Index Program Category:

Scale Method

OVERALL SCORE

(Sum of Scale Scores/7)

DUAL DIAGNOSIS CAPABILITY:

AOS (1 - 1.99) _______

AOS/DDC (2 - 2.99) _______

DDC (3 - 3.49) _______

DDC/DDE (3.5 - 4.49) _______

DDE (4.5 - 5.0) _______

DDCAT Index Program Category:

Criterion Method

% CRITERIA MET FOR AOS

(# of “1” or > /35) ____ 100%

% CRITERIA MET FOR DDC

(# of “3” or > scores/35) __________

% CRITERIA MET FOR DDE

(# of “5” scores/35) __________

HIGHEST LEVEL OF DD CAPABILITY

(80% or more) __________

Appendices 115

B. Frequently Asked Questions (FAQ)

1) Can I use the DDCAT to rate my wholeagency?

The DDCAT is intended to rate an individual program. Using the DDCAT to produce a single agency-level

rating is not recommended. If the entire agency is scored, the rater is forced to consider practices that differ

and diverge across multiple programs, usually resulting in scores that are not meaningful or helpful. An

examination of separate capability ratings across multiple programs within an agency, however, can assist

leadership in understanding variations in agency practice patterns. Such variation may be intentional, but also

may signal theneed to initiate quality improvement activities to establish consistency across programs within

an agency.

2) What do the DDCAT results tell me?

The DDCAT results will tell you the level of co-occurring capability in a program. Each of the 35 items in the

DDCAT is scored on a 1 to 5 scale, with 5 reecting the highest co-occurring capability. An average score is

obtained for each of the seven domains in the DDCAT. An overall score ranks the program at the Addiction

OnlyServices (AOS), Dual Diagnosis Capable (DDC), or Dual Diagnosis Enhanced (DDE) level.

3) Is the DDCAT a psychometrically valid instrument?

Yes. Please see the Psychometric Studies section and the journal articles by McGovern et al. (2007)

andGotham etal. (2010) listed in the appendix.

4) Is there an easy way to do the scoring?

Yes. An Excel workbook (available for download) accepts DDCAT item scores and calculates the program’s

average domain scores, an overall average score, and the categorical rank (i.e., AOS, DDC, or DDE).

Inaddition, the workbook creates several graphic displays.

5) Who can administer the DDCAT?

Behavioral health professionals can be trained to administer the DDCAT by others with experience doing these

assessments. Training typically involves a didactic component, one or more observations of an assessment, and

practice with supervision and feedback.

6) How long does it take to do a DDCAT assessment?

Typically, a DDCAT assessment takes from four to eight hours. Requesting documents for review in advance

ofthe visit can reduce the amount of time required at the program location. The number of charts reviewed

canalso impact the length of the visit.

116 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

B. Frequently Asked Questions (FAQ)

7) Can I ask programs to rate themselves on the DDCAT?

It is not recommended that programs use the DDCAT to rate themselves. Bias in DDCAT self-ratings

hasbeendocumented, with higher self-rated scores observed compared to ratings by an external assessor

(e.g., Lee & Cameron, 2009; please see the References section). Research also documents a “learning

curve” before raters consistently and accurately use this measure (Brown & Comaty, 2007). The DDCAT items

andanchors can generate valuable discussion among staff and provide the basis for programs to increase their

co-occurringcapability.

8) What is the incentive for programs to participate in a DDCAT assessment?

Each program receives concrete feedback on its co-occurring capability as expressed by its policies,

assessment and treatment services, stafng, and training, combined with information on how to increase

that capability. Increased co-occurring capability may lead to improved services for clients. Given widespread

expectations for programs to improve their performance in co-occurring disorders, programs nd the DDCAT

assessment and results valuable. Some state or regional funding agencies offer nancial incentives for

achieving a DDC or DDE rating.

9) How long does it take a program to improve their scores on the DDCAT?

It depends. As described in the Applications section, a comprehensive implementation plan based on the

results of an initial DDCAT can facilitate change by including targeted strategies for change, identifying

persons responsible for leading each task, and setting target dates for completion. Other components of a

successful change process often include an overall “champion” or change agent for the program, a steering

committee to support the efforts over time, targeted training and technical assistance, connections with peers

(i.e., other programs) also working on these kinds of changes for support and lessons learned, and ongoing

quality assurance (e.g., semi-annual or annual follow-up DDCAT assessments).

10) How can I nd out more about how others are using the DDCAT?

Dr. Mark McGovern of Dartmouth Medical School, the primary author of the DDCAT, chairs the national

DDCAT/DDCMHT Collaborative, which meets monthly by conference call to discuss ways that states

and programs are using the DDCAT to improve their policies and practices. He can be reached at

[email protected] if you are interested in joining the Collaborative.

Appendices 117

C. No or Low Cost Enhancements

toIncrease Co-Occurring Capability

Program Structure

IA. Revise mission statement to include focus on co-occurring disorders.

IC. Develop formal memorandum of understanding with a mental health program.

Program Milieu

IIA. Revise materials and procedures to welcome individuals with co-occurring disorders.

IIB. Display/distribute free educational materials about mental health/co-occurring disorders.

Assessment

IIIA. Implement free standardized mental health and substance use screening measures.

IIIB. Implement a standard set of mental health bio-psychosocial assessment questions.

IIID. Implement a standard section of the assessment to capture mental health history.

IIIG. Assess patients’ stage of change for both their substance use and mental health problems.

Treatment

IVA. Include mental health related interventions in treatment plans.

IVB. Observe and document changes in mental health and substance use symptoms over time.

IVC. Implement guidelines and advance directives for mental health emergencies.

IVD. Adjust objectives and interventions to match persons’ stages of change.

IVG. Incorporate free mental health/COD curricula into program services.

IVH. Implement family education/support group with co-occurring curricula.

IVI. Assertively link patients to peer support groups welcoming to co-occurring issues.

IVJ. Incorporate program alumni and other peer supports with COD into program.

Continuity of Care

VA. Implement discharge procedures that plan for mental health and substance use services.

VC. Focus on ongoing recovery from both disorders.

VD. Assertively link patients to peer support groups welcoming to COD upon discharge.

Stafng

VID. Implement routine case reviews that support co-occurring disorder treatment.

VIE. Include peers with co-occurring disorders on-site as paid or volunteer staff.

Training

VII . Implement training plan that routinely includes basic training on co-occurring disorders.

Appendices 119

D. The Site Visit

DDCAT — Multiple Chart Review Form

SECTION DDCAT ITEM #1 #2 #3 COMMENTS/NOTES

Intake, Screening,

Biopsycho-Social

IIIA. Mental health screening

IIIB. Assessment if positive screen

IIIC. Mental health and substance use diagnoses made

IIID. MH & SA history reected in medical record.

Treatment Plan IIIG. Stage-wise txt assessed/affect treatment planning

IVA. Treatment plans address both disorders

IVD. Stage-wise treatment

Progress Notes IC. Coordination and collaboration with SA or MH services

IVB. Assess monitor interactive courses of both disorders

IVF. Specialized interventions with mental health content

IVG. Education about mental health disorders

IVH. Family education part of treatment interventions

IVI. Specialized interventions to use peer support groups

Discharge

Planning &Plan

VA. COD addressed in discharge planning process.

VB. Capacity to maintain treatment continuity

VC. Focus on ongoing recovery issues for both disorders

VD. Facilitation to self-help COD support groups at d/c

VE. Sufcient supply of meds, conrmed follow-up appt

120 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

IA What is the agency/program mission statement? (get copy or view on website ahead of time)

IB What license(s) does your program have? MH? SA? Both?

Is lack of MH licensure a real barrier to providing services to individuals with COD? A perceived barrier?

IC How and where are MH services provided? Through relationship w/MH provider or integrated w/single tx plan?

Type of relationship: Minimal Coordination? Consultation? Collaboration? Collaboration w/some informal integration?

Formal/documented?

ID Do billing structures limit or incentivize provision of services for persons with COD?

Can program bill for both SA/MH tx? Must SUD be “primary”?

IIA What patients are expected and welcome? What percent of your patients have COD MH disorders?

IIB What kind of literature/educational materials is provided to patients?

SA? MH? Equal? Info on interaction? Routine?

Is literature distributed in waiting areas? Orientation packets? Posters? Handouts? Videos?

IIIA What type of MH screening occurs?

Self-report pre-admission? Basic pre-admission screen? Standard set of MH questions?

Routine standard/formal instrument for MH? Routine standard/formal instrument for MH and SA? Measure(s) used:

IIIB What is the process for following up on a positive MH screen? Type of assessment?

Detailed bio-psychosocial questions or mental status? Formal, standardized, assessment? Integrated MH/SUD assessment?

Variable? If necessary? Routine for all positive screens? Documented? Conducted onsite?

IIIC Are psychiatric diagnoses made at the program? By whom? Documented in chart?

IIIE Are there any admission limitations re: symptom acuity?

Need to be primarily stable? Can be moderate to high acuity, even unstable?

IIIF Does the program have any admission limitations re: symptom severity?

No severity of persistence of disability? Low to moderate (e.g. Quadrant III: Axis I mood, anxiety, PTSD or Axis II)?

High (e.g. Quadrant IV: bipolar disorder, schizoaffective disorder, schizophrenia)?

IIIG Does the program assess stages of change?

For both MH and SA? Formal measure? Documented in chart? Where? Measure(s) used:

IVD Do you monitor motivational stages ongoing throughout treatment? Use and match stage-wise treatments toindividuals?

Some examples:

IVC Does the program have any procedures for psychiatric emergencies and crisis management?

Just call 911? Written guidelines including a standard risk assessment that captures MH emergencies and identies

intervention strategies? Formal arrangement w/MH clinic to help manage crisis situations?

In-house crisis management standards/guidelines, goal to maintain individual in program? All staff competent tousein-house

procedures?

IVE Does the program accept individuals on medications? Does program have ability to prescribe?

Any medications restricted? Individual must bring own supply? Written policies/procedures for prescribing/monitoring

medications for COD?

Program has some access to prescriber (consultant)? Routine access to staff prescriber, not fully integrated into tx team?

Full access to staff prescriber, fully integrated into tx team?

Medication monitoring done by prescriber? With some staff assistance? Entire team can assist?

DDCAT — Agency Director/Program Director/Clinical Director Questions

Appendices 121

IVF Does the program use any specic therapeutic interventions/practices that target specic MH symptoms anddisorders?

Generic interventions (e.g. stress mgmt, coping skills)? Generic adaptation of EBP addiction tx (MI, CBT, TSF)?

Systematic (e.g. manualized) adaptation of EBP addiction tx for specic disorders?

Integrated EBP for COD (e.g. Seeking Safety, DBT-S)? Individual clinician driven or routine part of program? Examples of

interventions:

IVG Does the program provide education about MH disorders, tx, and interaction w/SUD?

Generic content tx (e.g. general orientation, education re: MH symptoms, appropriate use of psychotropic meds, interaction

of MH and SA)? Specic content for specic co-morbidities? Variably offered? Routinely offered? Toall patients?

Curriculum used? Give example(s):

IVH Does the program provide any education on COD to family members? (Note: “Family” can be broadly interpreted.)

No family education? SUD only? MH and SUD? MH routinely but informally incorporated into family education/support

sessions?

Generic group on site addresses MH and SUD, not regularly incorporated into tx interventions?

COD family education/support group standard part of tx? Majority of families participate?

IVI Does the program assist individuals with COD to develop a support system through self-help groups?

Variable interventions, mostly to addiction peer support groups? Generic on-site format, no intentional facilitation based on

MH disorders?

Variable facilitation to use addiction or COD peer support groups, targeting specic COD needs (e.g. identify a liaison,

individualize referral to particular groups, help w/how to (or not) discuss meds in groups)? Specic on-site format targeting

MH needs?

VD Does the program offer specialized interventions to facilitate use of community-based peer support groups during discharge

planning?

Variable, interventions mostly to addiction peer support groups (e.g. meeting lists, suggestions to “work the steps”)?

Generic on-site format, routine facilitation (e.g. meeting lists, making initial contacts), but not based on MH disorders?

Variable assertive linkages, targeting MH needs, to addiction or COD peer support groups (e.g. help w/how to (or not) discuss

meds in groups, help person w/PTSD nd meetings w/out members who may trigger her re-experiencing symptoms, help

person w’/social anxiety nd a small group)? Routine assertive linkages targeting MH needs? In-house mutual self-help

meetings? Examples:

IVJ Does the program match patients with individual peer supports and role models? Peer is person w/COD?

Off site? On site? Variable? Standard part of programming? Documented in treatment plan?

VIE Does the program maintain staff, or formal arrangement w/volunteers, in recovery from COD who can serve as peer/alumni

supports?

In community, variable referrals? In community, routine linkages made? On site, variable referrals? On site, routine matching?

Formal protocol to insure ongoing on site supports?

VC What is the program’s recovery philosophy (vs. symptom remission only)?

SUD only? SUD and MH depending on clinician? Routine SUD, MH viewed as potential relapse issue? Equalfocus on

both SUD/MH?

Symptom remission? SUD and MH seen as part of generic wellness, process of recovery and positive prospects forboth?

VE Does the program help with medication planning/prescription/access at discharge?

Variable/undocumented 30-day supply? Routine 30-day or supply to next appointment?

Maintains med management in program/agency until admission to next level of care? Prescription & conrmed admission

documented?

Maintains medication management in program/agency?

VIA Does the program have a formal relationship with a prescriber?

Off-site consultant/contractor? On-site medical/contractor who prescribes? Member of staff, clinical matters only?

Staff member who routinely participates in team activities and serves in clinical decision-making or supervisory role?

DDCAT — Agency Director/Program Director/Clinical Director Questions

122 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VIB What’s the percent of clinical staff with MH license/competency/substantive MH experience? (see toolkit for denition of

competency)

None? 1-24%? 25-33%? 43-49%? 50%?

VIC Does the program have access to licensed MH supervisor or consultant?

Variable off-site supervision? As needed on site? Routine on-site supervision by staff member?

Primary focus on case disposition and crisis management? Focus on in-depth learning?

VID Does the program conduct case/utilization reviews to monitor appropriateness/effectiveness of services for patients

w/COD?

Documented? Formal protocol? Off site consultant? Routine?

On site procedure, general COD coverage PRN? General review of patients with COD? Focus on targeted interventions for

COD?

VIIA What percent of ALL staff have basic training in attitudes, prevalence, common signs & symptoms, detection & triage for

COD?

None? 1-24%? 25-50%? 51-79%? 80%+? Systematic training plan that includes this training? Monitored by plan?

VIIB What percent of CLINICAL staff have advanced specialized training in integrated psychosocial or pharmacological txof

persons w/COD?

None? 1-24%? 25-50%? 51-79%? 80%+? Systematic training plan that includes this training? Monitored by plan?

DDCAT — Agency Director/Program Director/Clinical Director Questions

Appendices 123

IC How and where are MH services provided? Through relationship w/MH provider or integrated w/single tx plan?

Type of relationship: Minimal Coordination? Consultation? Collaboration? Collaboration w/some informal integration?

Formal/documented?

IIA What patients are expected and welcome? What percent of your patients have COD MH disorders?

IIB What kind of literature/educational materials is provided to patients?

SA? MH? Equal? Info on interaction? Routine?

Is literature distributed in waiting areas? Orientation packets? Posters? Handouts? Videos?

IIIE Are there any admission limitations re: symptom acuity?

Need to be primarily stable? Can be moderate to high acuity, even unstable?

IIIF Does the program have any admission limitations re: symptom severity?

No severity of persistence of disability? Low to moderate (e.g. Quadrant III: Axis I mood, anxiety, PTSD or Axis II)?

High (e.g. Quadrant IV: bipolar disorder, schizoaffective disorder, schizophrenia)?

IIIG Do you assess stage of change?

For both MH and SA? Formal measure? Documented in chart? Where? Measure(s) used:

IVD Do you monitor motivational stages ongoing throughout treatment? Use and match individuals to stage-wise treatments? Give

me some examples:

IVC Does the program have any procedures for psychiatric emergencies and crisis management?

Just call 911? Written guidelines including a standard risk assessment that captures MH emergencies and identies

intervention strategies? Formal arrangement w/MH clinic to help manage crisis situations?

In-house crisis management standards/guidelines, goal to maintain individual in program? All staff competent to use in-house

procedures?

IVF Does the program use any specic therapeutic interventions/practices that target specic MH symptoms anddisorders?

Generic interventions? (e.g. stress mgmt, coping skills)? Generic adaptation of EBP addiction tx (MI, CBT, TSF)?

Specialized (e.g. manualized) interventions for specic disorders? Systematic adaptation of EBP addiction tx? Integrated

EBP for COD? Individual clinician driven or routine part of program? Examples of interventions:

IVG Does the program provide education about MH disorders, tx, and interaction w/SUD?

Generic content? Specic content for specic co-morbidities? Variably offered? Routinely offered? Toallpatients?

Curriculum used?

Give example(s):

IVH Does the program provide any education on COD to family members? (Note: “Family” can be broadly interpreted.)

No family education? SUD only? MH and SUD? MH routinely but informally incorporated into family education/support

sessions?

Generic group on site addresses MH and SUD, not regularly incorporated into tx interventions?

COD family group standard part of tx? Majority of families participate?

IVI Do you assist individuals with COD to develop a support system through self-help groups?

Variable interventions, mostly to addiction peer support groups? Generic on-site format, no intentional facilitation based on

MH disorders?

Variable facilitation to use addiction or COD peer support groups, targeting specic COD needs (e.g. identify a liaison,

individualize referral to particular groups, help w/how to (or not) discuss meds in groups)? Specic on-site format targeting

MH needs?

DDCAT — Clinician Interviews

124 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

VD Do you offer specialized interventions to facilitate use of community-based peer support groups during dischargeplanning?

Variable interventions, mostly to addiction peer support groups (e.g. meeting lists, suggestions to “work the steps”)?

Generic on-site format, no intentional facilitation based on MH disorders?

Variable assertive linkages, targeting MH needs, to addiction or COD peer support groups (e.g. woman w/PTSD linked to

women’s AA meeting)? Routine assertive linkages targeting MH needs? In-house mutual self-help meetings? Examples:

IVJ Do you match patients with individual peer supports and role models? Peer is person w/COD?

Off site? On site? Variable? Standard part of programming? Documented in treatment plan?

VIE Does program maintain staff, or formal arrangement w/volunteers, in recovery from COD who can serve

aspeer/alumnisupports?

In community, variable referrals? In community, routine linkages made

On site, variable referrals? On site, routine matching? Formal protocol to insure ongoing on site supports?

VC What is the program’s recovery philosophy (vs. symptom remission only)?

SUD only? SUD and MH depending on clinician? Routine SUD, MH viewed as potential relapse issue? Equalfocus on

both SUD/MH?

Symptom remission? SUD and MH seen as part of generic wellness, process of recovery and positive prospects forboth?

VE Does program help with medication planning/prescription/access at discharge?

Variable/undocumented 30-day supply? Routine 30-day or supply to next appointment?

Maintains med management in program/agency until admission to next level of care? Prescription & conrmed admission

documented?

Maintains medication management in program/agency?

VIA (If program has a prescriber on site) Do you have access to the prescriber to discuss patients?

Prescriber only provides prescribing services? Limited access? Prescriber is member of treatment team?

VIB Please describe your license and/or mental health experience/expertise?

VIC Do you receive supervision from a licensed MH supervisor or consultant?

Variable, off-site? As needed, on site? Routine, on-site?

Primary focus on case disposition and crisis management? Focus on in-depth learning?

VID Does the program conduct case/utilization reviews to monitor appropriateness/effectiveness of services for patients

w/COD?

Documented? Formal protocol? Off site consultant? Routine?

On site procedure, general COD coverage PRN? General review of patients with COD? Focus on monitoring targeted

interventions for COD?

DDCAT — Clinician Interviews

Appendices 125

IIA Did you feel welcomed when you came to this agency for treatment?

IIB Have you received any materials about substance abuse and/or mental health issues? SA ? MH ? Equal? Info on

interaction? Routine?

IVE If you are on medications for a mental health issue, does the program prescribe them? If not, where do you get them?

Do providers communicate?

IVF Does program offer any groups related to emotional or mental health issues? E.g. anger management group? Seeking

Safety?

IVG Does program or your counselor provide general education about MH disorders, tx, and interaction w/substance

use disorders and tx (e.g. general orientation, education re: MH symptoms, appropriate use of psychotropic meds,

interaction of MH and SA? Anything specic to any emotional or mental health issue you may have?

IVH Does program provide any education on COD to family members? Regular support/ed group? Incorporated into

recovery planning? Majority of families participate? ("Family" can be broadly interpreted.)

IVI Does program assist you in developing a support system through self-help groups? Does the program talk about issues

someone with a mental health issue might have in some groups, and how to manage them (e.g. how to (not to) talk

about meds at a meeting)? Does the program make any special linkages or make some intros on a person’s behalf

depending on a person’s issues? (e.g. small group if have social anxiety).

IVJ Does program match clients with peer (a person w/a COD) supports and role models, e.g. consumer liaisons, alumni

groups? On site or off?

VC Does program talk about recovery for both SA and MH issues (vs. symptom remission only)? Are both SA and MH

seen as part of wellness, or is MH just a complicating factor of SA?

VD Does program link to self help groups at discharge? Recommendations, meeting lists and suggestions to "work the

steps"? Or link/match to specic groups relative to MH issues? Have on site ongoing alumni group or DRA group?

VIE Does program have staff or volunteers who are open about having a mental health issue that you can talk with? Part of

community, i.e. of-site linkages or H&I committee connection? Provided consistently? Or present on-site, i.e. program

maintains staff or volunteers on site?

DDCAT — Consumer Interview Questions

Appendices 127

Dual Diagnosis Capability in Addiction

Treatment (DDCAT) Scoring Scenario

Recovery Depot is housed in a modest brick building

next to the local health clinic. The waiting room is

light and airy with comfortable furniture. One wall is

covered with a large poster of the Twelve Steps and

there are racks of AA and NA materials and meeting

schedules, along with pamphlets on HIV/AIDS, and

state employment and nancial assistance services.

Abulletin board has an announcement for a Community

for Addiction Recovery sober dance, and a local Dual

Recovery Anonymous meeting. Aframed mission

statement near the receptionist says “Recovery Depot

iscommitted to the belief that recovery from addiction

ispossible through treatment and education of

individuals and theirfamilies.”

The Program Director describes the program as a

“typical” outpatient program. She says that RD is

licensed to provide substance abuse outpatient services,

and is funded primarily by state grants and fee-for-

service contracts. The clinic offers individual treatment,

and a number of different groups including relapse

prevention, anger management, stress reduction,

women’s group, a Seeking Safety group, and a weekly

“Coffee Club” group for individuals who are mandated

totreatment by the criminal justice system, many of

whom are not sure they have a substance abuse problem.

The interview with the Program Director indicates

that individuals are referred by the health clinic,

other agencies, the court, or are self-referrals. An

initial screening is done by phone or in person that

ascertains if the person has had prior substance abuse

treatment, their last use, drug of choice, etc. She gives

the assessors a copy of the program’s bio-psychosocial

evaluation which is done on intake. It includes a brief

mental status section, along with a series of questions

about both substance use and treatment histories,

and similar questions about mental health symptoms

and treatment. The form also asks if the individual

iscurrently on any psychiatric medications, and if so,

which ones.

The Program Director estimates that 15% of the

program’s 160 clients have co-occurring disorders.

Whenasked if there are any admission restrictions,

she says that program policies require individuals to

have a primary substance use disorder for licensing

and billing reasons. However, while it is not in writing,

she says the program will admit individuals with a co-

occurring mental health disorder if they are stable on

their medications. The policies exclude sex offenders

oranyone requiring pain medication. There are no other

medication restrictions, although the Program Director

says the program generally doesn’t work well with

individuals with psychotic disorders and does keep an

eye out for medications that would indicate this. These

individuals are referred tothe local mental health clinic.

Individuals who aresuicidal orhomicidal are likewise

notadmitted.

When asked about any specialized interventions for

individuals with co-occurring disorders, the Program

Director says that the Seeking Safety group has been

very successful, and receives regular referrals from

the local women’s center. The Program Director is also

very excited because two of her staff just completed

a half day workshop in Motivational Interviewing, and

the agency is hosting an on-site training on depression

next month, offered free by thehealth clinic’s APRN.

When asked more about staff training, she indicates

that salaries are low, so training is a benet the program

supports. There is noset program training plan, but the

E. Training Raters to Conduct

DDCATAssessments

128 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

Program Director has toapprove any training request.

Staff typically is allowed to choose whatever training

they want to go to. The Program Director stated that two

of the four counselors with prior experience in mental

health programs have a very good understanding of

co-occurring disorders and typically sign up for new co-

occurring trainings provided at the mental health center.

One of these counselors leads the Seeking Safety group.

When asked if the program’s intake and clerical staff

have basic training in co-occurring disorders the Program

Director states that hasn’t really been necessary since

they don’t treatclients.

The Program Director indicates that she provides

weekly individual supervision to each of the four full-

time counselors, and meets as needed with several

per diem clinicians. The Program Director isa LCSW;

two counselors have a Certied Addiction Counselor

Credential from the State Certication Board and are

working on completing their college degrees. One

counselor is an LPC, and one is an LADC with a Master’s

Degree in Psychology. The latter two are new hires. Both

of these have several years of counseling experience

in mental health clinics, one of which specialized in

treating co-occurring disorders.

The Program Director reports the program contracts

forthree hours a week with a psychiatrist who also works

at a nearby mental health clinic. The assessors have the

opportunity to speak with her briey. She says she does

psychiatric evaluations and will prescribe psychiatric

medications on a limited basis if a client does not have

a prescriber, as well as write a one-month “bridge”

prescription to insure the client has enough medications

at discharge tolast until a follow-up appointment with

a mental health provider. When asked if the program

has any medication policies or guidelines, she reports

not being aware of any, although she has been asked

to careful about prescribing any benzodiazepines.

Shealso mentions that the program has a good working

relationship with the local health clinic’s APRN who will

renew prescriptions as needed.

When asked about mental health emergencies or

crises, the Program Director reports they seldom occur.

However, 911 would be called if it appeared any client

was becoming symptomatic ordecompensating. She

notes that, if a client had to be hospitalized, Recovery

Depot would close the case and refer him/her to

the mental health clinic formore appropriate care

ondischarge.

The Program Director gives the assessors a tour of

the program, and points out a large group room which

she says is used for open AA meetings on Tuesdays

and Saturday mornings. Everyone in the program is

required to go to 12-step meetings in addition to their

outpatient sessions. When asked about the local Dual

Recovery Anonymous meeting yer in the reception

area,she is unfamiliar with it, but says the staff probably

knows about it. There are no particular efforts to link

individuals with co-occurring disorders to particular

groups, but everyone is given a meeting list and

encouraged tokeep trying different meetings until they

nd onethat works for them.

As the assessors enter one of the group rooms, several

people are leaving. The Program Director introduces

one as a Big Brother, a former client who volunteers

weekly to come to the Coffee Club group to share his

experiences and encourage the group members to stay

with treatment. The Program Director explains that the

program started the Big Brothers and Sisters project

with one volunteer three years ago and it has grown

to a formal volunteer program overseen by one of the

counselors. The “Bigs” regularly attend the on-site AA

meetings and the counselor frequently will introduce

aclient to a Big Brother or Sister so the client will know

someone at the meeting ahead of time. The Big Brothers/

Sisters also take turns leading a monthly program alumni

group for individuals who want to stay in touch with the

program for ongoing support, and routinely are invited

to share their experiences in the relapse prevention

groups. When asked later, the Program Director says

the Big Brother she introduced is one of three who have

co-occurring mental health disorders and are very open

DDCAT — Scoring Scenario

Appendices 129

about it, which is why the program actively recruited

them. They go regularly to the local mental health clinic

where they were referred after completing the Recovery

Depot program.

When meeting with two of the counselors, the assessors

ask how many clients have co-occurring disorders. They

reply that the majority of the clients do, although most

do not have anything so signicant that it impedes their

participation in the program. Since it is an addiction

program, formal screening for mental health issues is

rarely done and no mental health diagnoses are made.

However, if it seems that an individual’s mental health

issues are a potential relapse risk, he/she is referred

tothe contracted psychiatrist for further evaluation.

Thepsychiatrist will leave the counselor a note as to

theoutcome of the evaluation, and is available by

phoneifthere are any questions.

When asked about supervision, the clinicians smile and

say regular supervision sessions are often pre-empted

by the Program Director’s administrative duties. They

are quick to add that her door is always open and she

makes herself readily available when they are struggling

or “stuck” regarding next steps with a client whom

they suspect is using again or who is refusing to accept

a follow-up referral to the mental health clinic, for

example. Weekly staff meetings however are always

held. Typically several clients from each counselor’s

caseload are reviewed, any legal or other updates given,

general progress on treatment plan goals is reviewed,

and discharge plans gone over. Usually the need for

a referral to the psychiatrist or mental health clinic

isdiscussed if individual client symptoms or behavior

indicates a possible need. A review form is completed for

each client’s le for those clients reviewed, including any

referrals, and this becomes a tickler to insure referrals

are followed up on at the next staff meeting. When asked

about psychiatric emergencies or crises, both counselors

indicate they have never seen a program policy, but

common sense would dictate calling 911. They are not

aware of any formal policy with either the mental health

or local health clinics, but indicate that they have good

relationships with particular staff at each and are usually

able to get referrals seen relatively quickly. They insure

referred clients sign a release ofinformation so that staff

can conrm this.

When asked if they assess for stage of change, one

clinician references the recent Motivational Interviewing

training and says he’s decided to start using the stages

of change in his work with some clients. The other

indicates that he works mostly with the Coffee Club

group and other individuals referred by the courts,

sothere is no need since all of them are at the stage

ofthinking they have noproblem.

Both counselors are familiar with local 12-step groups,

and indicate that most are tolerant of individuals on

psychiatric medications. Neither does any specic

linking of clients to specic groups or individuals, but

one counselor says he’s referred a couple of his clients

who have bi-polar disorder to the local hospital’s Bi-Polar

Disorder Support Group. One counselor emphasizes that

the linkage with 12-step groups is important, especially

at discharge, because after discharge the clients no

longer have access to their counselor for support.

A review of ve client charts of discharged clients

with co-occurring disorders indicates that the mental

health section of the bio-psychosocial evaluation is

rarely lled in completely, sometimes not at all; this

is the case even in two charts where the evaluation

reported the individual was taking several psychotropic

medications. Treatment plan goals for substance

use problems are comprehensive and individualized.

Treatment plans in four charts include a mental health

problem framed as a relapse prevention issue with

goals to obtain a psychiatric evaluation and maintain

medication compliance. Overall, progress notes indicate

a lot of work on relapse prevention, and some education

about addiction takes place. Several of the charts have

documentation for anger and stress management groups,

and another client attended Seeking Safety groups.

All of the discharge plans include recommendations

to regularly attend AA/NA meetings, obtain a sponsor,

DDCAT — Scoring Scenario

130 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

and attend the program’s monthly alumni group. Two

discharge plans document conrmation of a follow-

up appointment at the local mental health clinic for

medication management, as well as a one-month rell

from the part-time psychiatrist. One counselor’s notes

indicates he worked with two of the clients on identifying

when they felt anxious or depressed, and teaching them

some coping skills to help manage their symptoms, e.g.

breathing exercises, journaling, etc. He also helped them

identify the relationship of their drug and alcohol use to

their mental health symptoms and noncompliance with

medication. These were not areas identied on their

treatment plans, however.

Three clients volunteer to be interviewed together. They

all report they are happy with the program, and the staff

is great. Two of them share they have mental health

problems. One of these clients had been diagnosed in a

prior program with PTSD and she nds the Seeking Safety

group very helpful. Theother has seen the program’s

psychiatrist and reports being been diagnosed with

depression. He goes to the nearby health clinic to receive

his medication. He has gotten some information from the

health clinic, but reports wanting to know more about side

effects, and is having trouble sleeping. All three report

that they can talk with their counselors about anything

in their individual counseling sessions, but two say their

counselors can really only listen to them as they don’t

have alot of information/knowledge about mental health

issues. The clients all indicate that mental health issues

are rarely discussed in group sessions, except for the

Seeking Safety group. One states that he had never shared

with the two other clients that he’d been diagnosed with

depression, even though they are in the same group.

When asked about family involvement, two report that

their families had attended one of the Family Orientation

groups the program offers every other month. The group

provided a lot of information about addiction and relapse,

and ways to be supportive of a family member in recovery.

They clients state they felt much supported by their

families’ participation.

DDCAT — Scoring Scenario

Appendices 131

Domain/Item Comments

Program Structure

IA. Mission Statement Score 1: The mission statement addresses addiction only.

IB. Organizational

Certication

andLicensure

Score 3: The program is licensed to provide substance abuse services. However, treatment plans list

mental health problems in the context of relapse prevention, i.e. there is no barrier to providing mental

health services within the context of addiction treatment.

IC. Collaboration

withMental Health

Services

Score 2: Staff has limited interaction with the contracted psychiatrist (only available by phone). The

program has no formal agreement with the mental health clinic, but there is follow-up to insure successful

referral (meets SAMHSA denition of consultation).

ID. Financial

Incentives

Score 1: The program can only bill for services for individuals with a primary substance use disorder.

Clarifying point:

• Iftheagencycanidentifyfundingforco-occurringormentalhealthservices,orisabletobillfor

mental health services they provide as long as the client has a substance use disorder, then score 3.

Program Milieu

IIA. Routine

Expectation

andWelcoming

Score 2: Program Director says 15% of clients have co-occurring disorders; however the counselors report

the majority do. Program policies and procedures do not address admission of individuals with co-occurring

mental health disorders, and waiting room décor and materials are primarily addiction focused. Clients

interviewed state that mental health issues are rarely discussed in group sessions, only individual sessions.

IIB. Display and

Distribution

ofLiterature

Score 1: The waiting area displays primarily addiction-related materials. The DRA notice on bulletin

board is the only visible item related to a co-occurring mental health disorder. One counselor provides

some information about mental health issues and one Seeking Safety group offered. However, educational

materials about mental health disorders are not made available.

Assessment

IIIA. Routine

Screening

Methods for

mental Health

Symptoms

Score 2: The biopsychosocial assessment has substance use and mental health history sections, but the

mental health section is not always completed.

Clarifying point:

• Iftheprogram’sbiopsychosocialassessmentincludesastandardsetofquestionstoscreen

for mental health problems, and these are questions are routinely asked and responses are

documented, then score 3.

IIIB. Routine

Assessment if

Screened Positive

Score 2: The program does not routinely screen (see IIIA) or assess for mental health problems; if a client’s

mental health symptoms seem a potential relapse risk the client is referred to the contracted psychiatrist

for evaluation.

IIIC. Mental Health

and Substance

Use Diagnoses

Score 1: No mental health diagnoses are made.

IIID. Mental Health

and Substance

Use History

Reected

inRecord

Score 2: The clinicians do not consistently complete the mental health history questions on the

biopsychosocial assessment.

IIIE. Program

Acceptance

Based on

Psychiatric

Symptom Acuity

Score 1: An individual’s symptoms must be stable in order to be admitted.

DDCAT — Case Study Scoring Key

132 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

Domain/Item Comments

IIIF. Program

Acceptance

Based on Severity

of Persistence

andDisability

Score 3: The program admits individuals with bi-polar disorder and PTSD, e.g., but does not admit

individuals with psychotic or other more serious mental health disorders.

IIIG. Stage-wise

Assessment

Score 1: One staff member “has decided” to start assessing stage of change after attending a recent

Motivational Interviewing training, i.e. program does not require it. The other has inaccurate understanding

of how to assess stage of change, i.e. he assumes that if an individual is mandated to treatment he/she

cannot be in a contemplation or action stage.

Clarifying point:

• Iftheprogramencouragesclinicianstouseaprotocoltoassessstageofchange,butnotall

clinicians use it on a regular basis, then score 2.

Treatment

IVA. Treatment Plans Score 3: Treatment plans routinely (80% of the plans reviewed) address both disorders, but primary focus

is on substance use issues. Mental health problems are typically listed as a relapse prevention issue with

general goals

IVB. Assess and

Monitor

Interactive

Courses of Both

Disorders

Score 2: One counselor is charting the progress his client is making on managing her mental health

symptoms.

IVC. Procedures for

Mental Health

Emergencies

and Crisis

Management

Score 1: The program has no policies and procedures; staff usually calls 9-1-1.

IVD. Stage-wise

Treatment

Score 1: Since the program does not have a mechanism to assess stage of change, treatment plans do not

reect state-wise treatments. The program offers the Coffee Club for individuals who may not be sure if

they have a substance use problem, but it is only open to individuals mandated to treatment.

IVE. Policies and

Procedures

forMedication

Management

Score 2: A contract is in place with a psychiatrist who prescribes on site, and there are no medication

restrictions except for pain medications. However, the program has no written policies and guidelines

forprescribing medications to clients with co-occurring disorders.

Clarifying point:

• Iftheprogramhasaccesstoaprescriber,andhaswrittenpoliciesandguidelinestoguidethe

prescribing, then score 3.

IVF. Specialized

Interventions

withMental

Health Content

Score 3: The program offers anger management and stress reduction groups (generalized interventions),

one counselor is helping client’s deal with their symptoms (symptom management) in individual sessions,

one is starting to use motivational interviewing, and Seeking Safety Group is offered. Chart review indicates

that most clients are receiving a generic mental health intervention.

IVG. Education

about Mental

Health Disorder,

Treatment, and

Interaction with

Substance Use

Disorders

Score 2: Variable by clinician, i.e. one counselor is educating his clients about symptom management and

providing education regarding the relationship of substance use to mental health symptoms and medication

noncompliance. Two of the three clients interviewed state their counselors do not provide mental health

education.

IVH. Family Education

andSupport

Score 1: The program’s family group is focused only on addiction information.

DDCAT — Case Study Scoring Key

Appendices 133

Domain/Item Comments

IVI. Interventions

toFacilitate Use

of Peer Support

Groups

Score 3: The program routinely encourages the use of self-help groups (a program requirement), offers

several on site, and provides general interventions to use peer support groups, e.g. meeting lists and

introductions to some of the Big Brother/Sister volunteers who attend the on-site groups.

IVJ. Availability of Peer

Recovery Supports

with Co-occurring

Disorders

Score 3: Big Brothers/Sisters are incorporated on-site in Coffee Club, Relapse Prevention, Alumni, and

self-help groups. Three with co-occurring disorders have been intentionally recruited. Linkage to peers is

not documented on treatment plans.

Clarifying point:

• Ifutilizationofon-sitepeersupportsisincorporatedintotreatmentplans,thenscore5.

Continuity of Care

VA. Co-occurring

Disorders

Addressed

in Discharge

Planning

Score 2: Two of the ve discharge plans (less than 80%) included a referral to the local mental health

clinic for medication management. The two clients had the same counselor, i.e. variability due to

individual clinician judgment or preference.

VB. Capacity

toMaintain

Treatment

Continuity

Score 1: One of the counselors stated clients no longer have access to their counselor after discharge.

Follow-up referrals are made to the local mental health clinic, but there is no formal agreement. Program

Director stated a client’s case would be closed and the client referred to the mental health clinic (rather

than be re-admitted to Recovery Depot once stabilized) if the client had to be hospitalized for mental health

reasons.

VC. Focus on Ongoing

Recovery Issues

for Both Disorders

Score 3: Treatment plans focus on recovery from addiction, view mental health issues as potential relapse

risk and include general goal of maintaining medication compliance.

VD. Specialized

interventions

toFacilitate Use

of Community-

Based Peer

Support Groups

During Discharge

Planning

Score 2: The program doesn’t provide any specialized interventions other than recommendations to attend

meetings and obtain a sponsor after discharge.

Clarifying point:

• Ifcounselorsandclientinterviews,ormedicalrecorddocumentedgeneralinterventionssuchas

guidance for talking about medications at 12-step meetings or recommendations of meetings

welcoming to individuals with co-occurring disorders, e.g., then score 3.

VE. Sufcient Supply

and Compliance

Plan for Medication

Score 2: Consulting psychiatrist will write bridge prescriptions at discharge to insure client has enough

medications until rst appointment post-discharge. However, it appears this is not a consistent (or

consistently documented) practice because only two of the ve charts reviewed documented conrmed

follow-up appointment and 30-day bridge prescription in two charts.

Clarifying point:

• Iftwoorthreeoftheotherchartsreviewedindicatedthattheclientdidnotneedongoing

medication management or mental health follow-up, or that the client refused a referral to the

mental health clinic, then score 3.

Stang

VIA. Psychiatrist/

Prescriber of

Psychotropic

Medications

Score 3: Consulting psychiatrist works at local mental health clinic (i.e. is competent to prescribe

medications for mental health disorders), is not a staff member, only provides evaluations and prescribing

on site, and is only available to staff by phone or communicates via note to staff.

DDCAT — Case Study Scoring Key

134 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

Domain/Item Comments

VIB. On Site Clinical

Staff with Mental

Health Licensure,

Competency

or Substantive

Experience

Score 5: 3 of 5 staff (4 counselors and Program Director) meet criteria = 60%. Three staff includes 1 LPC

with several years experience in a mental health clinic, 1 LADC with a Master’s in Psychology and several

years experience in a mental health clinic, and Program Director w/LCSW.

Clarifying point:

• Ifperdiemstaffworksroutinely,i.e.notjustcoverageforvacations,etc.,thenreviewersshould

inquire about their qualications/competency.

VIC. Access to

Mental Health

Supervision or

Consultation

Score 3: Weekly clinical supervision is provided by the Program Director who is an LCSW. Supervision

is often pre-empted by her administrative duties, but she has an “open door policy,” i.e. as needed

supervision, mostly for crisis/problem management.

VID. Case Review,

Stafng or

Utilization Review

Emphasizes and

Supports Co-

occurring Disorder

Treatment

Score 3: Regular procedure @ weekly staff meetings allows discussion of co-occurring disorder issues.

Casedispositions and symptoms/behaviors that prompt the need for referral to the psychiatrist are

discussed, as well as general progress toward treatment plan goals, but not specic mental health

treatments/interventions. Meetings are documented.

Clarifying point:

• Giventhattreatmentplansforindividualswithco-occurringdisordersroutinelyincludegeneral

mental health goals such as obtaining a psychiatric evaluation and maintaining medication

compliance, a review of progress toward treatment plan goals would touch on diagnosis, progress

with medication compliance, etc.

VIE. Peer/Alumni

Supports

Available

withCOD

Score 5: The program has a formal, on-site volunteer network of former clients in recovery (Big Brothers

and Big Sisters) that lead a monthly alumni group. The program has intentionally recruited three volunteers

with co-occurring disorders. Discharge plans document routine referrals to the on-site alumni group.

Clarifying point:

• Ifthereisnoprotocoltoinsurepeersupportsaremaintainedaspartofthisnetwork,thenscore4.

Training

VIIA. All Staff

Members Have

Basic Training

inCOD

Score 2: There is no strategic training plan, staff typically goes to whatever training they want to, non-

clinical staff isn’t considered to need training, and some staff is trained as result of their own interest.

Clarifying point:

• Reviewerswouldwanttoaskmorespecicsabouttheexperience/trainingofthetwostaffwithprior

mental health clinic experience, but for this exercise it is assumed their background includes the

basic training required in this item.

VIIB. Clinical Staff

Members Have

Advanced

Specialized

Training in

Integrated

Treatment

ofCOD

Score 2: There is no strategic training plan. Two counselors have several years of experience at a mental

health clinic, one specializing in co-occurring disorders treatment.

Clarifying point:

• Reviewerswouldwanttoaskmorespecicsabouttheexperience/trainingofthetwostaffwithprior

mental health clinic experience, but for this exercise it’s assumed their background includes the

advanced training required in this item.

DDCAT — Case Study Scoring Key

Appendices 135

F. Sample Memorandum of Understanding

Between

[mental health program]

and

[addiction treatment program]

The purpose of this Memorandum of Understanding (MOU) is to clarify agreements between ____ and ____.

These agreements form the basis to provide comprehensive and integrated treatment to people with co-

occurring disorders. This MOU covers arrangements for mental health and addiction treatment services.

Principles of recovery-oriented, co-occurring enhanced care that we agree to adhere to in the delivery

ofconcurrentservices:

Roles and responsibilities are dened as follows:

[dene for each organization]

Referral Protocol

[referral protocol between agencies is described]

Addiction Treatment Services

___ will provide the following services:

Intake and admission procedures:

Mental Health Services

___ will provide the following services:

Intake and admission procedures:

Both parties agree to the responsibilities and procedures stated above. This agreement will be in effect/valid

through FY ___ and FY ___ and will be reviewed and/or amended every 6 months. Any changes to this MOU

will be made with the approval of both parties.

In the event of termination of this MOU, each party should give or be given a 30-day notice.

Appendices 137

G. Screening for Mental Health

andSubstance Use Disorders

Modied MINI Screen (MMS)

Mental Health Screening Form-III (MHSF-III)

CAGE-Adapted to Include Drugs (CAGE-AID)

Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD)

Posttraumatic Stress Disorder Checklist

Social Interaction Anxiety Scale

Appendices 139

Introduction

In this program, we help people with all their problems—their addictions and emotional problems.

Our staff is ready to help you to deal with any problems you may have, but we can do this only if we

are aware of the problems.

Section 1

Section A

1. Have you been consistently depressed or down, most of the day, nearly every

day, for the past two weeks? YES _____ NO _____

2. In the past two weeks, have you been less interested in most things or less able

to enjoy the things you used to enjoy most of the time? YES _____ NO _____

3. Have you felt sad, low or depressed most of the time for the last two years? YES _____ NO _____

4. In the past month did you think that you would be better off dead or wish you

were dead? YES _____ NO _____

5. Have you ever had a period of time when you were feeling ‘up’, hyper or so

full of energy or full of yourself that you got into trouble, or that other people

thought you were not your usual self? (Do not consider times when you were

intoxicated on drugs or alcohol). YES _____ NO _____

6. Have you ever been so irritable, grouchy or annoyed for several days, that

you had arguments, verbal orphysical ghts, or shouted at people outside

your family? Have you or others noticed that you have been more irritable or

overreacted, compared to other people, even when youthought you were right

to act this way? YES _____ NO _____

Section B

7. Have you had one or more occasions when you felt intensely anxious,

frightened, uncomfortable or uneasy even when most people would not feel that

way? Did these intense feelings get to be their worst within

10 minutes? (If “yes” to both questions, answer “yes”, otherwise check “no.”) YES _____ NO _____

8. Do you feel anxious, frightened, uncomfortable or uneasy in situations where

help might not be available or escape might be difcult? Examples include:

___being in a crowd, ___standing in a line, ___being alone away from home or

alone at home, ___crossing a bridge, ___traveling in a bus, train or car? YES _____ NO _____

9. Have you worried excessively or been anxious about several things over the past

6 months? (If you answered “no” to this question, please skip to Question 11.) YES _____ NO _____

Modied MINI Screen (MMS)

140 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

Modied MINI Screen (MMS)

10. Are these worries present most days? YES _____ NO _____

11. In the past month, were you afraid or embarrassed when others were

watching you or when you were the focus of attention? Were you afraid

of being humiliated? Examples include: ___speaking in public,

___eating in public or with others, ___writing while someone watches,

___being in social situations. YES _____ NO _____

12. In the past month, have you been bothered by thoughts, impulses, or images

that you couldn’t get rid of that were unwanted, distasteful, inappropriate,

intrusive, or distressing? Examples include: ___Were you afraid that you

would act on some impulse that would be really shocking? ___Did you worry

a lot about being dirty, contaminated or having germs? ___Did you worry a lot

about contaminating others, or that you would harm someone even though

you didn’t want to? ___Did you have any fears or superstitions that you would

be responsible for things going wrong? ___Were you obsessed with sexual

thoughts, images, or impulses? ___Did you hoard or collect lots of things?

___Did you have religious obsessions? YES _____ NO _____

13. In the past month, did you do something repeatedly without being able

to resist doing it? Examples include: ___washing or cleaning excessively;

___counting or checking things over and over; ___repeating, collecting, or

arranging things; ___other superstitious rituals. YES _____ NO _____

14. Have you ever experienced or witnessed or had to deal with an extremely

traumatic event that included actual or threatened death or serious injury to

you or someone else? Examples include: ___serious accidents; ___sexual or

physical assault; ___terrorist attack; ___being held hostage; ___kidnapping;

___re; ___discovering a body; ___sudden death of someone close to you;

___war; ___natural disaster. YES _____ NO _____

15. Have you re-experienced the awful event in a distressing way in the past

month? Examples include: ___dreams; ___intense recollections; ___

ashbacks; ___physical reactions. YES _____ NO _____

Appendices 141

Modied MINI Screen (MMS)

Section C

16. Have you ever believed that people were spying on you, or that someone was

plotting against you, ortrying to hurt you? YES _____ NO _____

17. Have you ever believed that someone was reading your mind or could hear

your thoughts, or that you could actually read someone’s mind or hear what

another person was thinking? YES _____ NO _____

18. Have you ever believed that someone or some force outside of yourself put

thoughts in your mind that were not your own, or made you act in a way that

was not your usual self? Or, have you ever felt that you were possessed? YES _____ NO _____

19. Have you ever believed that you were being sent special messages through the

TV, radio, or newspaper? Did you believe that someone you did not personally

know was particularly interested in you? YES _____ NO _____

20. Have your relatives or friends ever considered any of your beliefs strange

orunusual? YES _____ NO _____

21. Have you ever heard things other people couldn’t hear, such as voices? YES _____ NO _____

22. Have you ever had visions when you were awake or have you ever seen things

other people couldn’t see? YES _____ NO _____

____ Screened positive for a mental health problem

• Totalscoreof6orhigherontheModiedMINI–OR–

• Question4=yes(suicidality)–OR–

• Question14AND15=yes(trauma)

Appendices 143

Instructions

In this program, we help people with all their problems, not just their addictions. This commitment includes

helping people with emotional problems. Our staff is ready to help you deal with any emotional problems you

may have, but we can do this only if we are aware of the problems. Any information you provide to us on this

form will be kept in strict condence. It will not be released to any outside person or agency without your

permission. If you do not know how to answer these questions, ask the staff member giving you this form for

guidance. Please note, each item refers to your entire life history, not just your current situation, this is why

each questions begins – “Have you ever…”

1. Have you ever talked to a psychiatrist, psychologist, therapist, social worker,

orcounselor about anemotional problem? YES _____ NO _____

2. Have you ever felt you needed help with your emotional problems, or have

youhad people tell you that you should get help for you emotional problems? YES _____ NO _____

3. Have you ever been advised to take medication for anxiety, depression, hearing

voices, or for any other emotional problem? YES _____ NO _____

4. Have you ever been seen in a psychiatric emergency room or been hospitalized

for psychiatric reasons? YES _____ NO _____

5. Have you ever heard voices no one else could hear or seen objects or things

which others could not see? YES _____ NO _____

6. a) Have you ever been depressed for weeks at a time, lost interest or pleasure

inmost activities, had trouble concentrating and making decisions, or had

thought about killing yourself? YES _____ NO _____

b) Did you ever attempt to kill yourself? YES _____ NO _____

7. Have you ever had nightmares or ashbacks as a result of being involved

insome traumatic/terrible event? For example, warfare, gang ghts, re,

domestic violence, rape, incest, car accident, being shot or stabbed? YES _____ NO _____

8. Have you ever experienced any strong fears? For example, of heights, insects,

animals, dirt, attending social events, being in a crowd, being alone, being

inplaces where it may be hard to escape or get help? YES _____ NO _____

9. Have you ever given in to an aggressive urge or impulse, on more than one

occasion that resulted in serious harm to others or led to the destruction

ofproperty? YES _____ NO _____

10. Have you ever felt that people had something against you, without them

necessarily saying so, or that someone or some group may be trying to

inuence your thoughts or behavior? YES _____ NO _____

Mental Health Screening Form III (MHSF-III)

144 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

11. Have you ever experienced any emotional problems associated with your

sexual interests, your sexual activities, or your choice of sexual partner? YES _____ NO _____

12. Was there ever a period in your life when you spent a lot of time thinking

and worrying about gaining weight, becoming fat, or controlling your eating?

For example, by repeatedly dieting or fasting, engaging in a lot of exercise to

compensate for binge eating, taking enemas, or forcing yourself to throw up? YES _____ NO _____

13. Have you ever had a period of time when you were so full of energy and your

ideas came very rapidly, when you talked nearly non-stop, when you moved

quickly from one activity to another, when you needed little sleep, and

believed you could do almost anything? YES _____ NO _____

14. Have you ever had spells or attacks when you suddenly felt anxious,

frightened, and uneasy to the extent that you began sweating, your heart

began to beat rapidly, you were shaking or trembling, your stomach was upset,

you felt dizzy or unsteady, as if you would faint? YES _____ NO _____

15. Have you ever had a persistent, lasting thought or impulse to do something

over and over that caused you considerable distress and interfered with normal

routines, work, or your social relations? Examples would include repeatedly

counting things, checking and rechecking on things you had done, washing

and rewashing your hands, praying, or maintaining a very ridgid schedule

ofdaily activities from which you could not deviate. YES _____ NO _____

16. Have you ever lost considerable sums of money through gambling or had

problems at work, in school, with your family and friends as a result of

yourgambling? YES _____ NO _____

17. Have you ever been told by teachers, guidance counselors, or others that

youhave a special learningproblem? YES _____ NO _____

Print client’s name:

Program to which client will be assigned: _______________________________________________________

Name of admissions counselor: _____________________________________________ Date: ____________

Reviewer’s comments: _______________________________________________________________________

____ Screened positive for a mental health problem

• Atleastone“yes”responsetoquestions3–17ontheMHSF-III

Mental Health Screening Form III (MHSF-III)

Appendices 145

1. Have you ever felt you should Cut down on your drinking or drug use?

Drinking: YES _____ NO _____

Drug Use: YES _____ NO _____

2. Have people Annoyed you by criticizing your drinking or drug use?

Drinking: YES _____ NO _____

Drug Use: YES _____ NO _____

3. Have you ever felt bad or Guilty about your drinking or drug use?

Drinking: YES _____ NO _____

Drug Use: YES _____ NO _____

4. Have you ever had a drink or used drugs rst thing in the morning

to steady your nerves or to get rid of a hangover (Eye opener)?

Drinking: YES _____ NO _____

Drug Use: YES _____ NO _____

____ Screened positive for a substance use problem

• Totalscoreof1orgreaterontheCAGE-AID

CAGE-Adapted to Include Drugs (CAGE-AID)

Appendices 147

Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD)

I’m going to ask you a few questions about your use of alcohol and other drugs during the past 6 months.

During the past 6 months…

1. Have you used alcohol or other drugs (such as wine, beer, hard liquor, pot,

coke,heroin or other opiates, uppers, downers, hallucinogens, or inhalants)? YES _____ NO _____

2. Have you felt that you use too much alcohol or other drugs? YES _____ NO _____

3. Have you tried to cut down or quit drinking or using drugs? YES _____ NO _____

4. Have you gone to anyone for help because of your drinking or drug use? YES _____ NO _____

5. Have you had any health problems? For example, have you:

___ had blackouts or other periods of memory loss?

___ injured your head after drinking or using drugs?

___ had convulsions, delirium tremens (DTs)?

___ had hepatitis or other liver problems?

___ felt sick, shaky, or depressed when you stopped?

___ felt “coke bugs” or a crawling feeling under the skin after you stopped

usingdrugs?

___ been injured after drinking or using?

___ used needles to shoot drugs?

Give a “YES” answer if at least one of the eight presented items is marked YES _____ NO _____

6. Has drinking or other drug use caused problems between you and family

orfriends? YES _____ NO _____

7. Has your drinking or other drug use caused problems at school or work? YES _____ NO _____

8. Have you been arrested or had other legal problems (such as bouncing

badchecks, driving while intoxicated, theft, or drug possession)? YES _____ NO _____

9. Have you lost your temper or gotten into arguments or ghts while drinking

orusing other drugs? YES _____ NO _____

10. Are you needing to drink or use drugs more and more to get the effect

youwant? YES _____ NO _____

11. Do you spend a lot of time thinking about or trying to get alcohol

orotherdrugs? YES _____ NO _____

148 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

12. When drinking or using drugs, are you more likely to do something you

wouldn’t normally do, such as break rules, break the law, sell things that

areimportant to you, or have unprotected sex with someone? YES _____ NO _____

13. Do you feel bad or guilty about your drinking or drug use? YES _____ NO _____

The next questions are about your lifetime experiences.

14. Have you ever had a drinking or other drug problem? YES _____ NO _____

15. Have any of your family members ever had a drinking or drug problem? YES _____ NO _____

16. Do you feel that you have a drinking or drug problem now? YES _____ NO _____

____ Screened positive for a substance use problem

• Questions1and15arenotscored

• Scoreof5orhigherontheSSI-AODmeasure

Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD)

Appendices 149

Listed below are a number of difcult or stressful things that sometimes happen to people. For each event,

circle one or more of the numbers to the right to indicate that: (a) it happened to you personally, (b) you

witnessed it happen to someone else, (c) you learned about it happening to someone close to you, (d) you’re

not sure if it ts, or (e) it doesn’t apply to you.

Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events.

Event

Happened

tome

Witnessed

Learned

about it Not sure

Doesn’t

apply

1. Natural disaster (for example, ood,

hurricane, tornado, earthquake)

0 1 2 3 4

2. Fire or explosion 0 1 2 3 4

3. Transportation accident (for example,

car accident, boat accident, train

wreck, plane crash)

0 1 2 3 4

4. Serious accident at work, home,

orduring recreational activity

0 1 2 3 4

5. Exposure to toxic substance

(forexample, dangerous

chemicals,radiation)

0 1 2 3 4

6. Physical assault (for example,

beingattacked, hit, slapped,

kicked,beaten up)

0 1 2 3 4

7. Assault with a weapon (for example,

being shot, stabbed, threatened with

aknife, gun, bomb)

0 1 2 3 4

8. Sexual assault (rape, attempted rape,

made to perform any type of sexual

act through force or threat of harm)

0 1 2 3 4

9. Other unwanted or uncomfortable

sexual experience

0 1 2 3 4

10. Combat or exposure to a war-zone

(inthe military or as a civilian)

0 1 2 3 4

11. Captivity (for example, being

kidnapped, abducted, held hostage,

prisoner of war)

0 1 2 3 4

12. Life-threatening illness or injury 0 1 2 3 4

13. Severe human suffering 0 1 2 3 4

14. Sudden, violent death

(for example, homicide, suicide)

0 1 2 3 4

15. Sudden unexpected death

ofsomeone close to you

0 1 2 3 4

16. Serious injury, harm, or death

youcaused to someone else

0 1 2 3 4

17. Any other very stressful event

orexperience

0 1 2 3 4

Traumatic Life Events Inventory and Post-Traumatic Stress Disorder Checklist

150 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

If an event listed on the previous page happened to you or you witnessed it, please complete the items below.

If more than one event happened, please choose the one that is most troublesome to you now.

The event you experienced was ___________________________________________________

___________________________________________________________ on ________________

Instructions

Below is a list of problems and complaints that people sometimes have in response to stressful life experiences.

Please read each one carefully, then circle one of the numbers to the right to indicate how much you have been

bothered by the problem in the past month.

Bothered by Not at all A little bit Moderately Quite a bit Extremely

1. Repeated disturbing memories,

thoughts or images of the stressful

experience?

1 2 3 4 5

2. Repeated, disturbing dreams of the

stressful experience?

1 2 3 4 5

3. Suddenly acting or feeling as if the

stressful experience were happening

again? (As if you were reliving it?)

1 2 3 4 5

4. Feeling very upset when something

reminded you of the stressful

experience?

1 2 3 4 5

5. Having physical reactions (e.g.,

heart pounding, trouble breathing,

sweating) when something reminded

you of the stressful experience?

1 2 3 4 5

6. Avoiding thinking about or talking

about the stressful experience or

avoiding having feelings related to it.

1 2 3 4 5

7. Avoiding activities or situations

because they remind you of the

stressful experience?

1 2 3 4 5

8. Trouble remembering important parts

of the stressful experience?

1 2 3 4 5

9. Loss of interest in activities that you

used to enjoy?

1 2 3 4 5

10. Feeling distant or cut off from other

people?

1 2 3 4 5

11. Feeling emotionally numb or being

unable to have loving feelings for

those close to you?

1 2 3 4 5

Traumatic Life Events Inventory and Post-Traumatic Stress Disorder Checklist

(Event)

(Date)

Appendices 151

Traumatic Life Events Inventory and Post-Traumatic Stress Disorder Checklist

Bothered by Not at all A little bit Moderately Quite a bit Extremely

12. Feeling as if your future will

somehow be cut short?

1 2 3 4 5

13. Trouble falling or staying asleep? 1 2 3 4 5

14. Feeling irritable or having

angryoutbursts?

1 2 3 4 5

15. Having difculty concentrating? 1 2 3 4 5

16. Being “super-alert” or watchful

oronguard?

1 2 3 4 5

17. Feeling jumpy or easily startled? 1 2 3 4 5

SCORING

1) Was the person exposed to at least one event that involved actual

or threatened death or serious injury, or threat to physical integrity

of self or others?

YES NO

2) Did the person respond with intense fear, helplessness or horror?

YES NO

3) Score of 44 or more? (add up all 17 items on the second page)

YES NO

If YES to all, PTSD: YES NO

Total Score: ____________________

Appendices 153

Social Interaction Anxiety Scale

Instructions

In this section, for each item, please circle the number to indicate the degree to which you feel the statement

is characteristic or true for you. The rating scale is as follows:

0 = Not at all characteristic or true of me.

1 = Slightly characteristic or true of me.

2 = Moderately characteristic or true of me.

3 = Very characteristic or true of me.

4 = Extremely characteristic or true of me

Characteristic Not at all Slightly Moderately Very Extremely

1. I get nervous if I have to speak with

someone in authority (teacher, boss).

0 1 2 3 4

2. I have difculty making eye contact

with others.

0 1 2 3 4

3. I become tense if I have to talk about

myself or my feelings.

0 1 2 3 4

4. I nd it difcult to mix comfortably

with the people I work with.

0 1 2 3 4

5. I nd it easy to make friends my own

age.

0 1 2 3 4

6. I tense up if I meet an acquaintance

in the street.

0 1 2 3 4

7. When mixing socially, I am

uncomfortable.

0 1 2 3 4

8. I feel tense when I am alone with

just one person.

0 1 2 3 4

9. I am at ease meeting people at

parties, etc.

0 1 2 3 4

10. I have difculty talking with other

people.

0 1 2 3 4

11. I nd it easy to think of things to talk

about.

0 1 2 3 4

12. I worry about expressing myself in

case I appear awkward.

0 1 2 3 4

13. I nd it difcult to disagree with

another’s point of view.

0 1 2 3 4

14. I have difculty talking to attractive

persons of the opposite sex.

0 1 2 3 4

15. I nd myself worrying that I won’t

know what to say in social situations.

0 1 2 3 4

154 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

Characteristic Not at all Slightly Moderately Very Extremely

16. I am nervous mixing with people I

don’t know well.

0 1 2 3 4

17. I feel I’ll say something embarrassing

when talking.

0 1 2 3 4

18. When mixing in a group, I nd myself

worrying I will be ignored.

0 1 2 3 4

19. I am tense mixing in a group. 0 1 2 3 4

20. I am unsure whether to greet

someone I know only slightly.

0 1 2 3 4

Social Interaction Anxiety Scale

SCORING

Total Score: ____________________

Reserve Items: 5, 9, 11

Interpretation:

34+ Social Phobia is probable.

43+ Social Anxiety is probable.

Appendices 155

H. Measuring Motivation for Change

andMotivation for Treatment

University of Rhode Island Change Assessment (URICA)

Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)

Substance Abuse Treatment Scale (SATS)

Appendices 157

URICA (Long Form)

(University of Rhode Island Change Assessment)

This questionnaire is to help us improve services. Each statement describes how a person might feel when

starting therapy or approaching problems in their lives. Please indicate the extent to which you tend to agree or

disagree with each statement. In each case, make your choice in terms of how you feel right now, not what you

have felt in the past or would like to feel. For all the statements that refer to your “problem,” answer in terms

of what you write on the “PROBLEM” line below. And “here” refers to the place of treatment or the program.

There are FIVE possible responses to each of the items in the questionnaire:

1 = Strongly Disagree 2 = Disagree 3 = Undecided 4 = Agree 5 = Strongly Agree

1. As far as I’m concerned, I don’t have any problems that need changing.

❑

2. I think I might be ready for some self-improvement.

❑

3. I am doing something about the problems that had been bothering me.

❑

4. It might be worthwhile to work on my problem.

❑

5. I’m not the problem one. It doesn’t make much sense for me to be here.

❑

6. It worries me that I might slip back on a problem I have already changed,

so I am here to seek help.

❑

7. I am nally doing some work on my problem.

❑

8. I’ve been thinking that I might want to change something about myself.

❑

9. I have been successful in working on my problem but I’m not sure I can keep

up the effort on my own.

❑

10. At times my problem is difcult, but I’m working on it.

❑

11. Being here is pretty much a waste of time for me because the problem doesn’t

have to do with me.

❑

12. I’m hoping this place will help me to better understand myself.

❑

13. I guess I have faults, but there’s nothing that I really need to change.

❑

14. I am really working hard to change.

❑

15. I have a problem and I really think I should work at it.

❑

16. I’m not following through with what I had already changed as well as I had hoped,

and I’m here to prevent a relapse of the problem.

❑

158 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

17. Even though I’m not always successful in changing, I am at least working on my problem.

❑

18. I thought once I had resolved my problem I would be free of it, but sometimes I still nd

myself struggling with it.

❑

19. I wish I had more ideas on how to solve the problem.

❑

20. I have started working on my problems but I would like help.

❑

21. Maybe this place will be able to help me.

❑

22. I may need a boost right now to help me maintain the changes I’ve already made.

❑

23. I may be part of the problem, but I don’t really think I am.

❑

24. I hope that someone here will have some good advice for me.

❑

25. Anyone can talk about changing; I’m actually doing something about it.

❑

26. All this talk about psychology is boring. Why can’t people just forget about their problems?

❑

27. I’m here to prevent myself from having a relapse of my problem.

❑

28. It is frustrating, but I feel I might be having a recurrence of a problem I thought I had resolved.

❑

29. I have worries but so does the next guy. Why spend time thinking about them?

❑

30. I am actively working on my problem.

❑

31. I would rather cope with my faults than try to change them.

❑

32. After all I had done to try to change my problem, every now and again it comes back to haunt me.

❑

Scoring

Precontemplation items 1, 5, 11, 13, 23, 26, 29, 31

Contemplation items 2, 4, 8, 12, 15, 19, 21, 24

Action items 3, 7, 10, 14, 17, 20, 25, 30

Maintenance items 6, 9, 16, 18, 22, 27, 28, 32

URICA (Long Form)

Appendices 159

Personal Drinking Questionnaire

(SOCRATES 8A)

Instructions

Please read the following statements carefully. Each one describes a way that you might (or might not) feel

about your drinking. For each statement, circle one number from 1 to 5, to indicate how much you agree or

disagree with it right now. Please circle one and only one number for every statement.

1 – No! Strongly Disagree

2 – No. Disagree

3 - ? Undecided or Unsure

4 – Yes Agree

5 - YES! Strongly Agree

1. I really want to make changes in my drinking. 1 2 3 4 5

2. Sometimes I wonder if I am an alcoholic. 1 2 3 4 5

3. If I don’t change my drinking soon, my problems are going to get worse. 1 2 3 4 5

4. I have already started making some changes in my drinking. 1 2 3 4 5

5. I was drinking too much at one time, but I’ve managed to change my drinking. 1 2 3 4 5

6. Sometimes I wonder if my drinking is hurting other people. 1 2 3 4 5

7. I am a problem drinker. 1 2 3 4 5

8. I’m not just thinking about changing my drinking, I’m already doing something about it. 1 2 3 4 5

9. I have already changed my drinking, and I am looking for ways to keep from slipping back

to my old pattern. 1 2 3 4 5

10. I have serious problems with drinking. 1 2 3 4 5

11. Sometimes I wonder if I am in control of my drinking. 1 2 3 4 5

12. My drinking is causing a lot of harm. 1 2 3 4 5

13. I am actively doing things now to cut down or stop drinking. 1 2 3 4 5

14. I want help to keep from going back to the drinking problems that I had before. 1 2 3 4 5

15. I know that I have a drinking problem. 1 2 3 4 5

16. There are times when I wonder if I drink too much. 1 2 3 4 5

17. I am an alcoholic. 1 2 3 4 5

18. I am working hard to change my drinking. 1 2 3 4 5

19. I have made some changes in my drinking, and I want some help to keep from going

back to the way I used to drink. 1 2 3 4 5

SOCRATES 8A

160 Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit

NH-Dartmouth Psychiatric Research Center – Version date: January 22, 2002

Client Name ______________________

Date of Rating _________________

Substance Abuse Treatment Scale

Instructions

This scale is for assessing a person’s stage of substance abuse treatment, not for determining diagnosis.

Thereporting interval is the last six months. If the person is in an institution, the reporting interval is the

timeperiod prior to institutionalization.

1. Pre-engagement: The person (not client) does not have contact with a case manager, mental health

counselor, or substance abuse counselor, and meets criteria for substance abuse or dependence.

2. Engagement: The client has had only irregular contact with an assigned case manager or counselor,

andmeets criteria for substance abuse or dependence.

3. Early Persuasion: The client has regular contacts with a case manager or counselor, continues to use the

same amount of substances or has reduced substance use for less than 2 weeks, and meets criteria for

substance abuse or dependence.

4. Late Persuasion: The client has regular contacts with a case manager or counselor, shows evidence of

reduction in use for the past 2 to 4 weeks (fewer substances, smaller quantities, or both), but still meets

criteria for substance abuse or dependence.

5. Early Active Treatment: The client is engaged in treatment and has reduced substance use for more than

thepast month, but still meets criteria for substance abuse of dependence during this period of reduction.

6. Late Active Treatment: The person is engaged in treatment and has not met criteria for substance abuse

ordependence for the past 1 to 5 months.

7. Relapse Prevention: The client is engaged in treatment and has not met criteria for substance abuse

ordependence for the past 6 to 12 months.

8. In Remission or Recovery: The client has not met criteria for substance abuse or dependence for more

thanthe past year.

SATS

Appendices 161

I. Tracking Changes in Substance Use

andMental Health

30-Day Timeline Follow Back Calendar of Substance Use and Mental Health Symptoms

For substance abuse entries: note substance and how much used

For mental health entries: note symptoms experienced and intensity on scale of 1 to 10

Sun Mon Tues Wed Thurs Fri Sat

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Alc: ________

Drugs: ______

MH: ________

Appendices 163

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K. Recommended Readings

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Substance Abuse and Mental Health Services

Administration (2002). Report to Congress on the

prevention and treatment of co-occurring substance

abuse disorders and mental disorders. Rockville,

MD: SAMHSA, DHHS.

Substance Use Disorders:

GeneralTexts

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patients with alcohol and other drug problems.

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Co-occurring Disorders:

Anxiety and Substance Use Disorders

Barlow, D.H. (2002). Anxiety and its disorders

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alcohol use disorders. Clinical Psychology Review,

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Randall, C.L., Thomas, S., & Thevos, A.K. (2001).

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Co-occurring Disorders: Depression

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Co-occurring Disorders: Posttraumatic

Stress and Substance Use Disorders

Ouimette, P., Brown, P.J. Trauma and substance

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Co-occurring Disorders: Personality

and Substance Use Disorders

Evans, K., Sullivan, J.M., Step study counseling

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Co-occurring Disorders: Adolescents

Riggs, P. Treating adolescents for substance abuse

and comorbid psychiatric disorders. Science &

practice perspectives 2, 18-32, 2003.

Implementation Science

Fixsen, D.L., Naoom, S.F., Blase, K.A., Friedman,

R.M., & Wallace, F. (2005). Implementation

research: A synthesis of the literature. Tampa,

Florida: University of South Florida, Louis de

la Parte Florida Mental Health Institute, The

National Implementation Research Network

(FMHIPublication #231).

Co-Occurring Disorders:

Web-based Bibliography

www.treatment.org/Topics/dual_documents.html

33437.0911. 8732010301