Guest Editorial: A radical advance in the integration of co-occurring mental health care within the addiction system

As an addiction psychiatrist and community psychiatrist I have worked on improving integrated systems and services for 40 years. Most recently, I helped to develop the updated standards in the 4^th Edition of The ASAM Criteria that encourage all addiction treatment programs to be co-occurring capable, at minimum. (See Chapter 12: Integrating Care for Co-occurring Mental Health Conditions.)

I want you to be inspired and excited about the opportunity for everyone in the addiction field to learn how to be more successful, and have more fun, working with individuals with co-occurring mental health (MH) needs, who are the expectation (not the exception) among the people we serve.

Consider The ASAM Criteria 4^th Edition’s definition of “co-occurring condition” (slightly paraphrased): “Any combination of any [Substance Use Disorder (SUD)] or addictive condition and any mental health condition (including trauma), whether or not they have been formally diagnosed.” (p. 320).

Considering this definition, does your program routinely serve people with co-occurring conditions? The answer is likely a resounding “Yes”.

And consequently, from Chapter 12: “Due to the high prevalence of co-occurring mental health...conditions among patients entering addiction treatment, ALL addiction treatment programs should, at minimum, meet the (ASAM Criteria 4^th Edition) standards for co-occurring capability. Throughout this chapter, when we refer to “standard” levels of care, the expectation is that they are co-occurring capable.  This means that they are prepared to identify and appropriately manage patients’ co-occurring needs.” (p. 321).

This means that all addiction programs start to become “co-occurring programs.” Why?  Because “co-occurring conditions” are the expectation among the people we serve, AND, if you’re program is NOT designed to be “co-occurring capable,” you and your staff are likely to be constantly frustrated because “they” keep sending you the “wrong” clients to serve.

This “mismatch” has been a source of frustration for decades. Now ASAM is providing detailed guidance for how the field can make progress to provide services more matched to what clients need and want, leveraging limited resources to the best possible effect.

In this article, therefore, I will share some of the simple approaches we have developed to support co-occurring capability, even within limited available resources.   The goal is not to create added burden, but to help you have more fun, and experience more success, with the people with co-occurring conditions that are already being served.

Defining and Achieving Co-occurring Capability

Co-occurring capability for any program at any level of care is about organizing everything about your program – policy, procedure, practice, programming – on the assumption that most people you see have co-occurring conditions, and it’s important to help those people learn to effectively manage BOTH types of conditions during SUD treatment to attain and maintain recovery.  Further, standard (co-occurring capable) programs “should NOT expect all patients with co-occurring conditions to be stable and asymptomatic. Patients treated appropriately in these programs routinely have mild to moderate acuity, instability, and/or functional impairment.”  (p. 323).  Most programs will also routinely have a small percentage of patients who have a harder time and will need additional support.  The more effective you are at developing co-occurring capability, the easier time you will have both with your usual (mild to moderately unstable) clients, as well stretching a bit to support those who are having a harder time.

ASAM Criteria 4^th Edition lists “12 Steps” of co-occurring practice and programming, as follows: (slightly paraphrased):

1. Welcoming patients with co-occurring conditions
2. Screening, identifying, and documenting the presence of any co-occurring MH concerns
3. Collaborating with any existing MH providers throughout treatment
4. Arranging for additional MH diagnostic or medication assessments, as indicated
5. Engaging patients with an “integrated” treatment team that provides help with both issues
6. Identifying stage of change and providing stage-matched interventions for each type of condition
7. Helping patients learn about their mental health concerns and helpful interventions
8. Helping patients learn basic skills for managing MH symptoms during SUD treatment, including using peer support
9. Helping patients develop skills for working with prescribers and to take medication as prescribed
10. Incorporating routine discussion of co-occurring MH concerns into programming
11. Developing a culture that is supportive of co-occurring recovery.
12. Ensuring that transition planning addresses continuing co-occurring MH needs

This may seem daunting, but it is not only do-able, but it also makes everything you do much more successful. Most “traditional” programs focus the energy and resources of the program on SUD alone, and then try to “work around themselves” providing “individualized” (and often parallel) care to address everyone’s MH issues.  The more that you gear everything to developing a co-occurring program recovery environment, the more effective will be the impact of all staff and programming on helping people with their co-occurring issues as a routine feature of your program.

Let me focus on steps 1, 8, 9, and 10 above to illustrate how this works:

Step 1: Welcoming:  Welcoming is not just about being “nice” – we’re all nice, and amazingly so in very challenging circumstances.  Welcoming is about specifically welcoming people who have co-occurring conditions, and welcoming the opportunity to hear about, learn about, and provide assistance with their co-occurring conditions.  The more we make it safe for people to share their MH experiences, even when (as is common) we – and they – have no idea how to “fix it” in the moment, the more we can help them learn how to manage what they are going through as they are working toward SUD recovery.   We tell them: “Thank you for sharing your MH experiences. You are in the right place. Thank you for coming. We love working with people who have both MH and SUD concerns. In fact, most of the people in our program do. The more we know about what you are experiencing, the better we – and everyone else here (all the staff and all the clients) can help you figure out how to be successful one day at a time.”

Step 8: Learning Basic MH Skills:   This is both more important – and less difficult – than it may sound. We used to think that once people entered SUD treatment and began working toward recovery, all or most of their MH symptoms would clear up relatively quickly. We now know this is not true.  In fact, while some symptoms may improve, others are still there, some may get worse, and new ones may show up. In any case, it is super important that we help people develop the skills they need to manage their MH symptoms one day at a time, just like they must manage their SUD cravings (addiction symptoms).  This is “symptom management,” not MH psychotherapy treatment (which, even if it were available in our program, would not work quickly.)   We also must let go of the fantasy that if they “just got on medication,” everything would be fine. That doesn’t happen, even for people with mild to moderate MH conditions (anxiety disorders, mood disorders, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, trauma-related conditions, dissociative symptoms) without SUD, let alone for those in early recovery.  With or without medications, our patients will still be struggling day to day.  So, one day at a time ALL staff must be able to provide simple tools, instructions, resources, and supports for helping people in the program get through the day, and to encourage and help them know how to ask us for help when struggling.   It is not necessary to be a MH expert to do this: these are simple skills for patients to learn – it is not unreasonable to expect that all our staff should have access to these skills and tools and know a little bit more than our patients about what to do.

Step 9: Medication Skills:   In the familiar AA pamphlet about medications, it states that people in recovery absolutely can take medications provided: 1. They are honest with their prescribers; 2. Take medication exactly as prescribed. 3. Never give or receive medication advice to or from other people in the program.   These are simple instructions, but most clients don’t know how to do any of these.  And it’s important in addiction treatment that patients learn these skills not from nurses or physicians alone, but from everyone – counselors and clients – through having open dialogue where the medication conversations that clients usually have with each other when we are not listening are brought out in the open, so people are learning a new healthy way to approach medications whether or not they are being currently prescribed.

Step 10: Programming:  Most SUD programs will have one or two “co-occurring groups,” but this is an undershoot of what is needed.  ALL groups should be “co-occurring groups” because co-occurring clients are an expectation in all groups.  ALL staff should have materials to incorporate co-occurring prompts into their groups.  If you are doing a group on “Leisure Time,” it’s important for clients to discuss: “how might your MH symptoms interfere with leisure time activities when you’re not using substances, and what are some good strategies to begin to address that.” Further, this approach involves ALL clients in sharing their co-occurring issues if they have them, which facilitates more open dialogue and a culture that supports dual recovery.  It’s not up to just the staff to be helpful with MH issues; everyone, including those people who don’t have them (or think they don’t) can be part of creating this type of culture.

Hopefully, these examples help you understand “where you are going’ to meet the co-occurring capability standards in the ASAM Criteria 4^th Edition.   Here’s some guidance for how to get there.

The ASAM Criteria 4^th Edition describes achieving “co-occurring capability” as a quality improvement process (p. 325).  (Link to ZiaPartners “12 Steps for Agencies working toward Co-occurring Capability”)

Here is a quick summary:

1. As a program leader, “say out loud” that co-occurring capability is a goal for the program and all staff.
2. Identify an inclusive and representative team (leaders and front-line staff of all kinds) designated to be the QI team to work on this for the program.
3. Perform a self-assessment using a “co-occurring capability tool.”  (The ASAM Criteria references DDCAT and COMPASS-EZ as options on page 325).
4. Develop and implement an ACHIEVABLE step-by-step action plan (or “Recovery Plan for Programs”) to make progress on 3-4 issues identified in the self-assessment.

Usual starting places are welcoming, screening/identification, integrated teamwork/competency, and teaching MH and medication skills in individual and group sessions.

Once you accomplish your first set of objectives over 3-6 months, KEEP GOING. It’s CONTINUOUS Quality Improvement.  Re-do the self-assessment after 12-18 months, celebrate your progress, and find new things to work on.

The final issue is the importance of ALL staff seeing themselves as “co-occurring helpers” and having basic “co-occurring competencies.”  This is much more powerful than having 30 clients, almost all with co-occurring issues, with 10 staff, only one of whom is defined as the “co-occurring specialist.”   That approach makes everything harder than it needs to be.  I could write an entire article about “co-occurring competency’ and how to achieve it, but I simply want to provide a few relevant references.

The first reference is our article titled “Scope of Practice for Counselors working with the Dually Diagnosed.” (Counselor Magazine, 2003)   This article illustrates what addiction counselors CAN and SHOULD do to help their clients with co-occurring issues. We have also created tools to assist supervisors helping their staff – not through training alone (which is the evidence based WORST practice for achieving and sustaining competency) but through routine coaching and case-based support. We have a competency self-assessment tool for staff and supervisors (CODECAT-EZ).

Finally, we have developed what we call the “12 Steps of Competency for (any type of helper) Staff”, which are abbreviated here. This provides simple steps that allow each staff person to consider what they already know how to do well, and where they need more practice and support.  Most important, none of the 12 competencies should seem overwhelming to anyone, and as you make more progress on this journey, everyone can feel more successful and have more fun.

12 Steps of Complexity Competency

1. Welcome individuals with co-occurring conditions.
2. Identify inspiring hopeful goals.
3. Screen for co-occurring issues.
4. Recognize and respond to immediate safety risk.
5. Integrate previous MH assessment information into the assessment.
6. Routinely identify individual strengths (what they are already doing right) for each issue.
7. Understand the recommendations for co-occurring issues as well as the client does.
8. Identify stage of change for each issue.
9. Provide stage-­‐matched interventions for each issue.
10. Provide skills-training for managing MH symptoms without using substances.
11. Collaborate with MH service providers to provide clients with an integrated message.
12. Teach skills for clients with co-occurring issues to participate in recovery support meetings.

A big ROUND OF APPLAUSE for every step you make toward achieving the vision of Co-occurring Capability described in the ASAM Criteria 4^th Edition.    

Waller RC, Boyle MP, Daviss SR, et al, eds. The ASAM Criteria: Treatment Criteria for Addictive,

Substance-Related, and Co-occurring Conditions, Volume 1: Adults. 4th ed. Hazelden Publishing; 2023.

Kenneth Minkoff, MD, is a board-certified addiction psychiatrist and community psychiatrist who is vice president and chief operating officer of ZiaPartners, Inc. in Tucson AZ. Dr. Minkoff contributed to the “Co-occurring Writing Committee” for The ASAM Criteria 4^th Edition.