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Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Co-Occurring Disorders:
Integrated Dual Disorders Treatment
Introduction
Integrated Dual Disorders Treatment (IDDT) overview
Substance abuse is a common and devastating disorder among persons with severe mental illness (SMI). Dual disorders (DD), which denotes the co-occurrence of substance use disorder and SMI, occur in about 50% of individuals with SMI (Regier et al., 1990) and is associated with a variety of negative outcomes, including higher rates of relapse, violence, hospitalization, homelessness, and incarceration (Drake et al., 2001). Integrated dual disorder treatment (IDDT) is an evidence-based practice that has been found to be effective in the recovery process for clients with DD. In IDDT, the same clinicians or teams of clinicians, working in one setting, provide mental health and substance abuse interventions in a coordinated fashion. As an evidence-based psychiatric rehabilitation practice, IDDT aims to help the client learn to manage both illnesses so that he/she can pursue meaningful life goals. The critical ingredients of IDDT include assertive outreach, motivational interventions, and a comprehensive, long-term, staged and individualized approach to recovery.
Overview of the scale
The IDDT Fidelity Scale contains 13 program-specific items that have been developed to measure the adequacy of implementation of IDDT programs. Each item on the scale is rated on a 5-point rating scale ranging from 1 (Not implemented) to 5 (Fully implemented). The standards used for establishing the anchors for the fully implemented ratings were determined through a variety of expert sources as well as empirical research.
What is rated
The scale is rated on current behavior and activities, not planned or intended behavior. For example, in order to get full credit for Item 3 (Access for IDDT Clients to Comprehensive DD Services), it is not enough that the agency is planning future changes in this area.
Unit of analysis
The scale is appropriate for organizations that are serving clients with SMI and for assessing adherence to evidence-based practices at the agency/clinic level, rather than at the level of a specific clinician. However, separate ratings may be completed for a specialty team in addition to the agency/clinic level.
How the rating is done
The fidelity assessment is done in person at the program site, following a prearranged schedule. The fidelity assessment requires a minimum of 4 hours to complete, although a longer period of assessment will offer more opportunity to collect information and hence should result in a more valid assessment. The data collection procedures include chart review, observation of team meeting or supervision, observation of one or more group or counseling sessions, and semi-structured interviews with the program leader, the medication prescriber(s), the clinicians providing the services, and clients.
We recommend that interviews with clinicians be done in a group format (the same applies to interviews with clients). If the program has 5 or fewer DD clinicians, it is desirable to interview all of them. If the program has more than 5 DD clinicians, attempts should be made to interview at least 5 of them. In terms of clients targeted for IDDT, we recommend interviewing 3 clients, ideally individuals who have received IDDT for at least one year.
For some items that require chart review for rating, the fidelity assessment involves the examination of 10 charts of IDDT clients. The ideal is that charts are randomly selected. We suggest that you ask the program's contact person to select 20 charts prior to your site visit, and then randomly select and review 10 of those charts during your visit.
Coding of many items requires both understanding on the part of clinicians and application of that understanding. If clinicians generally do not understand the concepts, then score as 1. If they understand parts of the concept and if they apply the understanding consistently, score as 3. To score 5, there needs to be consistent evidence that the concepts are applied consistently for 80% or more of clients, as documented across different sources of evidence.
Who does the ratings
Fidelity assessments can be made by both external groups as well as by the organization implementing IDDT. Both types of assessment are recommended. We will focus on fidelity assessments made by independent assessors. Fidelity assessments should be administered by individuals who have experience and training in interviewing and data collection procedures (including chart reviews). In addition, raters need to have an understanding of the nature and critical ingredients of IDDT. We recommend that all fidelity assessments be conducted by at least two raters.
Missing data
Missing data can occur for many reasons. One might be a failure on the assessor's part to collect the necessary information. This scale is designed to be fully completed, with no missing data on any items. Consequently, fidelity assessors should not leave any item uncoded because of insufficient information. Rather, the assessors should follow up with phone calls, emails, or additional visits to ensure completeness of the assessment. It is critical that raters record detailed notes of responses given by the interviewees.
Another reason that data might be missing is that the rating scale does not fit the organization's approach to services to this population. For example, the item of stage-wise treatment is rated on the basis of the percentage of clients receiving stage-wise services. However, if the clinicians in a program do not have an understanding of stage-wise interventions and therefore do not use this framework, then the proper scoring on this item is 1. It is not missing. We anticipate that many new programs will receive low fidelity ratings on many items for which the program has not yet formulated a policy.
References
Drake, R. E., Essock, S. M., Shaner, A., Carey, K. B., Minkoff, K., Kola, L., Lynde, D., Osher, F. C., Clark, R. E., & Rickards, L. (2001). Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services, 52(4), 469-476.
Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., & Goodwin, F. K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. Jama, 264(19), 2511-2518.
TOC | Protocol
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