Kenneth Minkoff, M.D. Foreword 2020

Over the course of the past several decades, both the mental health field and the substance disorder treatment field have experienced an ever-increasing influx of individuals who have co-occurring mental health and substance use disorders. From the time these individuals first began to be identified, in the early 1980s, they have been recognized as a group of clients who are challenging, and they are challenging in many ways. First of all, individuals with co-occurring disorders are challenging because they have poorer outcomes and higher costs. It may not be terribly surprising that individuals with more than one problem would do worse than those with only one problem, but nonetheless it has been very well studied, and we know that from the perspective of either service system these individuals have poorer outcomes in multiple domains. Specifically, individuals with co-occurring disorders are more likely to relapse and be rehospitalized, be treatment resistant and noncompliant, be medically involved (e.g., with sexually transmitted diseases), criminally involved, impoverished, and homeless, engage in self-destructive, aggressive, and violent behavior, and suffer from histories of trauma and victimization. In addition, these individuals tend to have poor outcomes in terms of service utilization as well, and are likely to be over represented among the highest cost recipients of scarce system resources in either system.

These individuals are further challenging because they are often experienced as “system misfits” at every level of the system. At the systems level, these are individuals who dare to have more than one disorder in systems of care that have been designed as if everyone had only one primary disorder at a time. In addition, the programs within those systems have been similarly designed, so that clinicians working with “real” clients in “real” programs constantly experience a need to contort programs to fit clients, or contort clients to fit programs. Finally, these individuals may be misfits at the level of most clinicians as well, since many of us were trained to be either mental health clinicians OR substance clinicians, but not both, so that when we encounter these individuals we immediately experience a misfit between what they need and what we know.

Furthermore, it has become increasingly clear over the past several decades that this population is not only not going away, it appears to be steadily growing. Mental illnesses and challenges of all kinds (responses to trauma, mood and anxiety disorders, ADHD, cognitive disorders) are increasingly recognized as common in the general population, and two to three times more common in populations of people with substance disorders. Epidemiologic studies (the Epidemiologic Catchment Area survey and the National Comorbidity Survey) identified a sufficiently high prevalence of comorbidity in all populations that SAMHSA’s 2002 Report to Congress on co-occurring disorders clearly stated that “dual diagnosis is an expectation, not an exception”.

In the face of the increasing number of people with co-occurring disorders, there has been a slow, but steadily increasing accumulation of data that identify evidence based best practices and interventions for the treatment of these individuals. The most important message that has emerged from this research is that treatment interventions need to be integrated, that is, the mental illness and the substance disorder need to be addressed at the same time, and the same place, ideally in the context of an empathic, hopeful, primary treatment relationship that promotes the ability of the client to develop skills for managing both disorders in a coherent, person centered way. Another important message that is emerging from this research is that integrated treatment interventions can be quite variable, and need to be individualized for clients based on diagnosis, stage of change, level of acuity, extent of disability, and level of care requirement. Further, because of the prevalence of co-occurring conditions, it is necessary for ALL programs to become “co-occurring programs” with the ability to provide properly matched integrated services to the populations they serve, within their mission and resources. This concept has been termed “Co-occurring Capability”. Similarly, all persons providing care for these individuals need to develop co-occurring competency as well, in line with their job and their level of training. Consequently, it is becoming increasingly clear that in any system of care, there need to be many types of co-occurring capable programs, including crisis services, outpatient services (for adults, youth, and children/families), intensive case management and wraparound services, programs, recovery support programs, addiction treatment programs at all levels of care, and psychiatric inpatient units.

Moreover, based on the principle that dual diagnosis is an expectation rather than exception, there have been increasing efforts to develop integrated systems of care in which all available resources are mobilized to treatment of individuals with co-occurring disorders in all treatment venues. Essentially, in this model of a Comprehensive, Continuous, Integrated System of Care (CCISC), all programs become co-occurring programs, with some expectation of basic integrated co-occurring capability, and all clinicians are expected to have basic co-occurring competencies in this area as well. The most recent version of the American Society of Addiction Medicine Patient Placement Criteria (2013 in fact, specifies criteria for Co-occurring Capability) are viewed as basic requirements for all addiction programs. A recent technical assistance paper released by NASMHPD (2019) describes policy goals and steps for implementing universal co-occurring capability across state MH and SUD systems.

As the expectation of system wide co-occurring capability has grown, and as the prevalence of integrated treatment interventions have become widespread, there has been increasing need for basic educational materials, for both staff and clients, regarding co-occurring services and dual recovery. In the absence of such material, development of effective integrated treatment curricula becomes much more difficult and problematic. For this reason, this treatment manual by Rhonda McKillip is a welcome and necessary addition to the programmatic armamentarium for integrated treatment of co-occurring disorders.

Rhonda McKillip is a highly experienced mental health and addiction counselor, who has been providing group treatment, training, and education for individuals with co-occurring disorders and the staff who work with them for many years. This book is the result of her compilation of this experience into a curriculum and manual that can be readily utilized by even novice dual diagnosis clinicians to develop a treatment program, in either addiction or mental health settings, for dually diagnosed clients who are seeking education regarding co-occurring disorders. The book is organized into a series of subjects that contain concrete material with which clients can be educated in a group format. The subjects are further designed to be flexible, so that the group leader can adjust the content based on the length of the group, and the level of functioning of its participants. Most important, each subject includes an extensive set of “Tips for Facilitators” that help both experienced and novice clinicians to implement the subjects successfully. As a result, Ms. McKillip is able to simultaneously train clinicians while developing a curriculum workbook to educate clients.

The availability of this manual will be of great value in promoting integrated treatment programming in both mental health and addiction treatment settings. I am delighted to be able to recommend this work for clinicians in both fields.

Kenneth Minkoff, M.D.

BIOSKETCH: Kenneth Minkoff, M.D.

Kenneth Minkoff, MD is a board-certified psychiatrist with a certificate of additional qualifications in addiction psychiatry. Ken is a dedicated community psychiatrist, and currently is a clinical assistant professor of psychiatry at Harvard Medical School. He is recognized as one of the nation’s leading experts on integrated treatment for individuals with complex (co-occurring) needs, including mental health and substance use conditions. In addition, Ken is the leading expert on the development of integrated systems of care through the implementation of a national consensus best practice model for systems design: The Comprehensive Continuous Integrated Systems of Care (CCISC), referenced in SAMHSA’s Report to Congress on Co-occurring Disorders (2002). 
More information about Dr. Minkoff can be located at www.ziapartners.com