12 Steps for Addiction Programs Working Toward Co-occurring Capability
As more addiction provider agencies and programs become aware of the new language in Chapter 12 of the ASAM Criteria, 4th edition regarding co-occurring capability, there is increasing recognition that all addiction programs will be expected to achieve this level of co-occurring capability over time. If you are one of the programs or agencies that is trying to implement the new ASAM Criteria, this expectation may be making you excited, or terrified, or both. But in any case, this blog is for you.
For the past 25 years, I have been working all over the world with my partner Dr. Chris Cline to help substance use disorder (SUD) and mental health (MH) programs, and county and state systems, implement universal co-occurring capability. Well-designed systems help organize all programs and all persons providing help to be welcoming, hopeful, and helpful in their offerings of integrated MH and SUD interventions to individuals with co-occurring conditions. One of the tools we have developed for agencies and programs is called the 12 Steps for Co-occurring Capability, which I’m going to share with you here.
An abbreviated, downloadable version of these steps is available here.
First, some context. Think of this not as a new and burdensome requirement, but rather an opportunity. Becoming a co-occurring capable program with co-occurring competent staff — within whatever resources you have available — is about helping your program be more successful, and have more fun, with the co-occurring clients you are already serving. And you are serving these folks every day!
Second, this process of change is best understood as a “quality improvement” or “practice implementation” initiative. It is not primarily a “training initiative”. Do not fall into the training trap! Many programs assume that the first thing they need to do is to put their staff through a series of "MH trainings”, often on tedious topics like understanding the DSM diagnoses. Trainings on their own are the evidence-based worst practice for making sustainable change in care delivery. Worse yet, if the trainings are tedious and complicated, and disconnected from practice supports and supervision to help your staff do the things they actually will feel successful doing, then the trainings may backfire and lead your staff to feel more scared rather than more competent. Hence, the 12 steps. Get organized to make progress one day at a time, and make sure any training is tied to the next step in implementation.
Third, start with the capacity you already have, and get the help you need to make change and the consultation you need to improve co-occurring capability. If you have the resources to hire additional MH supervisors and MH service providers that’s great, but whether you do or you don’t the goal is for all staff and all aspects of your program design to be organized to be helpful to the people with co-occurring conditions you're serving. It may be helpful for you to identify a MH agency to partner and share expertise with (cross-consultation), and/or to engage a consultant to help you with co-occurring capability. Those will be good investments in time and resources. And remember, don’t focus first on the most challenging people you see; focus first on the “usual” people with co-occurring conditions that come in the door, and get super organized to help them. The more you build a strong foundation for your program’s “co-occurring capability recovery”, the easier things will become over time.
12 Steps for Co-Occurring Capability
1. Say it out loud. Work with your leadership team to make a formal announcement and commitment statement that you are going to be working in partnership with all staff to help all your programs develop co-occurring capability — per the new ASAM Criteria — so your staff will feel more successful and have more fun working with the clients they are already seeing every day. Tie this communication to the program or agency’s existing mission and values. Once you’ve said out loud what you are doing, it is helpful to provide a basic training for everyone on what co-occurring capability means and the steps you are planning to help everyone make progress.
2. Organize a continuous quality improvement (CQI) change team. This is a quality improvement process for your agency, and you need a team to manage it. The CQI team needs to have good leadership, representation from all key components of your organization, and representation from passionate staff as well (see step 3). The team needs to meet regularly (at least monthly), take notes, and measure progress.
3. Identify change agents and champions. You are not doing this to staff; you are doing this with staff. There are already folks who work in your agency that are passionate about helping challenging people; these are the folks who can make great change agents. You should identify at least one change agent from every program, team, or unit, and look for diverse representation from different types of staff: addiction counselors, MH staff, nurses, doctors, residential aides, support staff, and admin staff. This group should also meet regularly and be led by someone on the leadership team. They should share their passion and see themselves as partners with leadership, their colleagues, and each other, to transform the organization to be more co-occurring capable. They can receive training on concrete steps to help implement within their teams, and they will be in place to help with the next steps. This empowered partnership for change is a fundamental feature of best practice improvement and will produce energy for creating better results for clients and staff over time. A subset of change agents can represent the whole group on the organization’s change team.
4. Communicate that co-occurring capability is about all staff. Although you are creating a change structure that involves a change team and change agents, and although you may have identified MH experts, make it clear that everyone will be learning how to be successful helping people with co-occurring conditions. The most powerful impact that you have as a program or agency is when everyone the clients interact with — including each other — are all on the same page about helping provide direction for progress in dual recovery.
5. Self-assess baseline co-occurring capability in each program. Co-occurring capability is grounded in developing a full array of policies, procedures, practice instructions, and protocols that are designed on the assumption that co-occurring clients are the expectation and that the program is routinely providing help for both issues within its mission and resources. The more organized the policies and practices are, the more successful the program will be. There are tools for conducting a baseline self-assessment (the COMPASS-EZ 2.0 [Minkoff & Cline] and DDCAT [McGovern et al]) which are best used to promote learning and consensus building by program teams, supported by program leaders and change agents. The more staff that participate, the more involved and informed everyone becomes in contributing energy to the changes. Make sure to read the instructions for using the tools and follow them carefully in order to ensure the best results. The point of the baseline assessment is to identify opportunities for improvement, so make sure to also take good notes on your discussion, and not just write down scores.
6. Develop agency-wide and program specific co-occurring capability action plans. The self-assessment process provides both quantitative and qualitative information about baseline co-occurring capability that informs the most important next step: the development of quality improvement “action plans” that define measurable and achievable targets for progress — usually with 6-12 month timeframes. In a typical addiction provider agency, there will be action plans for each program and an action plan for the organization as a whole. It is important that action plans are achievable; agencies should not try to change everything at once. The self-assessment process will help identify many opportunities for improvement; each program should identify 3-4 areas to prioritize that are viewed as both achievable and meaningful to staff in contributing to improved service delivery. It is helpful to view “action plans” as “recovery plans” for the program or the organization, and to engage in the quality improvement process as a hopeful, strength-based recovery process in which each program and the agency make progress — one day at a time, one measurable step at a time — toward the co-occurring capability recovery vision of the organization.
The remaining six steps are common starting places for action. A brief description of possible action steps is provided for each.
7. Welcoming and access. “Welcoming” starts with the philosophy and technology of customer service, in which specific procedures are put in place to purposefully welcome challenging customers. In an addiction program, people with co-occurring conditions are an expectation (not an exception), and it is important to welcome them exactly as they are. If staff are thinking that co-occurring clients are somehow in the “wrong place," they will constantly be frustrated.
Welcoming is more than just an attitude. It involves specific policies and practices. Many programs start with basic welcoming: creating a policy stating that people with co-occurring conditions are welcomed for help, and providing that message to clients on admission, as well as in distributed literature and posters on the walls. Then, change agents may prepare a welcoming speech for staff to use: “Welcome to our program. We are happy to work with people who have mental health challenges as well as substance use disorders, and we see that is part of your struggle. Thank you for coming. You’re in the right place. We want you to be able to trust us to share what you are struggling with so we can help you with all your issues while you are here to make progress toward your recovery goals.” Programs also may work on developing policies and procedures for eliminating non-welcoming and stigmatizing language, even when used in private: "Oh…she’s just a borderline, and they’re all manipulative." Further, programs may work to create a welcoming culture among all clients, so that people know that they are in a place where it is safe to share that they are struggling with MH issues.
Finally, improving access involves reviewing any rules that create barriers to admission based on arbitrary criteria — any suicidal ideation, “voices”, diagnosis of schizophrenia, antipsychotic medication, or medications for opioid use disorder (MOUD) — rather than evaluating people individually to help them feel welcome and determine their ability to be successful.
8. Integrated screening and identification. This step is not about implementing additional screening tools. Rather, it is about being purposeful and deliberate about identifying known or possible mental illness and mental health concerns (suicidal thoughts, trauma), tracking specific next steps in clinical documentation, and tracking the prevalence of co-occurring conditions in program data. This does not require your program to add additional licensed MH clinicians, but rather to become systematic in acting on the information that you currently collect.
Note that if your addiction program is asked “What percentage of your clients are co-occurring?”, the answer will invariably be 70 or 80%, or maybe just “lots.” If you are not counting your co-occurring population, then it means you are organized as if they don't count. That makes it harder for you and for them. Simple steps here involve instructions for staff to use existing screening to document results: Does the person have a co-occurring MH condition? Yes, no, maybe. If there is an existing diagnosis, document it. If they need further assessment, plan for it. If they need help with symptom management, plan for that. Make sure you track in your data how many co-occurring clients you are serving (whether they have meds or not, an established diagnosis or not); this will remind you that co-occurring is an expectation for you, and help you plan accordingly.
9. Integrated strength-based assessment. All addiction programs need to have some access to MH diagnostic assessments, whether performed internally by licensed staff or available through external consultation and partnership. The new ASAM criteria define the level of availability needed to align with the level of care provided. (Methods for developing partnerships that allow you to build capacity with limited resources are described in step 12.)
For this step, my recommendation is to focus on things that you can do internally with your own staff that have enormous value in co-occurring work. These are the three elements of an integrated assessment for the purpose of effective addiction treatment:
i. Hope for dual recovery. Help each client describe and document their most hopeful vision for a happy, meaningful life. This is about what would help them feel proud and successful in where they live, who they are living with, how they spend their time, and so on; even though they may need continued help and support for both addiction and mental illness.
ii. Identify strengths and periods of success, with a particular focus on what mental health symptoms they have struggled with during previous periods of sobriety — however brief — and what skills they have used to address those a day at a time. Clients are “recurrently successful”, not “chronic relapsers,” and finding out what they did well previously can be built on for the current episode. Focusing treatment on the reality that all MH symptoms will not clear up just by sobriety, nor by illusory “perfect” medication, but must be worked on a day at a time, becomes a helpful focus of treatment.
iii. Identify stage of change for multiple issues so that interventions and outcomes for each issue can be stage-matched. This will help your program to be partnering with clients, rather than struggling with them. Note that when asking “What stage of change is a client in?”, the correct answer is always “For which issue?” Stage of change for our clients — as for ourselves — is issue-specific, not person-specific, and integrated interventions must be stage matched for each issue (see step 11). This process begins by integrated assessment of stages of change.
10. Integrated strength-based recovery planning. The next two steps go hand-in-hand. The structure of integrated treatment plans is straightforward, and developing a template to work from is often a good starting place. Identify each client’s most hopeful goals for a meaningful life, and for each disorder or issue identified in the assessment, consider what strengths they are already using to manage those issues in working hard to both survive and make progress toward their goals. Then, identify the interventions that they need to work on (skills they need to learn, supports they need to engage) to build on their existing strengths and periods of success to help themselves make progress with both types of conditions/disorders during treatment. It is important to remember in creating such plans that integrated treatment begins with what you do in your program with your staff: it is far more than just referring someone out to get a prescription or psychotherapy. In this context, addiction and co-occurring mental illness and trauma are both treated as primary conditions. We recognize that as soon as anyone begins working toward sobriety, their mental illness needs to be managed. That’s what needs to be prompted and supported in creating the integrated treatment plan.
11. Integrated stage-matched interventions and programming. In helping addiction programs address step 11 for improving co-occurring capability, I usually recommend starting with the design of the treatment program itself. Many addiction programs have historically addressed co-occurring mental health conditions by emphasizing individual interventions, or perhaps one co-occurring group, to effectively “work around” their own program and milieu, which remains focused on addiction only. This makes everything much harder, for both staff and clients. In addiction treatment, the structure of the group program is often the most powerful tool for change, and the creation of a recovery culture in the groups is part of what extends the treatment power of treatment staff and (if provided) medication for addiction. To take the next step forward, addiction programs should begin to realize that if co-occurring is an expectation, then the entire treatment program should be designed with that in mind. The recovery culture developed should be a dual recovery culture, where all the clients are helped to use their own experience, strength, and hope to help each other in accordance with their stage of change for each condition, and to relieve the burden on asking each individual counselor to do work around their own program.
In this approach, every group becomes a co-occurring group, because for every topic, clients need to learn how to manage both types of illness (mental illness symptoms/medication side effects, right along with addiction cravings). A "relapse prevention” group is partially about helping people manage mental health symptoms that may trigger relapse; a “leisure time” group is about helping people figure out how to enjoy themselves while dealing with their mental illness/trauma without getting high; and so on. That is the goal. In addition, it is helpful to include in the program a “medication skills” group where clients discuss how to take psychiatric meds properly (including those clients who are not on meds), so that they learn how to talk to prescribers honestly, and take meds as prescribed.
12. Cross-consultation with MH providers/programs. All the previous steps emphasize the actions that can be taken by an addiction program to enhance its co-occurring capability, within whatever resources it has available, and with whatever limited outside mental health consultation it can engage on its own. I call this “operating within the serenity prayer of change”: the serenity to accept the things you cannot change (which is everyone else), the courage to change the things you can (your own work or your own program), and the wisdom to know the difference. But one thing that addiction programs can also do is create mutual help relationships with mental health partners. This type of relationship is not primarily about making referrals back and forth. Rather, this is literally sharing resources for mutual assistance through cross consultation and in-reach. As an addiction program, find a mental health provider in your same geography that works with a similar population (e.g. adults, pregnant women, adolescents), and start by offering to provide them consultation and in-reach to help their staff know how to more effectively manage the large number of co-occurring clients they have — recognizing that their clients are mostly not interested in referral to an addiction program. This helps you to help more people without straining your resources and helps to divert inappropriate referrals. In return, you are in a good position to encourage the MH provider to offer similar consultation and in-reach to your program, with the goal of helping your staff feel more supported in addressing MH issues, as well as having a MH partner join your team to help facilitate access to outside MH resources when needed.
This 12-Step Program of Recovery for you to make progress toward co-occurring capability is intended, like any recovery program, to guide you to build on your own strengths to make progress. One day at a time, one measurable step at a time, you align your staff and services to be better matched to the needs of the co-occurring clients you regularly serve, as well as to help you meet the guidelines offered in the ASAM Criteria 4th Edition. The ultimate goal is to have more fun and more success working with the clients with co-occurring conditions who are an expectation in your program, and need your help the most.
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