How We Approach The Co-Occurring Issues of Addiction and Mental Health Issues

In keeping with all treatment approaches at Ellenhorn, we take a whole-person approach to people with co-occurring issues. We believe addiction often must be approached seriously as a physical disease that can have significant and even life-threatening consequences. We also understand addiction as something deeply connected to the less-scientific concepts of hope, faith, connection to others, a sense of purpose and personal autonomy. Last, and specific to our program, we understand that the ravages of addiction and psychiatric issues often cause what we call psychosocial trauma.

Psychosocial trauma is the wound caused by the loss of social role, social status and identity suffered by people who spend a significant amount of time in treatment, and who are often removed from the world during this treatment. We believe that most of our clients, whether they engage in addictive behaviors or not, struggle with psychosocial injuries. These injuries cause them to disengage from others, to lose hope in their own future, and to lose faith in their fortitude to effectively face life challenges.

Taking seriously the impact of psychosocial trauma, we at Ellenhorn view what is considered the dual problem of psychiatric distress and addiction as, in reality, a tri-occurring problem that involves experiencing difficult psychological states, engaging in addictive behavior, and also suffering from psychosocial injury.

Many treatment approaches to co-occurring disorders only focus on the interplay between psychiatric issues and addiction, viewing the latter problem as a form of “self-medication” — a person’s attempt to manage psychiatric symptoms with harmful substances or other forms of addiction. In contrast, Ellenhorn takes the social injuries suffered by individuals who have been diagnosed and treated as mentally ill so seriously that we usually view addictive behavior and pain from these injuries as the key relationship in this triad, seeing psychosocial injury as often one cause of addictive behaviors, and in addition, as a very important factor in a person’s willingness to change this behavior. (Click here for Dr. Ellenhorn’s article on the concept of tri-occurring issues and the importance of community integration in mental health and addictions recovery.)

… Ellenhorn takes the social injuries suffered by individuals who have been diagnosed and treated as mentally ill so seriously that we usually view addictive behavior and pain from these injuries as the key relationship in this triad, seeing psychosocial injury as often one cause of addictive behaviors, and in addition, as a very important factor in a person’s willingness to change this behavior.

We are gratified that our tri-pronged approach is endorsed by current research on the most effective treatment for co-occurring issues of psychiatric experience and addiction.   The Substance Abuse and Mental Health Services Administration (SAMHSA) has conducted extensive research to determine which treatment model works best for people with co-occurring issues of mental illness and substance abuse.   SAMHSA found that Integrated Dual Disorder Treatment (IDDT) works best of all current treatment approaches, designating IDDT as SAMHSA’s evidence-based model.

What is IDDT?

IDDT stands for Integrated Dual Disorder Treatment.  IDDT teams are unique among co-occurring programs for at least three reasons: 1) They focus on helping people return to vocational, educational and family roles as a core source of recovery, rather than viewing these involvements as dependent on recovery; 2) They are interdisciplinary teams, in which all therapeutic work is integrated in a whole-person approach; and 3) They are mobile and outreach-oriented, conducting much of their work outside clinical settings. 

Ellenhorn is a national leader in using evidence-based IDDT as the sole model for our co-occurring disorders program. Ellenhorn meets and often exceeds SAMHSA best-practice measures.

Ellenhorn delivers IDDT care through high-intensity multidisciplinary outreach teams that collaboratively provide integrated substance abuse, medical, mental health, family and psychosocial care from one source, outside institutional settings.  Our teams use non-confrontational therapeutic approaches to substance abuse, while actively helping people pursue vocational, educational and familial goals.

Why does focusing on work, school and family promote good outcomes?

Ellenhorn’s IDDT teams support clients in getting back on a life track – whether returning to school, finding employment, or engaging in healthy relationships with their families. Working closely with clients to create meaningful futures fosters real human connection and promotes a sense of hope, while profoundly addressing substance abuse, mental health and psychosocial recovery.

Too often, co-occurring programs focus most of their efforts on helping people understand how to recover, rather than helping them see why they should.   Along with family and social connections, work and school are the “why.”  These activities offer hope, a belief in one’s own future, and a path toward success.  For years, community mental health programs have endorsed this view, seeing psychosocial recovery not only as a behavioral target, but also as the means to help people recover. Decades of research on psychiatric outcomes support this approach. 

Repeatedly, addiction research shows that a sense of purpose and meaning are intricately intertwined with recovery.   When a person can see a road ahead, one in which he or she has a meaningful role in society, that person has a reason to be sober beyond sobriety itself. 

From day one, Ellenhorn’s IDDT teams keep each client’s future front and center, by simultaneously helping clients pursue career, education and familial goals as they receive treatment.  At Ellenhorn, we do not view moving ahead with one’s life as conditional upon abstinence from substances – as if it is a reward or the result of passing a test. Rather, getting on a life track is a major component of achieving sobriety.

A harm reduction outlook

To build a partnering relationship, we want to have honest discussion with our clients about current use.  That means we need them to trust that talking about use with us will not lead towards negative consequences.  We thus rarely expel people from our program if they engage in addictive behavior, and we often take a non-judgmental approach to their use.   We take, what is called, a “harm reduction” approach.

To put it plainly, we work with clients even if they are currently using substances or are engaging in other addictive behaviors. While we may help someone transfer temporarily to a higher level of care if their use is putting them in serious medical danger, our larger goal is to serve our clients, whether they are abstinent from addictive behavior or not. Our approach is to meet people where they are, without preconditions.

… we work with clients even if they are currently using substances or are engaging in other addictive behaviors.

Some forms of treatment rely on people “hitting rock bottom” as a motivation to finally make changes. Many treatments also make abstinence from addiction a precondition for care. We see grave problems with these approaches. For our clients, hitting rock bottom probably means not only facing difficult and stressful quality-of-life situations, but potentially destructive psychiatric experiences. For them, being terminated from treatment means that the part of them that needs psychiatric and psychosocial help is also being discharged.

Our approach, has as its goal to keep working with people while they use. By “harm reduction,” we refer to a way of approaching ongoing substance abuse in which those around the person try to reduce the risky consequences of that abuse.  If we can lower the chance of harm, we can keep clients in our program, and thus continue our relationship with them, which is a pillar of their recovery.

Why does an integrated treatment approach work?

All too often, dual diagnosis programs described as “evidence-based” offer techniques or interventions on a piecemeal basis: They supplement psychiatric work with a substance abuse add-on; or add a mental health component to substance abuse work. Yet evidence shows that this piecemeal approach has little effect.  Real co-occurring work takes as its premise that the two issues of substance abuse and psychiatric disturbance cannot be separated from one another.  As parts of a single complex syndrome, both problems must be treated simultaneously, using an integrated approach. This means that co-occurring treatment is not simply a matter of using the right technique. It requires a particular system of care, one that balances the two issues at once.  IDDT is this kind of system of care. 

But IDDT is much more than a way to combine substance abuse and mental health treatments.  It is a “whole-person” approach, whose practitioners view every individual as distinct, and who see behavioral challenges as emerging from complex and unique tangles of roots.  That is why Ellenhorn’s teams are made up of professionals with diverse expertise. 

Why does a mobile community-based approach work? 

IDDT is the only evidence-based treatment model for co-occurring disorders that works with people while they live in the community.  That means people receive IDDT right where their challenges are, while also developing competency and confidence in dealing with those challenges, pride in what they have achieved, and a motivating life-direction.

Consider this irony:  In the United States, we spend significant resources on temporary ways to help people, provided in artificial surroundings that remove people from life challenges.  But we spend minimal resources on supporting these people once they leave institutional care (whether a hospital or residential setting) and must face the challenges of real life. Ellenhorn IDDT teams step into the gap, providing flexible levels of support so people with co-occurring issues learn to deal successfully with the stresses of life, thereby forming the foundation of lifetime recovery. 

Treatment in the community not only helps people meet their challenges, it also enables them to find sustainable natural supports for sobriety.  There is mounting evidence that recovery from addiction happens when people mend and form connections — to people and to their community – and when they develop a sense of purpose. These resources are only temporarily provided within institutional settings.  They are readily available in the community. 

The Ellenhorn treatment approach for co-occurring disorders is guided by this core belief: Being engaged in meaningful relationships and having a sense of a future are powerful determinants in a person’s desire to recover. Hope and connection are our targets.

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