A blog by Dr C Mouton
MBChB, FCPsychSA, KNMG Psychiatrist
Psychiatrist and Medical Director at Triora International
The science of addiction is developing rapidly. We are continuously learning more about the brain, behaviour, neural pathways and treatment methodologies. Around the globe we see improved treatment modalities and we are able to treat addiction even better than before. The variety of different settings and treatment models available ensures everyone’s specific needs are met. In many ways these shifts towards professionalising the field of addiction care are in the right direction, but are we truly moving away from the one-size-fits-all treatments? Or are we getting stuck on new islands in the my-treatment-modality-can-heal-all mentality?
Change in the field
One exciting driver, shifting the thinking in both psychiatry and addictionology, is the field of dual disorders. Even though there is no consensus on the term "dual disorder", it basically refers to the co-occurrence of addiction, and another mental health problem in one person, often referred to as co-occurring disorders. In the original definition, only severe mental illness, such as schizophrenia, bipolar mood disorder, severe depression and so on were included. Currently, it is also acceptable to include other psychiatric co-morbidities and also focuses on medical and psychosocial problems. Depending on how broadly one takes the term, one might argue that all patients with addiction have one, or more, other (mental) health problem; either now or in the past.
Impact of Dual Disorders
Regardless of the causal relationship between the other illness and addiction, the effect of one disorder on the other is evident - they impact each other negatively . Yes, addiction as comorbidity impairs the outcome of a psychiatric disorder. Similarly, the presence of a mental disorder worsens the outcome and course of the addiction.
Complicating the clinical picture is that dual disorders lead to complex psycho-social problems. Dual diagnosis are associated with higher likelihood of homelessness, incarceration, relationship problems, other medical illnesses, suicide, unemployment or even early death. Lastly, people with dual disorders have poorer access to health care due to stigma within the health sector, low availability of trained staff and reduced availability of facilities able to treat dual disorders.
So, what is needed to improve the fate of those with dual disorders?
Integrated Dual Disorder Treatment (IDDT) is considered to be the gold standard in assessing and treating patients with dual disorders. The model implies that the same team, in the same setting evaluates and manages all aspects of the addiction and other mental health problem. This model has been found to be more effective than parallel treatment (where different teams treat the patient at the same time) or the sequential treatment model (where one problem gets addressed after the other, often by different specialists).
IDDT excels because it approaches all problems simultaneously, regardless of causal relation, helping the patient to start the process of recovery from all issues at the same time. This prevents the negative impact on other problems and helps prevent frequent relapsing. It is also a patient centred approach, allowing for individualised treatment plans and shared decision making, further improving outcomes and patient satisfaction.
What do patients find helpful?
A recent meta-analysis done on what patients with dual disorders found helpful in their recovery process revealed four main themes. 
- The first theme focused on connectedness: being supported by family and peers as well as participating in the community;
- The second theme was holistic and individualised treatment, “seeing the person behind the symptoms”;
- The third theme focused on spirituality and regaining ownership over one’s life;
- The last theme stressed the importance of meaningful activities in one’s life.
Remarkably the process of IDDT resembles what patients found helpful in their experience. Or maybe IDDT merely satisfies the needs of the patients? Whichever way you look at it, the model of IDDT does answer many needs of our patients, and a collaborative approach improves outcomes dramatically.
The secret ingredient
For IDDT, or any other integrative model, to succeed, there is one essential ingredient: collaboration.
The first level of collaboration is with the patient. By making the patient part of the decision-making process, right from the start, the strengths of the patient can be accessed and utilised towards recovery. This process, also referred to as shared decision making improves autonomy and commitment to treatment and leads to patients taking ownership of their lives and recovery sooner.
The next level of collaboration is between the different healthcare professionals within the team. The traditional IDDT model allows for specific professionals to be involved. The original model suggested the following professional be part of the team: a team leader, case manager, substance abuse specialist, counsellor, physician/psychiatrist, nurse, employment specialist, housing specialist and criminal justice specialist.
However, the model could further be improved by extending the collaboration beyond the conventional team, especially in cases where the team can insufficiently address a problem. The team can broaden its own strengths base by incorporating help from outside to resolve all issues adequately and in a sustainable manner.
Outside your comfort zone?
Expanding the collaboration outside the traditional multidisciplinary team with other “newer” care professions can improve the effectivity of the team itself.
Some examples of professionals working in more modern teams:
- Self-help coaches, actively facilitating patient participation in 12-step / self-help groups
- Family therapists
- Recovery specialists, utilising family strengths by integrating family programmes which are invitational, such as ARISE® comprehensive care
- Recovery coaches
- Religious and spiritual guides
Collaborating even further than professionals and including the family from a very early stage will additionally improve outcomes. Utilising family strengths by integrating evidence-based, best practice family programmes which are invitational, such as ARISE® comprehensive care with intervention will allow access to family strength and resilience. Several studies support ARISE® as an effective method to engage patients in treatment, help the family and person with addiction to recover, and improve outcomes overall. 
The combination of these actions could increase sustainable recovery by adding the process of spirituality, connectedness, regaining ownership over one’s life, autonomy and participating in meaningful activities to the treatment goals.
The main prerequisite to adding these professions to a team is a shared commitment to the same core values, ethics and vision on recovery. If this is adhered to, extensive integrated treatment will allow for the individual problems of the patient to be sufficiently addressed.
Even though there are many different models of collaboration, the key benefits are similar across models. Collaboration leads to
- Enhanced capacity to treat and support patients with complex conditions
- Improved access to services
- Earlier detection and intervention
- A clinical value in integrated care
- Improved continuity of care
- More satisfied patients
- Improved outcomes and
- Reduced costs 
Extensive integrative models of collaboration in addiction care are indeed not new, but unquestionably the future when it comes to addiction care and co-occurring disorders. We need, however, to broaden our view on the topic and be more inclusive in our healthcare teams and think more laterally when developing new models, as long as we stick to solid core values and ethical principles.
The old African saying “If you want to go fast go alone; if you want to go far, go together” has never been more accurate.
- Brunette, M.F., & Mueser, K.T. (2006). Psychosocial interventions for the long-term management of patients with severe mental illness and co-occurring substance use disorder. Journal of Clinical Psychology, 67(7), 10-17.
- De Ruysscher C, et al. The Concept of Recovery as Experienced by Persons with Dual Diagnosis: A Systematic Review of Qualitative Research From a First-Person Perspective. J Dual Diagn. 2017 Jul 12:1-16.
- Ruehman, C. M., & Landau, J. L. (2018, August). Collaboration Among Families and Professionals for Recovery from Co-Occurring Disorders. Paradigm, 22(3), 7-9.
- Addiction and Mental Health Collaborative Project Steering Committee. (2015). Collaboration for addiction and mental health care: Best advice. Ottawa, Ont.: Canadian Centre on Substance Abuse.