IntroductionIntroduction Results and ConclusionsResults and ConclusionsOn counselor background variables, no differences were found between the MH and SA COSPD specialists on race/ethnicity, total years of counseling experience, or amount of COPSD training in the past year. The provider groups did display differences in the areas of experience and education. Although the two groups were essentially equivalent in years of general counseling experience, MH providers reported significantly more years of providing COPSD counseling services compared to SA specialists. The SA providers had a significantly higher proportion of individuals with graduate degrees relative to the MH providers. In the area of professional credentials, the two groups had approximately equal percentages of licensed chemical dependency counselors, other professional counselors, and paraprofessionals; however, the SA providers had a greater number of clinical interns providing services.

Analyses of the CODECAT results indicated that the MH counselors rated themselves as having lower competencies in knowledge and skills on two of the nine best practice principles: Principle 6: Disease and Recovery Model with Parallel Phases of Recovery and Stages of Change/Stages of Treatment, and Principle 7: Individualization of Treatment. These two principles emphasize the concepts of phases of recovery, stages of change, phases of treatment, and treatment matching.

Comparisons of COPSD client demographics by service setting revealed that clients in MH centers were more likely to be male, non-Hispanic, older, and not in the labor force. In the area of psychiatric diagnoses, MH clients were more often diagnosed with bipolar disorder and schizophrenia, whereas as clients in SA centers had the highest rates of depressive disorders (X2 = 77.31, p < .0001). Analyses of substance abuse treatment history indicated that the MH group had a higher incidence of previous non-detox treatment and had attended AA meetings more frequently in the 30 days prior to admission. Substance use patterns also differed between the groups. Clients in SA centers had greater rates of cocaine as the primary substance of abuse, had used their primary substance more days in the past month, and were more likely to engage in daily substance use. MH clients were more likely to use marijuana and engage in polysubstance use relative to SA clients.

A number of treatment characteristics were also found to be significantly different between clients in MH and SA centers. MH clients were predominantly treated in outpatient settings and had longer length of stay in treatment. SA clients had higher rates of residential placement and more often completed treatment relative to MH clients. At discharge, clients in SA centers were more likely to be abstinent, to have attended AA in the past 30 days, and to have close people supporting their recovery. Clients in MH centers were more often in living situations with exposure to alcohol or drugs at discharge.

Findings of this study suggest significant differences between MH and SA settings in Texas in both the client population base and counselor perceptions of competency. The results of the COSPD specialist counselor survey indicate that with the exception of the greater percentage of graduate degrees in the SA providers, the counselors are generally similar in their training backgrounds, years of counseling experience, and professional certifications. Despite the MH group’s greater length of experience providing COPSD services, the MH providers rated themselves lower in knowledge and skill competencies in the areas of stages of change, recovery models, and treatment matching concepts and may benefit from enhanced training in these areas. Analyses of COPSD client characteristics also suggest differences in psychiatric diagnoses, substance use severity, and treatment environment between the MH and SA settings. Identification of these types of distinctions in client base may inform development of training in evidence-based practices tailored to each setting’s characteristics.

AcknowledgementsAcknowledgements

Presented at the Addiction Health Sciences Research Conference, Santa Monica, California, October 25, 2005

Psychiatric Diagnoses

CODECAT Scale Scores

Demographics

Treatment History and Substance Use

Numerous studies have documented the high incidence of co-occurring psychiatric and substance use disorders (COPSD) in clients presenting for either substance abuse or mental health treatment. Knowledge of this substantial prevalence has resulted in the development of a variety of treatment interventions designed to address both psychiatric and substance use issues. Adaptation of both the substance abuse and mental health treatment systems is an inherent and crucial element in the evolution of specialized COPSD services. Few studies have examined features of these two service systems within the context of COPSD treatment.

The current study compares counselor, client, and substance abuse treatment characteristics of state-funded programs in Texas providing treatment for COPSD in either a mental health (MH) or substance abuse (SA) treatment setting. Identification of unique features of these systems in the treatment of COSPD may assist in targeting distinct training needs in MH versus SA programs.

Demographics and Training

The authors acknowledge the Texas Department of State Health Services (TDSHS), Mental Health and Substance Abuse Treatment Division for their assistance in providing data for this study.

The findings and conclusions of this in this presentation are the opinions of the authors and do not necessarily reflect the official position of TDSHS.

Counselor CharacteristicsCounselor Characteristics

Sample and MethodSample and Method

The counselor sample consisted of 96 COPSD specialists providing services in state-funded mental health and substance abuse treatment centers in Texas (MH: n = 42; SA: n = 54). Counselors completed a background survey and the Co-Occurring Disorders Educational Competency Assessment Tool (CODECAT; Minkoff, 1998). The CODECAT is an assessment tool that measures self-perceived clinical competencies associated with nine best practice principles developed by the SAMHSA Managed Care Initiative Panel on Co-Occurring Disorders. The CODECAT was administered on-line for an 8-day period. Participation in the survey was voluntary and anonymous, and resulted in a response rate of 67% of the statewide COPSD personnel. The survey results were compared between COPSD specialists working in mental health versus substance abuse treatment centers.

The client sample consisted of 4,981 COPSD clients who were served in these programs during the same fiscal year that the survey was conducted (MH: n = 2,038; SA: n = 2,943). Clients were contrasted by service setting using data from BHIPS, the mandatory data collection and outcomes monitoring system for state-funded substance abuse treatment programs in Texas. Clients were compared on demographic, admission, treatment, and discharge characteristics to assess for potential differences between mental health and substance abuse treatment settings. Continuous variables were analyzed using between-groups t-tests and Chi-square analyses were used to examine categorical variables.

Discharge Characteristics

MH Setting SA SettingPrinciple (N = 42) (N = 54) t p

1 - Dual Diagnosis is an Expectation, Not an Exception 17 17 0.46 ns

2 - Subtypes of Dual Diagnosis 16 16 0.33 ns

3 - Empathic, Hopeful, Integrated Continuous Relationships 20 21 -0.85 ns

4 - Balancing Cae Management and Care with Empathic Detachment, Consequences, and Contingent Learning 19 20 -0.85 ns

5 - Integrated Dual Primary Treatment 19 20 -1.62 ns

6 - Disease and Recovery Model with Parallel Phases of Recovery and Stages of Change/Stages of Treatment 26 28 -2.15 < .04

7 - Individualization of Treatment 25 28 -2.89 < .01

8 - Flexible Outcomes 16 17 -1.21 ns

9 - Comprehensive, Continuous Integrated Systems of Care 32 34 -1.06 ns

COPSD Client CharacteristicsCOPSD Client Characteristics

MH Setting SA Setting

(N = 2038) (N = 2943) X 2 p

Gender Male 51% 40% 64.64 < .0001

Race/Ethnicity Black 24% 20% Hispanic 11% 21% White 63% 58% Other 2% 1% 78.93 < .0001

Age Over 35 56% 47% 39.67 < .0001

Education Less than High School 9% 12% High School 68% 65% College Level 23% 23% 8.48 < .01

Employment Employed 13% 13% Unemployed 65% 79% Not in Labor Force 22% 8% 210.98 < .0001

35%

27%

46%

55%

16%

11%

4%7%

0%

10%

20%

30%

40%

50%

60%

Bipolar Disorder Depressive Disorder Schizophrenia Other

MH Setting SA Setting

MH Setting SA Setting

(N = 2038) (N = 2943) X 2 / t p

Substance Abuse Treatment History Prior Detox 43% 44% 0.37 ns Prior Non-Detox Treatment 60% 56% 8.09 < .01 Attended AA Past 30 Days at Admission 56% 49% 18.41 < .0001 Number of AA Meetings Past 30 Days 7 5 8.5 < .0001

Primary Substance of Abuse Alcohol 35% 35% Cocaine 7% 12% Crack 22% 23% Opiates 11% 11% Marijuana 11% 8% Other 14% 12% 43.72 < .0001

Average Days of Primary Substance Use 9.2 13.4 -13.09 < .0001

Daily Use of Primary Substance 40% 52% 101.28 < .0001

Polysubstance Use 69% 64% 9.89 < .002

Treatment Environment

MH Setting SA Setting

(N = 2038) (N = 2943) X 2 / t p

Length of Stay in Treatment in Days 143 81 16.46 < .0001

Completed Treatment 55% 60% 7.4 <.01

AA Involvement Attended AA Past 30 Days 48% 74% 246.7 < .0001 Number of AA Meetings Past 30 Days 6 8 -3.41 < .001

Abstinent Past 30 Days 65% 74% 28.48 < .0001

Employment Employed 21% 24% Unemployed 48% 66% Not in Labor Force 30% 10% 210.42 < .0001

Living and Social Environment Institutional Living Environment 12% 9% 4.53 < .03 Exposed to Alcohol or Drugs 28% 17% 37.75 < .0001 Has Close People Supporting Recovery 63% 81% 148.96 < .0001

MH Setting SA Setting

(N = 42) (N = 54) X 2 / t p

Race White 77% 66% Black or African American 13% 16% Asian American 0% 4% American Indian 0% 2% Other 10% 12% 3.08 ns

Ethnicity Hispanic 17% 22% 0.45 ns

Education Graduate Degree 25% 45% 4.04 < .04

Professional Credentials LCDC 50% 52% Other Licensed Professional 29% 31% Intern 2% 20% Paraprofessional 9% 9% 6.99 < .01

Experience and Training Years of Counseling 10.5 8.5 1.3 ns Years of COPSD Counseling 2.4 1.7 2.1 < .03 COPSD Training Past Year 15 15 -0.06 ns

Treatment of Co-Occurring Psychiatric and Substance Use Treatment of Co-Occurring Psychiatric and Substance Use Disorders inDisorders in

Mental Health Versus Substance Abuse Service SystemsMental Health Versus Substance Abuse Service SystemsLaurel Mangrum & Richard SpenceLaurel Mangrum & Richard Spence

University of Texas at Austin, Addiction Research InstituteUniversity of Texas at Austin, Addiction Research Institute

4%

35%

85%

55%

9%

1% 2%

9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Residential Outpatient Home-Based Other

MH Setting SA Setting