Algorithm-Driven Substance Use Disorder Treatment for Inner-City Clients With Serious Mental Illness and Multiple Impairments.

ABSTRACT: Mental health clients with serious mental illness in urban settings experience multiple chronic stresses related to poverty, unemployment, discrimination, homelessness, incarceration, hospitalization, posttraumatic stress disorder, pain syndromes, traumatic brain injury, and other problems. Substance use disorder exacerbates these difficulties. This study examined the efficacy of algorithm-driven substance use disorder treatments for 305 inner-city mental health clients with multiple challenges. Researchers assessed substance use quarterly using a combination of standardized self-reports and case manager ratings. Of the 305 multiply impaired clients who began treatment, 200 (66%) completed 2 years of treatment. One fourth (n = 53) of the completers were responders who developed abstinence and improved community function; one half (n = 97) were partial responders, who reduced substance use but did not become abstinent; and one fourth (n = 50) were nonresponders. Evidence-based interventions for substance use disorder can be effective for multiply impaired, inner-city clients, but numerous complications may hinder recovery.

Moving toward trauma-informed practice in addiction treatment: a collaborative model of agency assessment.

Clients in substance abuse treatment need, in addition to evidence-based and sensitive treatment services in general, a system of care that takes into account the impact of trauma and violence in so many of their lives. In addition, services need to be delivered in a way that avoids triggering trauma memories or causing unintentional re-traumatization. To that end, this article describes an agency self-assessment process that combines a trauma-informed assessment, a NIATx process of "walking-through" and use of the Institute of Healthcare Improvement's Plan-Do-Study-Act (PDSA) cycles, and a user-friendly format. The trauma-informed assessment is designed to address issues of safety of clients and staff members, reduction of re-traumatization, consistency in practice, and client empowerment. It brings a non-judgmental, collaborative approach to process and practice improvement. The article describes how the assessment process can be--and has been--used to develop an Action Plan, including trainings and the identification of "trauma champions"; i.e., staff who will continue to spread trauma-informed changes and new evidence-based practices throughout the agency. As we enter a period of healthcare reform, addressing trauma as an integral part of addiction treatment also allows us to better deal with the totality of our clients' health problems.

Safety and security in small-scale recovery housing for people with severe mental illness: an inner-city case study.

OBJECTIVE: The authors examined the lived experience of residents with severe mental illness in a small-scale recovery-housing building in the inner city. They attempting to identify and understand factors that influenced adjustment and stability. METHODS: Four focus groups with 17 residents and participant observation with residents, case managers, and supervisory staff were conducted longitudinally over a two-year period. Data were analyzed according to the tenets of qualitative content analysis. RESULTS: Safety and security was the most prominent issue raised by residents. Serious concerns about this issue could be divided into three categories: threats raised by the behavior of other residents (and their associates), threats raised by strangers, and threats related to loss of self-control. A related theme involved ongoing tension between residents' desire for communal connections and their conflicting desire for a bounded private life. CONCLUSIONS: Ongoing attention to the issue of safety and security should be a key component of recovery-oriented housing in inner-city residential areas. Further research may need to compare the experience of safety and security among residents living in recovery housing with the experience of those in independent scatter-site housing and traditional congregate housing.

Refuge or rehabilitation? Assessing the development of a women's empowerment center for people with severe mental illness.

Recent calls for psychiatric services to focus upon psychosocial recovery for people with severe mental illness has led to a renewed interest in recovery communities. Hence, Community Connections (Washington DC) set up a Women's Empowerment Center as an intentional recovery community. The aim of this paper is to qualitatively chronicle the development of this center to assess emerging challenges. Focus groups and participant observation were conducted regularly over a 16-month period. Analysis suggested three emerging challenges (i) concern regarding unmet practical and physical needs (ii) the struggle to establish internal rules and corrective mechanisms (iii) frustration regarding differential participation.

Qualitative interviews on substance abuse relapse and prevention among female trauma survivors.

OBJECTIVE: Complex relationships among trauma, substance abuse, and mental disorders raise significant questions for the study of long-term recovery. The purpose of this qualitative study was to examine key themes in sustaining recovery among women with co-occurring disorders who had survived trauma. METHODS: In semistructured interviews conducted at one of the nine sites of the Women, Co-occurring Disorders, and Violence Study, 27 female trauma survivors described the influences they considered most important in sustaining and hindering their recovery, with an emphasis on recovery from substance abuse. Recurring themes in the interviews were identified. RESULTS: Seven themes emerged from this analysis. Four of these themes supported recovery: connection, self-awareness, a sense of purpose and meaning, and spirituality. Three others served as obstacles to recovery: battles with depression and despair, destructive habits and patterns, and lack of personal control. The women in this study reported that, although caring relationships provided important supports for sustained recovery, some of these same relationships increased emotional stress and conflict and thus may impede recovery. CONCLUSIONS: It is important for women and clinicians to place a high priority on the development of boundary management and other relationship skills. In addition, clinicians need to attend to negative feelings such as boredom and loneliness and to help women develop a range of meaningful activities that are consistent with a strong sense of identity. Individual relapse prevention skills by themselves seem insufficient to sustained abstinence.

A randomized controlled trial of integrated versus parallel housing services for homeless adults with severe mental illness.

This study compared two contemporary approaches to linking housing and mental health services. In the integrated housing program, case management and housing services were provided by teams within a single agency and were closely coordinated. In the parallel housing condition, case management services were provided by mobile assertive community treatment teams and housing by routine community-based landlords. Adults with severe mental illness who were at high risk for homelessness (n = 121; 72.7% schizophrenia spectrum) were assigned randomly to integrated or parallel housing services and followed for 18 months. Integrated housing services led to more days of stable housing and greater life satisfaction than parallel housing services, especially for male participants. Integrated housing services were also associated with greater reductions in psychiatric symptoms. Closer integration between clinical and housing services, and greater use of supervised living settings, led to more time in stable housing for participants in the integrated housing services condition and was associated with greater gains in several outcome domains.

Case management with the chronically mentally ill: a clinical perspective.

While case management is frequently seen as a valuable part of treatment for chronically mentally ill patients, the focus is often on its managerial rather than its clinical elements. A rationale for case management as an intervention with clinical merit of its own is presented.

Reassessing the revolving door: a developmental perspective on the young adult chronic patient.

Recent literature has described the young adult chronic patient as a subgroup of the chronically mentally ill whose high demand for a variety of mental health services places a strain on the delivery system. This paper suggests that the revolving door syndrome reflects deficits among the target population at three different levels: intrapsychic, dyadic, and societal. A treatment program that includes strategies responsive to the deficits at each level is described.

The Trauma Recovery and Empowerment Model: A Quasi-Experimental Effectiveness Study.

OBJECTIVE: A quasi-experimental study tested the effectiveness of the Trauma Recovery and Empowerment Model (TREM), a group intervention for women trauma survivors, in comparison to services as usual. METHODS: Two hundred fifty-one women with histories of physical and/or sexual abuse and co-occurring serious mental illnesses and substance use disorders completed comprehensive study assessments at baseline and at 6 and 12 months. TREM groups were added to standard services at two community mental health agencies in Washington, DC (n = 153). Comparison group participants received usual services at two agencies in Baltimore, MD (n = 98). RESULTS: TREM participants showed greater reductions in alcohol and drug abuse severity, anxiety symptoms, and current stressful events, and they showed greater increases in perceived personal safety. There were no group differences in change for posttraumatic stress disorder and global mental health symptoms, physical and mental health-related quality of life, and exposure to interpersonal abuse. Changes in trauma recovery skills were associated positively with gains in study outcomes for TREM group participants. CONCLUSIONS: Despite design limitations, this study provides preliminary evidence for the effectiveness of the TREM intervention for a heterogeneous population of women trauma survivors with co-occurring disorders when added to usual services.

The Trauma Recovery and Empowerment Model (TREM): conceptual and practical issues in a group intervention for women.

This article describes the Trauma Recovery and Empowerment Model (TREM), a manualized group intervention designed for women trauma survivors with severe mental disorders, and discusses key issues in its conceptualization and implementation. TREM recognizes the complexity of long-term adaptation to trauma and addresses a range of difficulties common among survivors of sexual and physical abuse. Focusing primarily on the development of specific recovery skills and current functioning, TREM utilizes techniques shown to be effective in trauma recovery services. The group's content and structure are also informed by the role of gender in the ways women experience and cope with trauma.