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Welcome to Addiction Exchange, a forum for the exchange of clinical practice and research information among clinicians, scientists, educators, and administrators in the field of addiction. This is part two of a two-part series on treatment of patients with serious mental illness and substance abuse disorders, specifically discussing the research of Dr. Thomas Fox and Lindy Fox on this subject. In this issue we interview Dee Keenan, clinical services coordinator for the Virginia Beach Community Services Board, on the dual-diagnosis treatment project for seriously mentally ill (SMI) addicts based on the Foxes' research. Keenan, the project director, described the CSAT-funded, so-called "Green Team" project in the phone interview below.
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When did the project start? We received notification of the grant in October 2000. We hired a senior clinician/supervisor in mid-June. This is the first SAMHSA [Substance Abuse and Mental Health Services Administration] grant our agency has gotten - $1.5 million over three years, a targeted expansion grant.

Is the project based totally on the Foxes' research? The "Green Team" is based primarily on their work. We're having to make a few adjustments because it's a different locality, with things unique to Virginia. But in terms of phases or levels, we are following their research. One of the instruments we're using kind of guides our outcome measures. We called Dartmouth to measure our fidelity to the model to keep us on track.

How did you learn of the Foxes' research? They've been coming to Virginia for a number of years, when CSBs invite them. About 2 ½ years ago we had received an educational grant from a pharmaceutical company and decided we wanted to look at the dually diagnosed population and state-of-the-art treatment for them. One of our staff heard the Foxes at a conference and suggested they bring them down. We all walked away from it going, "We've got to do something with this."

Can you go into little more detail on the project? The team itself is made up of five clinicians. The staff will be spending a good deal of time in the community. The idea is that there are number of individuals out there who have both SMI and a substance use disorder. We know from past experience that they are difficult to engage in treatment. Our focus is to do a lot of outreach, to meet individuals where they are, to not push the whole issue of traditional treatment. If we find a client, we'll ask, What can I do for you? rather than, Here's what you need. They may say, I want you get me a job - historically, we'd have said, Let me get you to see the doctor and get on meds, then we'll help you with getting a job. The whole premise is, we basically do what the client wants. If they want a job we're going to get them that job, because that's how we engage them in treatment.

Where do you find these clients? There are a lot are homeless people. The places we're looking are homeless shelters; we have staff hanging out down at the beachfront these days. Some had treatment with us in the past, or in state hospitals. They may not have had a particularly good experience, and a lot don't believe that they have a problem. There's a real strong denial component to both the substance abuse side and the serious mental illness side.

How does your assessment differ from the assessment of non-SMI substance abusers? And speaking of assessment, is everyone involved in the project on site? Most are in the initial stages of treatment. [Note: "stages of treatment" include engagement, persuasion, active treatment, and aftercare]. Everything that goes on is inclusive among the Green Team staff. We made a point of having staff that know about SMI and substance abuse. Nursing hours are available to the team, and psychiatric hours, so we have the capacity for all of the evaluations. They are in addition to five full-time staff. In the grant we put in 15 hours of psychiatric time per week, on site. For medical problems, we make referrals to community resources. When they move to the persuasion stage, we offer a lot of group education, try to get the family involved. Again, this all would be done by the Green Team. It wouldn't be until they move to the active treatment stage that we try to integrate them into existing CSB services such as outpatient, individual therapy, and so on.

How will the project be evaluated for success? For each individual client, we'll look at how many times in the last 30 days they've used substances, or have worked. SAMHSA wants you to look at outcomes, tying research to practice. We've included some measures of our own, one of which is to track the number of days in the hospital. We're expecting for this population that that will decrease, and the amount of substance used will decrease. We'll track it on a quarterly basis.

What has the project done so far? A couple of our CSB staff interviewed (and were chosen) for the positions; three of the project staff are new. The start-up is incredible, it takes such a tremendous amount of time. There was money for vehicles, so we purchased them. We've gotten space set up for outreach contacts to homeless shelters, and internal tracking set up for our quarterly report. We've written up the program and job descriptions and have already started treating people. We've made between 50 and 100 outreach contacts. In terms of clients actually being in the project, we're up to about three now. The project model says that each staff person shouldn't carry a caseoad of more than 10, so we expect to be able to treat 50 people. By the end of the third year, we're hoping to treat about 125 to 150 clients, but that may be a little optimistic. These people can stay in either the engagement or persuasion stage for as long as three years, but it's very individualized.

It's been an incredibly complicated process. It took two to three months to "draw down" the money (to move the money from SAMHSA to Virginia Beach). They've been very helpful. They want to make sure your program is successful, and make sure you get some good outcome measures. Also included in the trainings is help in sustaining the program, so when the three years are gone there's a mechanism in place for funding so it can continue - not necessarily from them, but maybe closer to home, in the community. There are lots of activities they want us to be doing to make sure it's a very public project.

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Mid-Atlantic Addiction Technology Transfer Center
Funded by Center for Substance Abuse Treatment of
Substance Abuse and Mental Health Services Administration
mid-attc@mindspring.com
http://www.mid-attc.org
804-828-9910