“One-Stop Shop for Clients with Serious Mental Illness Who Often Use Substances”: A Qualitative Study on Assertive Community Treatment Clinicians’ Perspectives on Managing Substance Use Disorder

doi:10.21203/rs.3.rs-5253620/v1

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“One-Stop Shop for Clients with Serious Mental Illness Who Often Use Substances”: A Qualitative Study on Assertive Community Treatment Clinicians’ Perspectives on Managing Substance Use Disorder

https://doi.org/10.21203/rs.3.rs-5253620/v1

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Assertive community treatment (ACT) can be an integrated treatment model for peoples with serious mental illness (SMI), many of whom have co-occurring substance use disorder (SUD). With its capacity to provide integrated care, ACT presents opportunities for the effective management of both mental illness and addiction. This study aimed to explore the role of ACT in managing concurrent disorders (CD), specifically focusing on the barriers and facilitators in treating SUD among peoples with SMI, as perceived by ACT clinicians. Semi-structured interviews were

conducted with five ACT clinicians, from which five overarching themes and the 28 sub-themes were identified through thematic analysis. These established the role of ACT in managing CD, and identified systemic, clinician, and client-related barriers and facilitators in the management of SUD. The findings highlight the potential for integrating mental health and addiction services more effectively within ACT by addressing these barriers and enhancing the management of CD.

Community mental health

Assertive community treatment

Substance use disorder

Severe mental illness

Concurrent Disorder

Provider perspectives

Qualitative research

Integrated treatment models for mental health and addiction are designed to deliver comprehensive care to patients with co-occurring serious mental illness (SMI) and substance use disorders (SUD) (Peterson, 2013). Underscoring the intricate and interconnected nature of these disorders is the fact that approximately 50% of peoples with SUD concurrently experience SMI (Kessler, 2004), while 41.7% of individuals with SMI such as schizophrenia have a SUD (Hunt, Large, Cleary, Lai, & Saunders, 2018). Concurrent disorder (CD), the term for the simultaneous

presence of SUD and SMI, is associated with worse health outcomes than either disorder alone. Peoples with CD are at increased risk for homelessness, recurrent hospitalizations, and involvement in the criminal justice system (Fries & Rosen, 2011). In addition to these challenges, peoples with CD face significant barriers to accessing care, particularly because traditional treatment models often address SUD and SMI separately (Robert E. Drake, Kim T. Mueser, Robin E. Clark, & Michael A. Wallach, 1996; Osher, 2006). Integrated treatment models for treating concurrent conditions provide comprehensive, patient-centered care by addressing both conditions simultaneously and offers better outcomes for peoples with CD (Sterling, Chi, & Hinman, 2011)

Assertive community treatment (ACT) is a comprehensive, community-based treatment model developed in the 1970s to improve access and engagement for individuals with SMI, such as schizophrenia and bipolar disorder (Stein & Test, 1980). The key components of ACT include assessment and support, assertive outreach, a holistic service approach, multidisciplinary teams, and a low client-to-staff ratio to ensure care continuity (G. R. Bond & Drake, 2015). In addition to addressing mental health issues, ACT teams are designed to offer comprehensive support that includes managing co-occurring disorders such as SUD (Morse et al., 2006). By functioning as a “one- stop shop,” ACT teams provide integrated services directly, minimizing the need for clients to seek care from multiple providers (Ontario ACT Association, 2024). Several randomized controlled trials (RCTs) that looked at how well ACT works for treating SUD found that it can lessen the severity of substance use (Aubry et al., 2019; Aubry et al., 2016; Essock et al., 2006; Loubière et al., 2022; Morse et al., 2006; O'Campo et al., 2016; Pérez de León et al., 2011), reduce the prevalence of substance use, and improve treatment adherence (Abufarsakh, Kappi, Pemberton, Williams, & Okoli, 2022; Louise Penzenstadler, Carina Soares, Eleonora Anci, Andrew Molodynski, & Yasser Khazaal, 2019) making this recovery-oriented model, widely adopted in countries like the United States, Australia, Europe, and Canada.

In Ontario, Canada, ACT teams constitute a fundamental component of the province's mental health service delivery model, offering comprehensive and community-based care to individuals with SMI. The establishment of ACT

teams in Southwestern Ontario commenced in the 1990s, and their proliferation has since resulted in several operational teams across the region (Ontario ACT Association, 2018), underscoring their critical role in the continuum of mental health services and their sustained impact on community mental health outcomes. Ontario ACT standards require ACT teams to have expertise in managing SUD but many score low in their fidelity with this item of the standard (Randall, Wakefield, & Richards, 2012). Psychiatrists, nurses, social workers, and occupational therapists often comprise ACT teams, but few ACT teams include addiction specialists (Fries & Rosen, 2011). This lack of expertise makes it difficult for ACT teams to provide integrated treatment for SUD, resulting in fragmented care in which clients must seek addiction treatment from external services (Hubbeling, Alonso-Vicente, & Firn, 2017). Additionally, long wait times for addiction treatment and poor coordination between mental health and addiction services further complicate the care of peoples with CD (Macgabhann et al., 2004).

ACT teams exhibiting high fidelity through the incorporation of addiction treatment yield superior outcomes in SUD management relative to those with lower fidelity (McHugo, Drake, Teague, & Xie, 1999; L. Penzenstadler, C. Soares, E. Anci, A. Molodynski, & Y. Khazaal, 2019). An integrated treatment model, in which the same treatment team works on both substance use and addresses mental health problems simultaneously, are more effective than sequential or parallel treatment model (Mueser, Noordsy, Drake, & Fox, 2003). Despite this, implementation of integrated treatment models varies widely across jurisdictions, and many ACT teams struggle to fully integrate addiction treatment into their existing mental health frameworks (G. Bond, Drake, Mueser, & Latimer, 2001).

Despite the recognized importance of integrated care through ACT for peoples with CD, little is known about the challenges ACT clinicians face in integrating addiction treatment and managing SUD. Our study aims to explore these challenges in the identification, screening, assessment, and treatment of SUD, by interviewing ACT clinicians in Southwestern Ontario involved in treating clients with SMI. By capturing clinicians' perspectives, the study seeks to identify barriers and facilitators and provide recommendations for improving addiction treatment within the ACT framework. It also aims to fill a significant gap in the literature on the lack of qualitative research on the perspective of ACT clinicians, who play a vital role in providing care for peoples with CD.

Study Design

The study employed a qualitative research design to explore ACT clinicians' perspectives on managing SUD in peoples with SMI. Semi-structured interviews were conducted with clinicians from ACT teams in Southwestern Ontario.

Sample and Recruitment

A purposive sample of clinicians from two ACT teams in Southwestern Ontario was recruited for the study. Clinicians of ACT teams, who provide assessment and treatment of peoples with CD, such as psychiatrists, nurses, social workers, and occupational therapists were invited to participate. Inclusion criteria for participation in this study are clinicians to be ≥ 18 years of age, employed as a clinician on an ACT team in Southwestern Ontario, excluding the team where the investigator served as the most responsible clinician. Furthermore, participants were required to be able to read and verbally communicate in English, as well as provide informed consent for

participation in the study. Recruitment was conducted by sending emails and posters to ACT team coordinators, who then disseminated the study information to eligible clinicians. Interested clinicians contacted the research team

directly and initially met virtually with the investigator for 10 minutes to review the letter of information and consent (LOI/C) and make decision on participation. Eligible participants then received a LOI/C link via REDCap, a secure web application for building and managing online surveys and databases, through which they provided electronic informed consent.

Sample Size

Interpretative phenomenological qualitative analysis has no sample size guidelines, with saturation occurring when no new themes emerge from additional participants (Guest, Bunce, & Johnson, 2006). This study achieved thematic saturation after conducting five interviews.

Study Period

Data were collected from the participants between August and October 2023 as part of a master’s degree research project.

Data Collection

Data was collected by an investigator through semi-structured interviews, lasting 60 minutes via Microsoft Teams, a videoconferencing platform that enabled end-to-end encryption. The semi-structured interviews highlighted ACT clinicians’ professional experiences and focused on three topics: a) the role of the clinician and that of an ACT team in the management of clients with CD; b) the ACT team’s process and procedures for assessment and treatment of clients with CD; and the c) barriers and facilitators in assessing and treating SUD in ACT clients.

The topics for the interviews were deduced from the interview guide (Appendix B). The interview guide was adapted from Sharif et al. (2021) (Sharif, Karasavva, Thai, & Farrell, 2021) to better address the perspectives of

ACT clinicians on managing SUD through ACT. Modifications included changing the wording of questions to suit the study objective. The interviews were conducted, audio recorded, and transcribed utilizing the recording and transcription functions of Microsoft Teams. After all study components were completed, the participant was discharged with no follow-up.

Data Analysis

The data analysis was deductive and iterative using a thematic analysis approach (Strauss & Corbin, 1990).

Thematic analysis focuses on detecting patterns of themes or subjects in data that may be of relevance to the research. This study's thematic analysis follows the six steps of analysis established by Braun and Clarke (Braun & Clarke, 2006). The investigator evaluated all transcribed data after each interview and organized responses into sub- themes. Codes were created, altered, or eliminated by identifying parallels and differences in the transcribed interview materials and overarching themes were created from the identified sub-themes. Interviews were adjusted to reflect unexpected topics and collect interviewee viewpoints. After completion, a qualitative synthesis detailed the theme material. Selected quotations were used to accurately depict the participants' experiences.

Ethical Consideration

This study was approved by the Lawson Research Ethics Board (REB), Western University’s Health Sciences REB and the MSc Research Ethics Committee of the London School of Hygiene and Tropical Medicine (LSHTM).

A purposive sample of five ACT clinicians was recruited from the eligible ACT teams. They include one psychiatrist, two nurses, one social worker, and an occupational therapist. All are aged over 18 years. Apart from the psychiatrist, each ACT clinician had a case load of 15–16 clients and worked in a multidisciplinary team as a primary and secondary clinician in the mini teams of their respective ACT programs. The psychiatrist was responsible for their team's entire caseload of 75 clients. Table 1 illustrates the relationship between the five overarching themes and the 28 sub-themes identified during the thematic analytical process

Table 1

Summary of overarching themes and their relationship to subthemes
Assessing for substance use during intake and client sessions	Care planning and treatment of substance use disorder	Barriers	Facilitators
Involvement in intake depends on discipline and includes multidisciplinary assessments	Client’s care plan includes substance use	Systemic Factors
	Client’s care plan includes substance use	The original ACT model does not cater to the needs of the current client’s population	Need to adapt the ACT model to meet the needs of a new client population
Intake typically includes some assessment of substances use disorder	ACT staff recognize that substances can induce or exacerbate symptoms of mental disorders	Lack of timely access to community addiction services	Improved collaboration and coordination between ACT and community partners
Debate on accuracy of self-reports in assessing substance use	Effects of substances varies between peoples	Clinician Factors
	Effects of substances varies between peoples	Lack of skills and knowledge in assessing and treating substance use disorder amongst ACT clinicians	Additional training in assessing and treating substances use disorder
Stigmatization and fear of facing repercussions affect accuracy of self-reports	Absence of addiction specialist in teams to support care planning and treatment	Lack of expertise in providing specialized addiction treatment	Creating expertise by integrating treatment of SUD into the ACT model and incorporating specialized substance use specialist on ACT teams
Identifying substance use disorder can create bias and prejudice against clients	ACT team does not adequately provide treatment of substances use disorder	ACT clinicians find working with clients with complex mental health presentation challenging	Improved resources to support clinicians
Various degrees of comfort in assessing and discussing substance use with clients		Client Factors
		Chronicity of mental health symptoms and wanting to self-medicate affects their motivation for change	Use of psychoeducation and motivation interview skills by clinicians
Substance use frequently comes up in appointments with clients		Homelessness can create barriers in assessment and treatment	Providing safer supportive housing for people with mental illness

Theme One: ACT Team’s role regarding management of substance use disorders

Participants recognized that working with clients who use substances is a crucial aspect of an ACT team’s role, as many clients experience co-occurring Severe Mental Illness (SMI) and SUD. They highlighted that peoples with “schizophrenia and bipolar disorders would self-medicate with substances; the two conditions are part and parcels of one another.” Several participants also pointed out that the Ontario ACT standards mandate teams to provide comprehensive, integrated mental health and addiction services,” with one participant noting that the ACT model is intended to be a "one-stop shop for clients with serious mental illness who often use substances”. Despite this, participants acknowledged that ACT teams often struggle to address substance use effectively. One clinician explained that, within the ACT framework, substance use treatment “often involves facilitating formal assessments and connecting clients with substance use specialists, rather than providing direct treatment.” Harm reduction strategies align with the ACT model’s emphasis on individualized, community-based care for peoples with CD who are not motivated toward abstinence, as a participant emphasized that, "if a client has no intention of quitting, we focus on harm reduction—providing safe supplies and access to methadone or suboxone clinics."

Theme Two: Assessing for substance use during intake and client sessions

Referrals to ACT services are from inpatient, outpatient, and community healthcare providers. According to one participant, “the care coordinator reviews all incoming referrals to ensure they meet the admission criteria outlined in the Ontario ACT standards”. Following the initial screening, a clinician gathers background information through a review of the client’s historical records, as described by one participant who noted, "we conduct a chart review to look at clinically relevant notes that indicate diagnoses, comorbidities, and concurrent disorders." The stage of involvement of clinicians in the intake process varies. Psychiatrists, for instance, are involved early on, as they are "invited to conduct a first-time consultation, usually in the client’s home, to determine if they meet the criteria for the program." Once accepted, other team members, including social workers, nurses, and occupational therapists, conduct their discipline specific assessments. Substance use assessments are typically based on self-reports, as noted by a participant who stated, "there’s no formal substance use assessment; we rely on the client’s self-report and any information from the referral source." However, there was some debate about the accuracy of self-reports. One clinician suggested that clients tend to "underreport their use, especially in formal settings such as a medical appointment or a court proceeding," while in less formal settings “like a normal conversation in any context, they

are pretty reliable in giving accurate response”. One acknowledged that based on experience, "clients often underplay their substance use, even if they say they’re only using meth once a week, it’s probably more frequent."

Stigma and fear of legal repercussions contribute to inaccurate self-reports, as one participant explained, "many clients have experienced decades of stigma around drug use and fear being judged by healthcare providers or legal authorities." Another participant pointed out that clients may "avoid disclosing their use accurately due to fear of legal consequences for others involved in their substance supply."

Despite these challenges, participants recognized the importance of substance use assessments during intake, although one warned against letting substance use history "prejudice a patient’s acceptance into the ACT program on the basis of whether they have an addiction disorder, and the type of addiction problems they may have." Clinicians showed varying levels of comfort with assessing substance use. One participant felt confident asking about substance use informally but admitted, "I’m not as familiar with using standardized tools." Another expressed ease with both informal and formal assessments, stating, "I have no problem asking about substance use and using the Alcohol and Drug Use Scale as part of the ACT protocol." Regardless of their comfort level in conducting assessments, all participants acknowledged that substance use often comes up in client sessions. "It regularly comes up when we meet new clients, and we discuss what areas they need assistance with," one clinician explained.

Another participant emphasized that discussing substance use can strengthen the therapeutic relationship, suggesting that "raising these topics only enhances the potential for a stronger therapeutic alliance."

Theme Three: Care planning and treatment of substance use disorder

Participants explained that care planning in ACT is collaborative, with treatment goals developed and modified based on client feedback. When SUD management is identified as a goal, it is incorporated into the care plan. One clinician noted, "in our team, we use the OCAN¹ assessment tool, which includes questions on substance use, and we integrate addiction services into the treatment plan if needed." The need for a care plan directed at substance use management is on the premise that it impacts various aspects of clients’ lives, including mental health, relationships, housing, and legal involvement. "Substance use affects everything—mental health, family relationships, housing,

¹ Ontario Common Assessment of Need (OCAN) is a standardized, consumer-led decision-making tool that allows key information to be electronically gathered in a secure and efficient manner. It includes sections of self-assessment of alcohol drugs and other addictions. Ontario Common Assessment of Needs available at

https://iar.thinkingcap.com/OCANForms . Published 2021. Accessed September 19, 2023.

and often their involvement with the criminal justice system," one participant observed. Participants also discussed the complex relationship between substance use and mental health symptoms, noting that substance use can "significantly alter a client’s mental health symptoms, especially with substances like crystal meth, where we see big day-to-day changes depending on their use." They also acknowledged that the effects of substance use can manifest differently in each peoples, as one clinician explained, "substance use can present as psychiatric symptoms with varying levels of severity depending on the peoples." Despite recognizing the importance of addressing SUD, participants noted that their teams lack the necessary addiction expertise. One participant explained, "none of our ACT teams have an addiction specialist, though there’s talk of creating that role." Participants agreed that having a dedicated specialist would significantly benefit clients, with one stating, "having someone with addiction expertise would help keep clients motivated and engaged in their substance use treatment."

Theme Four: Barriers to assessment and treatment

Systemic Factors

Participants noted that the ACT model was originally designed to address deinstitutionalization, focusing on treating SMI. Over time, ACT has evolved to serve clients with co-occurring disorders, but the teams have not received the necessary resources to match this shift. "The ACT model was created for mental illness, but now we’re seeing more clients with substance use issues, without the resources to support them," one clinician explained. Additionally, long wait times for external addiction services were cited as a significant barrier, with participants expressing frustration that clients often lose motivation while waiting for treatment. "Long wait times mean we miss crucial opportunities to help clients when they’re ready for treatment," a participant stated.

Clinician Factors

Many participants felt that ACT clinicians lacked the knowledge and confidence to address SUD effectively. One participant noted, "the biggest barrier is the lack of knowledge about assessing and treating substance use." However, another clinician argued that many ACT staff have the necessary skills but lack confidence in applying them, explaining, "many of us have training in motivational interviewing and cognitive behavioral therapy, but we don’t always remember that we have these skills."

Client Factors

Participants also highlighted that clients often use substances to self-medicate for chronic mental health symptoms, making it difficult to engage them in treatment. "Clients don’t see substance use as a problem because it’s how they manage their mental illness," one clinician observed. Homelessness was also identified as a barrier to engagement, with one participant noting, "the transient lifestyle of homeless clients makes it hard to engage them in treatment consistently."

Theme Five: Facilitators of assessment and treatment

Systemic Factors

Participants called for a paradigm shift in how ACT teams address SUD, emphasizing that addiction treatment should be fully integrated into the ACT model. One clinician suggested, "substance use treatment should be incorporated into ACT because it would benefit so many clients in different ways." An integrated treatment model can also address the issue of long wait times for external services, as participants proposed training ACT clinicians to conduct initial assessments for addiction services, thereby reducing delays. "If ACT clinicians could do the initial intake for addiction services, it would reduce wait times and get clients into treatment faster," one participant proposed.

Clinician Factors

The organization’s recent efforts to offer training in motivational interviewing is a positive step toward addressing the gap in addiction expertise. However, one clinician suggested that the training needs to be adapted for the specific needs of ACT clients, stating, "the interviews in the training seem designed for clients with higher levels of insight than our population." All participants agreed that adding a substance use specialist to the ACT teams would improve the quality of care, with one participant explaining, "having an addiction specialist would make a huge difference, especially for clients who can’t easily access community services." This highlights the importance of adapting evidence-based practices to the unique context of ACT teams.

Client Factors

Clinicians emphasized that providing access to safe, supportive housing would help reduce clients’ exposure to substances and support their recovery. "Helping clients move into supportive housing can drastically reduce their exposure to substances and help them start their recovery," one participant explained.

The primary objective of this study was to address a gap in the empirical literature by exploring the perspectives of key stakeholders and mental health care providers working with peoples with SMI regarding the assessment and treatment of SUD. Specifically, this is the first study to directly engage ACT team clinicians, documenting their unique insights into how they approach clients with CD. Through qualitative analysis, five major themes emerged: the role and scope of ACT teams in managing SUD, assessing substance use during intake and client sessions, care

planning and treatment of SUD, and the systemic, clinician, and client factors that serve as barriers and facilitators to providing integrated care within the ACT model.

The findings underscore that ACT teams play a central role in managing clients with co-occurring SMI and SUD, with participants emphasizing the interconnectedness of substance use and mental health symptoms. Clients often self-medicate for their mental disorder with substances, highlighting the inseparability of these two conditions (R. E. Drake, K. T. Mueser, R. E. Clark, & M. A. Wallach, 1996). The ACT model’s mandate to provide integrated care was seen as a "one-stop shop" for clients, aligning with the principles of holistic, client-centered and integrated

treatment model (G. Bond et al., 2001). However, the study also identified a significant gap in ACT teams' capacity to create expertise in the management of SUD. While participants noted that their goal is to provide comprehensive care, they often rely on external specialists for addiction services. This reliance reflects a limitation in the internal

capacity of ACT teams, despite the integral relationship between SUD and SMI. Nonetheless, harm reduction strategies, such as providing safe supplies and referrals to methadone or suboxone clinics, were adopted to meet clients’ immediate needs. These pragmatic approaches demonstrate ACT teams' flexibility, but there remains an opportunity to enhance the delivery of direct interventions for SUD within the ACT framework (Fries & Rosen, 2011).

In terms of substance use assessment, participants described a process that begins with a comprehensive review of client histories and involves a multidisciplinary team. However, self-reported data—often influenced by stigma, fear of legal repercussions, or the context of the assessment—plays a key role in evaluating substance use (Connors &

Maisto, 2003). This reliance on self-reports presents challenges to obtaining accurate data, underscoring the need for standardized tools within ACT teams. Some clinicians expressed confidence in conducting formal assessments,

while others acknowledged unfamiliarity with formal assessment tools. This discrepancy highlights a gap in training

and underscores the importance of equipping ACT teams with systematic, evidence-based tools for substance use evaluation. Standardizing these assessments could improve the accuracy of the data collected, leading to better- informed treatment strategies and more effective care planning (Torrens, Gilchrist, & Domingo-Salvany, 2011). The collaborative nature of care planning in ACT was emphasized, with participants recognizing the profound impact that SUD has on clients’ mental health, relationships, housing stability, and legal involvement (Mueser et al., 2003).

Despite this clear need for ACT to have expertise in SUD management, the study identified a lack of addiction specialists within ACT teams as a major barrier to effective care. There is need for the creation of an addiction specialist role, consistent with literature that suggests integrated treatment models are most effective when

specialists in both mental health and addiction are included (R. E. Drake et al., 1996). The introduction of such a

role would enable ACT teams to offer more tailored, continuous support for clients with co-occurring SUD and SMI, ensuring that substance use is addressed as a core component of treatment.

The study highlighted that the original ACT model was developed to meet the needs of clients with SMI during deinstitutionalization, with an emphasis on mental health care. Over time, the client population has evolved to include more peoples with co-occurring SUD, but the ACT model has not been fully adapted to meet these new demands (Hubbeling et al., 2017). The lack of resources, particularly for addiction treatment, is compounded by long wait times for external services. Participants expressed frustration that clients often lose motivation while waiting for treatment, leading to missed opportunities for intervention. These findings indicate a pressing need for

systemic reforms aimed at reducing wait times for addiction services, thereby enabling ACT teams to engage clients when they are most receptive to treatment (Hoffman et al., 2011).

Many participants reported feeling ill-equipped to manage SUD due to a lack of training and confidence. While some clinicians had received training in techniques like motivational interviewing, they were uncertain about applying these skills effectively within the context of CD. This gap in training underscores the need for ongoing, specialized training that focuses on integrating SUD treatment into ACT services (Torrens et al., 2011). Providing ACT clinicians with regular, advanced training would better equip them to manage the complex needs of clients with co-occurring SUD and SMI. Addiction treatment should be fully integrated into the ACT model. Training ACT clinicians to conduct initial assessments for addiction services would be a practical solution to reduce wait times in

external addiction services and facilitate timely care. This would also allow ACT teams to play a more proactive role

in addressing SUD within the framework of their existing services, rather than relying solely on external providers (Robert E. Drake et al., 1996). The organization’s effort to offer training in motivational interviewing was

acknowledged as a positive step, but participants emphasized that such training should be tailored to the specific

needs of ACT clients, who may have lower levels of insight than other populations. This aligns with the importance of adapting evidence-based practices to the unique challenges faced by ACT teams (Torrens et al., 2011). There is a need for inclusion of a dedicated addiction specialist on ACT teams. Having a specialist on staff would enhance the team’s ability to offer integrated care and improve client outcomes by ensuring that substance use is treated as a core component of mental health care (Mueser et al., 2003).

Despite the considerable research and work in bringing awareness of cooccurrence of substance use and mental disorders, stigma surrounding substance use further complicates treatment engagement, as clients may not view their substance use as problematic or may fear judgment. Homelessness and the transient nature of some clients’ lifestyles further exacerbate these barriers, making sustained engagement in treatment difficult. These findings support the

need for flexible, client-centered approaches that address both the root causes of substance use and the broader

social determinants of health (Mueser et al., 2003). The importance of providing access to safe, supportive housing is a key facilitator of substance use treatment. Stable housing reduces clients' exposure to high-risk environments and creates the conditions necessary for recovery. This finding aligns with the principles of the Housing First model, which has been shown to improve outcomes for peoples with CD by addressing the social determinants of health (Aubry et al., 2016; Kirst, Zerger, Misir, Hwang, & Stergiopoulos, 2015; Loubière et al., 2022; Tsemberis, Kent, & Respress, 2012).

To overcome the barriers identified in this study, policymakers must take a comprehensive approach to reforming how ACT teams are funded, staffed, and supported in treating co-occurring SUD and SMI. By increasing funding for integrated care, incorporating addiction specialists, enhancing training for clinicians, expanding supportive housing initiatives, and streamlining access to addiction services, ACT teams can become more effective in managing SUD and supporting the recovery of clients with complex needs. These reforms will not only improve people’s outcomes but also contribute to a more efficient and responsive mental health care system.

Limitations of Study

While this study provides valuable insights into the role of ACT teams in managing SUD among peoples with SMI, several limitations must be acknowledged. The study used a cross-sectional approach, capturing the perspectives of clinicians at a single point in time. This limits the ability to observe changes over time, such as the impact of new training initiatives or changes in policies affecting ACT teams. Longitudinal studies would be better suited to

examine the evolving challenges and successes of ACT teams in managing SUD. Although the sample provided rich, qualitative data, the perspectives of a larger and more diverse group of clinicians could have yielded other insights. Future studies with larger sample sizes could provide more comprehensive data. The study was also conducted within ACT teams in Southwestern Ontario, which may not reflect the experiences of ACT teams in other regions, provinces or countries. Differences in healthcare policies, available resources, and regional standards for mental health and addiction care may influence how ACT teams manage SUD. As such, the findings may not be generalizable to other ACT teams.

The study employed a qualitative design, relying on the self-reported experiences and perspectives of ACT clinicians. While qualitative research is inherently subjective, its strength lies in exploring the depth and meaning of participants' experiences, which this study successfully achieved. However, future research could benefit from incorporating a quantitative approach to produce more standardized and generalizable results.

While the study focused on the views of ACT clinicians, it did not include the perspectives of other key stakeholders, such as clients, caregivers, or addiction specialists. The inclusion of these perspectives could have provided a more in depth understanding of the challenges and facilitators in managing SUD within the ACT

framework. Although clinicians provided insights into the impact of their practices on clients, the study does not include empirical data on client outcomes, such as treatment adherence, relapse rates, or recovery trajectories. Future research could examine the direct effects of integrated treatment models on clients with co-occurring SUD and SMI.

This study contributes to existing literature by providing a detailed examination of ACT clinicians’ perspectives on managing co-occurring SUD and SMI. Despite the strengths of the ACT model, significant challenges remain, particularly regarding access to addiction services and the lack of internal expertise in SUD treatment. The lack of addiction expertise and inconsistent assessment practices were identified as major barriers, while the inclusion of addiction specialists and increased training were seen as key facilitators. Addressing these challenges through policy

changes and enhanced collaboration between mental health and addiction services will be critical to improving care for peoples with CD. The limitations of the study highlights the need for further research to expand on the findings of this study. Addressing these limitations in future research could provide a more comprehensive understanding of how ACT teams can be optimized to better manage SUD in peoples with SMI. Despite these limitations, the study contributes valuable insights into the barriers and facilitators of integrated care within ACT teams. Further research is needed to explore the perspectives of clients and other stakeholders, as well as to evaluate the long-term outcomes of integrated treatment model for peoples with co-occurring SUD and SMI.

The authors declare that they have no conflict of interest and did not receive support from any organization for the submitted work.

Abufarsakh B, Kappi A, Pemberton KM, Williams LB, Okoli CTC (2023) Substance use outcomes among individuals with severe mental illnesses receiving assertive community treatment: A systematic review. Int J Mental Health Nurs 32:704–726. https://doi.org/10.1111/inm.13103
Aubry T, Bourque J, Goering P, Crouse S, Veldhuizen S, LeBlanc S, Bradshaw C (2019) A randomized controlled trial of the effectiveness of Housing First in a small Canadian City. BMC Public Health 19(1):1154. 10.1186/s12889-019-7492-8
Aubry T, Goering P, Veldhuizen S, Adair CE, Bourque J, Distasio J et al (2016) A Multiple-City RCT of Housing First With Assertive Community Treatment for Homeless Canadians With Serious Mental Illness. Psychiatric Serv (Washington D C) 67(3):275–281. 10.1176/appi.ps.201400587
Bond G, Drake R, Mueser K, Latimer E (2001) Assertive Community Treatment for People with Severe Mental Illness. Disease Manage Health Outcomes 9:141–159. 10.2165/00115677-200109030-00003
Bond GR, Drake RE (2015) The critical ingredients of assertive community treatment. World Psychiatry 14(2):240–242. 10.1002/wps.20234
Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative Res Psychol 3(2):77–101. 10.1191/1478088706qp063oa
Connors GJ, Maisto SA (2003) Drinking reports from collateral individuals. Addiction 98(Suppl 2):21–29
Drake RE, Mueser KT, Clark RE, Wallach MA (1996) The course, treatment, and outcome of substance disorder in persons with severe mental illness. Am J Orthopsychiatry 66(1):42–51
Drake RE, Mueser KT, Clark RE, Wallach MA (1996) The course, treatment, and outcome of substance disorder in persons with severe mental illness. Am J Orthopsychiatry 66(1):42–51. 10.1037/h0080153
Essock SM, Mueser KT, Drake RE, Covell NH, McHugo GJ, Frisman LK,. Swain K (2006) Comparison of ACT and standard case management for delivering integrated treatment for co-occurring disorders. Psychiatric Serv (Washington D C) 57(2):185–196. 10.1176/appi.ps.57.2.185
Fries HP, Rosen MI (2011) The efficacy of assertive community treatment to treat substance use. J Am Psychiatr Nurses Assoc 17(1):45–50. 10.1177/1078390310393509
Guest G, Bunce AE, Johnson L (2006) How Many Interviews Are Enough? Field Methods, 18, 59–82. Hoffman, K. A., Quanbeck, A. R., Ford, J. H., Wrede, F., Wright, D., Lambert-Wacey, D.,.. . McCarty, D. (2011)
Improving substance abuse data systems to measure ‘waiting time to treatment’: Lessons learned from a quality improvement initiative. Health Inf J, 17, 256–265
Hubbeling D, Alonso-Vicente M, Firn M (2017) Flexible Assertive Community Treatment. Psychiatric Serv 68 9:983
Hunt GE, Large M, Cleary M, Lai HMX, Saunders JB (2018) Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990–2017: Systematic review and meta-analysis. Drug Alcohol Depend 191:234–258
Kessler RC (2004) The epidemiology of dual diagnosis. Biol Psychiatry 56(10):730–737. 10.1016/j.biopsych.2004.06.034
Kirst M, Zerger S, Misir V, Hwang SW, Stergiopoulos V (2015) The impact of a Housing First randomized controlled trial on substance use problems among homeless individuals with mental illness. Drug Alcohol Depend 146:24–29
Loubière S, Lemoine C, Boucekine M, Boyer L, Girard V, Tinland A, Auquier P (2022) Housing First for homeless people with severe mental illness: extended 4-year follow-up and analysis of recovery and housing stability from the randomized Un Chez Soi d'Abord trial. Epidemiol psychiatric Sci 31:e14. 10.1017/S2045796022000026
Macgabhann L, Scheele A, Dunne T, Gallagher P, MacNeela P, Moore G, Philbin M (2004) Mental health and addiction services and the management of dual diagnosis in Ireland
McHugo GJ, Drake RE, Teague GB, Xie H (1999) Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study. Psychiatric Serv (Washington D C) 50(6):818–824. 10.1176/ps.50.6.818
Morse GA, Calsyn RJ, Klinkenberg D, Helminiak W, Wolff TW, Drake N, McCudden RE, S (2006) Treating homeless clients with severe mental illness and substance use disorders: costs and outcomes. Commun Ment Health J 42(4):377–404. 10.1007/s10597-006-9050-y
Mueser KT, Noordsy DL, Drake RE, Fox L (2003) Integrated treatment for dual disorders: A guide to effective practice. The Guilford Press, New York, NY, US
O'Campo P, Stergiopoulos V, Nir P, Levy M, Misir V, Chum A, Hwang SW (2016) How did a Housing First intervention improve health and social outcomes among homeless adults with mental illness in Toronto? Two-year outcomes from a randomised trial. BMJ Open, 6(9), e010581. 10.1136/bmjopen- 2015–010581
Ontario AA (2018) ACT Fast Facts. Retrieved from https://ontarioactassociation.com/fast-facts/
Ontario AA (2024) ACT Program Standards - Version 4.1. Retrieved from https://ontarioactassociation.com/wp-content/uploads/2024 /03/OAAF-Ontario-ACT-Standards-Version-4.1-March-8-2024-1.pdf
Osher FC (2006) IntegratIng Mental HealtH and SubStance abuSe ServIceS for JuStIce-Involved PerSonS wItH co-occurrIng dISorderS
Penzenstadler L, Soares C, Anci E, Molodynski A, Khazaal Y (2019) Effect of Assertive Community Treatment for Patients with Substance Use Disorder A Systematic Review. Eur Addict Res, 25, 56–67
Penzenstadler L, Soares C, Anci E, Molodynski A, Khazaal Y (2019) Effect of Assertive Community Treatment for Patients with Substance Use Disorder A Systematic Review. Eur Addict Res, 25(2), 56–67. 10.1159/000496742
de Pérez XY, Amodei N, Hoffman TJ, Martinez R, Treviño M, Medina D (2011) Real World Implementation of an Adapted ACT Model with Minority and Non-minority Homeless Men. Int J mental health Addict 9(6):591–605. 10.1007/s11469-010-9287-0
Peterson AL (2013) Integrating Mental Health and Addictions Services to Improve Client Outcomes. Issues Ment Health Nurs 34:752–756
Randall GE, Wakefield PA, Richards DA (2012) Fidelity to Assertive Community Treatment Program Standards: A Regional Survey of Adherence to Standards. Commun Ment Health J 48(2):138–149. http://dx.doi.org/10.1007/s10597-010-9353-x
Sharif N, Karasavva V, Thai H, Farrell S (2021) We're Working in a Trauma Avoidant Culture: A Qualitative Study Exploring Assertive Community Treatment Providers' Perspectives on Working with Trauma and PTSD in People with Severe Mental Illness. Community Ment Health J 57(8):1478–1488. 10.1007/s10597-020-00764-8
Stein LI, Test MA (1980) Alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical evaluation. Arch Gen Psychiatry 37(4):392–397. 10.1001/archpsyc.1980.01780170034003
Sterling SA, Chi FW, Hinman A (2011) Integrating Care for People With Co-Occurring Alcohol and Other Drug, Medical, and Mental Health Conditions. Alcohol Res Health 33:338–349
Strauss A, Corbin JM (1990) Basics of qualitative research: Grounded theory procedures and techniques Thousand Oaks CA US: Sage Publications, Inc.
Torrens M, Gilchrist G, Domingo-Salvany A (2011) Psychiatric comorbidity in illicit drug users: substance- induced versus independent disorders. Drug Alcohol Depend 113(2–3):147–156. 10.1016/j.drugalcdep.2010.07.013
Tsemberis SJ, Kent DD, Respress C (2012) Housing stability and recovery among chronically homeless persons with co-occurring disorders in Washington, DC. Am J Public Health 102(1):13–16

The authors declare no competing interests.

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“One-Stop Shop for Clients with Serious Mental Illness Who Often Use Substances”: A Qualitative Study on Assertive Community Treatment Clinicians’ Perspectives on Managing Substance Use Disorder

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Version 1

Abstract

Background

Method

Study Design

Sample and Recruitment

Sample Size

Study Period

Data Collection

Ethical Consideration

Results

Theme One: ACT Team’s role regarding management of substance use disorders

Theme Two: Assessing for substance use during intake and client sessions

Theme Three: Care planning and treatment of substance use disorder

Theme Four: Barriers to assessment and treatment

Systemic Factors

Clinician Factors

Client Factors

Theme Five: Facilitators of assessment and treatment

Systemic Factors

Clinician Factors

Client Factors

Discussion

Limitations of Study

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1