The Mentally Ill Chemical Abusers
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The Mentally Ill Chemical Abusers (MICA) patients are those individuals who abuse drugs because of their mental ill health (Reid & Silver, 2003). Those individuals who exhibit severe mental illness suffer from medical disorders and other psychiatric problems presents a variety of social, individual, political, and financial challenges both for program funding and the planning and implementation of effective reconstructive treatment programs (Reid & Silver, 2003). In addition to severe mental illness, the MICA patients may suffer from severe behavioral, personality, addictive, physical, or cognitive disease, which will require a treatment program to be extremely effective in treating the patients. The wide range of diseases that affect MICA patients has called for the development of a great deal of treatment models to cater for the multiple needs of the patients (Reid & Silver, 2003). There is need for evaluating the clinical effectiveness of the treatment models so that to avoid wastage of the limited treatment resources and to improve the clinical treatment strategies for those patients who undergo positive dual diagnosis (Reid & Silver, 2003).
This study looks into the clinical impact of various program models on the mentally ill chemical abusers. Researchers select specific study variables and outcome indicators to demonstrate the effectiveness of each model in meeting the therapeutic goals for patients, and to reject outcomes that result from the differences between the treatment programs, such as number of delivered services, level of MICA patient participation, and population differences. These indicators facilitate comparisons of the outcome efficaciousness between treatment programs. As such, the indicators directly relate to the stated goals of the programs under study. Since the staffing pattern, location, goals, and outplacement resources of the treatment programs are identical, and the patient population possessing similar characteristics, the results of the study should illustrate the impact of the integrated and disease specific program models as the best approaches in treating MICA patients.
Different treatment models may not be equally effective in the treatment of the MICA patients. Therefore, the program evaluation outcomes would be useful to administrators, program developers, policy planners, and legislators who must design and put into practice the most effective treatment program that will rely on the limited resources (Kloss, & Lisman, 2003). In addition to determining the most effective treatment and programmatic approach, this information can also be useful in improving the quality of care for MICA patients with severe problems. The programs for treating the dually diagnosed MICA patients primarily belong to two categories, namely, integrated program model and disease specific program model (Kloss, & Lisman, 2003). A disease specific program focuses treatment on distress as the primary area and minimizes the urgency or importance of other areas of MICA patient dysfunction. A great deal of hospital based mental health programs and substance abuse and addiction treatment programs model treatment programs model their treatment in this manner (Lessa & Scanlon, 2006). Research by Lessa & Scanlon (2006) shows that An integrated program model is common in both community based settings and hospitals, and its main purpose is to provide individualized treatment that can cater for all areas of dysfunction in a single program.
Governments base the development of the program models more on political interests in the treatment of specific MICA patient populations and availability of funding, and to some extent on clinical efficacy (Lessa & Scanlon, 2006). There has been perpetuation of the program models fragmentation through the development of arbitrary and artificial administrative divisions at the local, state, and federal levels without considering the clinical measures of the effectiveness for various treatment program models (Reid & Silver, 2003). Therefore, it is possible that most of the grant financed and public sector programs continue to benefit financially through various funding streams without provable clinical success. This leads to the siphoning of critical finances from those treatment programs that employ more clinically feasible models.
Programs that embrace a self-medication philosophy consider chemical dependency to occur either as a coping mechanism for primary psychopathology or as symptoms of mental illness (Reid & Silver, 2003). They view patients as those individuals who use chemicals for the purposes of alleviating the symptoms of mental disorders such as anxiety and depression. The treatment goals for these programs put more emphasis on improvements in mental functioning (Lessa & Scanlon, 2006). Clinicians expect the mentally ill individuals and chemical abusers to change to psychologically healthy. The integrated and disease specific treatment programs possess a major advantage of diagnosing psychiatric problems and offering treatment along with the symptoms of substance abuse. However, this is the main disadvantage of the models as well. Making assumptions that mental illnesses cause chemical abuse contradicts the possibility that can cause the psychopathology (Reid & Silver, 2003). Because the focus of treatment is on the outcome of the primary mental illness, problems of chemical abuse that may be actual clinical etiology may not undergo treatment. Lessa & Scanlon (2006) have confirmed that social deficit philosophies of treatment consider mental illness and chemical addiction as due to cultural, environmental, family or peer influences. Most people view the mentally ill individuals and drug abusers as the products of drug availability, poverty, family dysfunction, and peer pressure.
Lessa & Scanlon (2006) suggest that the objective of treatment in the integrated and disease specific treatment programs is to improve the social functioning of MICA patients by altering their environment or coping reactions to perceived stressors. Interventions may involve residential treatment, attending self-help groups, interpersonal therapy, and group therapy, whose goal is to improve social skills of the MICA patients (Lessa & Scanlon, 2006). According to Lessa & Scanlon (2006), the main disadvantage of embracing a social deficit philosophy for treating the MICA patients lies in the sole treatment of social factors for the multi-factored problems. This again means the need for acceptance of additional treatment schemes that depends on the competing philosophies. By accepting any of the primary assumptions alone, and depending solely on a single philosophic stance, practitioners and researchers perpetuate the state of affairs by staying uncritical regarding the problems underlying their models. Consequently, this process has produced service roadblocks that have excluded or discouraged a great deal of dually diagnosed MICA patients from getting admission to, seeking, or successfully finishing appropriate treatment programs (Lessa & Scanlon, 2006). Instead of producing additional philosophic and subpopulation barriers, the vital question for both researchers and MICA treatment providers should be how the clinicians can best match patients in the course of their treatment to various models and programs so that to maximize outcomes in multivariate and bio-psychosocial treatment programs (Kloss, & Lisman, 2003).
The dually diagnosed MICA patients possess complex interactive symptomatology and treatment needs that call for more integrated approaches than are generally employed (Reid & Silver, 2003). Therefore, it is more likely that the integrated treatment program would be more effective in the treatment of dually diagnosed MICA patients as compared to a disease specific program. However, because substance abuse and addiction present severe therapeutic challenges, a more restrictive substance abuse model may offer increased efficaciousness for the MICA patients (Reid & Silver, 2003). Evaluation of the treatment outcomes that various program models produce, treatment of the MICA patient population, should show the relative cost efficiency and clinical effectiveness of each treatment program model. Within the integrated treatment model, each system of care must include elements that meet the needs of MICA patients in every phase of rehabilitation and recovery (Lessa & Scanlon, 2006). In addition, treatment programs must address levels of disability and severity with each rehabilitation phase. For instance, treatment programs must provide the services of acute detoxification for both non-psychotic and psychotic patients; provide group and individual therapy services for alleviating various levels of dysfunction in both mental illness and substance abuse; and deliver services for stabilizing psychosis, whether the MICA patient is under active substance withdrawal or not (Lessa & Scanlon, 2006). Therefore, the integrated treatment program must contain a variety of types and sufficient numbers of clinicians to ensure that there is customized and comprehensive treatment inherent in the program.
An integrated treatment program for MICA patients involves more comprehensive treatment strategies and philosophies than the disease specific treatment programs (Lessa & Scanlon, 2006). Integrated approaches enable clinicians to use the most appropriate type and level of treatment technologies in the rehabilitation of MICA patients at their level of need. Therefore, through customization, integrative treatment program will meet both the addiction needs and mental health of the patient (Lessa & Scanlon, 2006). The disease specific treatment program is naturally more generic, requiring MICA patients to meet its expectations, as opposed to the program meeting the patients’ needs. A number of substance abuse programs emphasize individual and group counseling in a restrictive, substance free, and highly structured environment (Kloss, & Lisman, 2003). Both integrative and disease specific treatment models impose abstinence from all types of substances, which includes psychotropic medication. In mental health, disease specific treatment program concentrates on functional rehabilitation and adaptation in less restrictive surroundings, but minimize the consequences of addiction (Kloss, & Lisman, 2003). There is an assumption that the two treatment programs will facilitate the motivation of MICA patients to participate in treatments with an aim of alleviating their distress. Those patients who fail to meet the expectations of the programs are treatment refractory or treatment resistant, they should seek help in other programs, or the clinicians should discharge them from the treatment programs (Lessa & Scanlon, 2006).
According to Lessa & Scanlon (2006), clinicians encounter a number challenges from the clinical presentation of the MICA patients. The concurrent expression of symptoms from both mental illness and chemical abuse and addiction makes conceptualization, diagnosis, and treatment decision-making problematic, and in most cases leads to poor treatment reaction and outcome. Research has shown that when MICA patients go to agencies that offer treatment to patients with addictions, responsible personnel is likely to view the patients within disease model, because the perspective predominates among the institutions and providers of alcoholism treatment in the United States (Kloss, & Lisman, 2003). Conversely, individuals with psychoses receive treatment in mental health settings, and this is where the focus is pharmacological and medical. The adherence of clinicians to either of the one-dimensional frameworks may possibly be counter therapeutic for treating MICA patients. Enrolling the MICA patients in two different agencies may give desirable results.
The goal of this study is to identify the most appropriate treatment programs for mentally ill chemical abusers. However, the literature review shows that the integrated and disease specific treatment programs are the best for treating the MICA patients. It is easier to develop possible research questions after reading through the literature review.
The researcher will used purposive sampling method by administering questionnaires as quantitative research instruments to clinicians. The questionnaires ensure that information such as names from the clinicians is confidential. The investigation will look into patient outcomes for the integrated and disease specific treatment program models at Bellevue Hospital Center, which deal with the treatment of homeless, male MICA patients. The researcher will compare the clinical outcomes in the integrated MICA mental health program with the outcomes in the disease specific substance abuse and addiction treatment program. The goals of the two residential treatment programs are to rehabilitate MICA patients for a six-month period and to place the recovering patients in community based housing. The researcher will perform comparisons of MICA patient outcomes for efficaciousness indicators to determine the relative value of the integrated and disease specific treatment models in the treatment of MICA patients.
There are limited questions to help the participating clinicians stay accurate and focused in the answers they provide. The questionnaire is only asking those questions that will try to evaluate the experiences of clinicians who treat mental illness and substance abuse problems. The researcher will administer a questionnaire on one specific issue to ensure that the results and findings are extremely accurate. The questionnaire contains 17 questions, which considers the outcomes of patients in the two programs across seven indicators, namely successful community placement, cost efficiency, service hours, recidivism, subpopulation outcomes, treatment failures, and patient satisfaction.
The researcher will hand the questionnaires to the clinicians on the same day and ensure that the participants complete them at the same time in order to reduce the possibility of biasness in the answers they provide. It is necessary for the researcher to gain approval of a clinical director before administering the questionnaires. This will ensure that all clinicians in Bellevue Hospital Center will participate in completing the questionnaires. It will also allow the clinicians to provide accurate and clear answers, which will ready to a successful study.
The questionnaire should possess content validity, external validity, and internal validity. A researcher can achieve face validity of the questionnaire through careful inspection and determination of its viability. The researcher ensures that the questionnaire possesses content validity by checking whether it has questions that address possible interventions that Bellevue Hospital Center offers. The use of questionnaire will lead to external validity threats to this study, especially when the researcher involves few participants. The researcher will administer the questionnaires to a few clinicians who serve community, which will result in lack of the ability to relate outcomes to other communities. When the participants are aware that the questionnaire is for the purposes of a school assignment, they may fail to take it serious and provide less accurate responses.
The use questionnaires experience many validity threats, which require a researcher to be very careful before and after handing them out. When a researcher has ensured that questionnaires possess both internal and external validity, the outcomes of the study will be reliable. However, it is important to keep in mind that a valid measure is not necessarily a reliable measure. Therefore, even if this study may suffer from threats of validity such as small population and lack of randomized assignment of questionnaires, researcher’s goal is to ensure reliable study outcomes. Reliability testing such as a test and re-test technique is necessary because it will enable a researcher to achieve more accurate results from the study. A researcher can achieve this by administering the questionnaires to the same groups of participants at two or more different times to show whether he will get the same outcomes. Another test for reliability includes the rearrangement of the order of questions on the questionnaire and administration to the same group of participants. This would be the best way of assuring reliability but it would be impossible because of time and resource limitations. However, in spite of the threats, the researcher can collect meaningful information for analysis. The findings of the study can be show the effectiveness of integrated and disease specific treatment program models in treating the mentally ill and substance abusers, and in collecting information subsequent research in the future. The researcher can then be able to create a valid measure for further improvements in the condition of MICA patients.
The investigation will include the male, MICA patients who entered the integrated and disease specific treatment programs after 11/21/2009 and who left by 7/21/2011. Both programs will use similar admission measures homelessness as well as a major Axis I diagnosis and a substance abuse and addiction diagnosis. The patient referrals to the two programs will come from the same New York City homeless shelter programs and Bellevue inpatient psychiatric units. Therefore, the patient population for the programs under study is likely to be indistinguishable for the purpose of the study. The researcher will confirm this through the analysis of variance and by comparing the demographic features between the groups using the dimensions of substance abuse severity, diagnosis, prison history, age, number of hospitalizations in the past, medication, suicide history. Since the researcher determines the subject pool to be equivalent, he will compare the success of treatment program and determine a comparative rate across indicators.
In this study’s context, a Global Assessment Functioning (GAF) level of about 80 is necessary for successful rehabilitation and graduation of MICA patients. The researcher will record the functional level on the functional assessment forms of New York City Department of Mental Health. The addiction severity index as a survey instrument is a suitable research instrument in recording the type of abused substance, duration of substance abuse, work history, and prison. The clinical case managers will determine the functional level during graduation and the extent of addiction severity within the two programs. Clinical case managers from the afflicted case management programs will subsequently confirm the levels and scores. The MICA patients will complete a self-report questionnaire as the suitable instrument for collecting quantitative data. The case managers are responsible for patient follow-up of the MICA patients who will have recovered, graduated, and found a place in the community based housing. The clinical case managers, who put down the outcomes on the New York State Office of Mental Form 143a, Part 1 and 2, will perform a three-month post graduation outcome information on MICA patients in the community based housing. This data acts as the basis for recidivism and post graduation placement data.
The selection of Subjects
The study will include about 300 male patients, 200 from the MICA TLC and 100 from the TLC. The researcher will base the selection of the patients for the two programs on their meeting the criteria of both diagnosis and homeless admission. For instance, when the patients are homeless for more than three months, possess major depression and substance abuse and addiction, and are ambulatory and never require an acute care. The researcher will not impose other conditions for admissions. The study will include only the MICA patients, even if the TLC program admits patients without substance abuse diagnosis. However, the study included all admitted MICA TLC patients. In either program, the MICA patients will be included.
Calculations, analysis, interpretation, and presentation of the data will take place after data collection. Statistical Package for the Social Sciences will be a necessary program during the analysis and calculations.
This study investigates the relative impact of an integrated program model and disease specific program model on the treatment results for MICA patients. The goal of the research is to determine the effectiveness of the two treatment programs. The outcome results for the patients will demonstrate the difference between the two programs and the therapeutic models. The therapeutic failure and success rates, patient-satisfaction survey results, the differences in recidivism rates, and the cost efficiency level can be significant in differentiating the two treatment programs and their respective therapeutic models. Studies show that the integrated model is very effective in treating the MICA patients. However, the integrated program model can leave some problems unresolved. Full and comprehensive intervention can only take place simultaneously for the dually diagnosed MICA patients when there is sufficient program organization, staffing, and staff training. There is need for additional programmatic strategies to discourage substance abuse and to treat compromising medical disorders.
The integrated programs can effectively deal with a wide variety of therapeutic issues, once the professional level training includes integrative treatment strategies and technologies for multiple and interacting symptoms. Education programs for mental health include some form of training in psychotherapeutic paradigms. The psychotherapeutic paradigms may include client centered, cognitive behavioral, psychoanalytic, interpersonal, family, and systems treatment technologies and modalities. Additional professional training in an integrative and eclectic use of the therapeutic technologies with various dually diagnosed patients can enable clinicians to accurately evaluate and treat multiple types of dual diagnosis in the same mental health center. Careful integration of treatment program services will facilitate the normalization of coexisting disorders.
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