Early Implementation of Strengths Plus: The Strengths Model for People with Co-Occurring Mental Illness and Substance Use Disorders

Background and Purpose: Substance use among people with severe mental illness is highly prevalent with estimates as high as 50% in clinical populations. However, there has been a paucity in effective interventions for people with co-occurring mental illness and substance use disorders. For instance, Integrated Dual Disorder Treatment (IDDT) is one of the more widely used evidence-based practices, yet the reported effects on client outcomes are minimal. The implementation is often challenging and the association between improved model fidelity and client outcomes remains uncertain. This may be due in part to the unique challenges in working with people with co-occurring disorders (e.g., stigma towards substance use, difficulties in establishing working alliance, and lack of perceived treatment needs). In order to address these challenges, Strengths Plus, which integrates the Strengths Model Case Management (SMCM) approach with IDDT, has been developed and implemented. The purpose of the current study is to examine the experiences of service providers regarding early implementation in order to guide further program development.

Methods: Semi-structured focus groups were conducted with 11 case managers and individual face-to-face interviews with 3 team leaders as well as 3 administrators at three community mental health centers where Strengths Plus was implemented. The interviews were audio-recorded and transcribed verbatim for qualitative data analyses. The transcripts were coded and analyzed by two graduate research assistants using constant comparative method, and consensus was achieved through discussions. Senior researchers audited for the accuracy of the interpretation.

Results: All participants expressed positive experiences with the Strengths Plus implementation. On-going support by the implementation consultants and workers’ prior skill sets (e.g., familiarity with existing evidence based practices) were identified as two major facilitators for the successful implementation. Increased responsibility and training time introduced by the implementation, along with the lack of agency buy-in, on-going staff turnover, and a large case load size were identified as obstacles in the early stage of implementation. Regardless of the challenges, the participants acknowledged several positive changes in their practice. For example, all participants indicated that their clients were more engaged in their treatment/ recovery process, honest and open to providers about substance use and other struggles in life after the implementation. In addition, the participants felt they became more knowledgeable and skillful when engaging in conversations with clients about substance use. The participants perceived that the intervention tools, including Strengths Assessment and Personal Recovery Plan, were significantly helpful in acquiring new skills.

Conclusions and Implications: The current study examined the interview data obtained from case managers, team leaders, and administrators regarding the feasibility of implementing Strengths Plus. The study indicated the positive experiences of implementation that would address the unique challenges in treatment for those with co-occurring mental illness and substance use disorders. Obstacles that need to be overcome for successful implementation were also examined. Implications for further development and testing of Strengths Plus for people with co-occurring disorders will be discussed.