Institutional Analysis of Integrated Treatment for Concurrent Disorders in Ontario

Purpose: This study explores the institutionalized response of the mental health and addictions sectors in Ontario to the pervasive demand for integration of services for people with concurrent mental health and substance use problems. Different stakeholders on multiple levels, including provincial & federal governments, service providers, researchers, professional groups and clients, have voiced the call for integration (Health Canada, 2001; Rush, Fogg, Nadeau and Furlong, 2008). There has been a lack, however, of studies examining the broader contextual factors relating to the development and implementation of integrated treatment for concurrent disorders.

Method: The study draws on a qualitative case study of two treatment programs providing services to populations with co-ocurring mental health and addiction problems. Data was collected through the following methods: a) semi-structured interviews with 24 research participants (provincial service planners, researchers, clinicians and service users); b) review and analyses of relevant policy & organizational documents; and c) observations of relevant meetings at the two treatment programs. The interviews were recorded, transcribed, and analyzed using software for qualitative research analysis (NVivo). Content analysis of policy and organizational documents was conducted, along with the analysis of field notes taken during observations of clinical and business meetings at the programs. Constant comparative analyses of the data facilitated the identification of themes and an in-depth understanding of the institutionalized processes under study.

Results: Applying new institutionalism (DiMaggio & Powell, 1983; Hasenfeld, 2000; Meyer & Rowan, 1977) as a theoretical framework, we argue that in order to gain legitimacy the studied programs adopted integrated treatment ceremonially to demonstrate adherence to the rationalized myths in their institutional environments. We identified four main interrelated factors associated with this institutionalization process: a) changing public perceptions of mental health and addictions, and subsequent shifts in federal and provincial policies and mandates; b) the need to conform to the expectations of the public for more efficient services; c) conflicting interests related to the provision of client-centered care and the endorsement of evidence based practices; and d) the pursuit of different interests by professional groups and key individuals working in this field.

Conclusions and Implications: This study highlights the social and organizational implications of institutionalized arrangements for the treatment of concurrent disorders. A better understanding of the factors contributing to the development and subsequent implementation of integrated treatment for concurrent disorders can help policy makers, program managers, clinicians, and service users understand and address contradictions in current organizational practices.