Person-Centered Care for People with Co-Occurring Substance Use Disorders: A Mixed Methods Study

Background and Purpose: Despite a high prevalence of people with co-occurring mental health and substance use disorders (CODs), many disengage from treatment increasing the risk for symptom exacerbation, suicide, and overdose. One barrier to engagement is that providers often require abstinence as a treatment goal. Whereas Person-Centered Care Planning (PCCP), an emerging practice in community mental health, is an intervention that targets the service planning process to focus treatment on client self-determination and the pursuit of personally defined goals. Much of the research on person-centered care in mental health settings has focused on people with severe mental illnesses rather than those with CODs specifically. Using data from a NIMH-funded hybrid RCT of PCCP, this study aims to compare PCCP fidelity for individuals with and without CODs and explore provider perspectives on implementing PCCP among people with CODs.  

Methods: This study uses a longitudinal explanatory sequential mixed-methods design. An objective fidelity measure (PCCP-AM) assessed the person-centeredness of service plans using 13 items. Service plans (N=798) were sampled from 14 community mental health sites, which were randomized to PCCP training or treatment-as-usual. Mixed effects linear regression models examined the effect of time (baseline, 12-month, 18-month) and condition on fidelity, with interaction effects examining differences between service plans for individuals with and without CODs. The main effect of COD on fidelity across time and condition was also examined. Qualitative data from 15 provider focus groups expanded on the quantitative findings. These focus groups were conducted at the experimental sites and explored direct care staff and supervisor perspectives on the PCCP implementation process. Thematic analysis explored perspectives specific to implementing PCCP among people with CODs.

Results: PCCP fidelity increased for people with and without CODs across time and condition, with no significant difference between the groups [F(2,732.33)=.22, p= .80]. There was, however, a significant main effect with service plans completed for people with CODs having less PCCP fidelity holding time and condition constant [B=-.42, p<.05]. In the qualitative findings, some providers reported skepticism that PCCP could be implemented for people with CODs due to these individuals having poorer motivation and insight. At the same, they reported an understanding of PCCP as a way of practicing that incorporated harm reduction practices and “meeting clients where they’re at.” While some providers described difficultly buying in to this approach with people who use substances, those who did reported improved service engagement.  

Conclusion and Implications: The quantitative findings found that overall people with CODs had significantly less person-centered service plans when controlling for time and condition. However, within the experimental group PCCP fidelity did improve similarly for people with and without COD.  The qualitative findings suggested there was skepticism towards harm reduction but that people did become more open to this person-centered approach over time. More research is needed to understand how providers deliver person-centered care in relation to people who use substances. Ensuring that goals for substance use align with person-centered principles may improve engagement and prevent drug-related harm.