A Case Study of the Diffusion and Adaptation of the Integration of Mental Health and Addiction Services in Three Canadian Provinces: Implications for Problem Gambling Treatment

Background and Purpose:

In the past two decades, treatments focused on reducing problem gambling, and co-occurring mental health or substance use disorders have been developed and evaluated. Interventions designed to improve the functioning of individuals who experience such comorbidities demonstrate the feasibility and effectiveness of integration of their treatment. Most interventions were designed to be implemented in out-patient treatment settings and are focused on problem gambling, albeit to differing degrees; the severity of a co-occurring disorder is expected to improve as a secondary benefit of the gambling-focused treatment.

At the same time, different provincial jurisdictions across Canada followed their explicit agendas to better manage their health care systems. Thus, the promise of treatment-level integration and its benefits at the individual level has been used to support integration of mental health and addiction treatment systems — expecting the secondary benefits of such move for treatment of problem gambling. However, it is unclear to which extent the integration occurred or has been beneficial for problem gambling treatment services.

Methods:

This multiple instrumental case study conducted forty-six in-depth, semi-structured interviews with decision-makers in three Canadian provinces. Purposeful, stratified sampling was used to recruit participants at the provincial, regional and direct service delivery level of decision making. Additionally, a comprehensive review of integration and problem gambling treatment policies was conducted to provide contextual information and understand regional differences in integration. The analytic strategy of constant comparison was used to identify similarities and differences in experiences related to integration-related activities. The initial broad coding categories that were developed to capture the themes were refined and collapsed into theoretically-informed concepts.

Findings:

Data analyses revealed that: 1) all three provinces adopted the rationale for integration of their mental health and addiction treatment systems; 2) the localized structures and treatment systems were developed to address diverse demands for treatment but also the competing interests of decision-makers and service providers; 3) integration of problem gambling and co-occurring mental health and substance use disorders were affected by differing perspectives and approaches to problem gambling among mental health and addiction professionals, and 4) the sense of being “left out” of the discussions and decision making during the planning and executing the integration.

Conclusions and Implications:

This study illuminated why and how some concepts or practices enter new organizational fields and cause change, while others are never adopted or adopted only partially. This realistic treatment of organizations is necessary for practical discussions among organizational managers, service providers and policymakers. Ultimately, such studies and discussions are important in social work education, research and practice as they shed light on the mechanisms of organizational changes in integration-related efforts. Additionally, the practical value of the study is in its potential to facilitate research on the implications of service and system changes, which has been largely absent from the discussions about problem gambling treatment services.