Why Co-Occurring Treatment Still Gets Split in Two

We know far more now about integrated care than we did a generation ago. So why are mental health and substance use treatment still so often split apart?

So, I'm going to start this post with something that is probably pretty obvious to everyone working in this field: no one is coming to save us. The cavalry is not coming to save the day, and any meaningful change in the treatment of co-occurring disorders is going to have to come from us, from the ground up. That is part of the difference between having a job and having a vocation. We are not going to back our way into an integrated approach. We are going to have to fight for it.

TIP 42 came out in 2005. The recovery movement has been with us since at least the 1980s. We know what works, and we know much more now about why it works in terms of how human beings make change. We know a great deal more about the human nervous system. And, yet, we are still mired in systems that often seem far more intent on preserving their own form than on making the kind of difference that might otherwise be possible. So we have to ask: why is that, and what might we do about it?

This is where I think we must begin: the split in co-occurring treatment was never simply a matter of good clinical reasoning. It did not emerge because mental health and substance use naturally fall into two separate categories that make sense to clients or to the actual course of their lives. The split is institutional. It comes out of historical momentum, professional turf battles, and the ongoing question of how the money pie gets divided up. In other words, who gets to treat what, who gets reimbursed for what, and who gets to define the problem in the first place.

At the risk of some hand waving, obviously it is complicated. I am not going to fully explain all of the systemic forces that got us here in a single post. But I do think there are at least a few straightforward factors that have played a major role.

The first is the medicalization of human suffering and the reduction of the human being to a kind of machine that needs to be fixed. Along with that comes the tendency to turn unwanted thoughts, feelings, and behaviors into symptoms of an underlying medical condition.

The second is the logic of for-profit health care systems, which put dollars at the center of the enterprise and shape the workforce around that reality.

The third is professional turf battles, which are often downstream from the first two.

Taken together, these three factors form a kind of feedback loop, a wheel moving in the wrong direction with a lot of momentum behind it. In order to provide services, we have to justify cost, and we often do that by medicalizing human problems. Once we justify them that way, we create a means for making money through the current health care system, where profit becomes the overarching concern. And, once dollars collect into pools of money, people begin fighting over those dollars through professional turf battles, through deciding who owns which problem, who treats which symptom cluster, and who gets to claim which part of the person. That is one of the central ways co-occurring disorders treatment continues to get split in two.

I will come back to these three factors in later posts because each of them deserves more attention. For now, I think this gives us a place to begin.

This obviously leaves out many other causal factors, each of which deserves attention in its own right: social stigma around mental illness, or to use the older colloquial term, madness; social stigma around addiction; poverty, entitlement systems, and the great American obsession with who deserves what; the social determinants of health; racism, sexism, and the broader forms of discrimination that leave people out and create the haves and have-nots of our society. All of it plays a part. But it is also true that we have to start somewhere, and we have to ask where we might have the most leverage. That is where I would like to go next.