Albert Dijkhuizen and Johan Weterings explain how integrated treatment transforms therapeutic relationships, recovery in the Netherlands

—by Paul M. Kubek and Matthew K. Weiland

Columbus, OH—It may be easy to assume that psychiatrists, social workers, and other providers of behavioral healthcare in the Netherlands are light-years ahead of those in the United States when it comes to providing integrated treatment for mental illness and addiction. After all, the Netherlands is known for its more open approach to public-health concerns, such as the use of alcohol, tobacco, marijuana, and other addictive substances. Think of Amsterdam, and you'll probably think of those coffee shops that double as hash bars. .

Yet, if you listen to Psychiatrist Albert Dijkhuizen, MD, and Clinical Psychologist and Psychotherapist Johan Weterings, PhD, you will learn that the two countries are not that far apart. Historically, service systems in the Netherlands have been organized in a manner similar to those in the United States, with treatment for mental disorders and treatment for substance use disorders being delivered by separate organizations that have their own separate teams of treatment providers.

The good news is that the old, divided systems of care in the Netherlands, like those in the United States, are beginning to change as psychiatrists, psychologists, social workers, and others begin to embrace the principles and practices of Integrated Dual Disorder Treatment (IDDT), the evidence-based practice. Dijkhuizen and Weterings have been using the integrated approach since 2005. Both work at a mental-health and addiction-treatment center, called Geestelijke Gezondheidszorg Eindhoven en de Kempen (GGzE), in the city of Eindhoven, in the southern part of the country.

The Conversation

Dijkhuizen and Weterings attended the Annual Ohio SAMI CCOE/IDDT Conference, which took place in Columbus, Ohio, on September 16 & 17, 2008 (for related story, click here ). The conference was sponsored by the Ohio Substance Abuse and Mental Illness Coordinating Center of Excellence (SAMI CCOE), an initiative of the Center for Evidence-Based Practices (CEBP) at Case Western Reserve University.

Dijkhuizen and Weterings answered our open invitation to conference participants to join us in a conversation about their experiences with Integrated Dual Disorder Treatment. Their visit to Columbus continues a cultural exchange between the Center and several organizations in the Netherlands that began in 2005 (read the related story).

The Beginnings of Implementation (2m 4s)

Dijkhuizen began his career as a psychiatrist working at an addiction-treatment institute (center) and noticed that many of the people he was seeing in his practice also struggled with psychiatric issues, a condition known as co-morbidity (also called co-occurring disorders or dual disorders).

This inspired Dijkhuizen to make a career change, so he went to work for a mental health agency. That's where he met Weterings and others who were interested in providing Integrated Dual Disorder Treatment (IDDT), the evidence-based practice. They connected with the Trimbos Institute in the province of Utrecht for some advice. Trimbos referred them to Patrick Boyle at the Center for Evidence-Based Practices in Cleveland, Ohio, for consulting and training.
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A Challenge: Noticing and Acknowledging Symptoms of Both Mental Illness and Substance Abuse (1m 15s)

Weterings describes the division between addictions healthcare and mental healthcare as "awkward," because this makes it hard to give people the treatment they need. "It's difficult to get integrated treatment in Holland still," he says.

He notes that people are less likely to acknowledge the existence of co-occurring disorders when those who suffer do not exhibit problematic behaviors, for instance, when they participate in normal day-to-day routines like going to work. However, co-occurring disorders become more obvious when patients are homeless or handicapped in other ways.
Dijkhuizen explains further the hidden nature of dual disorders. In his practice, he notices that many people do not talk about the link between feelings of depression and anxiety and their use of addictive substances like alcohol and other drugs.
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The Importance of Building Trust & Supporting Motivation to Change (2m 28s)

Fidelity scales used in evidence-based practices are protocols or guides, but they are not treatment in themselves. Dijkhuizen advises providers not to take a cookbook approach to implementing integrated treatment. Instead, use the principles and practices to improve how you relate to other people.

"There has to be something between you and the patient," he says. "The patient needs to be valued and accepted by someone else. People who are addicted and people who have psychiatric problems are often alone, abandoned by other people, so they don't feel valued and acknowledged." He notes that the turning point for personal change in treatment often occurs when people begin to feel that others truly care about them. This makes it easier for individuals to invest in their own process of change.

Weterings adds that many people with co-occurring disorders do have an intrinsic motivation to change. They are eager to learn how to manage their addictions. They want new methods for responding to their mood changes and anxiety, instead of using alcohol or other drugs. Weterings uses the techniques of Motivational Interviewing to support this process of change (see track #5).

Dijkhuizen concludes that assertive outreach is one way to let people know that you care about their health, well-being, and recovery. Outreach can occur by making a trip by car or bike to visit a person or simply by writing a letter or making a phone call.
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Consumer Success Story #1: Prostitution and Heroin No More (3m 55s)

Dijkhuizen notes that his agency, the GGzE, has one service team for people with psychotic disorders. There is another team for 90 people with personality disorders, 60 to 70 of whom also have an addiction to alcohol or other drugs. Having learned the stage-wise principles of integrated treatment, service providers no longer hesitate to discuss substance use and abuse with consumers, who, in the past, would not have talked openly about it in a mental-health setting. "We are seeing dramatic changes," Dijkhuizen says.

He recalls the story of one woman's recovery from prostitution and heroin addiction. The treatment process started with assertive outreach from a forensic service team after the woman was discharged from the hospital following a yearlong admission.

"This may sound a little aggressive, but she could not escape from the treatment," Dijkhuizen says, explaining that the outreach team would not give up. They kept checking in on her. This assertiveness was a turning point for her, because she saw that people actually wanted to help her and not reject her.

The case manager started by helping her with basic needs, like finding food and safe housing. This lead to dramatic changes in her physical appearance and hygiene and in her lifestyle. She now has an apartment of her own and a regular job. She relapses, on average, twice a year to cocaine use but has the ability to stop the behavior herself. She has not returned to her old lifestyle of prostitution and heroin addiction.
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Consumer Success Story #2: Improving Friendships, Social Supports  (1m 56s)

Weterings tells a story about a young man with schizophrenia who was a user of multiple drugs, a victim of trauma, and a regular client of the mental-health center for five or six years. Weterings took the case at a time when he started to use Motivational Interviewing and stage-wise treatment (two core components of Integrated Dual Disorder Treatment). These therapeutic approaches, Weterings reports, helped him and the consumer become more acquainted. They worked together for a year and a half.

"He stopped feeling bad about himself and was eager to learn techniques to manage his drug addiction," Wetterings says. "He got his relationships straightened up. He had more friends ... and was able to view himself as a former addict becoming human again."
Weterings is pleased to note that the man no longer relies as much upon mental-health services and offers an interpretation about the therapeutic turning point in this story. He believes the young man began to trust him more. As a result, the two of them (clinician and consumer) started "taking steps together in a mutual direction."
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Cross-Cultural Learning | Ohioans Understand Organizational Change, the Dutch Understand Working Alliance (3m 26s)

Dijkhuizen visited two service agencies in the Cleveland area in 2005 (Neighboring in Mentor and Nord Center in Lorain) and noticed that service-team members expressed a genuine enthusiasm for integrated treatment. He was also impressed by their willingness to start treatment groups for co-occurring disorders when two or three people would present with similar issues. In contrast, in the Netherlands, service agencies hesitate a bit if they don't think there are enough people to justify the time it takes to start and maintain group treatment.

Weterings has observed that organizations in Ohio seem to manage issues of organizational change effectively, for instance, nurturing buy-in for integrated treatment and group therapy among service-team members and administrators alike. In contrast, Weterings notes that people in his organization seem concerned about the potential costs of integrated services and discuss it a lot.

Here's what Ohioans can learn from the Dutch

Dijkhuizen explains that he and his colleagues in the Netherlands and colleagues in Belgium are very interested in the effects of "working alliance" (also known as therapeutic alliance) upon treatment outcomes. Working alliance examines the dynamics of the clinical relationship: it describes what is occurring between those who provide help and those who receive it.

"We can research a lot of things and see which (evidence-based) protocols work, but in the end, the only thing that counts is the meeting between two persons," Dijkhuizen says. "I don't see this (working alliance) in the fidelity scale."
Dijkhuizen hopes that working alliance will be added as an item in the fidelity scale of the Integrated Dual Disorder Treatment (IDDT) model, so organizations will have the opportunity to measure its impact upon treatment outcomes.
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A Message to Dutch Colleagues (46s)

Dijkhuizen and Weterings provide some words of encouragement in their native Dutch language for colleagues in the Netherlands. Weterings also provides an English translation.
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