Center Shares Lessons Learned about Addiction, Mental Illness, Primary Health, ACT with European Collaborators

—by Paul M. Kubek

Patrick Boyle and other consultants from the Center for Evidence-Based Practices at Case Western Reserve University have this knack for connecting with people who share a common vision about behavioral healthcare services for addiction and mental illness. The vision is this. Create integrated services that help people reduce the impact of symptoms from both disorders and live as independently as possible in the community with the highest quality of life.

While the Center continues to provide consultation and training to innovators in public policy and direct practice in cities and small towns throughout Ohio and 17 other states, Boyle has been expanding the Center's reach to organizations in the Netherlands and other European Countries. He is sharing lessons learned from implementing and integrating best practices in the United States, and he is learning from European collaborators as well.

Boyle is director of implementation services at the Center, where he oversees the technical-assistance services of all Center projects, including three Ohio Coordinating Center of Excellence (CCOE) initiatives. He is a licensed social worker and chemical-dependency counselor who has practiced in Ohio for over 40 years and has taught at the Jack, Joseph and Morton Mandel School of Applied Social Sciences (school of social work) at Case Western Reserve University as an adjunct instructor for 24 years.

Tolerance, harm reduction & stages of change

Boyle describes his work in Europe as a cultural exchange that helps advance core components of evidence-based practices developed in the U.S., especially the principle that recovery from addiction and mental illness often occurs gradually over time through stages of treatment and stages of personal change.

He explains that many service systems, organizations, and clinicians in the United States now utilize this stage-based approach to recovery. However, there are many who do not. For instance, some programs still adhere to a zero tolerance, all-or-nothing abstinence expectation when treating addiction. The problem with this approach, he explains, is that people with addiction are often not ready for such a big change. They experience the abstinence-expectation as a demand or imposition from others (from outside the self), which often activates psychological defenses and resistance to change.

In contrast, Dutch culture tends to emphasize tolerance and harm reduction when addressing addiction. The Dutch acknowledge that some people have the ability to use less and less alcohol and other drugs over time and, thus, are able to reduce their exposure to the negative consequences (harm) of addiction. To the Dutch, abstinence is typically a long-term goal. However, they do acknowledge that rapid change and rapid abstinence is possible and necessary for some people. Boyle explains that the attitudes of tolerance and harm reduction in Dutch culture invite people to have honest conversations with treatment providers about their struggles with substance abuse and their fears and desires for change.

"We have seen in clinical practice in the Netherlands and the United States that people typically make personal changes, like cutting down on drinking and smoking and drug use, when they are helped to discover and express their own desire and motivation for change," Boyle says. "The Dutch culture of tolerance and harm reduction allows this to happen more often than in America. It allows change to occur from the inside out, which enables people to own their achievements and integrate those successes into their own sense of self. The harm reduction, stage-wise approach is more genuinely rehabilitative. The Dutch have a deep respect and compassion for individual resilience and capacity for change and is much admired by us."

Criminal justice & rehabilitation

During his visits to the Netherlands over the years, Boyle has also discovered a very different approach to addiction and mental illness in the criminal justice system. Prisons in Dutch communities have been implementing comprehensive integrated treatment programs for co-occurring mental illness and addiction as a way to rehabilitate people—to help them manage their symptoms, their cravings, and their social relationships with friends and family members who still use alcohol and other drugs. The prisons actually help incarcerated people develop attitudes and skills for living in the community with success by helping them minimize and avoid risk factors for arrest and re-incarceration. Boyle cites an impressive statistic. The Netherlands has a population of approximately 5 million more people than Ohio. Yet, it has less than one-fifth the prison population of Ohio.

"The Dutch invest in institutional services that help people begin the process of re-integration into the community as soon as they enter the institution," Boyle says. "This is true not only for imprisoned inmates but also for people being treated in inpatient psychiatric hospitals. In the United States, the criminal justice community would benefit by continuing to learn from our Dutch colleagues and friends."

Boyle hopes the ongoing cultural exchange with organizations in the Netherlands and other European countries will help the Center for Evidence-Based Practices foster a culture of tolerance and harm reduction among service providers and within organizations and institutions in Ohio and other states.


Below is a summary of recent, ongoing collaborations.

Breda | The Netherlands

International Video Classroom

  • April-May 2014 & November - December 2013
  • Topic: Integrated Dual Disorder Treatment (IDDT) and the Role of Social Psychiatric Nurses
  • Collaborator: Avans University of Applied Sciences, School of Health
  • Instructor: Koen H. Westen, BN, BPHN, lecturer at Avans University of Applied Sciences, School of Health, Member of the Board at CCAF
  • Presenter: Patrick E. Boyle, MSSA, LISW-S, LICDC-S

In Review:

This video classroom series explores Integrated Dual Disorder Treatment (IDDT), the evidence-based practice, and its use in community-based and inpatient care. It describes the core clinical components of IDDT, the process of fidelity, and the process of integrating IDDT with Functional Assertive Community Treatment (FACT) in organizations in the Netherlands.
The presentations include a dialogue with nursing students, who conduct field observations and write papers about the facilitators and barriers of implementing ACT and IDDT. The dialogue also includes some action planning about next steps for implementation.

More Information | Related Links:

More Information | Functional Assertive Community Treatment (FACT):

The Hague & Rotterdam | The Netherlands

In Review:

Raisa Kumaga is a social work student at The Hague University of Applied Sciences who is concluding her bachelor's degree program with a visit to Ohio mental health organizations that are implementing Assertive Community Treatment (ACT), the evidence-based practice for people with severe mental illness. She will explore how people who receive ACT services learn to self-manage the symptoms of their mental illness. Her analysis of ACT services in Ohio will inform the future of her practice at home in the Netherlands.

A resident of Rotterdam, Ms. Kumaga's internship (field experience) is with the Bavo Europoort Functional-ACT Noord Ambulant Team. The Dutch have developed Functional ACT (or FACT) as one function of a team of service providers from multiple disciplines (e.g., social work, psychiatry, nursing, chemical-dependency counseling, and peer support) who are trained to provide a continuum of care for a continuum of symptom severity. For instance, team members will share caseloads and provide more assertive, almost daily outreach (in-person contact) for people who have more severe symptoms and are at risk of psychiatric relapse, hospitalization, and institutionalization for a few weeks or months. Members of the same FACT team will also provide less intensive outreach to people whose symptoms are or become less severe and, thus, are less at risk for relapse and hospitalization. The intensity of treatment is fluid: it is based upon client needs, which are reviewed in daily team meetings. The daily caseload review is a core component of the Assertive Community Treatment (ACT) model.

More Information | Related Links:

More Information | Functional Assertive Community Treatment (FACT):

Amsterdam & Rotterdam | The Netherlands

  • International Study-Abroad
  • March 9-16, 2014
  • Course Title: Mental Health Issues and Practice: Integrated Mental-Health and Substance-Use Treatment (for undergraduate and graduate students)
  • Instructor: Patrick E. Boyle, MSSA, LISW-S, LICDC-S

In Review:

This international study-abroad course (3 credits) is sponsored annually by the Jack, Joseph and Morton Mandel School of Applied Social Sciences, the graduate school of social work at Case Western Reserve University in Cleveland, Ohio. The weeklong trip is opened to undergraduate, graduate, and doctoral students of Case Western Reserve and other colleges and universities as well as to interested health and human-service professionals. Boyle has been teaching the course since 2006. He has been consulting with organizations in the Netherlands since 2004.

This year, the group visited a range of treatment settings and interacted with Dutch clinicians, program managers, researchers, and policymakers, as well as with people who receive services. Students learned about the similarities and differences between American and Dutch attitudes toward mental illness and substance use disorders, and, more importantly, how each culture treats the people it serves. Students visited community-based outpatient clinics, residential addiction-treatment centers, prisons, universities, and user rooms (government-regulated safe spaces that also provide access to treatment). Students interacted with Dutch people who receive services and are in treatment. Students also attended presentations by government officials, social workers, healthcare providers, and many of Holland's most prominent scholars. These experiences challenged students to compare Dutch and American policies and practices and helped students evaluate the strengths and weaknesses of social policies and human services in both countries.

Additional Courses:

Boyle's course was one of four that took place in the Netherlands in Spring 2014. The other courses included the following:

  • Course 2/ Title: Social Justice: Health & Violence Prevention (for undergraduate students)
  • Instructor: Cleve Gilmore, PhD, Jack, Joseph and Morton Mandel Dean in Applied Social Sciences
  • Instructor: Sarah Parran, LISW, MSSA (‘84)
  • Course 3/ Title: Social Justice: Health & Violence Prevention (for graduate students)
  • Instructor: Mark Singer, MSSA (‘79) PhD, (‘83), Leonard W. Mayo Professor in Family and Child Welfare at the Mandel School
  • Course 4/ Title: Gender and Sexuality Justice: LGBT Life in Contemporary Dutch Culture
  • Instructor: Elisabeth Roccoforte

Questions & More Information:
Direct all questions about attending future trips to the following:
Debby Jacobson, PhD, assistant professor & director of International Programs, Mandel School
Email: ((RETIRED))

Bennebroek | The Netherlands

Integrated Behavioral Healthcare & Peer Support
Thursday, March 13, 2014
Topic: Implementation of F-ACT & IDDT and the Role of Peer Support
Collaborator: GGZ inGeest (a behavioral healthcare organization)
Co-Presenter: Patrick E. Boyle, MSSA, LISW-S, LICDC-S
Co-Presenter: Russell Lawrence Cummins

In Review:

This presentation was attended by service providers, team leaders, program managers, and policymakers from GGZ inGeest and other behavioral healthcare organizations in the Netherlands. At this event, Patrick Boyle engaged in dialogue with participants about lessons learned from and tips for implementing Integrated Dual Disorder Treatment (IDDT) and Assertive Community Treatment (ACT).

Russell Cummins, a resident of the city of Haarlem, discussed his recovery from co-occurring mental illness and substance abuse and his role as a peer specialist on a Functional-ACT (FACT) team at GGZ inGeest. He discussed the benefits of harm reduction (a stages-of-change approach to recovery from addiction and mental illness) as a way for service providers to build trust and therapeutic alliance with people they serve.

More Information | Related Links:

More Information | Functional Assertive Community Treatment (FACT):

Utrecht | The Netherlands

In Review:

In this master class for psychiatric nurses, Patrick Boyle discussed the epidemiology and impact of smoking upon the health and mental health of people with severe mental illness, including tobacco's negative impact on the effectiveness of psychiatric medications. He presented Tobacco: Recovery Across the Continuum (TRAC), which was developed in Ohio by the Center for Evidence-Based Practices under the direction of Deb Hrouda, MSSA ('94), LISW-S, as a best-practice approach to tobacco recovery for people with severe mental illness.

Boyle discussed lessons learned from the implementation of TRAC principles in Ohio, including the importance of service providers to address their own addiction to tobacco. Nurse practitioners who participated in this discussion examined how their own attitudes toward and use of tobacco might interfere with their ability to encourage people with mental illness to discover and develop the motivation to change their behavior and kick the habit of tobacco use.

TRAC is a unique intervention for tobacco addiction because it uses a stages-of-change-and-treatment approach. It not only helps people who have already decided to quit smoking but also those who have yet to discover the benefits and motivation to change.

More Information | Related Links:

Aviles, Asturias | Spain

  • Second European Congress on Assertive Outreach: Improving Integration
  • June 27, 2013, 9:30 to 10 am
  • Plenary: Integration of Addiction Services in Assertive Outreach ((DEAD LINK))
  • Keynote Presenter: Patrick E. Boyle, MSSA, LISW-S, LICDC-S
  • Collaborator/Sponsor:  European Assertive Outreach Foundation (EAOF) ((DEAD LINK))
  • Collaborator/Sponsor: Prof. Dr. C.L. (Niels) Mulder, chairman of the board of the European Assertive Outreach Foundation (EAOF) ((DEAD LINK))

In Review:

This conference was attended by policymakers, practitioners, and faculty of universities from the European Union. Patrick Boyle's plenary was introduced by Prof. Dr. C.L. (Niels) Mulder, chairman of the board of the European Assertive Outreach Foundation (EAOF). In his presentation, Boyle described the facilitators and barriers to the integration of addiction services in assertive outreach to people with serious mental illness.

He described the difference between a dual disorder specialist and a dual disorder specialty, emphasizing the importance of team-based expertise and approaches to integrated services for addiction and mental illness. He explored lessons learned in Ohio and the United States while integrating chemical-dependency counseling into the following: assertive outreach, clinical assessment, treatment planning, treatment, and transitional care (transitioning people to less-intensive levels of service). He described core components of evidence-based practices that emphasize person-centered care; stage-based recovery (stages of change and treatment); and motivational interviewing.

More Information | Related Links:

  • European Assertive Outreach Foundation (EAOF)
  • Second European Congress on Assertive Outreach: Improving Integration (Congress Archives) ((DEAD LINK))
  • Second European Congress on Assertive Outreach: Improving Integration (Program PDF) ((DEAD LINK))

Utrecht | The Netherlands

Landelijk Expertisecentrum Dubbele Diagnose (LEDD)  | National Expertise Center Dual Diagnosis

2005 to present
A Technical-Assistance Center for the Implementation of Integrated Treatment and Other Best Practices for Co-occurring Disorders

  • Collaborator: Hans Kroon, program director, Trimbos Institute, Utrecht University
  • Collaborator: Anneke Van Wamel, research assistant, Trimbos Institute
  • Collaborator: Sonja van Rooijen, researcher, Trimbos Institute
  • Collaborator: Albert Dijkhuizen, psychiatrist, GGZ Eindhoven and Kempen
  • Collaborator: Johan Wettering, GGZ Eindhoven
  • Collaborator: Martje Van Giffen, dual diagnosis project manager, Mentrum, Arkin,
  • Collaborator: Bas van der Hoorn, psychiatrist, Center Dual Problem of Palier, Parnassia Bavo Groep

In Review:

Patrick Boyle has been providing consultation since 2005 to Dutch collaborators who created Landelijk Expertisecentrum Dubbele Diagnose (LEDD) [the National Expertise Center Dual Diagnosis], a national technical-assistance center in the Netherlands that is funded by the Dutch Ministry of Health.

Boyle's consultation helped the collaborators design LEDD, which opened its doors in 2010. LEDD provides practical assistance for those who give care to clients with co-occurring mental and substance use disorders. This includes the dissemination of Integrated Dual Disorder Treatment (IDDT), the evidence-based practice. IDDT integrates treatment for mental illness with treatment for substance abuse and is provided by the same treatment team from the same organization. IDDT principles and practices are integral to Assertive Community Treatment (ACT & FACT). IDDT is being integrated more frequently with FACT in the Netherlands and with ACT in the United States.

LEDD is a technical-assistance organization at Trimbos Institute that has included the participation of collaborators from Arkin, GGZ Eindhoven and Kempen, Palier (Parnassia Bavo Group), and Delta Psychiatric Centre. The Trimbos Institute conducts research on mental health, addiction, and mental resilience. LEDD is committed to knowledge and innovations that actively improve mental health in the Netherlands and abroad. LEDD is structured, in part, upon the Center for Evidence-Based Practices at Case Western Reserve University (and its Ohio Substance Abuse and Mental Illness Coordinating Center of Excellence initiative). Boyle helped Dutch colleagues translate the structure and activities of this Ohio-based consultation and training center into a culturally appropriate organization that meets the needs of Dutch behavioral healthcare providers.

LEDD has translated into Dutch an implementation tool created by the Center for Evidence-Based Practices, titled "Implementing IDDT: A step-by-step guide to organizational change." LEDD has also translated the original SAMHSA "Integrated Dual Disorder Treatment Tool Kit," which Boyle helped edit. Both tools are used in the Netherlands.

More Information | Related Links:

LEDD | Landelijk Expertisecentrum Dubbele Diagnose
A technical-assistance organization that is a partnership between Trimbos Institute, Arkin, GGZ Eindhoven and Kempen, Palier (Parnassia Bavo Group), and Delta Psychiatric Centre.
3500 AS Utrecht

Trimbos Instituut
A national research and dissemination institute for mental health, mental resilience, and addiction within Utrecht University.
3521 VS Utrecht

PO Box 75848
1070 AV Amsterdam

GGzE | Geestelijke Gezondheidszorg Eindhoven en de Kempen
A mental-health and addiction-treatment center.
Boschdijk 771
5626 AB Eindhoven

A mental-health and addiction-treatment center for adults.
1070 AV Amsterdam

More Information | Related Resources:

Ric Kruszynski, Paul M. Kubek, Patrick E. Boyle, and Lenore A. Kola (2006). Implementing IDDT: A step-by-step guide to stages of organizational change. Cleveland: Center for Evidence-Based Practices, Case Western Reserve University.

SAMHSA (Substance Abuse and Mental Health Services Administration) (2009). Integrated Treatment for Co-Occurring Disorders Evidence-Based Practices (EBP) KIT. Rockville, MD: US Department of Health and Human Services, SAMHSA, DHHS Publication No. SMA-08-4366. ((LINK TO TOOL))

Boyle has been consulting with organizations in the Netherlands since 2004 about the implementation and integration of behavioral healthcare innovations.