Cultural exchange with the Netherlands examines integrated treatment for drug use, mental illness

—by Paul M. Kubek

Cleveland, Ohio—If you ask most people in this country to free associate to the words Amsterdam or the Netherlands, you may get responses that include images of canals, windmills, tulip farms, hash bars, red-light districts, and a nation of people tolerant of drug use. Yet, the perception of the Dutch being casual about prostitution and drugs is beginning to shift toward a more accurate and realistic perception as people here travel there to study and consult with policymakers and providers of health and human services.

Ask Patrick Boyle, MSSA ('89), LISW-S, LICDC, director of implementation services at the Center for Evidence-Based Practices at Case Western Reserve University, about what he has learned from his consulting and training in several regions throughout the Netherlands, and he will explain that the availability of addictive substances in Dutch communities does not mean that use of these substances is rampant and free, because the distribution of alcohol, tobacco, and other drugs is, above all, controlled. Permits to sell and serve these substances are made by a government agency equivalent to a department of health in the United States. And, as part of that permit, distributors are required to provide information about the dangers of use, abuse, and addiction, as well as the benefits and availability of treatment.


"The concept of tolerance among the Dutch is an age-old cultural way of dealing with issues that are morally and socially sensitive," Boyle says. "Tolerance is actually a pragmatic tool that they use to solve problems. They publicly acknowledge difficult issues and educate people. It's a public-health approach to social problems. The Dutch approach is a lot different from the popular American belief in zero tolerance, and it appears to produce positive results. When compared to Americans, the Dutch actually have a much lower use of substances at all ages."

Cross-cultural comparisons are important learning opportunities, Boyle emphasizes. It's one of the reasons he continues to co-teach the annual study-abroad course in the Netherlands that is sponsored by the Mandel School of Applied Social Sciences, the graduate school of social work at Case Western Reserve University. The weeklong trip is a for-credit college course for undergraduate, graduate, and doctoral students. It is opened to students of Case Western Reserve and other colleges and universities as well as to interested health and human-service professionals (see "Spring-Break Study Abroad" below). Boyle has been co-teaching the course since 2006.


Boyle is a licensed social worker and chemical-dependency counselor who has practiced in Ohio for over 35 years and has taught at the Mandel School as an adjunct instructor for 21 years. He is a 1989 graduate of the master's program, having studied in both its mental-health and alcohol-and-other-drug specializations. He has worked for the Center for Evidence-Based Practices since its inception in December 1999.

The center is a technical-assistance organization that provides consulting, training, and evaluation services to policymakers and service organizations that are implementing evidence-based practices and other emerging best practices for people diagnosed with mental illness and substance use disorders. Boyle works with a staff of 14 people, which includes eight consultants, trainers, and evaluators; he maintains his own consulting caseload; and he oversees the day-to-day operations of the organization, which has gained a national and international reputation for its work. The center is a partnership between the Mandel School of Applied Social Sciences and the Department of Psychiatry at the Case School of Medicine.


Since the center's inception, Boyle and his colleagues have been helping community agencies, hospitals, and health clinics throughout Ohio and 25 other states implement several evidence-based approaches to service delivery, including Integrated Dual Disorder Treatment (IDDT), which improves quality of life and other outcomes for people diagnosed with co-occurring mental illness and substance use disorders. IDDT is a service model that combines principles and practices of social work, psychiatry, chemical-dependency counseling, and mental-health treatment into a single integrated, stage-wise approach. It was developed by researchers at the Psychiatric Research Center of Dartmouth Medical School and has been advanced with numerous contributions from staff of the Center for Evidence-Based Practices at Case Western Reserve. Since 2004, Boyle has been transferring knowledge and experience from the center's work in Ohio and other states to the Netherlands by helping Dutch government organizations, service providers, and Utrecht University develop a collaborative technical-assistance organization to inform the development of public policies and to support the implementation of integrated treatment over time (see "Dutch Collaborators" section below).

"People who use and abuse addictive substances like alcohol, tobacco, and other drugs often experience severe emotional distress and many other symptoms of mental illness at the same time," Boyle says. "The Dutch have learned as we in Ohio and other states have learned: you cannot treat one disorder without treating the other and expect people to get better. You have to address symptoms of substance use and mental illness at the same time."

Boyle explains that drug abuse does not necessarily cause mental illness and vice versa; however, they are often linked or associated with one another. He cites a statistic from research in the U.S. that helped inspire the creation of the IDDT model: over 50 percent of people diagnosed with a severe mental illness like schizophrenia and schizoaffective disorder will likely experience a substance use disorder at some point in their lives.


The Center for Evidence-Based Practices has been helping the organizations listed below implement Integrated Dual Disorder Treatment (IDDT), the evidence-based practice. The center has also been helping these organizations develop or enhance their capacities to provide technical assistance for the implementation of evidence-based practices to service organizations in the Netherlands.

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

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

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

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


An at-a-glance timeline of the cultural exchange between the Center for Evidence-Based Practices at Case Western Reserve University and institutions and organizations in the Netherlands:


The center is introduced to colleagues from the Netherlands.

March 2005

A group of 21 Dutch researchers, program managers, and clinicians who represent six provinces in the Netherlands travel to Cleveland to learn about strategies for implementing and evaluating Integrated Dual Disorder Treatment, the evidence-based practice. The group is trained by the following:

  • Patrick Boyle, MSSA ('89), LISW-S, LICDC, director of implementation services
  • Ric Kruszynski, MSSA ('93), LISW, LICDC, director of consulting and training for substance abuse and mental illness (SAMI) initiatives
  • Deb Hrouda, MSSA, LISW-S ('94), director of quality improvement

During this consultation in Cleveland, the Dutch participate in site visits at two service organizations in Northeast Ohio, where they observe service teams at work and meet with program managers and direct-service staff to discuss their experiences and lessons learned. Both of these organizations—The Nord Center in Lorain and Neighboring in Mentor—receive technical assistance from the Center for Evidence-Based Practices to support implementation of evidence-based practices. Both have also served as field education sites for master's degree students of the Mandel School.

January 2006

Boyle accompanies staff of the Trimbos Institute on a visit to all Dutch sites that are implementing IDDT to provide consultation about fidelity action-planning. The consultation is a follow up to the first annual fidelity assessments conducted by Trimbos staff at these sites.

September 2007 and October 2010

Dutch researchers and practitioners from Amsterdam, Eindhoven, and Nijmegen attend and present at the center's evidence-based practices conferences, which are held in Columbus, Ohio. The center also coordinates site visits for the Dutch visitors at inpatient and community-based treatment programs in central Ohio.

March 2006 to present

The Mandel School of Applied Social Sciences sponsors its annual study-abroad trip to the Netherlands. As part of this initiative, Boyle teaches a course on Integrated Mental Health and Substance Abuse Issues and Practice for undergraduates at Case Western Reserve University and graduate and doctoral students at the Mandel of Applied Social Sciences. It is one of three courses offered by Mandel School colleagues as part of the trip (see "Spring Break" sidebar). While in the Netherlands, Boyle provides consulting and training to Dutch institutions, policymakers, and organizations that are implementing Integrated Dual Disorder Treatment.

Spring 2009 and 2010

Boyle helps introduce Integrated Dual Disorder Treatment at the Dubbel diagnose kliniek (dual diagnosis clinic), Dijk en Duin, Amsterdam. He also consults with an Assertive Community Treatment (ACT) team in Breda. The Mandel School sponsors its annual study-abroad trip to the Netherlands. Boyle teaches one of three courses offered by Mandel School colleagues.

September 2010 and 2011

Boyle teaches an overview of the center's Integrated Dual Disorder Treatment Inpatient Adaptation to bachelor's-level nursing students at Avans Hogeschool, University of Applied Sciences in Breda, Netherlands, via videoconference from the Mandel School in Cleveland.

March 2011

The Mandel School sponsors its annual study-abroad trip to the Netherlands, visiting service organizations in Amsterdam, Rotterdam, and The Hague. Boyle teaches one of three courses with Mandel School colleagues (see "Spring Break" sidebar). While in the country, Boyle consults with leaders of the LEDD, the national technical-assistance center for integrated dual-disorder services, and with regional program leaders.

November 2011

The GGZ Haagstreek High Care Clinic, in Leidschendam, the Netherlands, invites Boyle to present during its symposium on Integrated Dual Disorder Treatment. The High Care Clinic in Leidschendam is a specialized clinic for chronic psychiatric patients, ages 18 to 65. Boyle presents via video conferencing from the Mandel School.  

Paul M. Kubek, MA, is director of communications at the Center for Evidence-Based Practices at Case Western Reserve University