SAMHSA logo Report to Congress - Nov 2002








Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Chapter 1 - Characteristics and Needs of the Population - The NASMHPD/NASADAD Conceptual Framework


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The NASMHPD/NASADAD Conceptual Framework

A four-quadrant conceptual framework for co-occurring disorders was adapted from a model used in New York State and originally proposed by Rosenthal (1993). Developed with support from SAMHSA by the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of State Alcohol and Drug Abuse Directors (NASADAD), the structure helps to frame the systems of care for serving people with co-occurring substance abuse disorders and mental disorders and does so in terms of symptom multiplicity and severity rather than specific diagnoses. The framework delineates symptom severity and level of service system coordination on a continuum from less severe to more severe disorders and from consultation and collaboration to integration, respectively (NASMHPD/NASADAD, 1999). The framework also specifies the typical locus of care based on symptom severity (see Figure 1.1, below).

Figure 1.1 - Co-Occurring Substance Abuse Disorder and Mental Disorder Conceptual Framework

It is important to recognize that individuals at various stages of recovery from substance abuse disorders and mental disorders may move back and forth among these quadrants during the course of their illnesses. The framework is designed to serve as a general guide. In this way, the framework encompasses the full range of co-occurring substance abuse disorders and mental disorders and allows both fields to move beyond a focus on only those individuals with the most severe disorders (NASMHPD/NASADAD, 1999). Critically, the framework is not for the purposes of classifying individuals, but rather is widely regarded as the best way to depict the universe of clients who have co-occurring disorders (CSAT, in press).

A Common Language

Development of this framework provides a common language and establishes shared priorities between the mental health and substance abuse treatment systems for individuals who have co-occurring disorders and their families. Perhaps the most important contribution of the NASMHPD/NASADAD conceptual framework is the fact that it represents a major shift in attitude on the part of both the mental health and substance abuse treatment communities. There is now joint recognition that both disorders deserve equal attention. Prevention and early intervention are appropriate for individuals in quadrant I, for whom any mental and substance abuse problems they might have would not require specialty care. Strategies can also be applied to quadrants II, III and IV to prevent increases in mental or substance abuse disease severity.

Innovative Programs and Funding Strategies

SAMHSA also has supported development of three additional documents on co-occurring disorders by the NASMHPD/NASADAD Joint Task Force that provide guidance to the field. A report on financing and marketing within the context of the conceptual framework outlines a set of general principles needed to finance a continuum of care for people who have co-occurring substance abuse disorders and mental disorders, among them joint purchasing of effective services, use of funding combined from multiple sources, and adoption of performance-based contracts that align financial incentives and disincentives with system goals (NASMHPD/NASADAD, 2000).

Another report (Bixler and Emery, 2000) highlights successful programs for individuals with co-occurring disorders developed in Massachusetts, New York, Pennsylvania, Washington State, and Wisconsin. These sites were successful because 1) they responded to locally identified consumer needs; 2) they employed high quality clinical leadership; 3) they used various models of integrated mental health and substance abuse treatment; 4) they had strong referral relationships with other providers; and 5) they had support and encouragement from State and county agencies.

Finally, the most recent NASMHPD/NASADAD Joint Task Force report (2002) highlights various methods of financing integrated services for people with co-occurring disorders (see Appendix III).


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