GHPC conducted a realist synthesis to guide design of integrated systems to improve outcomes for individuals with a co-occurring diagnosis.
The challenge of coordinating services for people with co-occurring mental health and substance use disorders is one of those complex environments that Schön refers to. Recognizing that critical shortages of integrated services plague behavioral health systems worldwide, the Ireland Research Board and the Georgia Health Policy Center looked to a realist review to provide real-world and evidence-based insights to shape how Ireland could develop a system of integrated care between its mental health and drug and alcohol services.
Rather than testing whether an intervention works, a realist approach examines how it works. Ideally suited for complex situations, the realist approach describes patterns of relationships between how an intervention is delivered, contextual factors, and the observed outcomes.
The realist synthesis of the literature was combined with perspectives of service users and providers in Ireland providing a comprehensive examination of why certain interventions work (or do not work) for some people with dual diagnosis and under what conditions.
One of the key things about doing a realist synthesis of the literature is understanding the mechanisms, says Karen Minyard, GHPC’s CEO, who led this project. Mechanisms can include resources — the intervention itself — as well as changes in mindset, reasoning, decisions, or actions that are or are not triggered by the introduction of resources into a particular context.2
“But, mechanisms are not always apparent in the literature, particularly in randomized control trials. So, we had to get really smart about how to tease out the mechanisms,” says Minyard. “At the individual level, what leads a person to be ready to be in treatment? The things we discovered included trust, hope, and having a stable home, employment, food, and social support. At the organizational level, of course institutional and financial support emerged as key factors, but so did having a common language, a culture of hope, and provider confidence.”
Understanding mechanisms at four levels — policy/system, organization/provider, service/treatment, and individual/family — can help to demystify some of the complexity of the behavioral health care system, which Minyard says is not only a great contribution to Ireland, but a hallmark of how GHPC approaches problem-solving. ●●
1 Pawson, R., & Tilley, N. (1997). Realistic Evaluation. Thousand Oaks, CA: Sage Publications.
2 Dalkin, S. M., Greenhalgh, J., Jones, D., et al. (2015). What’s in a mechanism? Development of a key concept in realist evaluation. Implementation Science, 10, 49.