Strategies for Developing Treatment Programsfor People With Co-Occurring Substance Abuse and Mental Disorders

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services Administration www.samhsa.gov

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

5600 Fishers LaneRockville, MD 20857

Strategies for Developing Treatment Programsfor People With Co-Occurring Substance Abuse and Mental Disorders

AcknowledgmentsMany people contributed to the publication of thisreport. The document was researched and written byJeannie Campbell, National Council for CommunityBehavioral Healthcare (NCCBH), and PamelaPetersen, State Associations of Addiction Services(SAAS). Eileen Elias and Jennifer Fiedelholtz servedas project officers for the Substance Abuse andMental Health Services Administration (SAMH-SA). Lee Ann Slayton (Slayton Consulting, LLC)and Neal Cash (Community Partnership ofSouthern Arizona) served as writers and specialexpert panel facilitators. Technical assistance wasprovided by Kenneth Minkoff. Expert advice andguidance was provided by the following SAMHSAstaff members: Paul Brounstein, Carol Coley, MarieDanforth, Thomas Deloe, Michael English, EdithJungblut, George Kanuck, Cathy Nugent, LarryRickards, Carole Schauer, Jane Taylor, andStephanie Dant Wright. Expert guidance also wasprovided by Tom Leibfried (NCCBH), RobertAnderson (National Association of State Alcoholand Drug Abuse Directors), and Bruce Emory (seniorconsultant to the National Association of StateMental Health Program Directors).

SAMHSA acknowledges the time and valuableinput from individuals representing mental healthand substance abuse providers, consumers, andadministrators who participated in the special expertpanels and who described the barriers to receivingand providing services to individuals with co-occur-ring substance abuse and mental disorders, theirexperiences, and their recommendations.

DisclaimerThis report was developed under Purchase Order No.00M008538010 with the Substance Abuse andMental Health Services Administration, U.S.Department of Health and Human Services(DHHS). The views, opinions, and policy state-ments expressed in this report are those of the par-ticipants and do not necessarily reflect those ofSAMHSA or DHHS, nor do they necessarily reflectthe views of NCCBH and SAAS.

Public Domain NoticeAll material appearing in this report is in the publicdomain and may be reproduced or copied withoutpermission from the Substance Abuse and MentalHealth Services Administration. Citation of thesource is appreciated. However, this publication maynot be reproduced or distributed for a fee withoutspecific, written authorization from the SAMHSAOffice of Communications, DHHS.

Electronic Access and Copies of the PublicationThis publication can be accessed electronicallythrough the following Internet World Wide Webconnection: http://www.samhsa.gov. For additionalfree copies of this document, please call the SAMHSA National Mental Health InformationCenter at (800) 789-2647 or the NationalClearinghouse for Alcohol and Drug Information at(800) 729-6686.

Recommended CitationSubstance Abuse and Mental Health ServicesAdministration. Strategies for Developing TreatmentPrograms for People With Co-Occurring SubstanceAbuse and Mental Disorders. SAMHSA PublicationNo. 3782. Rockville, MD: SAMHSA, 2003.

Originating OfficeSubstance Abuse and Mental Health ServicesAdministration, 5600 Fishers Lane, Rockville, MD20857.

Research has confirmed that people with co-occurring substance abuse and mental disorders

are a large, significantly underserved population inthe United States. They experience multiple healthand social problems and require a panoply of servic-es that cut across systems of care, including substanceabuse treatment, primary health care, mental healthservices, and long-term care. People with co-occur-ring mental and substance abuse disorders also expe-rience a broad range of social service needs; they maybe homeless or located within the criminal justicesystem. Few have substantial resources or supports.No one single care system is sufficiently equipped—in resources, training, and service capacity—to serveindividuals with co-occurring substance abuse andmental disorders.

A variety of factors contribute to the inability ofindividual service systems to provide people with co-occurring disorders the full range of needed andappropriate services, including:

Separate, uncoordinated mental health and sub-stance abuse treatment providers and service pro-grams

Disparate health insurance benefits for the treat-ment of mental illness compared with substanceabuse and for the treatment of both comparedwith other health problems

An absence of a single locus of responsibility forthe treatment of individuals with co-occurring dis-orders

Insufficient numbers of cross-trained staff

Differing treatment philosophies within the men-tal health and substance abuse communities, cou-pled with clinician discomfort in working in areasbeyond the scope of their specific training

An insufficient services research base to supportevidence-based practices in the treatment of per-sons with co-occurring disorders

A dearth of instruments and trained personnel toassess and screen accurately and reliably for co-occurring mental and substance abuse disorders

Inadequate funding not only for substance abusetreatment and mental health services in generalbut also for the treatment of co-occurring disor-ders in particular.

We recognize that, ultimately, service system changemust occur at the level of the community-based serv-ice provider. To help move toward this changedvision of service delivery, the Substance Abuse and Mental Health Services Administration(SAMHSA) joined with the National Council forCommunity Behavioral Healthcare (NCCBH) andthe State Associations of Addiction Services(SAAS) to identify problems and seek solutions. Specifically, this report— “Strategies for Developing Treatment Programs for People WithCo-Occurring Substance Abuse and MentalDisorders”—highlights challenges to service deliv-ery, delineates strategies to overcome these chal-lenges, identifies methodologies to help publicpurchasers build integrated care systems, anddescribes core competencies and training from whichtreating professionals and the people they serve canbenefit.

As this initiative began, the field shared the singularassumption that the barriers to providing integratedservices for people with co-occurring substance abuseand mental disorders were insurmountable.

The knowledge gleaned from the collaborationamong SAMHSA, NCCBH, and SAAS, however,tells a different story. Through special expert paneldiscussions, investigators identified and broughttogether individuals who developed and today oper-ate successful programs serving people with co-occurring substance abuse and mental disorders.Moreover, those individuals helped identify howthey successfully overcame barriers to service deliv-ery. Project investigators discovered many replicableand often inexpensive and simple strategies and tools

Foreword

available for people in the mental health and sub-stance abuse treatment fields to use to provide treat-ment for people with co-occurring substance abuseand mental disorders.

The information in this report often is anecdotal innature; yet the results, in many instances, have beenstunning. It is true that our ability to deliver effective

treatment for co-occurring disorders to all popula-tions in all settings remains a formidable challenge;however, this document describes how, with theleadership of administrators, clinicians, and con-sumers, we can overcome the challenge and turnwhat was insurmountable into a reality of services forpeople with co-occurring substance abuse and men-tal disorders.

Charles G. Curie, M.A., A.C.S.W.AdministratorSubstance Abuse and Mental Health Services Administration

Charles G. RayPresident and CEONational Council for Community Behavioral Healthcare

David Faulkner, M.A.Board PresidentState Associations of Addiction Services

i . . . . . . . .Executive Summary

1 . . . . . . .Chapter 1: Introduction

3 . . . . . . .Chapter 2: Methodology

5 . . . . . . .Chapter 3: Key Lessons

17 . . . . . .Chapter 4: Next Steps

23 . . . . . .Glossary

25 . . . . . .Appendix A: Co-Occurring Disorders by Severity Matrix

27 . . . . . .Appendix B: Nomination Form

29 . . . . . .Appendix C: Profile of Participants in Expert Panels and Telephone Surveys

31 . . . . . .Appendix D: Findings From Expert Panel I

37 . . . . . .Appendix E: Findings From Expert Panel II

43 . . . . . .Appendix F: Training Curricula

45 . . . . . .Appendix G

Table of Contents

i

Increasingly, people receiving public-supportedhealth care are seeking help for and/or presenting

with both substance abuse and mental disorders.People with these co-occurring disorders often requirehelp from many different care systems—not only sub-stance abuse and mental health care services but oftenprimary health care, criminal justice, and social serv-ices as well. Consequently, no single system of care isadequately prepared to help people with both mentaland substance abuse disorders on its own, and manypeople with co-occurring disorders do not receive thecontinuum of specialized services they need.

Both substance abuse and mental health treatmentproviders recognize the importance of creating pro-grams to treat people with co-occurring disorders. For avariety of reasons, however, they face many challengesin their efforts to fund, staff, and operate such programs.

To help address this situation, the Substance Abuseand Mental Health Services Administration(SAMHSA) commissioned this project in August2000 to identify strategies of developing effectivetreatment programs for people with co-occurring disorders. This project is also designed to supportSAMHSA’s ongoing national training and technicalassistance initiatives by identifying:

Challenges to providing treatment

Proven strategies and tools that providers use toovercome these challenges

Strategies and tools that public purchasers use tobuild integrated care systems

Core competencies and specific training thattreatment staff should acquire.

A national screening of the mental health and sub-stance abuse fields identified programs in diverse set-tings that deliver effective treatment for differenttypes of people with co-occurring disorders. Leadersof these programs—as well as nationally recognizedexperts and people who have received treatment for

co-occurring disorders—helped provide a great dealof the information in this report by participating infocus groups and telephone interviews.

Participants discussed community-based programs andevaluated systemic support at the State, county, andregional levels. Systems-level participants describedtheir strategies to build more comprehensive services.

Throughout the process, participants described awide range of clinical, financial, programmatic, andtraining barriers to delivering treatment and buildingsystems of care. However, none of these obstacles areinsurmountable; indeed, with consistency and clarity,participants described how they overcame each one.Their approaches included:

Using replicable strategies and tools that are oftensimple and inexpensive

Employing strong leadership at both the providerand systems levels

Involving important stakeholders, including consumers and family members.

In this report, the term “systems level” focuses on the public purchaser level. In most cases, the Statemental health and substance abuse agencies areresponsible for purchasing services and creating systems of care to meet the needs of service recipi-ents. When it comes to implementation, some Statesdelegate authority to county- and/or regional-levelbodies. And in some areas, large provider networksserve as another level of purchaser/care coordinatorwithin other divisions (State/county/regional).

Participants acknowledged that provider-level pro-gramming (i.e., direct care) is currently more developedthan systems-level initiatives. Nevertheless, well-organized and integrated care systems can expandthe power of individual treatment programs. Theycan provide effective pathways for consumers tomove between services and can assist consumers intransitioning from active treatment to community-

Executive Summary

The authors have

included quotes from

panel participants in

text blocks throughout

this report. These

quotes reflect the

personal perspectives

of people engaged in

building and sustaining

effective programs

for individuals with

co-occurring disorders.

i i

based support systems. Thus, as systems of care forpeople with co-occurring disorders continue toevolve, they will provide support for the advancesthat treatment providers have made.

An assumption in planning this project was thatclient variables (e.g., ethnicity and geographic location) create significantly different needs. Thesedifferences, however, did not appear as significant as expected. For that matter, neither were providervariables (e.g., mental health/substance abuse settings,hospital-/community-based settings).

Moreover, while obtaining adequate funding is alwaysa challenge to providing a full range of mental healthand substance abuse services, participants describedhow they were able to access and leverage local,State, and Federal funds that provide basic programsupport. For example, Medicaid—a primary fundingsource for most public-sector treatment programs—provides greater financial support for mental disordersthan for substance abuse disorders. Yet most successfulprograms and systems of care addressed this chal-lenge by finding ways to supplement Medicaid.

Funding, therefore, is a predictable but not necessarilyinsurmountable barrier to success. Interestingly,State- and/or county-defined benefit packages andthe regulatory environment were identified as moresignificant variables.

Finally, this report outlines a series of recommenda-tions and “next steps,” including:

Promoting networking among participants andother stakeholders involved in building treatmentprograms and systems of care for people with co-occurring disorders

Enabling these same groups to share informationand tools more easily

Increasing program support, especially for transi-tioning from grants to ongoing funding sources

Strengthening systems of care at the State, county,and regional levels

Fostering workforce development strategies

Creating “roadmap” products that will build on current knowledge for developing treatmentprograms and systems of care

Establishing new approaches to funding issues.

C H A P T E R 1

Mental health and substance abuse programshave faced the growing challenge of treating

people with co-occurring mental and substanceabuse disorders for more than 25 years. The currentnumber of people with co-occurring disorders is high,and it is increasing. Conservative estimates suggestthat, in any given year, as many as 10 millionpeople in this country have a combination of co-occurring mental and substance abuse disorders,according to the 1994 National Comorbidity Survey.Field reports from member organizations of theNational Council for Community BehavioralHealthcare (National Council) and StateAssociations of Addiction Services (SAAS) indicatethat the number is actually significantly higher, andcommunity providers belonging to the CaliforniaCouncil of Community Mental Health Agenciesreported in 2000 that as much as 80 percent of peo-ple seeking treatment presented with some form ofco-occurring mental and substance abuse disorders.

Nevertheless, many people with co-occurring disor-ders receive treatment for only one of their disorders.Even when a person receives treatment for both, it ismost often from separate, uncoordinated systems.Therefore, experts widely believe that people withco-occurring disorders are inadequately served in thiscountry—a problem that affects all age groups.

People with co-occurring disorders often experiencemultiple health and social problems and require treat-ment that cuts across several systems of care, includingsubstance abuse, mental health, primary health care,and other services. Moreover, many people with co-occurring disorders are homeless and/or connected tothe family court, juvenile, or criminal justice system.Yet no single system of care is—on its own—adequate-ly prepared to help people with co-occurring disorders.

Providing the appropriate types of services (i.e.,when and to what degree they are required) presentsformidable challenges in public health settings.These challenges are intensified when coupled withthe numerous barriers that often limit coordinationand integration efforts, including:

A lack of any significant connection betweenmental health and substance abuse provider andservice programs

Separate, and often unequal, public and privatehealth insurance benefits for the treatment ofmental and substance abuse disorders

The lack of a single center of responsibility for thetreatment of individuals with co-occurring disorders

A shortage of training opportunities, creating asituation whereby too few staff are trained in treat-ing both mental and substance abuse disorders

Differing treatment philosophies in the mentalhealth and substance abuse treatment fields

A reluctance by clinicians to address co-occurringdisorders, particularly when one of the disorders isin an area in which the clinician is untrained

Too little research-based guidance for the treatmentof people with less severe co-occurring disorders

Limited staff assessment skills and the infrequentuse of assessment/screening tools that can accu-rately identify co-occurring disorders

Funding shortages for substance abuse and mentalhealth treatment in general and for co-occurringdisorders in particular

Differences in the ways States fund and regulatecare (and in some cases, differences between counties and regions within the same State).

Despite all these barriers, numerous programs andsystems of care—many of them community-based—are successfully operating. The Substance Abuse andMental Health Services Administration commis-sioned this project to identify how they have beenable to surmount obstacles and provide coordinatedcare for this vulnerable population. To minimize misperceptions, promote inclusion, and ensure that

Introduction

1

C H A P T E R 1

the full range of successful programs were considered,SAMHSA contracted with two of the Nation’s lead-ing nonprofit associations to conduct research andprepare this report:

The State Associations of Addiction Services isthe only national organization of State alcoholand drug abuse treatment and prevention providerassociations, representing 33 such groups in 29States. As a result, SAAS has ongoing access tothousands of community-based substance abuseprograms across America.

As the country’s largest and oldest membershiporganization of its kind, the National Council forCommunity Behavioral Healthcare is dedicated toensuring that everyone can access appropriate andaffordable community-based mental health andsubstance abuse treatment. Built on a network of 750 member organizations in 39 States, theNational Council is committed to creating andsustaining communities that are healthy and secure.

2

Methodology C H A P T E R 2

A s a first step, SAMHSA, SAAS, and theNational Council educated their members

about the project to ensure they fully understood itsoverall goals. With this preparation, they were ableto help identify and solicit potential candidates fortwo distinct expert panels and for telephone inter-views. As a result, leading thinkers on co-occurringdisorders from across the Nation participated in theproject.

For the first panel, SAAS and the National Councilasked their members to identify program representa-tives, consumers, and experts who could provideinsights on program-level issues. The first expertpanel focused on how providers can initiate and sustain programs—identifying barriers and strategiesfor overcoming them and highlighting the necessarysupports, including staff training and curriculaneeds.

Two months later, SAAS and National Councilmembers helped identify State-, regional-, and county-level managers and other systems experts for the second panel. This group of experts would focusmore on administrative perspectives, concentratingon how to create and sustain systems of care that foster coordination and continuity between treat-ment providers and programs.

SAAS and National Council members canvassedproviders, consumers, and experts in their States toidentify diverse representatives at both the programand systems-of-care levels. This process involvedtelephonic, electronic, and written communicationwith providers and organizations that fund systems of care for people with co-occurring disorders. Theyalso sought nominations from experts who could recommend programs and systems that were in various stages of development. More advancedmethods included meeting with representativesfrom organizations specifically concerned with thisissue. For example, one State association’s dual diag-nosis committee took responsibility for nominatingand prioritizing the most suitable experts within the State.

Using the Co-Occurring Disorders by SeverityMatrix (Appendix A), nominators had to provideinformation on the nature and severity of the co-occurring disorders that the nominees treated. To provide detailed information about a nominee’sassociated program, nominators had to complete astandard nomination form (Appendix B). This formalso requested that the nominee attach programbrochures and other evidence of his or her program’seffectiveness, such as published outcomes and evalu-ation reports. To address a different project goal, thisform also requested that nominees provide names of and/or copies of co-occurring disorder trainingcurricula (Appendix F).

Because many States nominated multiple individuals,SAAS and National Council members used a specialscreening process to establish a final slate of partici-pants. Although informal, the screening criteria generally included the following:

Degree of the nominee’s expertise

Diversity of the populations that the nominee’streatment program serves

Willingness and availability of the nominee toparticipate during the scheduled timeframes.

The first criterion—the nominee’s degree of expertise—was not itself sufficient to guide the selectionprocess. Many individuals were identified as experts,and determining who had the most expertise was difficult. To narrow the list of possible participants,SAAS and National Council members made followup calls to nominees and further reviewedtheir resumes and their references from colleagues.

The second criterion—the diversity of the popula-tions served by the nominee’s treatment program—proved to be one of the most useful variables in the selection process. The nomination form provided information about the demographic diversity (e.g., age, race, gender, area of residence) ofthe co-occurring populations that the nominee served.

3

C H A P T E R 2

As an attachment to each form, the Co-OccurringDisorders by Severity Matrix helped nominatorsdescribe the problem severity diversity of the nomi-nees’ programs. This matrix is based on the followingcategories:

Less severe mental disorder/less severe substanceabuse disorder

More severe mental disorder/less severe substanceabuse disorder

Less severe mental disorder/more severe substanceabuse disorder

More severe mental disorder/more severe sub-stance abuse disorder.

SAAS and National Council members made a con-scientious attempt to create panels that reflectedvarious demographic characteristics and problemseverity categories.

The third criterion—the nominee’s willingness andavailability to participate in the expert panel duringthe scheduled timeframes—was also an importantconsideration. Some individuals possessed the requi-site background but were either unavailable on thescheduled dates or reluctant to participate for otherreasons.

When scheduling was the issue, SAAS and theNational Council made efforts to capture as muchinput as possible via telephone interviews. Whenindividuals were reluctant to participate, SAAS and

the National Council tried to identify the reasonsand attempted to reduce these barriers. Some individuals expressed concern over the recordingmethods that would be used during the expert panelmeetings. For example, some said their ability tooffer candid opinions would be restricted if theirremarks would be formally attributed to them.Others were worried that their opinions and recom-mendations may not be representative of theiremployers. SAMHSA project officers and represen-tatives and Dr. Ken Minkoff—a nationally renownedexpert on co-occurring disorders—reviewed the finalslates for each panel. The process helped solidify thefinal selections and a few backup nominees to fill inshould there be cancellations. To enable each expertto participate fully, each panel had a maximum of 12people, thus promoting open dialog. (Please seeAppendix C for participant profiles.)

SAAS and the National Council conducted tele-phone interviews with the experts who were unableto attend a panel in person or who could enhanceexpert panels with their specific knowledge and/orexperience. It should be noted that although somegaps needed to be filled, the actual number of phonecalls was lower than originally expected.

Both expert panels met in Washington, D.C.—thefirst in February 2001 and the second in April of thatyear. For a summary of the important findings fromthese panels, please see Appendices D and E of thisdraft report.

4

Key Lessons C H A P T E R 3

A common assumption heading into this projectwas that there are insurmountable barriers

to providing integrated treatment for people with co-occurring disorders—especially funding barriers.As a result, both the expert panels and telephoneinterviews were structured to elicit discussion ofthese barriers.

The information gathered via this project, however,tells a very different story. Without a doubt, fundingand regulatory issues, tight labor markets, and thehistorical differences between the fields of mentalhealth and substance abuse can cause difficulties inestablishing and sustaining successful treatment pro-grams for people with co-occurring disorders.1 Yetevery day across America, providers and systemsadministrators use their perseverance, creativity, andleadership to minimize, sidestep, and/or overcomethese types of obstacles. Consequently, this projectoffers a crucial overarching lesson: These so-calledbarriers are not insurmountable.

Five specific lessons from this project—outlinedbelow—build on this premise. In this chapter, exam-ples and quotes from the participants help illuminatethese lessons.

1. There are many replicable strategies and tools—often simple and inexpensive—that people in the mental health and substance abuse treatmentfields can use to successfully provide treatment forpeople with co-occurring disorders.

2. Leadership is a key ingredient for ensuringprogress at both the provider and systems levels.

3. When initiating and sustaining programs and sys-tems, it is important to involve numerous stake-holders, including consumers and family members.

4. On the whole, provider-level programs are furtherdeveloped than systems-level initiatives.

5. Demographic differences (e.g., geography, popula-tions served) and differences between types of

providers (e.g., mental health/substance abuse,hospital-/community-based) appear to bear littlesignificance when developing and sustainingtreatment programs and systems of care for peoplewith co-occurring disorders. By contrast, State and county benefit packages and the regulatoryenvironment appear to be much more significantvariables.

Together, these lessons highlight that providing integrated treatment for people with co-occurringdisorders is becoming an expectation within qualitycare.

Lesson One:There are many replicable strategies and tools—often simple and inexpensive—that people in themental health and substance abuse treatmentfields can use to successfully provide treatmentfor people with co-occurring disorders.

Participants identified many strategies for initiatingand sustaining programs and systems of care for peo-ple with co-occurring disorders. Sometimes, however,initiating a program or system can require differentapproaches and skills than are needed to maintain orgrow it. (When applicable, the following sectionsnote this distinction.) The following eight strategiesaddress that issue:

1.Start with what you know and build from there.Many of the success stories at both the provider andsystems levels evoked this simple premise. Instead ofstarting an entirely “new” program, this strategyenables programs and systems to build on their current knowledge, skills, and strengths whileexpanding gradually, for example:

An addictions detox provider bolstered the program by adding a trained mental health profes-sional for treatment and consultation.

A hospital-based mental health program reversedan old policy and began accepting patients with a co-occurring substance abuse disorder.

“We don't really have

to wait for more

money to do this job

right, we just have

to focus on one and

one makes three.”

1 Detailed lists of barriers, as described by the expert panelists, can be found in Appendices D and E of this draft report.

5

C H A P T E R 3

A halfway house and a mental health clinic formeda partnership to provide more care for their mutualclients.

Rather than building new clinics or programs, alarge metropolitan public provider used its exist-ing community-based mental infrastructure as afoundation for its co-occurring disorder initiatives.This provider used State demonstration grantmoney to foster training, coordination activities,and specialized services.

Many systems administrators, especially State andcounty purchasers, convened workgroups fromacross funding lines to discuss clearly identifiedproblems. Workgroups cochaired by staff fromboth substance abuse and mental health fields can often clarify problems and identify the bestsolutions.

Some State and county systems administrators responded to pressure from criminal and juvenile,child welfare, and other service systems by devel-oping pilot programs that worked across traditionalbarriers.

A number of systems administrators studied datathat highlighted how some difficult clients weredoing better than others and found common treat-ment themes in both mental and substance abusedisorders. These administrators then championedthese programs as best practices from which otherscould learn.

2.Use an incremental approach.An incremental approach enables individuals, pro-grams, and systems to build confidence as they takeon the task of providing treatment to people with co-occurring disorders. Incremental approaches alsomade the transitions much easier for both clients andstaff members, greatly decreasing the providers’ senseof being overwhelmed. For systems, an incrementalapproach enhanced planning and provided time tochange regulations, purchasing requirements, andother potential obstacles, for example:

A residential treatment program for people with sub-stance abuse problems began accepting people withco-occurring disorders—one diagnosis at a time. Itfirst accepted people with co-occurring schizophreniaand substance abuse disorders. Staff memberslearned about the characteristics of schizophrenia,the appropriate treatments and medications, andother necessary supports. As they gained compe-tence and confidence in helping this population,they gradually added people with different diag-noses, gaining the knowledge and skills they neededat a manageable pace. This incremental approachallowed them to modify their program gradually,thus easing the transition for existing clients.

Although recognizing that people with co-occur-ring disorders need an array of services, many participants suggested beginning with one or twoservices or programs and adding more gradually.This approach gives systems administrators timeto work with their existing provider network2

to expand staff and strengthen support tools inreadiness for broadening treatment programs.

Incremental approaches are also well suited to the fact that treatment facilities, programs, andindividual providers often face vastly differentlicensing and certification standards. Participantsstressed interim steps, such as simplifying andchanging licensing and certification requirementsfor serving people with co-occurring disorders.They accomplished this in various ways, such as:

Employing both certified mental health andsubstance abuse counselors and helping thembecome dually certified

Encouraging governing bodies to meld regula-tions for facilities and programs seeking tobecome licensed in both mental health and sub-stance abuse treatment (but it is vital that suchfacilities and programs “get the ball rolling”under the current guidelines)

2 Organizations, professional groups, or professionals that align themselves (or are chosen by a purchaser) in a formal or informal way to ensure a broad continuum of

services to defined populations.

6

“We said we’re going

to use the existing com-

munity infrastructures.

Instead of developing

new residential pro-

grams, we used the

existing program and

added one staff mem-

ber in there. Instead

of developing a whole

new system for the

mental health agency,

we put one (substance

abuse) counselor

in here.”

“So what we look for

is interagency initiatives

which require little

or no money, which

require a lot of collabo-

ration, and just building

on very carefully what

we're doing already,

that we could just do

slightly differently.”

C H A P T E R 3

Having systems administrators contract withtwo different agencies—each one providing adistinct mental health or substance abuse serv-ice but under the provision that they worktogether on joint clients.

3.Bring together existing local resources and personnel to provide seed dollars to develop a program or system.

Although grants or demonstration funds are almostalways welcome, participants in this project foundways to provide quality treatment without new fiscalresources. At both the provider and systems levels,they discussed the “savings” that occurred once theirco-occurring treatment services were in place.Simply removing systemic and programmatic duplications led to financial savings that could be reinvested in treatment. Providers and systemstaking the initiative to use existing funds more efficiently were also better positioned to acquirefunds from other sources.

At the provider level, the type of savings dependedin large part on how the programs were funded.Some programs saved money by reducing crisisexpenditures, some reduced the number of rehospi-talizations for which they were financially at risk,and others were able to leverage their improved efficiency to expand treatment without increasingstaff. One program for co-occurring disorders reportedgetting a larger contract from a health maintenanceorganization because it reduced patients’ use of costlyemergency services.

At the systems level, most savings were realized byreducing expenditures on more intensive and expen-sive levels of care. These savings then became asource of funding for the programs’ maintenance andexpansion.

Funds for serving people with co-occurring disorderscan also emanate from outside the traditional mentalhealth and substance abuse public purchasers.Providers are able to contract with numerous publicservices (e.g., criminal and juvenile justice, educa-tion, child welfare, welfare-to-work programs) to

serve people within their jurisdiction. State andcounty systems can take this approach a step furtherby implementing Intergovernmental Agreements(IGAs) or a Memoranda of Understanding (MOU).These cross-agency agreements can give the behav-ioral health system more funds to expand to betteraccommodate people with co-occurring disorders.Technically, these are not new funds; they wereavailable within the public system.

Similarly, program and systems representativesexamined methods of sharing human resources. Forexample, a mental health program and a substanceabuse treatment program could both provide coun-selors to start a treatment group for people with co-occurring disorders. Likewise, an experiencedclinical supervisor or psychiatrist could work withstaff across programs. At the systems level, teamsworking on dual diagnoses draw from existing staff indifferent State or county departments.

4.Establish a colocation.Programs enjoyed more success when staff, clients,and treatment areas were geographically closetogether. They were least successful when staffand/or clients had to travel to different locations forvarious services—even when they were merely ondifferent floors of the same building. Proximityenabled programs to create multiple strategies to provide more integrated treatments, for example:

When mental health and substance abuse pro-grams were merged to initiate programs or expand into new areas, colocation took many forms. Someof the more successful approaches included establishing joint supervision (e.g., coleaders orco-program directors from each program) andsharing office space.

Sometimes colocation meant placing staff fromone program into another environment. Forexample, mental health caseworkers were placedat a substance abuse detoxification, treatment,and followup facility. In a contrasting case, mentalhealth and substance abuse counselors were placedat the local emergency room or county jail.

7

“I think the one thing

that helped us was

really just getting both

staffs together and

sitting down and

talking. It’s almost

as simple as that.”

“And if you have a

budget that never goes

up—I mean, we’ve

been operating under

the same budget

forever—and you’re

trying to make it go

around as fairly as

possible, it’s in your

best interest for people

to get well or to need

a less intensive level

of services than they

would need otherwise.”

C H A P T E R 3

Furthermore, a residential program hired a pharmacist, enabling clients to get their medica-tions on site rather than having to be transportedto a mental health facility.

Providing onsite psychiatric consultation andtreatment can be crucial. More access and availability problems arose when psychiatrists hadto go “out of the way” to provide treatment. Forinstance, one program using psychiatrists from ahospital 4 miles away had difficulty maintainingregular psychiatric services for clients with co-occurring disorders. The situation changedwhen the program moved across the street fromthe hospital.

Organizing regular joint staff meetings and train-ing opportunities also increased the success oftreating people with co-occurring disorders. Byfocusing on shared clients, staff members frommental health and substance abuse programs wereable to bridge their differences of approach, philosophy, and professional background.

Systems administrators also reported that jointtraining on serving people with co-occurring dis-orders was a key strategy to laying the foundationfor future success.

Many program representatives reported that stafffrom different programs and backgrounds neededto get to know each other personally as well asprofessionally. Opportunities to socialize (e.g.,staff picnics, placing offices next to each other)helped foster teamwork and a healthy respect fordifferent philosophies and skills.

5.Collect and use data on effectiveness.Collecting and using data related to program effec-tiveness can help initiate and sustain treatment programs and spark systemic change. Indeed, manyparticipants reported that data on relapse rates (i.e.,how often a client returned to a more intensive levelof care or resumed abusing substances) was oftentheir first and most powerful measure. When they

discovered that their treatment programs for co-occurring disorders reduced relapse rates, they hadpowerful tools for expanding their programs. By collecting this vital data, programs could seek other sources of funding and convince opponents of the validity of their approach to treating co-occurring disorders.

Successful programs and systems rapidly learned theneed to measure many variables, including clinical,financial, and social effectiveness. At the systemslevel, for instance, data that demonstrated costreductions and showed that clients experiencedimproved quality of life were powerful ammunitionfor additional systemic changes, especially for tack-ling difficult regulatory obstacles.

Participants stressed the importance of starting withsimple, realistic expectations about using data, asexisting information systems often capture only partof the story. For example, co-occurring treatment pro-grams might not be able to access data about rehospi-talization that is contained within the mental healthdata system. Likewise, privacy regulations intended toprotect the confidentiality of people receiving sub-stance abuse treatment might limit the amount ofdata available to a psychiatric provider. As a result,programs for co-occurring disorders, and systems seek-ing to evaluate their treatment and approaches, mustoften create their outcome measures and data sets.

6.Employ a problemsolving approach.Successfully building programs and systems oftenrequires taking a problemsolving approach—onethat stresses being helpful instead of complaining.Participants at both the program and systems levelsreported that this type of approach was often morepowerful than approaches based on philosophy orneed, for example:

A rural substance abuse residential service noticedthat its recidivism rate (i.e., the frequency of repeatadmissions) was highest for clients who also hadmental disorders. As a result, representatives offeredto provide the local mental health clinic with a

8

“One of the myths I

get back to again is,

if I only had a single

stream of funding, I

wouldn't have these

problems. Yet it flies in

the face of everything

we know about health

care. We have all kinds

of collaborative, coop-

erative relationships in

health care. When I go

to the hospital, I have

a primary care clinician,

but I'm going to see

a specialist if needed.

They don't have to

pool their funded

money to get paid.”

C H A P T E R 3

substance abuse case manager to assist with theseclients when they were released from the treat-ment center. They started with the more difficultcases, but when this dual approach showed results,a more formal treatment partnership was formed.

Mental health professionals can provide trainingfor substance abuse caregivers on how to handle disruptive behaviors.

By working at a substance abuse treatment facility,a mental health case manager can develop rela-tionships with clients before their release and helpwith discharge and transitional planning.

Many programs for co-occurring disorders werecreated in response to clients’ deaths or neardeaths. For instance, a mental health patient candie from an overdose due to self-medicating, or a substance abuse client might commit suicide.Programs for co-occurring disorders are potentialsolutions to these types of problems.

7.Use assessment and other tools.Specific tools for co-occurring disorders (rather than just mental or substance abuse disorders) canimprove assessment, outcome measurement, servicedelivery, and other aspects of care at both the program/provider and systems levels. Most represen-tatives report developing these tools in isolation, butthis situation is beginning to change with better distribution and federally supported disseminationstrategies. The following tools proved valuable inbuilding and growing programs and systems of carefor people with co-occurring disorders:

Common values and principles—At the pro-gram level, common values and principles mostoften develop when mental health and substanceabuse programs fused. As for systems—especiallyState and county systems—developing shared-value statements and principles is often the first step to bridging departmental and agency differences.

Core competencies—Several States have out-lined the core competencies needed to serve peo-ple with co-occurring disorders. These lists provideprograms with roadmaps for selecting, training,and supervising staff and for developing treatmentservices.

Clinical/treatment guidelines—An increasingnumber of scientifically based treatment and med-ication guidelines and best practices are emerging inthe arena of co-occurring disorders. Some States andcounties found that creating treatment guidelineswas one of the crucial developmental steps in build-ing a system of care. Historically speaking, treat-ment guidelines are usually derived from actualclinical practices and are then used to promote con-sistency across service delivery sites and individualproviders. While only a few participants had fullyimplemented clinical guidelines, they all believedthat these tools were important to have soon.

Assessment tools—Many programs and cliniciansmay have assessment tools designed specifically foreither substance abuse disorders or mental disor-ders. However, tools that can identify needs inboth areas enable more integrated treatment.

Outcome measurements—As another key tool,outcome measurements specific to the treatmentof people with co-occurring disorders make it easierfor both programs and systems to achieve progress.Accordingly, many organizations are starting tomodify their single-focus outcome measurementsto be more useful for treating people with co-occurring disorders.

Common vocabulary—Programs and systemsboth reported the need to develop a commonvocabulary. Indeed, terms such as recovery,relapse, community support, self-help, and con-sumer involvement are often used differentlywithin the substance abuse and mental healthfields. Many participants reported that the processof developing the common vocabulary sparkednew training tools.

9

“I have three residential

directors who actually

sat down with our

information technology

person and developed

their own database

because they were so

frustrated with what

they were getting from

the State. Now not

only can they compare

what’s going on within

their own programs,

but they can compare

data sets between the

two detox programs

or between the two

transitional support

programs so that we

can really see who’s

doing better where.”

C H A P T E R 3

Psychiatric services—Participants from successfulprograms reported that having access to an experi-enced psychiatrist who understands how to treatpeople with co-occurring disorders was critical.Having such a professional on staff can promoteeven better results.

Consensus building—SAMHSA CommunityAction Grants addressed the formal consensus-building processes by providing funds for developingand disseminating common language, values, andtools. The Community Action Grants alsoenabled States and counties to replicate the pro-cess, which has proven to be valuable in a varietyof settings.

8.Promote training.Participants often cited training—at all levels—as themost critical factor in building programs and systems ofcare. Whether geared to systems and program changeor to staff development, training was most valuable asan ongoing process. This approach allowed staff toapply their existing skills and knowledge within anevolving environment, while gaining new knowledgeand skills. Programs and systems found many trainingtools and strategies to be effective, for example:

Increasing the attention paid to training issuestook commitment from senior leaders of providerorganizations and systems administrators. Forinstance, one State initiated a multiyear process ofbuilding readiness and staff competencies withinits provider network.

Training covers a wide range of activities, such asskill building, knowledge acquisition, and attitudeshaping. Important areas include:

Common vocabulary (outlined above)

Different conditions and treatment approachesin both the substance abuse and mental healthfields

Medications and their appropriate uses

Symptoms

Family support

Training for managers and supervisors on howto support co-occurring disorder programming.

Several programs for co-occurring disorders suc-cessfully used “shadowing” and “buddy” training.In these models, new employees and transfers fromsingle-focus programs learn from exemplaryemployees in programs for co-occurring disor-ders—usually for 1 week or more. This approachenables new employees to gain practical knowl-edge and skills and to learn about the program’sculture and philosophy.

In one State, new staff members rotate throughco-occurring treatment programs, spending 60hours in these settings as if they were clients.

Taking exemplary staff from an existing settingand making them the core team is a useful strate-gy to expand programs for co-occurring disordersinto new settings. This provided the new programwith successful strategies immediately, enablingnew staff to learn from the best.

Many programs and systems enlist the help oflocal colleges and universities to develop stafftraining programs.

Providing special training programs for behavioraltechnicians and encouraging staff to get certifiedin dual diagnosis can help overcome workforceshortages.

Consumers and their family members can be powerful trainers and help initiate beneficial program and system changes.

Physicians who have only worked in mentalhealth settings often need training on the impactand interaction of medications for people withsubstance abuse disorders.

1 0

“I think the hardest

question was determin-

ing what we need first.

The challenge is to

figure out in which

sequence our needs

must be met and what

has to be sequenced

and what can happen

concurrently.”

“I think that it is incred-

ibly important to have

people who are in

recovery and beyond

the treatment process

to speak about what it

was like for them too.”

“But, you know, it's

face time and it's legis-

lation by anecdotes.

And the anecdotes

need to be mine.”

C H A P T E R 3

Importing staff with experience in building andsustaining treatment programs for people with co-occurring disorders can jump-start the develop-ment process.

Lesson Two: Leadership is a key ingredient for ensuring progressat both the provider and systems levels.

One of the most striking issues during the expertpanels and telephone interviews was the role of indi-vidual leadership. At provider and systems levels,initiating and sustaining beneficial change requiredongoing vision, perseverance, motivation, and hardwork. Although not everyone working in the fieldhas had leadership training, many leadership strate-gies can be used across the field of co-occurring disorders, for example:

Many participants stressed the importance of takingtime to build personal relationships when forgingpartnerships between treatment teams, programs,organizations, and public purchasers. They tooktime to seek out counterparts, listen to areas of con-cern (i.e., resistance), forge problemsolving coali-tions, and discover common goals and values. Theyshaped relationships in both formal and informalsituations, including task forces, negotiating meet-ings, private conversations, and shared meals.

Successful leaders took a strong interest in settingthe culture of their program or system. They estab-lished a “can-do” approach that strengthenedproblemsolving and created conduct norms to bet-ter define their organizations and cultures. Thesenorms included rules such as:

“We will respect each other’s backgrounds.”

“We will not tolerate violence—in language orin action.”

“We will find ways to learn from each other andembrace collaboration instead of seeing whichside wins.”

Leaders, particularly in provider settings, reported hav-ing to reinforce these values by disciplining employeeswho took competitive or disrespectful stances.

Successful leaders also cultivated relationshipswith the “people at the top,” including directbosses, provider CEOs, State agency directors, andcounty health directors. Leaders kept these impor-tant people informed and helped strengthen theircommitment to providing treatment programs forpeople with co-occurring disorders. Strong leadersalso prepared these VIPs for possible disruptions or discontent during systems changes so that theywould not be dissuaded. Moreover, leaders useddata on program effectiveness and cost-efficiencyto enlist stakeholder support for broadening andexpanding these programs.

For many participants, “people at the top” alsoincluded elected State and county officials as wellas consumer and stakeholder groups. Educatingelected officials and other people about financingneeds and the potential results for consumers,their families, and communities—in languagethey and their constituents can easily comprehend—is a critical relationship-building skill.

Leaders at both the provider and systems levels regularly commented that changes always tooklonger than originally planned. As a result,patience and perseverance were major compo-nents of effective leadership. At the same time,leaders must keep staff motivation strong by regularly stressing that, although things were moving slowly, there was still progress. Duringlengthy preparation periods, leaders frequentlyneeded to reinforce the initiative’s ultimate goals.

Whether building and expanding systems of care or programs at the provider level, partici-pants reported that stakeholder requirements canbe overwhelming and complex. As one respon-dent said, “That’s a struggle—do we just do it all at once or can we just bite off a small piece?”Despite working in complex systems, successful

1 1

“Over the course of

the last 3 years, we’ve

developed a shared

philosophy among both

chemical dependency

and mental health

about how we’re both

viewing this patient

philosophically and

how we’re treating

the individual.”

“What helped me

break through barriers

between programs was

solving problems for

people. I was able to

go to the treatment

staff and say I can help

you with that problem,

and then I’m going to

show you how to keep

doing it so that you

can keep solving that

problem.”

C H A P T E R 3

leaders can maintain their focus and overcomethese challenges by focusing on one task at a time.

Lesson Three:When initiating and sustaining programs and systems, it is important to involve numerous stake-holders, including consumers and family members.

Two points on this topic stood out:

1.There is a broad range of stakeholders.Within provider agencies, stakeholders includestaff at all levels, especially those directly involvedin delivering treatment. Employees in areas suchas reception, billing, and information systems arealso very important, as their work could affect programming success. Personnel who could referconsumers to the program for co-occurring disor-ders are also critical, as are those who could provide other levels of care.

Many programs were initiated as partnershipsbetween two or more provider organizations. Theemployees at these organizations were obvious stakeholders. More broadly, it is important toinvolve other provider organizations that couldrefer consumers and/or serve them and their families in other capacities.

Consumers and family members who are or mightbe served by the program are key contacts.Especially at the systems level, consumer involve-ment and family member advocacy organizationsare also critical for broadening support. Thesegroups contributed in many ways, such as organizingadvocates, providing testimony, raising awarenessand money, and describing how treating peoplewith co-occurring disorders can make a positiveimpact on voters and communities.

Serving people with co-occurring disorders is a complex process at every level. Many people needingtreatment require services for other needs, includingcriminal justice, domestic violence, homelessness,childhood and adult education, juvenile justice,

child welfare, public health, and employment services.At the systems level in particular, stakeholdersalso include representatives from the police, emergency rooms, and the crisis system. Strongrelationships with these stakeholders can lead toincreased cooperation and new types of partnerships.

Legislative and governing bodies, such as countyboards of supervisors, mayors, or State lawmakers,are key stakeholders. By involving and educatingthem, many participants established greater support for a coordinated approach to serving people with co-occurring disorders.

2.A great deal of behavioral health history hasinvolved building consensus with stakeholdersbefore taking action.

Many participants in this project described theimportance of involving and informing stakeholdersbut also stressed that providers and systems shouldact before consensus is reached. The goals of inter-acting with stakeholders are to provide informationand build relationships. One expert described thisapproach (in contrast to the consensus approach) as“inviting participation in the change process ratherthan in the design process.”

Lesson Four:On the whole, provider-level programs are furtherdeveloped than systems-level initiatives.

There are many models and examples of successfultreatment programs for people with co-occurring disor-ders. In fact, some treatment programs were establishedas long as 20 years ago. Some participants describedprograms that had failed after starting up but wererebuilt with a better understanding of what not to do.

Almost all participants had experienced severaldevelopmental stages within their own programs andregularly communicated with programs in theirregion and/or State, sharing stories, skills, and strate-gies. Respondents discussed how they got started andmaintained their programs—growing, changing, and shaping them over the years. Programs and

1 2

“We spent time develop-

ing a common language.

For the substance abuse

providers we had to

differentiate what a

hallucination is—how

you differentiate that

from an idea, what’s

the difference between

a delusion and just a

religious thought. We

did the same thing on

the mental side. When

we talk about addic-

tion, we’re not making

any distinction between

a schizophrenic who

has three beers a month

and somebody who is

drinking a quart of

whiskey a day.”

C H A P T E R 3

systems can use this collective body of experience toinitiate better treatment programs for people withco-occurring disorders.

This rich history also underscores the overarchingtheme of this report: Obstacles are not insurmount-able. Many programs have had years to find ways toresolve or circumnavigate obstacles. Although morerecent programs may still experience frustrations,they have “older siblings” they can turn to for strate-gies, advice, and support. Now there are numeroustools, including guidelines, curricula, and programdefinitions. As late as 10 years ago there were noneat all. Current challenges, therefore, focus not oncreating new models or tools but rather on applyingwhat is known and quantifying results.

Conversely, most planned systems of care for peoplewith co-occurring disorders, including State, county,and regional provider networks, are in their infancy.Only recently—within the past few years—havethey crafted plans to maximize existing services, fill ingaps, and coordinate services that provide integratedtreatment for people with co-occurring disorders.

Often these public purchasers had developmentalplans that simply placed the substance abuse agencyand the mental health agency in the same Statedepartment or division. Sometimes they were blendedtotally. Even with this administrative blending, twodistinct provider networks often remained, separatedby their contracts, licensing requirements, regulations,service definitions, and payment mechanisms.

Many counties and States are currently in the pilotor demonstration stage of developing their systems;others are in the planning stage, forming “dual diag-nosis task forces.” A few are now laying the ground-work among providers and stakeholders via trainingand knowledge dissemination. Although some are inthe early stages of implementing proposals, others arejust now ready to issue Requests for Proposals (RFP)and Requests for Implementation (RFI), solicitingproposals for developing, funding, and implementingprograms for people with co-occurring disorders.

As a result, even the experts know less about whichapproaches will work best in initiating programs forco-occurring disorders at the systems level. Becausethere is a heavy emphasis on development, it is hardto make conclusions at this time about what willwork best to sustain and grow these systems.

However, people developing systems should build onthe best practices that are currently emerging in thefield. Indeed, numerous models are materializingfrom the Comprehensive Continuous IntegratedSystem of Care grants in at least 10 States.(Additional information on these grants is availableon SAMHSA’s Web site at www.samhsa.gov.)

In States with strong county-level systems, countiesmay be at different points than their State funders.Some county systems are ahead; others lag behind.These differences arise, in part, because many coun-ties have a history of providing direct treatment aswell as being contractors and systems administrators.On the other hand, being smaller than their Statecounterparts, and enjoying greater geographic proximity to their provider networks, many county-level systems require fewer resources.

In any case, county-level systems and their regionalprovider networks are often in a blended position,with the difficulties and advantages of both providersand State systems. As a result of this complex mix,counties and regional networks may benefit fromexamples that are specific to their situations. These“in-between” systems have used a variety of strategies:

Some counties purchase co-occurring disorderprogramming. Perhaps serving only a small numberof people, they are significant nonetheless, repre-senting a new category of service for the county.

Other counties promote “capacity building” viacontracting and purchasing. For example, one coun-ty systems administrator and purchaser described agap analysis that demonstrated areas of need withintheir provider network. The county then used discretionary funds to develop programming to fill

1 3

“The first year we put

$100,000 into training;

the second year they

told us we couldn’t

spend any money

on training at all—

it had to go to client

services. But if I’d

had my druthers, I

would’ve spent another

$100,000 on training.”

C H A P T E R 3

in some of the gaps—increasing its capacity to buildmore co-occurring disorder programming.

In some areas, counties selectively apply “waivers”for regulatory requirements, such as obtaining licen-sures to get a program jump-started. As one countydirector said, “Sometimes you just have to start serv-ing the people and then fill out the paperwork.”

Some States are issuing RFIs and RFPs for county- and/or regional-level services; others arecreating service definitions and reimbursementmethodologies.

Systems of care—whether at the State, county, orregional levels—actually serve as wraparound sup-port. Even very successful programs may only providetwo or three points on a continuum of care for people with co-occurring disorders. Without othertreatment options to meet the consumer’s needsbefore and after treatment, any program is less effec-tive, leaving the consumer without necessary care.Fortunately, a system of care can identify program-ming gaps and then build treatment and supportcomponents that meet the most acute needs in a particular area.

On another front, many programs often face—andovercome—similar obstacles, including regulationsand differing service definitions, licensing require-ments, accounting standards, and workforce devel-opment strategies. County, regional, and Statesystems can help resolve or diminish some of theseobstacles, leaving programs with more resources fordelivering treatment.

Lesson Five:Demographic differences (e.g., geography, populations served) and differences betweentypes of providers (e.g., mental health/substanceabuse, hospital-/community-based) appear tobear little significance when developing and sustaining treatment programs and systems ofcare for people with co-occurring disorders. By contrast, State and county benefit packages

and the regulatory environment appear to bemuch more significant variables.

SAMHSA, SAAS, and the National Council wentto great lengths to make sure this project reflecteddiversity, inviting a wide range of representatives toparticipate in the expert panels and telephone inter-views. This goal was at least partially rooted in theassumption that differences among the representa-tives (e.g., geographic location, types of consumersthey served) would produce significant differences inapproaches, needs, and strategies.

Differences were noted, but a lot of common groundwas revealed as well. For example, representativesfrom large, rural areas serving fewer than 20,000 peo-ple could often relate to the experiences of inner-city,minority providers who served populations largerthan 1 million. Moreover, faith-based providers andState agencies faced many of the same challenges,and hospital-based programs discussed many of thesame issues as community-based programs.

Therefore, although participants acknowledged thechallenges of serving culturally, ethnically, andsocio-economically diverse client populations, theirbigger challenges lay in navigating the benefit andregulatory designs.

Benefit Design and Regulatory IssuesSignificant differences did emerge when participantsdescribed the limitations imposed by State and county benefit packages and regulations. For exam-ple, some States have public mental health money available for treating only people with serious andpersistent mental illnesses. Other States have broaderdefinitions. These differences also affect how peoplewith co-occurring disorders are treated.

Additionally, Medicaid—a major funder—pays differently in most States for mental and substanceabuse disorders. Many States manage public funds formental health differently from those for substanceabuse. In fact, these funds are often managed by different agencies.

1 4

“Those are the three

things: letting people

talk it out, helping the

lead person have a

presence and a history

on both sides, and

getting people at the

top to buy in.”

C H A P T E R 3

Some States delegate significant regulatory, licens-ing, and contracting authority to the county orregional level. Providers working across counties orregions in these States have to meet a larger varietyof regulatory and contracting standards thanproviders in a single jurisdiction or in States that donot encourage more local control. County andregional systems administrators reported being“caught in the middle.” They were tasked with build-ing systems of care at the local level but had little orno control over State regulations or licensingrequirements.

Without exception, participants expressed their frustration at regulatory and licensing requirements.There is an unwieldy number of service definitions,regulations, facility licensing requirements, rules forstaff certification, and funding mechanisms at thecounty, State, and Federal levels. To make mattersworse, they often contradict one another.

Participants referred to these disparities as some oftheir biggest challenges and wanted to make reduc-ing and simplifying these requirements a top priority.One State is going to replace its tangle of local and State licensing and certifying requirements byturning to national accreditation. Participantsapplauded this strategy heartily.

ModelsDue to the wide range of State and county benefitand funding design models, systems-level partici-pants were almost unanimously in agreement on howto best use them. In short, they agreed that manymodels are most helpful when modified to reflect thespecific conditions of the State and/or county—a better alternative than demanding strict fidelity tothe original model. Although this adaptive approachcan sometimes make researching effectiveness morecomplicated, participants believed that it increasedthe chance for success and provided opportunities to involve more stakeholders.

On another note, applying best-practice modelsenabled systems participants to focus on their mainobjective: to make funding and systems more efficient to better help people with co-occurring disorders.

1 5

“You need somebody

who has knowledge

on both sides and the

respect of both sides,

or it just won’t happen.”

Next Steps C H A P T E R 4

1 7

Based on the findings outlined in the precedingchapter, participants identified clear priorities

and strategies to foster additional program and systems developments. These require the attentionof decisionmakers at several levels, includingSAMHSA, the Center for Medicaid and MedicareServices (formerly known as the Health CareFinancing Administration [HCFA]), State and countymental health and substance abuse directors, Medicaiddirectors, and trade and professional associations.

The broad areas for action, discussed in more detailbelow, include:

Dissemination and networking

Program support

Systems-level development

Regulatory issues

Workforce development

Roadmap products

Funding issues.

Some recommendations cut across several categoriesbut are discussed under the heading that fits best. Insome cases, no specific steps were outlined, but forareas that need more attention, participants stresseddefinitive steps.

Dissemination and NetworkingParticipants were hungry to obtain informationabout other programs and strategies and to shareideas and concerns with colleagues facing similarchallenges. The following recommendations addressthese desires:

Demonstrations, pilot projects, and research/demonstration grants can provide important lessons, but only limited circles of people knowabout them, especially at Federal and State levels.

For example, State-level grant projects are rarelyknown in other States, but establishment of a central “library”—preferably a Web-based clear-inghouse—would help make existing informationmore widely available. SAMHSA might be thebest organization to implement this recommenda-tion, with cooperation from State, county, andregional grantors.

Enabling people who have successfully initiatedand/or sustained programs to help others do thesame, via face-to-face meetings, would be verybeneficial. Participants found the interaction inthis project stimulating and educational. In fact,they asked for more opportunities to meet repre-sentatives from other programs or systems thatmight be a step ahead of theirs—people they couldcall on for guidance. SAMHSA could implementthese ideas at the Federal level, but they wouldalso be extremely beneficial at the State level.

Participants requested items such as:

Coaches/mentors, either informal or paid, whocould help establish strategies, priorities, andnext steps. These experts should be at least one step ahead of the person seeking the information.

Regular regional, State, and national meetingsand teleconferences that would facilitate shar-ing of strategies and information. Participantsasked for both formal presentations and plannedopportunities for sharing among contributors atthese meetings.

Strategies for increasing networking among peopleat the county or regional levels should beexplored. Their concerns often differ from those atother levels. This type of networking might bebest organized by the Federal Government, bytrade associations that have county behavioralhealth directors as members, and by States that arein the process of encouraging or requiring programs for people with co-occurring disorders.

“SAMHSA should just

bring a group like this

together periodically

during the course of

the year, because look

at all the learning that

can take place.”

C H A P T E R 4

Systems-Level DevelopmentBecause systems development is in its infancy, astrong focus on growing the knowledge and skill basein this area is required. Strategies include:

Finding ways to aggressively support the initiationand ongoing development of coordinated care sys-tems, especially at the Federal and State levels, forinstance:

Funding pilots in States with different types ofbenefit design and/or funding structures

Supporting person-to-person, State-to-State,and county-to-county networking, informa-tion sharing, strategy sharing, and tool development

Enhancing dissemination opportunities at the systems level, particularly with regard toeffective strategies and tools.

SAMHSA and other funders can target demon-stration funding for building systems of care thatcan easily access:

Different funding mechanisms

Various provider panels

A range of prevention, early intervention, treat-ment, rehabilitation, and recovery services

Treatment for people in all quadrants of the Co-Occurring Disorders by Severity Matrix(Appendix A).

SAMHSA and States could target research anddemonstration projects to identify ways that sys-tems can better provide coordination and wrap-around services to programs instead of just addingmore layers of bureaucracy. These activities shouldfocus on key issues, such as:

Providing a continuum of care and services

Making communication easier among differentsystem components for both consumers andproviders. With better communication, con-sumers would more easily move through care sys-tems by using whatever providers and programsthey need to address their disorders. Strengthenedcommunication would also help providers bettercoordinate care for people with co-occurring disorders, who often need a variety of services.

SAMHSA and States could develop resources forsystems. (SAMHSA could focus on the Statelevel, and States on their counties or regions.)Such resources include:

Model contracts

Network development strategies

Methods of modifying joint licensure/certifica-tion processes

Systemwide approaches to staff development

Involving stakeholders

Building on existing infrastructure rather thatcreating parallel systems

Monitoring and compliance issues.

Program SupportParticipants reported that receiving grant money fordemonstration projects or pilots was often a double-edged sword. They gained knowledge and skills andprovided treatment to people who needed it, but theprograms often disappeared at the end of the fundingcycle. As a countermeasure, people should focus onsustaining and integrating these demonstration proj-ects once funding has ended.

Similarly, demonstration and pilot projects oftenoperated outside of the State or county local benefitand funding design, making them difficult to sustainonce the Federal or special State funding ended. This

1 8

“If there's a pilot proj-

ect, then you think

about how you may

replicate it—what are

the things you're going

to learn from that

project—and be able

to have a strategic plan

in terms of what the

next steps would be.”

C H A P T E R 4

problem might be alleviated by specific strategies forprograms that operate within the State and localregulatory frameworks. An additional recommenda-tion, building internal financial support to replaceseed money and demonstration project funding,would also address this issue, for example:

Using grants to facilitate large-scale change inorganizations and systems to promote better inte-grated treatment for people with co-occurring disorders. The goal should be to make all mentalhealth and substance abuse treatment programs“co-occurring capable.”3

Creating “knowledge and skill transfer” sections of a central Web-based library and fosteringopportunities for face-to-face networking and conferences that focus on how to make program-ming for people with co-occurring disorders morefinancially viable.

Helping programs—with specific supports andrequirements—to convert these projects intoongoing business concerns once the demonstra-tion/pilot funding is finished (for project funders).

Building demonstration projects or granting seedmoney in conjunction with Federal, State, andlocal funders so that the Federal dollars are help-ing State and local working relationships to develop.

Continue to focus on developing and widely disseminating tools to help initiate and sustainprograms. Many outstanding tools are currentlyavailable, but there is a general lack of knowledgeabout them. Federal and State governments couldassist with:

Clinical and practice guidelines

Models and effective language

Workforce competencies

Strategic planning models

Training materials for all staff and consumers

Easy-to-use and cost-effective outcome measures

Administrative and managerial guidelines forrunning or partnering with these kinds of programs

A list of frequently asked questions—andanswers—about strategies for overcoming various obstacles.

Regulatory IssuesBoth providers and systems representatives said reg-ulatory and licensing contradictions and burdenswere the most frustrating obstacles they faced. Theseburdens consumed valuable staff resources and creat-ed complications for blending services in sensibleways for the consumer. At all levels—national,State, and local—simplifying the tangled regulatoryburden will go a long way toward promoting bettercare for people with co-occurring disorders. The rec-ommendations include:

SAMHSA could develop strategy toolboxes forState and local people to clarify and/or reduce regulatory licensure and other funding inconsis-tencies, duplications, and roadblocks. Providingdata on service outcomes from States that aremoving to national accreditation in lieu of locallicensing and certification would also be benefi-cial. In addition, data should be provided on thecosts—both financial and in human suffering—of contradictory, overlapping layers of regulation,compliance, and audits. SAMHSA’s technicalassistance centers could also help in this area,including the Addiction Technology TransferCenters (ATTC)—a nationwide, multidisciplinaryresource that draws on the knowledge and experi-ence of recognized leaders in the addiction field.

SAMHSA could help interface with the keyaccrediting bodies, aligning organizational stan-dards and treatment delivery. Also, facilitatingdialog among accrediting bodies, regulators at

3 This approach will build on the American Society of Addiction Medicine’s (ASAM) goal of making all addiction programs dual-diagnosis capable. ASAM publishes

national guidelines for the placement, continued stay, and discharge of people with alcohol and drug problems.

1 9

C H A P T E R 4

every level, and systems of care for people with co-occurring disorders would raise awareness ofthe need for streamlined and more applicable certification and accreditation standards.

Workforce DevelopmentPrograms and systems of care are not alone in theirstruggle with workforce issues. In fact, they plaguebehavioral health and health care, along with otherservice industries nationwide. But programs servingpeople with co-occurring disorders encounter work-force issues that go beyond having to find qualified,caring people who are trainable and are willing towork for relatively low salaries.

Participants noted that many local settings try todevelop a trained workforce to serve in behavioralhealth care settings and, more specifically, in pro-grams for co-occurring disorders. In many cases, it is inefficient for local programs to create a work-force. Programs for co-occurring disorders often must retrain their existing behavioral health careworkforce.

Federal and State assistance is important to build up the number of caregivers who are knowledgeablein delivering care to people with co-occurring disorders. This process must incorporate both classroom-based education as well as on-the-job skill and attitude development. (This is differentfrom orientation, in-house training programs, andbroad-based State training that is meant to foster systems change.) This area requires more attention,but the following strategies may be beneficial:

SAMHSA, perhaps in conjunction with broaderHealth and Human Services (HHS) leadership,could initiate dialog with professional associations,including the American Psychiatric Association,the American Psychological Association, and theNational Association of Social Workers. Such dialog may produce ways of increasing the focuson serving people with co-occurring disorders via core curricula and postgraduate traininginternships.

SAMHSA could explore ways to promote dialogamong community colleges and other educationalfacilities. Such a process would help disseminatecurricula and associate degree programs that prepare students for working in the field of co-occurring disorders. In fact, some participantshad already developed local programs in theircommunity colleges to train behavior techniciansand other support personnel. SAMHSA is in anoptimum position to promote this approachnationwide and could also help States buildbehavioral health curricula into their State university systems, incorporating courses and/orspecialty programs. All behavioral health curriculashould stress competency building.

In conjunction with States, SAMHSA could convene meetings to discuss how to make it easierfor people already certified in one field to gain certification as a co-occurring disorder specialist.

RoadmapsThis project revealed that people already know agreat deal about initiating and sustaining program-ming for people with co-occurring disorders. There isa smaller but growing body of knowledge about “howto grow a system.” Yet much of this information is unavailable—especially to newer programs. It isimportant then to develop products that will serve as“roadmaps,” highlighting key decision points,resources, strategies, and potential landmines.

These products could be housed in a special sectionof the Web-based central library and might promoteincreased networking with existing programs.

Funding IssuesAlthough many programs and systems were able toovercome them, funding challenges are still very realand often complicate the processes of deliveringtreatment and building systems of care. Fundingissues require more than just identifying where themoney will come from and what it can be used for.Each funding stream—Federal, State, and local—carries its own accounting, documentation, licensure,

2 0

“SAMHSA could

approach the main

professional associa-

tions in psychology,

social work, and sub-

stance abuse about

the fact that a large

percentage of the

people we're serving

are co-occurring and

explain that curricula

and certification pro-

cesses should be

adjusted so that people

are coming out of

school with knowledge

on that subject and

are expected to get

updated.”

C H A P T E R 4

staffing, and other requirements and may definealmost identical treatment in different ways.Moreover, funding streams may target different typesof consumers and have disparate philosophies.Similar programs often have greatly different fundingexperiences.

The issue of funding is complicated by universal tension. From consumers to legislators, there is a tension between the desire for “pots of money” totreat specific populations and the desire to simplifyhow funding is administered.

Interestingly, funding is not necessarily a “problem tobe resolved,” but it is an area that would benefit frommore coordination. This is especially true for systemsthat almost always require funding from multiplesources. Programs within SAMHSA are exploringthis issue, and there are some other areas that areripe for further exploration.

Many States use Medicaid as a core component of their behavioral health funding. As a result, the Center for Medicaid and Medicare Services(formerly HCFA) should be invited to participatein dialogs with SAMHSA, State funders, StateMedicaid directors, other significant fundingsources, and trade and professional associations(especially those representing public purchasers).These discussions should focus on how to stream-line and coordinate funding requirements for thefollowing purposes:

Reducing the costs of administering the funds atevery level

Increasing the amount of funding for treat-ment instead of administration and benefitcoordination

Supporting local programs and systems of care by reducing the complications associatedwith accessing and using a variety of fundingstreams.

It is also important to consider the HealthInsurance Portability and Accountability Act(HIPPA), which protects workers and their fami-lies in terms of health insurance coverage. It alsocalls for the standardization of electronic patienthealth, administrative, and financial data as wellas security standards to protect the confidentialityand integrity of “individually identifiable healthinformation.” Implementing HIPAA could produce mixed results in terms of the regulatoryburdens for co-occurring disorder programs andsystems.

HIPAA may ease some obstacles by standardizingelectronic transaction processing. Items such asclaims, service authorizations, referrals, and otherelectronic transactions should become consistentacross disorders, thus reducing paperwork.However, HIPAA and 42 CFR-part 2 (the Federalconfidentiality section of the Substance AbusePatient Records Statute) are inconsistent on theirrequirements for privacy and for the consent andauthorization needed to release information bypatients. In other words, programs serving peoplewith mental disorders have different requirementsthan programs serving people with substanceabuse disorders.

This situation is complicated by a variety of Statelaws that govern privacy for people seeking sub-stance abuse treatment. SAMHSA reconciled theprivacy, consent, and authorization requirementscontained within both 42 CFR-part 2 and HIPAAand posted this work on its Web site in fall 2001. Followup clarification and additional dissemination activities would be helpful.

2 1

Glossary

2 3

Accreditation An extensive process whereby health care and behavioral health care organizationsapply, are surveyed, and receive certification for a set time period, indicating theymeet established national standards. The lengthy process involves policy develop-ment and standards of care based on strategic planning, system/organizational monitoring, and continuous improvement. The Joint Commission on Accreditationof Healthcare Organizations, the Rehabilitation Accreditation Committee, and theNational Committee for Quality Assurance are examples of national organizationsthat provide accreditation.

Clinical Guidelines A set of clinical standards that defines best practices for a particular disorder. Thesestandards can help evaluate treatment outcomes.

Continuum of Care An array of flexible service options designed to meet the needs of people with substance abuse and mental disorders. Treatment within the continuum ranges from least restrictive (outpatient) to most restrictive (inpatient) settings and is available to individuals based on clinical need during the course of treatment. (See System of Care.)

Co-Occurring Substance abuse and mental disorders that affect an individual simultaneously. In manyDisorders cases, the disorders are not treated in an integrated way, leading to less than desirable

outcomes. Co-occurring substance abuse and mental disorders are discussed in thisreport. However, outside of this report, the term can refer to other pairings of disorders.

County-Level The systems of care provided by counties, either directly or through subcontractedSystems relationships. (See System of Care.)

Gap Analysis A formal needs assessment that looks at existing systems of care in conjunction with the needs of particular populations. The findings from a gap analysis help determine necessary treatment services and enhancements, geographic accessibility,cultural barriers, and more. This process is critical for purchasers when developing RFPs. Providers and provider networks can also use this information tostrengthen their systems.

Health Insurance A complex set of Federal regulations and requirements intended to protect thePortability and security and confidentiality of health care information. Created in 1996, these Accountability Act regulations focus on policies, procedures, and data transactions within and across

health care and behavioral health care organizations.

Intergovernmental Usually a formal agreement between two or more government entities. These Agreements agreements describe the responsibilities each entity will assume in a coordinated

effort to affect service delivery to defined populations.

Level of Care A specific type of service intended to meet the medical and clinical needs of an individual with a substance abuse or mental disorder. Examples include outpatient,partial hospital, and residential. (See Continuum of Care.)

Memorandum of An agreement between two or more organizations to define a given relationship Understanding and each party’s responsibilities within the agreement. (See Intergovernmental

Agreements.)

Outcomes The desired results of a treatment intervention. Outcomes are measurable and shoulddemonstrate whether a particular treatment goal was achieved. Outcomes can beindividual or aggregate indicators of the level of success achieved during and after aparticular treatment intervention.

Provider A contractor or subcontractor who treats people with mental or substance abuse dis-orders. Usually, providers are community-based, for-profit, or nonprofit, but govern-ment agencies that assume the role of direct service delivery are also in this category.

Provider Network Agencies, professional groups, or professionals that align themselves in a formal orinformal way and provide a continuum of treatment services to defined populations.

Public Purchaser Mostly governmental entities that secure subcontractors through a procurementprocess and pay them to provide treatment to defined groups or populations.

Reimbursement The method for reimbursing providers for treatment delivery. There are a variety of ways Methodology to align payment with service delivery, including fee-for-service, capitation, and case rates.

Request for A process that enables purchasers to gather information from potential providers.Information An RFI can help a purchaser assess a provider’s capacity, experience, and interest in

delivering a particular service or continuum of treatment services.

Request for A process for purchasers to formally obtain a proposal from parties interested inProposal delivering treatment. This competitive process usually results in the selection of one

or more specific providers to deliver treatment through contractual arrangements.

Service Definitions The operational definition of specific treatment services that correspond to particularbilling codes. These codes become the mechanism for reimbursement.

Stakeholder Individuals or groups with an interest in the development, implementation, monitoring, and impact of treatment/support services.

Systems Administrators involved in overseeing a comprehensive continuum of treatmentAdministrators delivered to a defined population. (See System of Care.)

System of Care A comprehensive continuum of mental health, substance abuse, and other supportservices coordinated to meet the multiple, changing needs of people with substanceabuse and mental disorders.

Systems Level The public purchaser—usually the State mental health agency and the State sub-stance abuse agency—responsible for creating systems of care in partnership withcounties, regional authorities, and provider networks.

2 4

Co-Occurring Disorders by Severity MatrixAPPENDIX A

2 5

Participants in this inquiry used a four-quadrantseverity matrix to categorize the co-occurring popu-lations they serve. The idea to use this matrix as atool emerged from discussions between the NationalAssociation of State Mental Health ProgramDirectors (NASMHPD) and the NationalAssociation of State Alcohol and Drug AbuseDirectors (NASADAD).

The matrix represents an initial effort to create aunifying language among service providers in thearea of co-occurring disorders. The quadrants identifythe continuum of these disorders as follows:

ILess severe mental disorder/less severe substance abuse disorder

IIMore severe mental disorder/less severe substance abuse disorder

IIILess severe mental disorder/more severe substance abuse disorder

IVMore severe mental disorder/more severe substance abuse disorder

Figure I: Quadrants describing the continuum of individuals with less to more severe mental disorders andless to more severe substance abuse disorders.

The matrix helped identify participants who servediverse populations and clarified language within theexpert panels and interviews. It also served as aframework for focus group participants to describetheir agencies’ services and clients.

On June 16 and 17, 1998, NASMHPD andNASADAD cosponsored the National Dialogue onCo-Occurring Mental and Substance Abuse Disorders.The meeting was supported by the Center for MentalServices (CMHS) and the Center for SubstanceAbuse Treatment (CSAT) of SAMHSA.

Participants developed a national framework forconsidering the needs of people with co-occurringdisorders and the systems-level requirements toaddress these needs. This new framework is similar to one developed in New York that determines thelocation within the service system in which peoplereceive care (e.g., primary health care, substanceabuse programs, mental programs) based on theseverity of their problems.

National Dialogue participants expanded on the NewYork model to include several noteworthy features.For instance, the revised framework now:

Is based on symptom multiplicity and severity, not on specific diagnoses

Uses language familiar to both mental health andsubstance abuse providers

Encompasses the full range of people with co-occurring disorders

Identifies windows of opportunity within whichproviders can act to prevent symptoms frombecoming more severe.

SAAS and the National Council used the graphicsversion of this national framework to support the panels’ nominee selection process. It also helpedguide discussions, particularly in the first panel meet-ing. For both the screening and panel discussions,the selected expert panel members representeddiversity in terms of the consumer populations theyserved, recognizing that barriers and solutions differbetween the various levels of problem severity.

APPENDIX B

Focus Group To Identify Barriers to Implementing Effective Treatment for Individuals With Co-Occurring Disorders

Name:

Title:

Organization:

Phone: Fax:

E-mail:

Co-Occurring Disorders by Severity MatrixPlease review the grid below and circle the severity quadrant that is most applicable to the individualsserved by the program or person being nominated.

Setting of Your Organization (circle one): Rural Urban

Description:

Describe the Co-Occurring Treatment Program (attach additional pages if necessary):

2 7

Nomination Form

ILess severe mental disorder/less severe substance abuse disorder

IIMore severe mental disorder/less severe substance abuse disorder

IIILess severe mental disorder/more severe substance abuse disorder

IVMore severe mental disorder/more severe substance abuse disorder

APPENDIX B

2 8

Describe Evidence of Effectiveness (attach additional pages if necessary):

Any Additional Details About the Co-Occurring Population Served (e.g., adolescents, adults, women,racial minorities, all populations, etc.):

APPENDIX C

Expert Panel I: 12 ParticipantsRepresenting providers: 11Parent of consumer: 1States represented: PA, WI, AZ, TX, RI, MN, MI, NY, MA, CA, FLProviders serving children and adolescents: 4Medical director: 1

Expert Panel II: 12 ParticipantsRepresenting providers: 3Representing State mental health or substance abuse agencies: 4Representing county MH/SA agency: 1Representing regional advocacy group: 1Representing MH/SA trade association: 1Representing regional network: 1States represented: AZ, ME, FL, PA, NY, MA, KS, OH

Telephone ContactsCounty mental health/substance abuse directors: 2State medical director: 1State MH director: 1Physician/consultant: 1Statewide network contractor: 1Consumer consultant to States on program development: 1Multicounty provider network: 1

2 9

Profile of Participants in Expert Panels and Telephone Surveys

APPENDIX D

3 1

I. General Factors for Initiating Co-Occurring Programs

A. Critical issues or events

B. Clinical/practitioner/payer identification of needs

C. Mandate from payers and public authorities

D. Data showing the costs of recidivism for specific populations

E. Funding and grant availability

F. Leadership

II. Key Issues That Impact the Design and Implementation of Programs and Systems

A. Funding

1. Categorical funding—funding restricted to specified populations

B. Distance between mental health and substance abuse professionals and/or sites (always a problem if either the clients or the service providers have to travel between sites)

C. Workforce issues

1. Lack of trained staff 2. Difficulty finding able and willing psychiatrists 3. Finding staff who can learn treatment modalities and be client centered 4. Service providers who do not see or identify a need for co-occurring disorders treatment

D. Regulatory/funding/administrative requirements

1. Site certification differences (State and local levels)2. Separate funding streams, with separate accounting, audit, and other requirements3. Separate regulatory systems and requirements4. Separate State/county data systems, making it difficult to obtain good data about co-occurring

disorders within existing systems—many programs had to build their own (i.e., unfunded mandates)5. Diverse legal confidentiality requirements6. Regulations and/or funding requirements addressing abstinence7. Difficulty getting permits for facilities8. Lack of standardized accreditation for co-occurring disorders programs9. A greater number of “hoops to jump through” than for single-diagnostic programs

Findings From Expert Panel I

APPENDIX D

E. Continuum of care issues

1. Limited access to psychiatrists when individuals are in crisis2. Lack of detox facilities and payment3. Lack of a co-occurring continuum of care and services4. Limited followup funds and programs

F. Wraparound services issues

1. Lack of funding for family treatment2. Lack of access to medical care and all ancillary services3. Cost of prescription medications4. Lack of supportive housing5. Lack of transportation, especially when services are geographically diffuse6. Lack of child care

G. Service delivery issues

1. Lack of clinical practice guidelines2. Disagreement within and between fields as to appropriate treatment modalities, lengths of stay, etc.3. Lack of respect between fields4. Rigid treatment modalities (i.e., therapeutic communities) in either service area5. Fixed lengths of stay6. Closed referral system7. Limited research, especially on special populations like adolescents and transitional-aged youth8. Lack of standard, effective outcome tools9. Caseload management10. Lack of informative material for staff, clients, and families

H. Organizational issues

1. Outdated provider organization policies that do not support treatment and programs for people with co-occurring disorders

2. Many small organizations involved—difficulty accessing capital to upgrade infrastructure

III. Effective Strategies for Overcoming, Avoiding, and Defusing Barriers When Initiating Programs(Beginning With What You Know and Growing It)

A. Patching together local resources, existing resources, and personal, which can provide seed dollars

B. Increasing awareness of client needs among direct service providers so that they support the programming (at least in theory)

3 2

APPENDIX D

C. Proximity/colocation

1. Joint staff meetings between and among organizations that are partnering2. Staff from each specialty colead all programs and groups3. Staff from one program in the same location as staff from another (i.e., mental health case work

located at a substance abuse treatment facility)

D. Understanding that it takes time

E. People who can serve as “bridges” between groups

F. Data on effectiveness

1. Data on relapse rates often comes first—either for substance abuse or hospitalization or even more intensive treatment

G. Assuming a problemsolving approach in working with other organizations, divisions, units, and programs

1. Provide services in other organizations, helping them with their problems2. Starting with “toughest” clients can show dramatic improvements quickly

H. Build on individual and organizational relationships

I. Incremental implementation—helps with mastery, decreases sense of being overwhelmed, and eases staff and client transitions

1. Incremental inclusion of a mental health diagnosis into substance abuse programs2. Incremental programming

J. Steady, supportive, and proactive psychiatrist who knows both areas

K. Assessment and other tools

1. Outcomes2. Clinical guidelines3. Vocabulary

IV. Supports for Effective Programs

A. Supports for program initiation

1. Consumers and family members who help raise awareness and money2. Put as much money and energy as you can into staff training3. Import staff, especially in leadership positions4. Administrator and CEO support, from all agencies if possible5. Take core staff from existing programs and use them to open new programs—infuses competency,

confidence, and culture

3 3

APPENDIX D

B. Supports for program continuance

1. Put as much money and energy as you can into staff training2. Ongoing supervisor training (supervisors need to make it part of the culture)3. Developing and nurturing program culture4. Opportunities for staff to socialize together at all levels (e.g., picnics, graduation)

C. Source of needed supports

1. Federal GovernmentDisseminating information to a wide group (e.g., current findings and lessons from pilot projects, demo projects, research grants, meetings)

2. StateState trade associations coming together and working on joint projects

3. Level not importantPeer mentoring on starting, building, and running a co-occurring disorders program—networking

V. Other Findings

A. Descriptions of unserved or underserved populations

1. Middle of quadrants (people who cluster near the center line)2. Children3. Children of people with co-occurring disorders4. Families of people with co-occurring disorders (e.g., spouses, parents, siblings)5. Gay-lesbian-bisexual-transsexual6. Transitional-age youth, 16-247. Specific cultural and linguistic groups (varies by location), usually based on a shortage of therapists

who speak certain languages and/or who understand cultural issues8. Tridiagnosed—substance abuse-mental illness-physical disability (physical and/or cognitive)9. People in either the juvenile or criminal justice systems10. Grey zone (i.e., too much to qualify for Medicaid/public funds, no health insurance, underinsured)11. Noncustodial parents12. People who do not meet rigid diagnostic standards to qualify for co-occurring programs13. People who avoid treatment because of stigma14. Homeless15. Elderly

B. Description of growing and emerging populations

1. “Older people” – between 40 and 552. Younger people and children (should be doing treatment in elementary schools, not just awareness)

3 4

APPENDIX D

C. Gaps in service continuum and systems

1. Role of consumers and family members2. Recovery models3. Knowledge and skills

D. Core competencies needed for effective programming

1. ICRC core competencies (18) (Joe Hyde)2. AZ DBHS-developed core competencies3. MA-developed core competencies

E. Training and curricula

1. Harris County programs at the community college, the continuing education arm of the local university, and the nursing school to train and recruit staff

2. Los Angeles County dual diagnosis certification program (30 people at a time—half mentalhealth, half substance abuse)

3. New York State example (staff members sit through programs as if they were clients—about 60hours per employee)

4. Behavior tech training course (Project PARS)5. Shadow training (Bay Cove)6. Latino Counselor-in-Training Program (RI)7. Rhode Island example (statewide curriculum committee—get input from actual providers, not

just higher ups)

F. What is needed

1. Other knowledge and skills acquisition needs and strategies2. Need staff who “play well with others”3. Motivational interviewing that changed practices in Rhode Island4. Need a best practice about when to start medication treatment on a patient following detox and

other similar clinical guidelines

3 5

Findings From Expert Panel IIAPPENDIX E

I. Early Stages: Initiation of Dialog—Leading up to Change

A. External factors

1. Suicides2. Violence3. Drug overdoses4. Closure and/or transition from State hospitals to communities5. Consumer dissatisfaction6. Consumer/family stories7. HIV/AIDS8. Grassroots advocacy9. Privatization of services10. Managed care

B. Federal dialog

1. SAMHSA2. CSAT/CMHS3. Congressional activity4. TIPs/TAPs5. ATTCs6. Transfer of technology7. Funding priorities

C. Role of collateral systems

1. Mental health2. Substance abuse3. Child welfare4. Juvenile justice5. Adult corrections6. Jails7. Juvenile corrections8. Medicaid authorities9. Domestic violence10. Other social service agencies

D. Counties

1. Relationship between counties and States2. Role of counties as providers3. Relationship between counties and regional systems4. Role of counties as health providers

3 7

APPENDIX E

E. Regional models

1. Privatization2. Provider collaboration3. Local emphasis4. Potential efficiencies

F. Customer demands

1. People in collateral systems not happy2. Consumer/family dissatisfaction3. Criteria for satisfaction4. Necessary responses5. Who needs to be at the table

G. Other external forces

1. Mental service planning councils2. Professional and trade associations3. Colleges and universities4. Drug and mental health courts5. Related community resources

H. Internal dialog (how to best serve people with co-occurring disorders)

1. Diagnosis versus function2. Problem identification3. Workgroups4. Study sessions5. Task forces6. Role of crisis systems7. Defining collaboration (administrative and clinical)

I. Role of leadership

1. Factors that affect leadership2. Convening dialog3. Defining vision and values4. Best practices5. Research to practice6. Standards of care7. System mandates8. Steps necessary prior to MOUs and IGAs9. What should collaboration look like

3 8

APPENDIX E

II. Barriers to Change

A. Regulatory barriers

1. Licensure regulations2. Legal mandates of various State agencies3. Different policies and procedures4. Different operating guidelines5. Medicaid regulations6. Lack of clear guidelines for developing IGAs and MOUs7. Categorical funding8. Legislative rules and regulations9. Procurement regulation

B. Agency barriers

1. Diagnostic criteria2. Different funding requirements3. Agencies not working together4. Different agency mandates (e.g., child welfare, corrections, treatment)5. Turf battles6. Friction between State, county, and local jurisdictions7. Bureaucracies interfering with work in the trenches8. Tendency to make questionable requirements 9. Accountability more complicated than necessary10. Data systems not compatible or unable to communicate11. Specific procedure codes for reporting services not always compatible

C. Organizational barriers (provider)

1. Different organizational cultures2. Licensure requirements3. Accreditation4. Training needs of staff at all levels5. Managed care not always flexible or compatible with changing needs6. Overwhelming paperwork requirements7. Workforce issues—availability of qualified, competent staff8. Midlevel management training not always available9. Current knowledge and research from the field not always available

3 9

APPENDIX E

III. Strategies for Overcoming Barriers

A. Programmatic and systems strategies

1. Start small—pilot and demonstration projects2. Collaboration with other agencies and provider systems3. Cross-training4. Engage willing partners for collaboration5. Create staff and provider incentives6. Collaborative multidisciplinary teams with families and consumers7. Network development8. Home-grown provider networks9. Keep systems local and community-based10. Parallel agencies coming together11. Utilize multiple contracts to create greater flexibility12. Dual licensure

B. Funding strategies

1. Pool resources to build pilot and demonstration projects2. Utilize procurement process to align desired system changes with funding3. Utilize MOUs and IGAs that can evolve over time and facilitate system change4. State procurements that structure funding for integrated and co-occurring systems, allowing for

creativity5. Using funding from one system to purchase and integrate services from another system6. Flexible funding7. Build a mosaic of funding

C. Opportunities for leadership

1. Use advocacy to foster change2. Engage other leaders to move agendas forward3. Apply external pressure in a positive way4. Collaboration at the highest levels of leadership5. Figure out what all sides need to move forward6. Develop criteria for agreements/MOUs and IGAs7. Keep your eyes on the big picture while taking small steps8. Use licensure, procurement, payment methodologies, and policies 9. Public/private funding opportunity10. Funding not the only solution11. Expansion of covered services12. Other forms of financing (e.g., cap)

4 0

APPENDIX E

IV. Supports Needed To Move Forward

A. Dissemination of research and best practices

1. State offices2. National organizations3. Trade associations4. Universities and colleges5. Accreditation organizations6. TIPs and TAPs7. Moving toward outcomes8. Public health9. State and national meetings10. Technical assistance

B. Training supports

1. Cross-trainingCorrectionsMental healthSubstance abuseChild welfareLaw enforcementDomestic violence

2. Training throughout all organizational levels3. Time off and other staff incentives4. Training curricula and materials5. Customized training6. Clinical and administrative training and cross-training7. Strategic planning8. Mentoring

C. Workforce supports

1. Recruitment2. Retention3. Career ladders4. Field placements5. Training6. Continuing education7. Productivity8. Cultural diversity and competency9. Role of consumers and families10. Procurement11. Alternative financial models (local, State, and Federal)12. Regulatory

4 1

D. Administrative supports (local, State, and Federal)

1. Licensing2. Credentialing3. Procurements4. Alternative financial money5. Regulatory changes6. Legislative collaboration

4 2

APPENDIX E

The State Associations of Addiction Services andthe National Council for Community BehavioralHealthcare used a multifaceted methodology to create the following, one-of-a-kind collection of co-occurring disorder training materials.

SAAS and NCCBH polled their State associationand provider members to identify training curriculathat could help people develop core competencies.Participants in this project also made significantcontributions. In addition, SAAS and NCCBHasked the people they initially polled to identifyother experts who could recommend additionaltraining curricula—a process that gave voice to Stateleaders.

As a final step, Dr. Ken Minkoff—a nationallyrenowned expert on co-occurring disorders—reviewed the list to make certain all items were onpoint. Although it is not exhaustive, this unique collection includes resources for beginner, interme-diate, and advanced audiences in a variety of electronic and other formats. There are even programs that offer continuing education credits.Although some of the items on the list are free, others must be purchased.

The field of co-occurring disorders is rapidly evolv-ing. As a result, it is likely that additional trainingmaterials will continue to emerge, and the SAMHSACenter for Mental Health Services CommunityAction Grants are potential sources of support. Theyenable communities to convene partners, build consensus, eliminate barriers, and adapt service models that meet local needs. Encouragingly, somerecent grantees chose to focus on co-occurring mental and substance abuse disorders.

Two unexpected observations emerged throughoutthis project. First, although participants providedanecdotal evidence, there was a lack of any credibletools and effectiveness data to assess co-occurringdisorder training curricula.

Second, many of the items in this compendium aregeared to specific populations. Curricula for correc-tional populations were the most prevalent, whereasitems for adolescents were the least prevalent. Someitems deal with the needs of women and specificracial groups. However, there is an apparent need formore items to cover these areas.

Training CurriculaAPPENDIX F

4 3

4 5

APPENDIX G

The

“Tr

aini

ng o

n Tr

eati

ng O

ffend

ers

Wit

h C

o-O

ccur

ring

Dis

orde

rs”

prog

ram

can

be

tailo

red

to t

he s

peci

fic n

eeds

of t

he r

eque

stin

g ag

ency

and

del

iver

ed o

n si

te a

t a

loca

-ti

on p

rovi

ded

by t

he r

eque

stin

g ag

ency

.

Offe

rs t

echn

ical

ass

ista

nce

to p

lan,

impl

emen

t, an

d op

er-

ate

appr

opri

ate,

cos

t-ef

fect

ive

prog

ram

s. T

he G

ains

Cen

ter

deve

lops

sta

ff tr

aini

ng c

urri

cula

for

Stat

es, l

ocal

i-ti

es, a

nd c

rim

inal

just

ice

and

prov

ider

org

aniz

atio

ns in

the

proc

ess

of d

evel

opin

g or

impl

emen

ting

co-

occu

rrin

gdi

sord

er s

ervi

ces

for

thos

e in

the

just

ice

syst

em.

Thi

s m

anua

l is

avai

labl

e on

line

. A

sta

tem

ent c

redi

ting

the

auth

ors

and

The

Inf

orm

atio

n E

xcha

nge,

Inc

., m

ust a

ccom

pany

any

use

of th

ese

mat

eria

ls.

The

man

ual i

s sp

lit u

p in

to n

umer

ous

Web

pag

es b

ecau

se

of it

s le

ngth

(ab

out

165

prin

ted

page

s). T

he fi

rst

sect

ion

revi

ews

liter

atur

e co

ncer

ning

thi

s po

pula

tion

; the

sec

ond

sect

ion

is a

gui

de fo

r se

ttin

g up

a c

ross

-tra

inin

g pr

ojec

t;an

d th

e th

ird

sect

ion

is a

mod

el, 1

2-se

ssio

n cu

rric

ulum

that

cou

ld b

e us

ed fo

r tr

aini

ng p

rofe

ssio

nals

abo

ut t

his

popu

lati

on.

A 3

-hou

r co

urse

tha

t pr

ovid

es n

eed-

to-k

now

info

rmat

ion

abou

t du

al d

isor

ders

. Spe

cific

info

rmat

ion

focu

ses

on t

hege

nera

l tre

atm

ent

need

s re

late

d to

dua

l dis

orde

rs a

s w

ell

as p

harm

acol

ogic

al m

anag

emen

t is

sues

.

Cos

t: $

40–I

nter

net v

ersio

n; $

55–h

ard

copy

form

at—

inst

ruct

or:

Kev

in S

chee

l.

OJP

On

site

Tra

inin

gPr

og

ram

s

The

Gai

ns

Cen

ter

tech

-n

ical

ass

ista

nce

, cu

r-ri

culu

m d

evel

op

men

t,cu

sto

miz

ed t

rain

ing

Dev

elo

pin

g a

Cro

ssTr

ain

ing

Pro

ject

fo

rSu

bst

ance

Ab

use

,M

enta

l Hea

lth

an

dC

rim

inal

Ju

stic

ePr

ofe

ssio

nal

s W

ork

ing

wit

h O

ffen

der

s w

ith

Co

-Exi

stin

g D

iso

rder

s(S

ub

stan

ce A

bu

se/

Men

tal I

llnes

s)

Du

al D

iag

no

sis

Part

1:

Co

nce

pts

an

dTr

eatm

ent

Issu

es

Yes

Yes

Yes

Yes

(wit

hau

thor

an

d so

urce

cita

tion

)

http

://w

ww.

ojp.

usdo

j.gov

/cpo

/co

nfer

ence

s.htm

Offi

ce o

f Jus

tice

Pro

gram

s

The

GA

INS

Cen

ter

262

Del

awar

e A

venu

eD

elm

ar, N

Y 1

2054

ph

one:

(80

0) 3

11-G

AIN

fax:

(51

8) 4

39-7

612

e-m

ail:

gain

s@pr

ainc

.com

Ber

t Pe

pper

, M.D

., an

d Ed

war

d L.

Hen

dric

kson

, M.S

.T

he I

nfor

mat

ion

Exch

ange

, Inc

.12

0 N

orth

Mai

n St

reet

New

Cit

y, N

Y 1

0956

1996

http

://w

ww.

toad

.net

/~ar

ctur

us/

dd/d

dhom

e.ht

m

Han

ley

Haz

elde

n on

line

cour

ses

atth

e H

azel

den

Dis

tanc

e Le

arni

ngC

ente

r fo

r A

ddic

tion

Stu

dies

http

://w

ww.

dlca

s.com

/co

urse

listin

g.ht

ml

DLC

AS

P.O

. Box

176

Cen

ter

Cit

y, M

N 5

5012

-026

6ph

one:

(80

0) 3

28-9

000

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main

4 6

APPENDIX G

A 3

-hou

r co

urse

tha

t pr

ovid

es d

etai

led

info

rmat

ion

abou

tth

e m

ore

prev

alen

t di

sord

ers

in c

hem

ical

ly d

epen

dent

popu

lati

ons.

The

cou

rse

incl

udes

spe

cific

dia

gnos

tic

and

trea

tmen

t co

nsid

erat

ions

for

moo

d di

sord

ers,

anxi

ety

dis-

orde

rs, p

erso

nalit

y di

sord

ers,

and

psyc

hoti

c di

sord

ers.

Cos

t: $

40–3

hou

rs–I

nter

net v

ersio

n; $

55–h

ard

copy

fo

rmat

—in

stru

ctor

: K

evin

Sch

eel.

The

Add

icti

on T

echn

olog

y Tr

ansf

er C

ente

r of

New

Engl

and

offe

rs o

nlin

e ed

ucat

ion

prog

ram

s.

The

“C

hem

ical

Dep

ende

ncy”

cou

rse

prov

ides

an

over

-vi

ew o

f the

con

nect

ion

betw

een

Post

-Tra

umat

ic S

tres

sD

isor

der

(PT

SD)

and

chem

ical

dep

ende

ncy.

Bot

h co

ndi-

tion

s ar

e di

scus

sed

as t

o th

eir

diag

nost

ic c

rite

ria,

pre

sent

-in

g sy

mpt

omat

olog

y, b

iolo

gica

l asp

ects

, and

pre

disp

osin

gva

riab

les.

The

“D

ual D

iagn

osed

” co

urse

intr

oduc

es a

nd/o

r ex

pand

sth

e cl

inic

ian’

s kn

owle

dge

of s

peci

fic t

reat

men

t ap

proa

ches

repr

esen

ting

inte

grat

ed t

reat

men

t fo

r pe

ople

suf

feri

ngw

ith

emot

iona

l and

add

icti

ve d

isor

ders

. It

expl

ores

key

fact

ors

in t

he r

ecov

ery

proc

ess,

incl

udin

g m

etho

ds fo

rim

prov

ing

mot

ivat

ion,

rai

sing

aw

aren

ess

leve

ls, a

nd

focu

sing

on

skill

s tr

aini

ng.

Du

al D

iag

no

sis

Part

2:

The

Prev

alen

tD

iso

rder

s

Ch

emic

al D

epen

den

cyan

d P

ost

-Tra

um

atic

Stre

ss D

iso

rder

Du

al D

iag

no

sed

Trea

tmen

t: A

MA

P to

Rec

ove

ry

Yes

Yes

Yes

Han

ley

Haz

elde

n on

line

cour

ses

atth

e H

azel

den

Dis

tanc

e Le

arni

ngC

ente

r fo

r A

ddic

tion

Stu

dies

http

://w

ww.

dlca

s.com

/co

urse

listin

g.ht

ml

DLC

AS

P.O

. Box

176

Cen

ter

Cit

y, M

N 5

5012

-026

6ph

one:

(80

0) 3

28-9

000

Cen

ter

for

Alc

ohol

an

d A

ddic

tion

Stu

dies

B

row

n U

nive

rsit

yB

ox G

-BH

Pr

ovid

ence

, RI

029

12

(p)

401-

444-

1808

(f

) 40

1-44

4-18

50

http

://w

ww.

caas

.bro

wn.

edu/

ATTC

-NE

Cen

ter

for

Alc

ohol

an

d A

ddic

tion

Stu

dies

B

row

n U

nive

rsit

yB

ox G

-BH

Pr

ovid

ence

, RI

029

12

(p)

401-

444-

1808

(f

) 40

1-44

4-18

50

http

://w

ww.

caas

.bro

wn.

edu/

ATTC

-NE

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main

4 7

APPENDIX G

Tho

ugh

not t

ruly

a tr

aini

ng m

anua

l, th

is se

rvic

e gu

idel

ine

docu

men

t is a

read

y so

urce

of t

rain

ing

info

rmat

ion.

Thi

s pr

ogra

m d

escr

ibes

the

act

ivit

ies

of t

he A

rizo

naIn

tegr

ated

Tre

atm

ent

Con

sens

us P

anel

, whi

ch d

evel

oped

the

visi

on, p

rinc

iple

s, go

als,

obje

ctiv

es, a

nd s

trat

egie

s fo

rth

e lo

ng-t

erm

impl

emen

tati

on o

f int

egra

ted

trea

tmen

tse

rvic

es in

Ari

zona

.

The

pro

gram

des

crib

es t

he b

asic

pro

blem

s w

ith

the

curr

ent

trea

tmen

t of

indi

vidu

als

wit

h co

-occ

urri

ng d

isor

ders

and

the

stra

tegi

es t

hat

have

pro

ven

to b

e ef

fect

ive

in im

prov

-in

g tr

eatm

ent.

It a

lso

delin

eate

s th

e vi

sion

and

pri

ncip

les

that

wer

e us

ed t

o de

sign

an

inte

grat

ed d

eliv

ery

syst

em.

The

cou

rse

is a

n in

trod

ucti

on to

co-

occu

rrin

g di

sord

ers a

ndis

mea

nt fo

r all

leve

ls of

staf

f. It

last

s app

roxi

mat

ely

1.5

hour

s.

The

Cen

ter

offe

rs t

he s

ix fo

llow

ing

prog

ram

s—al

l of

whi

ch a

re d

esig

ned

to e

nhan

ce e

valu

atio

n ca

paci

ty:

1.T

he C

onsu

ltatio

n Pr

ogra

m—

cons

ulta

tion

tai

lore

d to

the

need

s of

indi

vidu

al p

roje

cts

2.Th

e To

pica

l Eva

luat

ion

Net

wor

ks—

prov

ide

a fo

rum

for

ongo

ing

dial

og v

ia e

lect

roni

c co

nfer

enci

ng3.

The

Too

lkit

Prog

ram

—pr

ovid

es e

valu

ator

s w

ith

test

edm

etho

dolo

gies

and

inst

rum

ents

rela

ted

to sp

ecifi

c to

pics

4.T

he M

ater

ials

Pro

gram

—an

eva

luat

ion

mat

eria

ls

prog

ram

tha

t su

pplie

s ev

alua

tors

wit

h or

igin

al p

aper

son

sel

ecte

d to

pics

and

iden

tifie

s re

leva

nt li

tera

ture

in

the

fiel

d5.

The

Min

i-G

rant

Pro

gram

—pr

ovid

es s

eed

gran

ts fo

rsi

gnifi

cant

eva

luat

ions

in t

he a

rea

of a

dult

men

tal

heal

th s

yste

ms

chan

ge6.

The

Trai

ning

Pro

gram

—de

sign

ed to

enh

ance

the

eval

-ua

tion

ski

lls o

f pro

duce

rs a

nd c

onsu

mer

s of

eva

luat

ions

.

Stat

e o

f A

rizo

na

Serv

ice

Plan

nin

gG

uid

elin

es

Co

-Occ

urr

ing

an

dSu

bst

ance

Dis

ord

ers

(ed

ited

ver

sio

n)

2000

Ari

zon

a In

teg

rate

dTr

eatm

ent

Serv

ices

Co

nse

nsu

s Pa

nel

Trai

nin

g

The

Eval

uat

ion

Cen

ter@

HSR

I To

olk

it:

Eval

uat

ing

Su

bst

ance

Ab

use

in P

erso

ns

wit

hSe

vere

Men

tal I

llnes

s

Yes

Yes

Stat

e of

Ari

zona

http

://w

ww.

trea

tmen

t.org

/To

pics

/AZ_

guid

elin

es.p

df

Aut

hore

d by

: Ken

neth

Min

koff,

M.D

.12

Jef

fers

on D

rive

Act

on, M

A 0

1720

781-

932-

8792

, x31

1K

min

kov@

aol.c

om

Ari

zona

Int

egra

ted

Trea

tmen

tSe

rvic

es C

onse

nsus

Pan

el

http

://w

ww.

hs.st

ate.

az.u

s/bh

s/ai

tcp.

htm

SAM

HSA

, Cen

ter

for

Men

tal

Hea

lth

Serv

ices

Aut

hors

:K

im T

. Mue

ser,

Rob

ert

E. D

rake

,R

obin

E .C

lark

, Gre

gory

J. M

cHug

o,C

arol

yn M

erce

r-M

cFad

den,

and

The

iman

H. A

cker

son

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main

4 8

APPENDIX G

New

ly d

evel

oped

tra

inin

g m

anua

l and

par

tici

pant

w

orkb

ook

for

trai

ning

clin

icia

ns in

gro

up w

ork

wit

hof

fend

ers

who

hav

e co

-occ

urri

ng d

isor

ders

. Cur

rent

lybe

ing

field

-tes

ted.

A g

uide

to

prog

ram

impl

emen

tati

on fo

r du

al/m

ulti

ple

diso

rder

s. It

s fo

rms,

clin

ical

too

ls, a

nd s

taff

deve

lopm

ent

crit

eria

pro

vide

a fo

unda

tion

for

prog

ram

dev

elop

men

tan

d tr

eatm

ent

inte

rven

tion

s in

the

sub

stan

ce a

buse

and

men

tal h

ealt

h tr

eatm

ent

sett

ings

.

see

abov

e

Mul

tipl

e tr

aini

ng m

anua

ls fo

r Fl

orid

a’s

Dep

artm

ent

ofC

orre

ctio

ns p

erso

nnel

who

wor

k w

ith

offe

nder

s di

agno

sed

wit

h co

-occ

urri

ng d

isor

ders

.

Co

-Occ

urr

ing

Dis

ord

ers

Trea

tmen

t M

anu

al

Men

tal I

llnes

s, D

rug

Ad

dic

tio

n a

nd

Alc

oh

ol-

ism

, MID

AA

(R),

MIC

A

MID

AA

Ser

vice

Man

ual

:A

Ste

p b

y St

ep G

uid

e to

Inte

gra

ted

Tre

atm

ent,

Pro

gra

m D

evel

op

men

tan

d S

ervi

ces

for

Du

alD

iag

no

sis

Phas

e I D

ual

Dia

gn

osi

sG

rou

p T

reat

men

tM

anu

al

Yes

Yes

Yes

Sunc

oast

Pra

ctic

e an

d R

esea

rch

Col

labo

rati

veU

nive

rsit

y of

Sou

th F

lori

da

Flor

ida

Men

tal H

ealt

h In

stit

ute

1333

0 B

ruce

B. D

owns

Bou

leva

rdTa

mpa

, FL

Rog

er H

. Pet

ers,

Ph.D

. D

epar

tmen

t of

Men

tal H

ealt

h La

w a

nd P

olic

yph

one:

813

-974

-192

3fa

x: 8

13-9

74-9

327

Aut

hore

d by

Kat

hlee

n Sc

iacc

a, M

.A.

299

Riv

ersi

de D

rive

, 3E

New

Yor

k, N

Y 1

0025

Man

uals

are

$65

eac

h, p

lus s

hipp

ing

Aut

hore

d by

Rog

er H

. Pet

ers,

Ph.D

.,an

d H

olly

Hill

s, Ph

.D.

Uni

vers

ity

of S

outh

Flo

rida

Flor

ida

Men

tal H

ealt

h In

stit

ute

Flor

ida

Dep

artm

ent

of C

orre

ctio

nsB

urea

u of

Sub

stan

ce A

buse

Prog

ram

Ser

vice

sTa

llaha

ssee

, FL

Pam

Den

mar

k, B

urea

u C

hief

(850

) 41

0-44

30

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main

4 9

APPENDIX G

Onl

ine

publ

icat

ion

that

is n

ot t

ruly

a t

rain

ing

man

ual

but

can

be u

sed

as s

uch.

I.M

ISA

: Int

egra

ted

Con

cept

s an

d A

ppro

ache

s—M

inko

ff’s

para

llels

are

pres

ente

d al

ong

with

a re

view

of

the

com

plex

itie

s th

at m

ulti

ple

diso

rder

s m

ay p

rese

ntfo

r en

gage

men

t, di

agno

sis,

trea

tmen

t, an

d re

cove

ry.

II.

MIS

A: T

reat

men

t an

d Su

ppor

ts—

Incl

udes

indi

vidu

-al

ized

app

roac

hes

to d

evel

opin

g tr

eatm

ent

stra

tegi

esan

d re

late

d le

vels

of s

uppo

rt, a

s w

ell a

s th

e ro

le o

fca

se m

anag

emen

t in

pro

vidi

ng t

he c

onti

nuit

y, li

nk-

age,

and

sup

port

s ne

eded

to

faci

litat

e re

cove

ry.

III.

MIS

A R

ecov

ery,

Reh

abili

tati

on, a

nd S

elf H

elp:

Wha

t, W

hen,

and

How

—T

his

sem

inar

focu

ses

onth

e in

tern

al p

roce

ss o

f rec

over

y, s

tage

s, an

d po

ssib

lesu

ppor

ts n

eede

d. I

t al

so in

clud

es t

he t

ypes

of s

truc

-tu

res

and

uses

of p

sych

iatr

ic r

ehab

ilita

tion

in fa

cili-

tati

ng r

ecov

ery

and

prov

idin

g ne

eded

ski

lls a

ndal

tern

ativ

e co

ping

str

ateg

ies.

Du

al D

iso

rder

sR

eco

very

Co

un

selin

g

Co

re T

rain

ing

Co

urs

esfo

r M

anag

emen

t o

fM

ISA

Tre

atm

ent

and

Acc

om

mo

dat

ion

Pro

gra

ms

Yes

NID

A A

ppro

ache

s to

Dru

g A

buse

Cou

nsel

ing

Aut

hore

d by

Den

nis C

. Dal

ey, M

.S.W

.A

ssist

ant P

rofe

ssor

of P

sych

iatr

y an

d Pr

ogra

m D

irect

or

Cen

ter

for

Psyc

hiat

ric

and

Che

mic

al D

epen

denc

y Se

rvic

es

Uni

vers

ity

of P

itts

burg

h M

edic

al C

ente

r W

este

rn P

sych

iatr

ic I

nsti

tute

an

d C

linic

38

11 O

’Har

a St

reet

Pi

ttsb

urgh

, PA

152

13

http

://1

65.1

12.7

8.61

/AD

AC/

AD

AC3.

htm

l

PA M

ISA

RFP

Req

uire

d Tr

aini

ng—

Penn

sylv

ania

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main

5 0

APPENDIX G

IV.

MIS

A C

risi

s an

d R

elap

se I

nter

vent

ion—

Rev

iew

of:

The

cyc

le o

f cri

sis

vuln

erab

ility

, cri

sis

stat

e, a

nd

reso

luti

onPr

even

ting

a c

risi

s—cr

eati

ng s

itua

tion

sD

esig

ning

inte

rven

tion

s fo

r lo

wer

ing

arou

sal

Cre

atin

g op

port

unit

y fo

r te

achi

ng n

ew c

opin

g sk

ills

in t

he d

irec

t af

term

ath

of a

cri

sis.

V.M

ISA

Gro

ups a

nd G

roup

s Ski

lls—

Rev

iew

s prin

cipl

esan

d sk

ills

need

ed t

o de

velo

p sp

ecifi

c ki

nds

of m

odal

-it

ies

and

grou

p go

als,

norm

s, an

d pr

oces

ses.

Psyc

ho-

educ

atio

nal a

nd s

kills

-bas

ed g

roup

s ar

e a

maj

or fo

cus.

VI.

MIS

A a

nd P

sych

opha

rmac

olog

y: A

n O

verv

iew

—Pa

rt 1

rev

iew

s ba

sic

clas

ses

of p

sych

oact

ive

med

ica-

tion

s, po

tent

ial m

ajor

sid

e ef

fect

s, an

d in

tera

ctio

ns.

Part

2 r

evie

ws

stre

et d

rugs

and

alc

ohol

and

the

iref

fect

s.

VII

.M

ISA

: Wor

king

Res

pect

fully

wit

h Fa

mily

Mem

bers

and

Sign

ifica

nt O

ther

s—T

his

sem

inar

exa

min

es t

hece

ntra

lity

and

impa

ct o

f fam

ilies

of o

rigi

n an

d ot

her

cons

truc

ted

“fam

ilies

.”

VII

I.Et

hics

and

Bou

ndar

ies

for

Effe

ctiv

e M

ISA

Pra

ctic

e—

Thi

s co

urse

add

ress

es b

asic

eth

ical

pri

ncip

les

onw

hich

all

hum

an-s

ervi

ce e

ndea

vors

are

bas

ed.

IX.

MIS

A T

reat

men

t Pla

nnin

g an

d D

ocum

enta

tion

Issu

es—

Prin

cipl

es o

f col

labo

rati

ve t

reat

men

t pl

anni

ng.

X.

MIS

A P

ract

ice

Prin

cipl

es fo

r C

onti

nuou

s Q

ualit

yIm

prov

emen

t an

d C

olla

bora

tion

—Pr

inci

ples

for

inco

rpor

atin

g th

e at

titu

des

and

skill

s ne

eded

for

effe

ctiv

e pr

acti

ce, w

orki

ng in

col

labo

rati

on w

ith

othe

rs, a

nd in

corp

orat

ing

an o

utco

mes

-bas

ed fo

cus.

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main

5 1

APPENDIX G

XI.

Prin

cipl

es o

f Eng

agem

ent:

Chi

ldre

n an

d A

dole

scen

tsw

ith

Co-

Occ

urri

ng D

isor

ders

and

The

ir F

amili

es—

Expl

ores

inte

rper

sona

l dyn

amic

s th

at fa

cilit

ate

inte

r-ac

tion

bet

wee

n th

erap

ist,

clie

nt, a

nd fa

mili

es a

ndth

at a

ffect

the

pro

cess

of r

ecov

ery.

The

Con

tinu

ous,

Com

preh

ensi

ve, a

nd I

nteg

rate

d Sy

stem

of C

are

(CC

ISC

) m

odel

pri

ncip

les

in t

his

repo

rt a

pply

to

the

broa

d po

pula

tion

of p

eopl

e w

ith

co-o

ccur

ring

dis

or-

ders

. The

pri

ncip

les

are

as fo

llow

s:

Prin

cipl

e #1

—In

tegr

atio

n Pr

inci

ple

#2—

Con

tinu

ity

Prin

cipl

e #3

—C

ompr

ehen

sive

ness

Pr

inci

ple

#4—

Qua

lity

Prin

cipl

e #5

—Im

plem

enta

tion

.

Thr

ough

a P

hase

I g

rant

from

SA

MH

SA, t

he A

rizo

naD

epar

tmen

t of

Hea

lth

Serv

ices

form

ed t

he A

ITC

P in

Janu

ary

1999

to

forw

ard

com

mun

ity

cons

ensu

s on

impl

e-m

enti

ng in

tegr

ated

tre

atm

ent

in A

rizo

na. T

he A

ITC

Pin

clud

ed r

epre

sent

ativ

es o

f the

sub

stan

ce a

buse

and

m

enta

l hea

lth

syst

ems

in A

rizo

na, c

onsu

mer

s, fa

mily

mem

bers

, ser

vice

pro

vide

rs, a

nd a

dvoc

ates

.

Phas

e II

will

con

tinu

e to

bro

aden

the

wor

k of

the

Pha

se I

Pane

l in

key

area

s: (1

) st

aff c

ompe

tenc

ies

and

(2)

supp

ort

for

the

ongo

ing

plan

ning

and

impl

emen

tati

on a

ctiv

itie

sof

the

sta

tew

ide

stee

ring

com

mit

tee

and

RB

HA

.

Trai

ning

Mod

ules

: Thi

s pr

ogra

m a

ims

to p

rovi

de in

tro-

duct

ory

trai

ning

for

staf

f new

to

clin

ical

ser

vice

s. It

is

also

for

expe

rien

ced

clin

ical

sta

ff to

use

as

a re

fere

nce.

Prin

cip

les

for

the

Car

e an

d T

reat

men

t o

f In

div

idu

als

wit

h C

o-O

ccu

rrin

gPs

ych

iatr

ic a

nd

Sub

stan

ce A

bu

seD

iso

rder

s as

Th

eyA

pp

ly t

o In

div

idu

als

wit

h S

erio

us

and

Pers

iste

nt

Men

tal

Illn

ess

(SPM

I),

Oct

ob

er 1

998

Co

-Occ

urr

ing

Psyc

hia

tric

an

dSu

bst

ance

Ab

use

Dis

ord

ers:

Dia

gn

osi

san

d T

reat

men

t—Ps

ych

o-p

har

mac

olo

gy

Prac

tice

Gu

idel

ines

(Min

koff

et

al.,

1998

)

Ari

zon

a In

teg

rate

dTr

eatm

ent

Co

nse

nsu

sPa

nel

: Tra

inin

gM

od

ule

s

Yes

Com

mun

ity

Con

sens

us-B

uild

ing

Col

labo

rati

ve: C

omm

unit

y A

ctio

nG

rant

for

Exem

plar

y Pr

acti

ce

A p

roje

ct o

f the

Mas

sach

uset

tsD

epar

tmen

t of

Men

tal H

ealt

h in

Col

labo

rati

on w

ith

the

Dep

artm

ent

of P

ublic

Hea

lth,

the

Div

isio

n of

Med

ical

Ass

ista

nce,

the

Mas

sach

uset

ts B

ehav

iora

lH

ealt

h Pa

rtne

rshi

p, c

onsu

mer

s,fa

mily

mem

bers

, and

pro

vide

rs

The

Ari

zona

Dep

artm

ent

ofH

ealt

h Se

rvic

es/D

ivis

ion

ofB

ehav

iora

l Hea

lth

Serv

ices

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main

5 2

APPENDIX G

The

tra

inin

g m

odul

e sh

ould

be

used

as

a st

arti

ng p

oint

for

furt

her

stud

y. T

he e

nd o

f the

mod

ule

feat

ures

a c

olle

ctio

nof

jour

nal a

rtic

les

and

sugg

este

d re

adin

gs.

Thi

s re

port

is t

he r

esul

t of

the

col

lect

ive

effo

rts

of a

nati

onal

pan

el o

f dua

l dia

gnos

is e

xper

ts b

etw

een

Oct

ober

1996

and

Feb

ruar

y 19

98. T

he p

anel

met

to

deve

lop

nati

onal

sta

ndar

ds, w

orkf

orce

com

pete

ncie

s, an

d tr

aini

ngcu

rric

ula

for

the

trea

tmen

t of

peo

ple

wit

h co

-occ

urri

ngdi

sord

ers

in m

anag

ed c

are

syst

ems.

The

pan

el m

embe

rsw

ere

sele

cted

to

repr

esen

t co

nsum

ers,

fam

ily m

embe

rs,

and

prov

ider

s. T

hey

also

rep

rese

nted

peo

ple

wit

h ge

o-gr

aphi

c, c

ultu

ral,

and

raci

al d

iver

sity

as

wel

l as

peop

lefr

om p

ublic

-sec

tor,

priv

ate-

sect

or, p

sych

iatr

ic, a

nd s

ub-

stan

ce a

buse

dis

orde

r ba

ckgr

ound

s.

Add

ress

es t

he c

omm

on is

sues

and

str

uggl

es p

rofe

ssio

nals

desc

ribe

whe

n w

orki

ng w

ith

thes

e sp

ecia

l nee

ds c

onsu

mer

s.T

he p

eer-

led

cros

s-tr

aini

ng is

des

igne

d fo

r su

perv

isor

s an

dpr

acti

tion

ers

alik

e. P

arti

cipa

nts

are

not

requ

ired

to

have

any

spec

ial e

xper

tise

—ea

ch is

an

equa

l par

tner

in t

hele

arni

ng e

xper

ienc

e.

Part

icip

ants

mee

t in

sm

all g

roup

s of

5 t

o 10

peo

ple

who

brin

g di

ffere

nt li

fe e

xper

ienc

es a

nd in

sigh

ts. E

ach

smal

lgr

oup

has

a re

sour

ce le

ader

(s).

Con

trov

ersi

al t

opic

s st

imu-

late

ope

n an

d ho

nest

com

mun

icat

ion

and

prov

ide

oppo

r-tu

niti

es fo

r ne

w d

isco

veri

es.

Co

-Occ

urr

ing

Psyc

hia

tric

an

dSu

bst

ance

Dis

ord

ers

in M

anag

ed C

are

Syst

ems:

Sta

nd

ard

s o

f C

are,

Pra

ctic

eG

uid

elin

es, W

ork

forc

eC

om

pet

enci

es, a

nd

Trai

nin

g C

urr

icu

la

Cu

rric

ulu

m f

or

MIC

AA

and

CA

MI D

irec

t C

are

Pro

vid

ers:

Men

tal

Illn

ess,

Dru

g A

dd

icti

on

and

Alc

oh

olis

mM

IDA

A®: T

rain

ing

,C

ross

Tra

inin

g, a

nd

Pro

gra

m D

evel

op

men

t

A C

olla

bo

rati

veR

esp

on

se: A

dd

ress

ing

the

Nee

ds

of

Co

nsu

mer

s w

ith

Co

-O

ccu

rrin

g S

ub

stan

ceU

se a

nd

Men

tal

Dis

ord

ers—

Pa

rtic

ipan

t G

uid

e

Als

o in

clu

des

a C

D-R

OM

Yes

Yes

Rep

ort

of t

he C

ente

r fo

r M

enta

lH

ealt

h Se

rvic

es M

anag

ed C

are

Init

iati

ve: C

linic

al S

tand

ards

and

Wor

kfor

ce C

ompe

tenc

ies

Proj

ect

Co-

Occ

urri

ng M

enta

l and

Subs

tanc

e D

isor

ders

(D

ual

Dia

gnos

is)

Pane

l

Janu

ary

1998

Mid

-Am

eric

a A

ddic

tion

Tech

nolo

gy T

rans

fer

Cen

ter

Kan

sas

Cit

y, M

isso

uri

ww

w.m

attc

.org

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main

5 3

APPENDIX G

The

tra

inin

g bu

ilds

a co

llabo

rati

ve r

espo

nse

amon

g m

ulti

disc

iplin

ary

prof

essi

onal

s. O

ppor

tuni

ties

for

inte

rdis

-ci

plin

ary,

sm

all-

grou

p in

tera

ctio

n en

able

par

tici

pant

s to

appl

y ne

w in

form

atio

n, id

enti

fy a

genc

y or

pro

gram

inte

rnal

reso

urce

s, ex

plor

e co

mm

unit

y re

sour

ces,

and

prov

ide

feed

-ba

ck t

o le

ader

ship

reg

ardi

ng im

prov

ed s

ervi

ce fo

r pe

ople

wit

h co

-occ

urri

ng d

isor

ders

.

A s

econ

d an

d eq

ually

impo

rtan

t go

al e

ncou

rage

s pa

rtic

i-pa

nts

to p

rovi

de fe

edba

ck t

o le

ader

ship

reg

ardi

ng e

xist

ing

or p

oten

tial

bar

rier

s an

d op

port

unit

ies

in e

xist

ing

agen

cy/

prog

ram

min

g.

The

re is

an

eval

uati

on fo

rm a

t th

e co

nclu

sion

of e

ach

mod

ule.

Thi

s m

aste

r’s le

vel c

ours

e is

ava

ilabl

e fo

r cr

edit

on

line

thro

ugh

the

Uni

vers

ity

of I

owa.

A p

aper

-and

-pen

cil v

er-

sion

is a

lso

avai

labl

e. I

nstr

ucto

rs w

ho w

ant

to r

eplic

ate

the

cour

se c

an o

btai

n a

sylla

bus.

VH

S o

n D

rug

Ab

use

and

th

e B

rain

fro

m

the

NC

AD

I Vid

eoR

eso

urc

e Pr

og

ram

Psyc

ho

ther

apeu

tic

Med

icat

ion

s 20

01:

Wh

at E

very

Co

un

selo

rSh

ou

ld K

no

w

Cu

ltu

ral I

ssu

es in

Sub

stan

ce A

bu

seTr

eatm

ent

Co

ord

inat

ion

of

Alc

oh

ol,

Dru

g A

bu

se,

and

Men

tal H

ealt

hSe

rvic

es

Ass

essm

ent

and

Trea

tmen

t o

f Pa

tien

tsw

ith

Co

exis

tin

g

Men

tal I

llnes

s an

dA

lco

ho

l an

d O

ther

Dru

g A

bu

se: T

reat

men

tIm

pro

vem

ent

Pro

toco

l(T

IP)

Seri

es

Ass

essm

ent

of

Sub

stan

ce R

elat

ed

and

Men

tal H

ealt

hD

iso

rder

s

Yes

Prai

riel

ands

AT

TC

319-

335-

5368

http

://w

ww.

uiow

a.ed

u/~a

ttc

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main

5 4

APPENDIX G

A c

urri

culu

m p

acka

ge a

ddre

ssin

g th

eory

, too

ls, a

nd

skill

s in

cha

ngin

g be

havi

or fo

r re

side

ntia

l and

non

resi

-de

ntia

l TC

env

iron

men

ts. T

his

cour

se c

an b

e ap

plie

d to

com

mun

ity

trea

tmen

t en

viro

nmen

ts a

s w

ell a

s co

rrec

-ti

onal

-, m

enta

l hea

lth-

, ado

lesc

ent-

, and

wom

en w

ith

child

ren-

focu

sed

prog

ram

s. Le

ngth

equ

als

36 h

ours

—in

clud

es le

ctur

e an

d le

arni

ng a

ctiv

itie

s.

Rev

iew

of d

iagn

osti

c cr

iter

ia r

elat

ed t

o su

bsta

nce

abus

ean

d ad

dict

ion.

Com

pare

s di

agno

stic

cat

egor

ies

for

men

tal

and

subs

tanc

e ab

use

diso

rder

s. A

lso

prov

ides

an

intr

oduc

-ti

on t

o as

sess

men

t sk

ills

and

tool

s.

Thi

s 1-

day

cour

se fo

r m

enta

l hea

lth

spec

ialis

ts p

rovi

des

incr

ease

d un

ders

tand

ing

of M

HS

role

s and

att

itud

es to

war

dal

coho

l, to

bacc

o, a

nd o

ther

dru

gs (

AT

OD

), k

now

ledg

eab

out

prev

enti

on o

f AT

OD

pro

blem

s, an

d th

e sk

ills

tode

tect

and

app

ropr

iate

ly re

fer c

lient

s with

AT

OD

pro

blem

s.

Key

obj

ecti

ves

of t

he c

ours

e ar

e to

:Es

tabl

ish

a le

arni

ng c

omm

unit

y en

viro

nmen

tC

lari

fy t

he m

enta

l hea

lth

spec

ialis

t’s r

ole

in t

he

prev

enti

on o

f AT

OD

Des

crib

e th

e hi

stor

y an

d de

velo

pmen

t of

the

pr

even

tion

app

roac

hD

efin

e pr

even

tion

Prov

ide

info

rmat

ion

on a

ddic

tion

Dem

onst

rate

effe

ctiv

e co

mm

unic

atio

n sk

ills

whe

n di

scus

sing

pri

mar

y pr

even

tion

and

ear

ly id

enti

ficat

ion

stra

tegi

esD

evel

op a

n ac

tion

pla

n.

The

com

plet

e cu

rric

ulum

pac

kage

is a

vaila

ble

in p

rint f

orm

.

Beh

avio

r Sh

apin

g/

Man

agem

ent

in

the

Ther

apeu

tic

Co

mm

un

ity

Sett

ing

Du

al D

iag

no

sis

and

th

e D

SM-I

V C

ateg

ori

es

Men

tal H

ealt

hSp

ecia

list

Trai

nin

gC

ou

rse—

Prev

enti

on

o

f A

lco

ho

l, To

bac

co,

and

Oth

er D

rug

Pro

ble

ms

Yes

Yes

Yes

Paci

fic S

outh

wes

t A

TT

C85

8-55

1-29

44

http

://w

ww.

attc

.ucs

d.ed

u

Paci

fic S

outh

wes

t A

TT

C85

8-55

1-29

44

http

://w

ww.

attc

.ucs

d.ed

u

New

Eng

land

AT

TC

401-

444-

1808

http

://w

ww.

caas

.bro

wn.

edu/

ATTC

-NE

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main

5 5

APPENDIX G

A t

rain

ing

man

ual/c

urri

culu

m fo

r su

bsta

nce

abus

e co

un-

selo

rs o

r th

ose

trai

ning

to

beco

me

subs

tanc

e ab

use

coun

-se

lors

. The

pro

gram

aim

s to

edu

cate

par

tici

pant

s on

how

subs

tanc

e us

e an

d ab

use

affe

ct t

he o

utco

me

of t

raum

atic

brai

n in

jury

(T

BI)

, ski

lls fo

r fu

ncti

onal

ly a

sses

sing

indi

-vi

dual

s w

ith

alco

hol a

nd o

ther

dru

g is

sues

and

TB

I or

men

tal d

iagn

osis

, and

pro

cedu

res

for

inte

rven

tion

and

clie

nt e

ngag

emen

t w

ith

this

pop

ulat

ion.

A t

rain

ing

mod

ule

that

pre

sent

s an

eco

logi

cal t

reat

men

tm

odel

for

mul

tidi

agno

sed

pati

ents

/con

sum

ers

(and

the

irfa

mili

es)

who

pre

sent

wit

h co

mpl

ex m

edic

al, a

ddic

tive

,ps

ychi

atri

c, a

nd p

sych

osoc

ial p

robl

ems.

Thi

s in

nova

tive

tre

atm

ent

appr

oach

bri

dges

cor

e m

edic

al,

psyc

hiat

ric,

soc

ial w

ork,

nur

sing

, and

rec

over

y pr

inci

pals

as w

ell a

s be

liefs

, pra

ctic

e re

alit

ies,

and

stra

tegi

es.

The

cur

ricu

lum

incl

udes

han

dout

s, w

orks

heet

s, ov

er-

head

s, ou

tlin

es, a

nd a

tra

inin

g m

anua

l.

Tho

ugh

not

a tr

ue t

rain

ing

curr

icul

um, t

his

book

pro

vide

sgu

idan

ce t

o le

ader

s of

men

tal h

ealt

h, s

ubst

ance

abu

setr

eatm

ent,

and

beha

vior

al h

ealt

h sy

stem

s.

The

boo

k de

tails

gui

delin

es fo

r pl

anni

ng a

nd m

anag

ing

dual

dis

orde

rs p

rogr

ams.

It in

clud

es a

33-

page

Exe

cuti

veSu

mm

ary

and

a 21

9-pa

ge d

etai

led

text

wit

h ex

hibi

ts a

ndap

pend

ices

.

Prep

ared

for

the

Com

mun

ity

Supp

ort

Prog

ram

. Con

tain

sch

apte

rs a

ddre

ssin

g:R

evie

w o

f the

Lit

erat

ure

Trea

tmen

t Pr

inci

ples

Org

aniz

ing

Dua

l Dis

orde

rs S

ervi

ces

Trea

tin

g A

lco

ho

l an

dO

ther

Dru

g C

lien

tsM

ult

i-d

iag

no

sed

wit

hTr

aum

atic

Bra

in In

jury

and

/or

Men

tal H

ealt

hD

iag

no

sis

An

Eco

-Sys

tem

icA

dd

icti

on

an

d M

enta

lH

ealt

h T

reat

men

tM

od

el: A

Tra

inin

gM

od

ule

Sub

stan

ce A

bu

seTr

eatm

ent

for

Peo

ple

wit

h S

ever

e M

enta

lD

iso

rder

s: A

Pro

gra

mM

anag

er’s

Gu

ide

Yes

Yes

Yes

Nor

thea

ster

n St

ates

AT

TC

518-

442-

5702

http

://w

ww.

alba

ny.e

du/p

dp/a

ttc

Har

d co

py–$

25, d

iske

tte–

$5

Nor

thea

ster

n St

ates

AT

TC

518-

442-

5702

http

://w

ww.

alba

ny.e

du/p

dp/a

ttc

Har

d co

py–$

20, d

iske

tte–

$5

New

Ham

pshi

re-D

artm

outh

Psyc

hiat

ric R

esea

rch

Cen

ter

$29.

95

Aut

hors

: Car

olyn

Mer

cer-

McF

adde

n,R

ober

t E.

Dra

ke, R

obin

E. C

lark

, Nic

hola

s Ver

ven,

Dou

glas

L. N

oord

sy,a

nd T

hom

as S

. Fox

Ord

er fr

om: K

aren

Dun

nN

ew H

amps

hire

-Dar

tmou

th P

RC

2

Whi

pple

Pla

ce, S

uite

202

Leba

non,

NH

037

6660

3-44

8-01

26

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main

5 6

APPENDIX G

Lead

ersh

ip a

nd I

mpl

emen

tati

onC

ost

and

Fina

ncin

g Is

sues

Clin

ical

Con

trov

ersi

es

The

cur

ricu

lum

is p

rese

nted

in t

hirt

een

3-ho

ur w

orks

hops

or a

s a

15-w

eek

grad

uate

-lev

el p

sych

olog

y co

urse

at

McN

eese

Sta

te U

nive

rsit

y.

It is

inte

nded

for

trea

tmen

t pr

ofes

sion

als

in a

ddic

tion

s or

men

tal h

ealt

h an

d us

ually

pre

sent

ed t

o bo

th g

roup

s at

the

sam

e ti

me.

Pre

inst

ruct

ion

and

post

inst

ruct

ion

eval

uati

ons

show

hig

h le

vels

of s

atis

fact

ion

wit

h th

e tr

aini

ng, a

long

wit

h sh

ifts

in k

now

ledg

e an

d at

titu

des

cons

iste

nt w

ith

trai

ning

obj

ecti

ves.

The

cur

ricu

lum

con

tent

incl

udes

:O

verv

iew

of L

ouis

iana

Int

egra

ted

Trea

tmen

t Se

rvic

es M

odel

Cha

ract

eris

tics

of S

ubst

ance

and

Men

tal D

isor

ders

Cha

ract

eris

tics

of C

o-O

ccur

ring

Dis

orde

r Po

pula

tion

Spec

ial P

opul

atio

nsFa

mily

Nee

ds/C

ontr

ibut

ions

Beh

avio

ral P

harm

acol

ogy—

basi

c pr

inci

ples

Beh

avio

ral P

harm

acol

ogy—

impl

icat

ions

for

trea

tmen

tSc

reen

ing

and

Ass

essm

ent

Mot

ivat

iona

l Int

ervi

ewin

gG

roup

Int

erve

ntio

nFu

ncti

onal

Ana

lysi

s/Tr

eatm

ent

Plan

ning

Rel

apse

Pr

even

tion

Com

mun

ity

Rei

nfor

cem

ent

and

Fam

ily T

hera

py

(CR

AFT

)/C

ase

Man

agem

ent.

Lou

isia

na

Inte

gra

ted

Trea

tmen

t Se

rvic

esC

urr

icu

lum

Yes

For

info

rmat

ion

cont

act:

Cam

L. M

elvi

lle, P

h.D

. Pr

ofes

sor

Dep

artm

ent

of P

sych

olog

y M

cNee

se S

tate

Uni

vers

ity

Lake

Cha

rles

, LA

706

09

(337

) 47

5-54

62

mel

ville

@m

ail.m

cnee

se.e

du

Cos

t is

$60

0 pe

r w

orks

hop.

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main

5 7

APPENDIX G

Thi

s cu

rric

ulum

will

be

avai

labl

e in

Jan

uary

200

2. I

t is

atw

o-vo

lum

e se

t (6

00 p

ages

eac

h) a

nd in

clud

es:

Cro

ss-t

rain

ing

for

men

tal h

ealt

h an

d su

bsta

nce

abus

e pr

acti

tion

ers

Full

inst

ruct

ions

to

trai

ners

and

con

tent

mat

eria

lW

orks

heet

s/ha

ndou

t m

aste

rs.

The

cur

ricu

lum

can

be

used

wit

h pr

acti

tion

ers

and

clie

nts.

The

aut

hor

is a

vaila

ble

to p

rovi

de t

rain

ing

for

use

of t

he c

urri

culu

m.

Thi

s tr

ain-

the-

trai

ner

curr

icul

um h

as s

ever

al c

ompo

nent

s.To

olki

t #2

is fo

r cl

inic

al c

ompe

tenc

ies,

Tool

kit

#3 c

om-

pris

es c

ase

vign

ette

s, an

d To

olki

t #5

is fo

r pr

ogra

m

self-

asse

ssm

ent.

A W

eb s

ite

for

the

mat

eria

ls is

cur

rent

lyun

der

cons

truc

tion

.

The

SA

MH

SA C

ente

r fo

r M

enta

l Hea

lth

Serv

ices

fund

sC

omm

unit

y A

ctio

n G

rant

s th

at s

uppo

rt c

omm

unit

ies

toad

opt

spec

ific

exem

plar

y pr

acti

ces

into

the

ir s

yste

ms

ofca

re fo

r ad

ults

wit

h se

riou

s m

enta

l illn

ess

and

child

ren

wit

h se

riou

s em

otio

nal d

istu

rban

ces.

The

se g

rant

s en

cour

age

com

mun

itie

s to

con

vene

par

t-ne

rs, b

uild

con

sens

us, e

limin

ate

barr

iers

, sup

port

dec

i-si

ons,

and

adap

t se

rvic

e m

odel

s to

mee

t lo

cal n

eeds

. Som

egr

ante

es h

ave

chos

en t

o fo

cus

on c

o-oc

curr

ing

diso

rder

s.

The

Bas

ics:

A

Cu

rric

ulu

m

for

Men

tal a

nd

Sub

stan

ce U

seD

iso

rder

s, S

eco

nd

Edit

ion

Co

-Occ

urr

ing

Dis

ord

ers

Serv

ice

Enh

ance

men

tTo

olk

it

Pote

nti

al S

ou

rces

of

Futu

re T

rain

ing

Cu

rric

ula

—C

MH

SC

om

mu

nit

y A

ctio

nG

ran

t R

ecip

ien

ts

Yes

Yes

Yes

Rho

da M

cKill

up, A

utho

rSp

okan

e, W

A50

9-25

8-73

14

Cos

t: $1

00 fo

r th

e 2

volu

mes

Zial

ogic

6501

Wyo

min

g B

oule

vard

, N.E

.,Su

ite

205

Alb

uque

rque

, NM

871

1150

5-82

3-66

87ca

c@sw

cp.c

om

Cos

ts v

ary

depe

ndin

g on

the

ent

ity

or p

erso

n re

ques

ting

the

mat

eria

ls(i

.e.,

nonp

rofit

age

ncy

vs. S

tate

agen

cy).

Pote

ntia

l sou

rces

are

gra

ntee

s in

Okl

ahom

a, F

lori

da, M

aryl

and,

Mai

ne, a

nd R

hode

Isl

and

Pu

bli

c Pri

vate

Tr

ain

ing

Pro

du

ct D

esc

rip

tio

nSo

urc

eD

om

ain

Do

main