COSIG CONFERENCE BROCHURE.pdf - Drexel University College ...

Program Description: 

The Commonwealth of Pennsylvania was one of the first states to receive a five-year Co- 

Occurring Systems Integration Grant (COSIG). At the time that this grant was received, there 

were already five pilot projects underway for integrating treatment and support services for 

persons with mental and substance use disorders. All five of these projects are presenting data 

and experiential information that can assist other programs in their attempts to provide effective 

integrated interventions. 

This conference also provides the opportunity to learn from nationally- and internationallyknown 

experts in the field of co-occurring mental and substance use disorders as well as 

workshops that address systems concerns; clinical practices and specific combinations of 

disorders; child, adolescent, adult and elder issues; criminal justice involvement considerations; 

cultural considerations; specific supports – all within the context of supporting personal 

recovery from both/all disorders. 

Target Audience: 

• State and County level administrators, program specialists and licensing staff 

• Clinical and support staff in mental health and substance use treatment programs 

• Psychiatrists, physicians and licensed professionals who work with persons 

having CODs 

• Criminal justice and juvenile justice staff and those who work with adolescents and 

families 

Educational Objectives: 

Those attending the full conference will have the opportunity to: 

• Examine national and multi-state perspectives on systems integration to provide more 

holistic treatment and support services for persons having co-occurring mental and 

substance use disorders; 

• Deepen clinical and specialized knowledge and skills for serving this population; 

• Identify and discuss recovery-oriented practices and service structures; 

• Review evidence-based and promising approaches and interventions; 

• Share personal expertise with colleagues and contribute to the field of co-occurring 

disorders.

CONTINUING EDUCATION CREDITS 

CME: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation 

Council for Continuing Medical Education (ACCME) through the joint sponsorship of Drexel University College of Medicine and 

OMHSAS, IRETA and SAMHSA. The Drexel University College of Medicine is accredited by the Accreditation Council for 

Continuing Medical Education to provide continuing medical education for physicians. 

AMA: The Drexel University College of Medicine designates this educational activity for a maximum of 20.5 AMA PRA Category 1 

Credit(s) . 

AOA: This program is eligible for 20.5 credit(s) in Category 2A of the American Osteopathic Association. 

Physicians should only claim credit commensurate with the extent of their participation in the activity. The evening Psychiatric 

Special Event can award a maximum of 2 additional hours. 

Faculty Disclosure Statement: It is the policy of Drexel University College of Medicine to insure balance, independence, objectivity, 

and scientific rigor in all its sponsored educational programs. Speakers at continuing medical education activities are required to 

disclose to the audience their financial relationships with the manufacturer(s) of any commercial products, goods or services related to 

the subject matter of the program topic. Any conflicts of interest must be resolved prior to presentation and announced to the audience. 

The intent of this disclosure is to allow participants to form their own judgments about the educational content of this activity and 

determine whether the speaker's commercial interests influenced the presentation. In addition, speakers are required to openly disclose 

any off-label, experimental, or investigational use of drugs or devices discussed in their presentation. 

APA (Psychology): Drexel University College of Medicine, Behavioral Healthcare Education is approved by the American 

Psychological Association to sponsor continuing education for psychologists. Drexel University College of Medicine, Behavioral 

Healthcare Education maintains responsibility for this program and its content. This program is offered for 20.5 credits. The 

Psychiatric Special Event can award a maximum of 2 additional hours. 

ASWB (National Social Work): This organization, Drexel University College of Medicine, Behavioral Healthcare Education, 

provider #1065, has pending approval as a provider for continuing education by the Association of Social Work Boards 400 South 

Ridge Parkway, Suite B, Culpeper, VA 22701. www.aswb.org. ASWB Approval Pending. Social Workers should contact their 

regulatory board to determine course approval. Social workers will receive 20.5 continuing education clock hours in participating in 

this course. The Psychiatric Special Event can award a maximum of 2 additional hours. 

LSW (PA SBSWE Licensed Social Workers in Pennsylvania): This conference is approved for a maximum of 20.5 credit hours 

through a formal agreement with the Bryn Mawr College Graduate School of Social Work and Social Research. Bryn Mawr College 

GSSWSR, as a CSWE accredited school of social work, is an approved provider of continuing education for social workers in 

Pennsylvania and many other states. The Psychiatric Special Event can award a maximum of 2 additional hours. 

NAADAC (National D&A): This training has been approved by the National Association of Alcoholism and Drug Abuse Counselors 

for a maximum of 20.5 educational hours. NAADAC Approved Provider #000125. The Psychiatric Special Event can award a 

maximum of 2 additional hours. 

NBCC (National Counselors): Drexel University College of Medicine is recognized by the National Board for Certified Counselors 

to offer continuing education for National Certified Counselors. We adhere to NBCC continuing education guidelines. We can award 

a maximum of 20.5 hours of continuing education credit. The Psychiatric Special Event can award a maximum of 2 additional hours. 

PA Educators Act 48: Drexel University College of Medicine, Behavioral Healthcare Education is recognized by the Pennsylvania 

Department of Education to offer continuing education credits under Act 48 guidelines. Drexel University College of Medicine, 

Behavioral Healthcare Education adheres to Act 48 Continuing Education Guidelines. PA educators will receive a maximum of 20.5 

hours of credit for attending this complete conference. The Psychiatric Special Event can award a maximum of 2 additional hours. 

PCB (PA Certified Addictions Counselor): Drexel University College of Medicine, Behavioral Healthcare Education will award a 

maximum of 20.5 PCB Approved Hours of Education for this training. Our program is certified by the Pennsylvania Certification 

Board, Provider # 133. The Psychiatric Special Event can award a maximum of 2 additional hours. 

PSNA (Nursing): Drexel University College of Medicine, Behavioral Healthcare Education, an approved provider of continuing 

nursing education by the PA State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s 

Commission on Accreditation. Participants will be awarded a maximum of 24.6 contact hours for attending this conference. The 

Psychiatric Special Event can award a maximum of 2.4 additional hours. 

CEs (Continuing Education – if not requesting one of the other types above): 

The Drexel University College of Medicine, Behavioral Healthcare Education will award a certificate of attendance for up to 20.5 

hours for the conference to each participant who attends the conference. The Psychiatric Special Event can award a maximum of 2 

additional hours.

Conference Information: 

The Pennsylvania Office of Mental Health and Substance Abuse Services, Department of 

Public Welfare, in partnership with the Division of Behavioral Healthcare Education in the 

Department of Psychiatry at Drexel University College of Medicine and the Institute for 

Research, Education and Training in Addictions/Northeast Addiction Technology Transfer 

Center, is pleased to welcome you to “Beyond 2006: Promoting Recovery-Oriented Programs 

and Practices for Persons with Co-occurring Mental and Substance Use Disorders.” Please 

note the following in order to help this conference experience be a very pleasant one for you 

and your colleagues: 

The registration table will be staffed for the duration of the conference. We are happy to 

answer any questions or to provide information and/or directions related to conference events. 

Please let us know about any special needs in advance of the event. 

There will be a message board at the registration area for phone messages, any last minute 

workshop changes, or other announcements. Please check this board periodically during your 

stay. 

Please turn off pagers and cell phones or put them on “silent” or “vibrate” mode throughout the 

conference. If you must respond to them, please leave the presentation room and be sure you 

are not within hearing range of the room when you return the call or page. We thank you for 

your consideration of your fellow attendees. 

Please dress in layers (keep a sweater or light jacket with you) when in conference 

presentations. We try to ensure your comfort but are not always able to control room 

temperatures. 

Please turn in your workshop evaluation forms to the convener in each workshop as you exit. 

Turn in your conference evaluation form and continuing education validation form at the 

registration desk just before you leave the conference. [There is no other verification of your 

attendance, other than your signature on your form.]

Exhibitors: 

A special thanks to our exhibitors (listed below). Please stop by and visit them. 

Roxbury Treatment Center 

601 Roxbury Road 

Shippensburg, PA 17257 

1-800-648-HOPE (4673) 

PsyTech Solutions, Inc 

1138 Stone Creek Drive 

Hummelstown, PA 17036 

866-3-PSYTECH 

Substance Abuse and Mental Health Services Administration 

11426 Rockville Pike 

Rockville, Maryland 20852 

240-747-4817 

Institute for Research, Education and Training in Addictions - IRETA 

PA Regional Drug & Alcohol Training Institutes 

425 Sixth Avenue, Suite 1710 

Pittsburgh, PA 15219 

412-258-8569 

MHM Services, Inc 

Pennsylvania Regional Office 

Anchor Place 

645 North 12th Street 

Lemoyne, PA 17043 

866-293-4940 

717-761-4002 

Drexel University 

Behavioral and Addictions Counseling Sciences Program 

245 North 15 th Street, MS 507 

Philadelphia, PA 19102 

215-762-7190

MONDAY 

May 15 th , 2006

Monday Morning Plenary Session 

“Federal Perspectives and Initiatives Regarding 

Co-Occurring Disorders” 

Charles G. Curie, MA, ACSW 

Administrator, SAMHSA 

(US Department of Health & Human Services, 

Substance Abuse and Mental Health Services Administration)

Monday Morning Plenary Session 

“State Models for the Development of Co-Occurring Disorder 

Services” 

A Panel Presentation moderated by: 

Stanley Sacks, PhD 

Panel Members: 

Carole Baxter, Project Director, Arkansas COSIG 

Andrew L. Homer, PhD, Project Director, COSIG Missouri 

Tanya M. McGee, MS, BCSAC, BCCGC, COSIG Project 

Director, Louisiana & 

Robert L. Primrose, Director, Division of Substance Abuse 

Services, PA OMHSAS

COSIG Co-Occurring Disorders Conference, Hershey PA, May 15-17, 2006 

COCE Learning Community 

State Models for the 

Development of Co-Occurring 

Moderator – Stanley Sacks, PhD, Expert Leader, SAMHSA’s Co-Occurring 

Center for Excellence, National Development & Research Institutes, Inc. 

Panel Presenters – Carole Baxter, MS, Project Director, Arkansas COSIG; 

Andrew Homer, PhD, Project Director, Missouri COSIG; Tanya McGee, MS, 

Project Coordinator, Louisiana COSIG; Robert Primrose, Director, Division 

of Substance Abuse Services, PA OMHSAS 

COSIG I 

States 

COSIG III 

States 

COSIG II 

States 

CT 

AZ 

AK AR 

Other States 

Policy Academy States 

NM 

HI 

DC 

LA 

ME 

OK 

MO 

VT 

VA 

PA 

COCE Learning Community 

TX 

2006 Pennsylvania COSIG Conference: Beyond 2006 – Promoting Recovery-Oriented Programs and Practices 

for Persons with Co-Occurring Mental and Substance Use Disorders May 15- 17, 2006 Hershey, PA 

What is a Learning Community? 

The community of learners approach originated in the 

educational community and is built on a few basic 

assumptions. 

learning is fundamentally a social phenomenon. 

knowledge is integrated in the life of communities 

that share values, beliefs, languages, and 

ways of doing things. 

knowledge is inseparable from practice. 

Empowerment― or the ability to contribute 

positively to a community ― enhances the 

potential for learning. 

Arkansas COSIG 

Meeting the Needs of Dually 

Diagnosed Arkansans 

Carole Baxter, M.S., L.A.D.A.C., L.P.E. 

COSIG Project Director 

Pennsylvania COSIG Conference 

May 15, 2006 

Background 

Arkansas COSIG Goals 

Arkansas, like so many other states, has 

provided services to individuals with cooccurring 

disorders in two separate silos. 

• Develop and implement screening and assessment 

protocols that identify individuals with cooccurring 

disorders which are acceptable to both 

mental health and substance abuse treatment 

communities. 

• Develop a training program for mental health and 

substance abuse providers in the use of these 

protocols and on the needs of and services 

available to those with co‐occurring disorders 

(COD). 

1


COSIG Committees 

Committees have been set up to identify issues 

and address problems. Those committees 

are: 

Advisory Committee 

Goal: 

• Provide direct oversight and overall direction for 

the grant 

• Advisory Committee 

• Financial Incentives Review Committee 

• Licensure & Credentialing Review Committee 

• Data Coordination Committee 

• Screening & Assessment Committee 

• Training Committee 

Tasks: 

• Receive progress reports 

• Ensure project activities are on schedule 

• Make decisions regarding project activities 

• Troubleshoot problems 

Financial Incentives Review Committee 

Goal: 

• Identify reimbursement policies that act as 

disincentives, and explore options to increase financial 

incentives to treat individuals with co‐occurring 

disorders 

Task: 

• Develop financial incentives to providers to provide 

integrated services 

Licensure and Credentialing Review 

Committee 

Goal: 

Review existing licensure and credentialing 

requirements and identify ways to revise them to 

increase the number of facilities and/or the availability 

of trained personnel able to treat individuals with a cooccurring 

disorder 

Task: 

Develop a “specialty” designation to treat persons with 

co‐occurring disorders for various license/certifications 

in the state 

Data Coordination Committee 

Screening and Assessment Committee 

Goal: 

Task: 

• Explore ways to coordinate the data collection and 

management of the two systems to ensure the 

availability of unduplicated client information 

• Set up a system to get basic common data elements for 

unduplicated clients 

Goal: 

• Develop screening and assessment protocol 

appropriate for substance abuse and mental health 

settings respectively which are acceptable to both sets 

of providers 

Task: 

• Select, modify, test, and disseminate appropriate, 

reliable and well validated screening tools and 

assessment protocols 

2


First Pilot Results 

Training Committee 

TCU Pilot n=344 

23% 

Positive 

MHSFIII Pilot n=422 

Negative 

77% 

40% 

60% 

*These are the results from our initial pilot in March 2005. 

Positive 

Negative 

Goals: 

‐ Train mental health and substance abuse providers: 

• In the use of the screening and assessment protocols 

• About common mental illnesses and substance abuse 

• About problems associated with COD, and the need for 

integrated treatment 

• About treatment options and resources available in their 

communities 

• About cultural competence and cultural sensitivity 

Task: 

‐ Identify curriculum 

Evaluation Committee 

Approach 

Goal: 

‐ Evaluate the implementation processes 

Translating evidence based research into policies, 

systems and practices by: 

Task: 

Document stakeholders’ participation in, and 

satisfaction with, the implementation process. 

Goal: 

‐ Support the implementation process. 

Task: 

Conduct the “study” phase of the Plan‐Do‐ 

Study‐Act cycle. 

• Identifying stakeholders 

• Challenging preconceived beliefs 

• Identifying shared goals 

• Generating discomfort for status quo 

• Encouraging change 

Lessons Learned … 

• Increase ownership of clients’ situations 

• Increase skills of workforce 

• Increase communication among providers 

Missouri’s Journey: Implementing 

Evidence-Based Practices 

Andrew L. Homer Ph.D. 

Missouri Institute of Mental Health 

2006 Pennsylvania 

COSIG Conference 

May 15, 2006 

3


Co-occurring Disorders 

Impact 

• Poor Outcomes 

– Twice as many days in the hospital 

– Higher Relapse 

– Higher Suicide Risk 

– Higher Arrest Rates 

– More Violence 

– More HIV Infection 

– Higher Treatment Drop-out 

Basic - 

SA Only 

Institute of Medicine 

Conceptualization of Co-occurring 

Treatment 

Levels of Program Capacity in Co-occurring 

Disorders 

Substance Abuse System 

Intermediate - 

COD Capable 

Advanced - 

COD Enhanced 

Fully Integrated 

Advanced - 

COD Enhanced 

Mental Health System 

Intermediate - 

COD Capable 

Basic - 

MH Only 

Self-Report Capability to Provide COD 

Services 

Results: Overall Capability to Serve 

Clients with COD 

50 

Advanced 

Intermediate 

Basic 

Basic 30% 

Intermediate 

59% 

Advanced 11% 

% of Sites 

40 

30 

20 

10 

0 

Basic 

Basic/Intermediate 

Intermediate 

Intermediate/Advanced 

Advanced 

Basic – 4 programs; 

Basic/Intermediate – 6 programs; 

Intermediate – 3 programs; 

Intermediate/Advanced – 1 program; 

Advanced – 0 programs 

Missouri DMH 

COSIG: MISSOURI 

• Comprehensive Psychiatric Services 

– State Hospitals and “Administrative Agents” 

– Non-competitive contracts & Territories 

– Restrictive Eligibility (SMI) 

– Heavy Reliance on Medicaid 

• Alcohol and Drug Abuse 

– Providers in non-exclusive territories 

– Competitive Bid Contracts\ 

– Little Medicaid 

– Managed Care 

• Andrew Homer, Ph.D., Missouri Institute of 

Mental Health – Project Co-Director 

• Joseph Parks, M.D., Missouri Department 

of Mental Health – Project Co-Director 

• Pat Stilen, LCSW, CADAC, Mid-America 

ATTC – Training Director 

• Heather Gotham, Ph.D., Missouri Institute 

of Mental Health – Evaluation Director 

4


COSIG: MISSOURI 

Goals 

• Policy Analysis 

•Training 

• Standardized Screening and Assessment 

• Treatment Pilot 

• Evaluate Project 

Policy Analysis 

• Governor’s Steering Committee 

• National Policy Academy 

Training 

Screening/Assessment 

Instruments 

• Mid-America ATTC – Provider training 

– Gain COD information 

– Develop a new or different perspective re. 

clients with COD and cross-disciplinary fields 

– Openness and motivation to make changes 

– Develop Personal Action Plans utilizing core 

components of COD curriculum 

– Continually revise and implement Personal 

Action Plans 

Screening 

Assessment 

Mental Health 

Mental Health 

Screening Form III 

Computerized 

Diagnostic Interview 

Schedule-IV 

M.I.N.I. 

Substance 

Abuse 

CAGE-AID 

Addiction Severity 

Index 

Treatment Pilot 

Treatment Pilot 

Rural Setting 

Urban Setting 

Kirksville 

%U #S 

Separate CPS 

and ADA 

Contractors 

4 sites (2 CPS, 2 

ADA) 

Joint CPS/ADA 2 sites, each 

Contractors with joint 

contracts 

4 sites (2 CPS, 2 

ADA) 

1 site with joint 

contract 

LEGEND 

COSIG Sites 

%U ADA Program 

#S CPS Program 

ÊÚ 

Training 

KANSAS CITY 

#S%U ÊÚ 

Clinton 

%U #S 

Jefferson City 

ÊÚ 

ST. LOUIS 

ÊÚ %U #S 

Cape Girardeau 

Kennett 

Hayti 

#S %U 

%U #S 

ÊÚ 

5


Consensus Based 

Essential 

Guiding Principles 

Programming 

Techniques for 

Working with 

Clients with COD 

(with evidence 

based in substance 

abuse treatment) 

Evidence Based 

Evidence-Based 

Practices for the 

Models 

Severely 

Mentally Ill 

Change Management 

Employ a Recovery 

Perspective 

Screening, 

Assessment, and 

Referral 

Motivational 

Enhancement 

Assertive 

Community 

Treatment 

Collaborative 

Psychopharmacology 

Adopt a Multi-Problem 

Viewpoint 

Psychiatric and Mental 

Health Consultation 

Contingency 

Management 

Techniques 

Modified 

Therapeutic 

Community 

Family Psycho-education 

Develop a Phased 

Approach 

to Treatment 

Intensive Case 

Management 

Cognitive–Behavioral 

Therapeutic 

Techniques 

Supported Employment 

Address Specific Real-Life 

Problems Early in 

Treatment 

Prescribing 

Onsite Psychiatrist 

Relapse Prevention 

Illness Management and 

Recovery Skills 

Plan for the Client’s 

Cognitive and Functional 

Impairments 

Medication and 

Medication Monitoring 

Repetition and 

Skills-Building 

Assertive Community 

Treatment 

Use Support Systems to 

Maintain and Extend 

Treatment Effectiveness 

Psychoeducational 

Classes 

Double Trouble Groups 

(Onsite) 

Dual Recovery Mutual 

Self-Help Groups 

(Offsite) 

Client Participation in 

Mutual Self-Help 

Groups 

Integrated Dual Disorder 

Treatment (Substance Use 

and Mental Illness) 

Adapted from TIP 42 by S. Sacks 

When you’re up to your neck in 

alligators, its hard to drain the swamp! 

1st Barrier = Funding 

2nd Barrier = Attitudes 

• N= 148 

• Funding for providers/staff 

• Agency budget constraints 

• Reimbursement & insurance/billing issues 

• Funding for continuing training 

• n= 94 

• Philosophical differences among providers 

• Rigid belief systems 

• Resistance to change policies/procedures 

• Lack of readiness to change 

• Turf/Territory issues 

• Competition between fields 

3rd Barrier = Lack of 

Knowledge/Education & Need for 

Training in… 

• = 87 

• Treatment for COD 

• Mental health issues 

• Substance abuse issues 

• Cultural diversity issues 

• Time & resources to implement 

training/knowledge gains 

4th Barrier = Service 

Delivery Issues 

• n= 65 

• Limited resources available (e.g., staff time, 

large caseloads, wait-lists, consumer access to 

services) 

• Service eligibility requirements for clients 

(e.g., diagnostic issues, provider certification 

for treatment) 

• Poor client outcomes 

• Inefficient treatment system 

6


5th Barrier = Stigma 

• n= 59 

• Negative perceptions toward substance abuse clients & 

counselors 

• Negative perceptions toward mental illness & mental health 

field 

• Prejudice toward clients in recovery utilizing medication 

• Negative attitude toward use of medication in treatment 

• “Fear of the unknown” 

6th Barrier = Lack of Experiential Base, 

“Top-Down” Leadership 

• n= 58 

• Influence of politics & the treatment system 

• Lack of understanding regarding the actual 

needs of consumers 

• Gap between policy-makers & consumer 

services 

• Lack of priority for stigmatized groups 

• Lack of priority for social services 

7th Barrier = Lack of Collaboration 

between Fields 

Preliminary Screening Results 

• n= 22 

• Lack of communication between mental health 

& addiction treatment counselors/staff 

• Lack of a “common language” to discuss COD 

• Lack of communication w/ other provider 

agencies 

• Lack of cooperation between fields 

• 63% Screened Positive for on Both Screeners 

• 67% of those who screened positive for substance 

use disorder also screened positive for other 

mental disorders 

• 97% of those who screened positive for a mental 

disorder also screened positive for a substance use 

disorder 

Preliminary Assessment Results 

Utility of Assessments 

• 86% had positive assessments for substance use 

disorders and other mental disorders 

• 91% of those who had a positive assessment for a 

substance use disorder also were positive for other 

mental disorders 

• 95% of those who had a positive assessment for a 

mental disorder also were positive for a substance use 

disorder 

• 74% of workers surveyed rated the ASI 

either helpful or very helpful 

• 18% rated the CDIS as either helpful or 

very helpful 

• We replaced the CIDS with the M.I.N.I. 

7


References 

• Wright, S., Gournay, K., Glorney, E., & Thornicroft, G. (2000). Dual diagnosis in the suburbs: 

Prevalence, need, and in-patient service use. Social Psychiatry & Psychiatric Epidemiology, 35, 297- 

304. 

• Pollack, L., E., Cramer, R. D., & Varner, R. V. (2000). Psychosocial functioning of people with 

substance abuse and bipolar disorders. Substance Abuse, 21, 193-203. 

• Caton, C. L. M., Shrout, P. E., Eagle, P. F., & Opler, L. A. (1994). Risk factors for homelessness 

among schizophrenic men: a case-control study. American Journal of Public Health, 84, 265-270. 

• Rosenberg, S. D., Goodman, L. A., Osher, F. C., Swartz, M. S., Essock, S. M., Butterfield, M. I., 

Constantine, N. T., Wolford, G. L., & Salyers, M. P. (2001). Prevalence of HIV, hepatitis B, and 

hepatitis C in people with severe mental illness. American Journal of Public Health, 91, 31-37. 

• National Association of State Mental Health Program Directors/National Association of State 

Alcohol and Drug Abuse Directors. (1999, June). Financing and marketing the new conceptual 

framework for co-occurring mental health and substance abuse disorders. 

http://www.nasadad.org/index.php?base_id=101) 

• SAMHSA Toolkits - 

http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/about.asp 

• Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-Occurring 

Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 05- 

3922. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005 

Andrew L. Homer Ph.D. 

Missouri Institute of Mental Health 

(573) 751-8055 

Andrew.Homer@dmh.mo.gov 

Funded by Grant TI15347 to the Office of the Governor of 

Missouri from the Substance Abuse and Mental Health 

Services Administration 

Louisiana Integrated 

Treatment Services 

Initiative 

Funded by the LA COSIG 

Goal of LITS Initiative 

To develop a treatment delivery system within the 

state of Louisiana in which all publicly-funded 

Mental Health and Substance Abuse programs 

are Co-occurring Diagnosis Capable (CODC). 

Tanya M. McGee, MS, LAC, CCGC 

COSIG Project Coordinator 

HQ COSIG Structure 

COSIG Task Force 

Tanya 

Areas of Focus 

CAB 

COSIG Leadership 

• Workforce Development 

• Clinical Protocols 

HQ Committees 

Local COSIG Structure 

Facilitator 

Steering Committee 

CNG 

Clinics 

LITs 

Evaluation 

Funding 

Clinical 

IT 

Workforce Dev 

• Information Management 

• Program Evaluation 

• Funding 

8


Workforce Development 

• Completed 1-day Basic Orientation Trainings provided in 

10 local areas for over 1800 MH and AD staff 

• 2-day Advanced Clinical Training scheduled in 10 local 

areas for May 2006 

– Staff readiness for change 

– Structure for COD Capable and COD Enhanced programs 

– Integrated Screening and Assessment process 

– Treatment Planning 

• Advanced Clinical Trainings Specific to Professional 

Discipline as requested by local areas 

Clinical Protocols 

• Developed models of CODC Screening and Assessment 

Processes for both OAD and OMH – emphasis of work on 

PROCESS 

• Within each model are Shared Modules that Identify COD 

persons 

• Adoption of a Common Co-occurring Screening tool – MINI 

• COSIG Needs Addressed within Different Initiatives: 

– OMH JCAHO Accreditation Application 

– OAD Access to Recovery Initiative 

Information Management 

• Established a Common Data Warehouse 

OPEN IN BOTH 

OAD & OMH 1937 

UNDUPLICATED CLIENT 

(3%) 

COUNTS 

OPEN IN 

OAD ONLY HAD CASE OPEN IN BOTH OAD & 

24226 

OMH 1937 

HAD CASE OPEN IN OAD 26163 

OPEN IN 

OMH ONLY 

40206 

HAD CASE OPEN IN OMH 42143 

• SAS Data Management System Opportunity 

Program Evaluation 

• Adoption of the DDCAT developed by McGovern 

& the DDCAT- MH Version developed by Heather 

Gotham (MO COSIG) 

• Dual uses of the DDCAT 

• Plans for Outcome Collection Underway 

– Anticipation of PPG’s 

– Stakeholder involvement 

Funding 

• Identify resources to provide psychiatric services 

and medications, primarily within OAD system. 

– Evaluate Medicaid funding through establishment of 

Addictive Disorder (AD) clinics as satellite Mental Health 

(MH) clinics 

– Expand Patient Assistant Programs within AD and MH 

systems 

• Identify resources to support drug screening 

within OMH system. 

Learning to Adapt 

• Move from state to local authority 

Challenge: 6 state authority regions & 4 local authority districts 

Opportunity: implement integration consistently 

• Natural Disasters (Hurricanes Katrina & Rita) 

Challenge: loss of infrastructure & state financial burden 

Opportunity: integrated rebuilding 

• Merge OAD and OMH into Office of Behavioral Health 

Challenge: complex task not in original plan & creating anxiety 

Opportunity: utilize COSIG work as foundation 

9


Pennsylvania’s COSIG Initiative 

Background 

State COD Conference 

May 2006 

Robert Primrose 

Office of Mental Health and Substance Abuse Services 

Pennsylvania Department of Public Welfare 

The Mental Health and Substance Abuse 

Systems in Pennsylvania have been 

challenged for years with the complicated 

issues associated with co-occurring mental 

illness and substance use disorders. 

Department of 

Public Welfare 

OMHSAS 

Medicaid $ 

- FFS 

- Managed Care 

ACT 152 

BHSI 

CMHS Block Grant 

MH Licensing 

State Agencies 

SCAs 

MH/MR 

Department of 

Health 

BDAP 

SAPT Block Grant 

D&A Licensing 

Milestones 

Since 1997 

Pennsylvania Departments of Health & 

Welfare collaboration: 

MISA Consortium 

County Pilot Projects 

COSIG award 

National Policy Academy 

COSIG Proposal 

• To affect statewide infrastructure change, building on 

existing resources, to support COD services 

• To create and test an approval process for providers to 

deliver co-occurring services 

• To develop a dedicated reimbursement mechanism for cooccurring 

services 

• To ensure core and advanced training curriculums and 

credentials are available to support workforce 

development 

• To identify a menu of screening and assessment 

instruments for co-occurring service utilization 

• To develop a process for data integration for behavioral 

health 

Two fold- 

COSIG Approach 


– Credential development 

– State wide training 

• Program Development 

-- Program credentialing process 

– Increase door, increase access, improve quality 

10


Co-Occurring Disorder 

Advisory Committee 

CODAC Sub-Committee 

Structure 

Purpose of CODAC 

• Stakeholder input to: 

• To examine policy and program issues 

impacting co-occurring service delivery 

• To recommend program and policy changes 

to support infrastructure development for 

integrated co-occurring service delivery 

• To reach consensus and support the 

infrastructure development projects 

• Screening and Assessment 


• Provider Credentialing/Certification 

• Data Integration 

• Reimbursement 

• Others as identified by CODAC 


• Training – 

• Core Curriculum and Advanced Skill Sets 

• Co-Occurring Disorder Professional Credential 

• Competency Based 

• Experience and training 

• Clinical Staff 

Co-Occurring Disorder Professional 

Credential 

• The Departments of Health & Welfare and the 

Pennsylvania Certification Board (PCB) convened 

a stakeholder workgroup to develop the cooccurring 

credential 

• Developed a scope of practice for co-occurring 

professionals and requirements to meet the scope 

• Developed tasks, skill sets, and knowledge areas 

• Two year stakeholder process 

• 1000+ credentialed in first year 

Program Certification 

• Establishes Co-Occurring Disorder Competency 

Approval Criteria via Bulletin 

• Voluntary certification process for licensed 

providers who wish to be identified as COD 

competent, sanctioned and endorsed by the state. 

• Goal- to move the entire behavioral health system 

toward the achievement of core competency to serve 

individuals with co-occurring psychiatric and 

substance use disorders - to have to have all licensed 

mental health and substance abuse facilities become 

certified over time. 

Program Certification 

COD Program Approval Criteria 

COD Mission and Philosophy 

COD Screening 

COD Assessment Process 

COD Program Content 

Integrated Care Planning 

Medication 

Crisis Intervention Procedures 

Communication, Collaboration, & Consultation 

Staff Competencies 

Transition/Discharge/Aftercare 

11


COSIG Opportunity 

Building partnerships 

• Federal 

• State 

• Academic-IRETA Univ of Penn, COCE, 

Recovery Community, Provider 

Community 

• Other COSIG States 

• Local 

“learning community” 

Accomplishments 

• Partnerships 

• Training curriculum 

• CCDP 

• COD Program standards 

• CODAC Exec Report 

• State COD Conference 

• Local project expansion- Beaver forensic. 

Co-Occurring Website 

• Visit www.pa-co-occurring.org for 

• Co-occurring Resources 

• Co-occurring Training Information 

• Co-occurring Links 

• COSIG Information 

• CODAC Intranet 

• Service Pilot Information and Data 

Analysis 

Challenges 

• Philosophies 

• Approaches 

• Vocabulary 

• Bureaucratic Complexity 

Program Regulation 

Payment Regulation 

Statutory Requirements 

• Turf Issues 

• Fear 

Future Directions -Plans 

• Housing, Vocational Supports, 

Community Programs 

• Criminal Justice Interface 

• Workforce Credentialing and Training 

• Policy and Program development 

• Financing 

• Recovery Culture 

. . . This is the beginning 

of a system that is: 

Welcoming 

Accessible 

Integrated 

Continuous 

and 

Comprehensive 

= “No Wrong Door” 

With a common goal of 

RECOVERY 

12


Discussion 

Arkansas 

•Using COSIG and Policy Academy efforts to further services and system 

development 

•Identifying MH and SA screening instruments to be implemented statewide and 

amending Behavioral Health contracts requiring the use of these tools 

•Providing state-wide training for providers, using electronic conferencing 

Incorporating family & consumer leadership into all planning and processes 

Missouri 

•Partnership with Mid America ATTC 

•Focusing on workforce development 

•Establishing alliance with provider and scientific community 

Discussion (continued) 

Louisiana 

•Coordinating one plan across COSIG and Policy Academy efforts 

•Obtaining endorsement of both substance abuse and mental health authority 

•Focusing on screening and workforce development 

•Developing community boards across the states 

Pennsylvania 

•Consolidating COSIG and Policy Academy efforts 

•Involving executive level of government 

•Emphasizing credentialing 

•Employing lessons from pilot projects for statewide, sustainable change 

•Developing a statewide consensus as they move forward 

CRITICAL INPUTS 

Mental Health, SAMHSA’s 

Substance Mission & 

Abuse,& COD Priorities 

Research 

State/Local 

Federal Experience & 

Policy 

Innovation 

State 

Consumer 

Policy 

Needs And 

Perspectives 

THE COD SERVICE SYSTEM 

SAMHSA’s COCE 

COCE: 

Transmit Guide Foster 

COCE GOALS 

CLARIFYING AND 

ESTABLISHING 

Definitions 

Nosology 

Measurement 

Evidence & Consensus-Based 

Practices 

Unified Approach to 

Treatment 

AGENDA SETTING 

Professional Education 

Practice Improvement 

Research 

Policy 


RESOURCE TO SAMHSA 

Logistical/Operational 

Execution/Implementation 

Informational 

WORK OF THE COCE 

PRODUCTS 

Overview Papers 

Templates for Product 

Development 

Technical Reports 

Articles 

Literature Reviews 

ACTIVITIES 

Training 

Diffusion of Innovation 

Field Application and Study 

Technical Assistance 

Training of Trainers 

Institutes 

Coordination with other 

SAMHSA Centers 

Stanley Sacks, Ph.D., Expert Leader, 

SAMHSA's Co-Occurring Center for Excellence (COCE) 

Contact information: 

Stanley Sacks, Ph.D. 

Director, Center for the Integration of Research & Practice 

National Development & Research Institutes, Inc. 

71 W 23rd Street, 8th Floor 

New York, NY 10010 

tel 212.845.4429 fax 212.845.4650 

http://www.ndri.org stansacks@mac.com 

http://coce.samhsa.gov/ 

Contact Person: Jill Hensley 

COCE Project Manager 

tele. 301.654.6740 

email: jillhensley@cdmgroup.com 

13

M01: The Addiction Psychiatry Counseling Internship Project (APCIP): 

Student Characteristics, Service and Vocational Outcomes, and Change in Students, Teachers, 

Colleagues, and Employers 

Stefan Larkin, EdD, Dorinda Welle, PhD, Carmelo Romeo, MS, CRC, Maia Mamamtrashvili, MD, 

Jeffrey A. Barrett, MD & Rodney A. Waldron, APCIP graduate 

1.5 hours Focus: System Integration 

Description: 

Beginning in 1992, the Addiction Psychiatry Counseling Internship at Bronx Psychiatric Center has trained over 

600 recovering substance abusers for entry level counselor jobs serving clients with co-occurring disorders. 

APCIP’s structure, student characteristics, and service and vocational outcomes are presented and discussed in 

terms of skill development and clinician support issues in COD practice. Program related changes in attitude 

and understanding in multi-disciplinary COD care are discussed as they apply to the field. 

Educational Objectives: Participants will be able to: 

• Identify the key elements in a safe and effective environment for learning COD care skills; 

• Discuss the implications of APCIP intern characteristics for COD clinician skill development and clinician 

support needs; 

• Compare and contrast the impact of a COD clinical internship for recovering substance abusers on the 

students, faculty, colleagues, and patients. 

NOTES:


The Addiction Psychiatry Counseling Internship Project: 

Student Characteristics, Service and Vocational Outcomes, and 

Change in Students, Teachers, Colleagues, and Employers 

Student Characteristics, Service and Vocational 

Outcomes and Change in Students, Teachers, 

Colleagues and Employers 

• Background and Overview - Stefan Larkin, Ed.D. 

• From Conformity to Complexity: The Personal and Professional 

Development of MICA Interns - Dorinda Welle, Ph.D. 

® 

Stefan Larkin, Ed.D. 

Carmelo Romeo, M.S. (CRC) 

Jeffrey A. Barrett, M.D. 

Dorinda Welle, Ph.D. 

Maia Mamamtrashvili, M.D. 

Rodney A. Waldron 

• Who are the interns, where do they come from, where do they 

stop on the way to where they are going? - Carmelo 

Romeo, M.S. (CRC) 

• And what about trauma? - Jeffrey Barrett, M.D. 

• Add four psychiatric residents, two recovering interns, some 

salt, 20 complex cases, and a teaching faculty - Maia 

Mamamtrashvili, M.D. 

® 

© 2006, Dual Diagnosis Resources and Research, LLC. 

• And when you are done you begin to… - Rodney Waldron, 

TASC 

The Addiction Psychiatry 

Counseling Internship Project: 

Background and Need 

Background and Need 

Proposal to use advanced recovery TC clients as counselors-intraining 

in adolescent foster care system leads to interagency 

planning regarding mental health aftercare system. 

Initial view in 1990 by MHCoD Coordinator, SA Vocational Services 

Director, and President of aftercare consortium is of three systems in 

deficit: 

1. Residential aftercare for post-psychiatric hospitalization clients (group 

homes and community residences) is characterized by extensive client 

substance abuse, poorly trained staff, virtually no CoD trained staff, and 

high staff turnover. 


President, CEO, Dual Diagnosis Resources and Research, LLC 

Clinical Instructor, Department of Psychiatry, 

Albert Einstein College of Medicine 

1. Substance abuse treatment agencies face increased pressure to reduce 

length of stay, have housing options for clients but job pathways and 

vocational options are limited at best. 

2. New York State Office of Mental Health Psychiatric Centers are asked to 

provide services for CoD clients with zero substance abuse counselor 

positions allocated by Civil Service Department. 

® 


Internal and External Resources 

1. Bronx Psychiatric Center organizational self-concept as 

pioneering agency in mental health (Family Studies Institute, 

Schizophrenia Research Institute, Hispanic Units, Consumer 

Operated Co-op Center, Peer Counselor/Case management 

Research Grant, Family Run Resource Center). 

2. Closet community of cross-trained and recovering staff 

(including leadership) that communicates with one another, and 

expectation among resisters that new ideas will be tried once 

they are formally approved. 

3. Competition for program resources offset by low cost of program 

and desire of mental health focused staff to have someone else 

deal with substance abuse disorders. 

4. New Clinical Director arrives with Forensic Psychiatry 

background and mandate to end single CoD ward and expand 

CoD services to all locations with CoD clients. 

Key Steps 

1. Program submitted to and formally approved by both Bronx 

Psychiatric Center (BPC) Executive Cabinet (Administrative) 

and Medical Staff Organization (Clinical). 

2. Office of Alcohol and Substance Abuse Services organizes 

outreach to vocational counselors at SA treatment agencies to 

recruit candidates for internship. 

3. Association for Community Living pre-commits to consider 

internship graduates for job openings in aftercare agencies. 

4. All BPC clinical departments agree to allow masters degree or 

higher members to add supervision of interns to their 

workload. 

® 


® 


1


Rules, Regulations, Procedures, Luck 

1. Internship acceptance standard is substance abuse recovery 

program referral, maintaining good standing in your program, 

maintenance of stable recovery with community access. 

2. Internship candidates are pre-oriented, and interviewed by a 

screening team prior to selection. 

3. Interns are registered as volunteers at Bronx Psychiatric 

Center and receive two-week orientation modeled on new staff 

training prior to fieldwork assignments. 

4. All interns participate in rounds and both hospital and Albert 

Einstein College of Medicine teaching events. 

5. Interns are assigned in pairs. 

6. Initial sites are chosen based on need for CoD counseling and 

presence of CoD trained or recovering masters level staff. 

7. First intern graduation involves families, teaching faculty, 

supervisors, referring vocational counselors, clients, staff from 

teaching sites, BPC leadership and invited guests. 

First outcomes 

1. All eight accepted interns from Class 1 complete their 

internship, with field placements in male and female 

admissions wards, CoD ward, and an OPD clinic. 

2. Seven of eight interns in Class 1 get jobs in the field. 

3. The eighth intern stays home to take care of her young 

children and later finishes her Bachelor’s degree. 

4. Two interns later relapse. Both return to treatment and are 

currently abstinent. 

5. An intern from Class 1 is voted Employee of the Year at 

Services for the Underserved in New York and later 

switches to working with developmental disability clients 

with substance abuse disorders. 

6. Five of eight interns from Class 1 refer clients to the 

internship who then graduate and become counselors 

themselves. Some of them later refer intern candidates. 

® 


® 


First Lessons 

• Interns assigned to clinical site where project 

staff believes they will experience the most 

stress and they are gleefully told about it. 

• Expectation is communicated that “it is for you”, 

that going through more stressors with peer, 

program, faculty and treatment support will 

enable coping when a paid employee providing 

care to people in need 

• Constant emphasis that APCIP was created to 

train future staff and that we expect students to 

follow clinical professional standards . 

® 

From Conformity to Complexity: 

The Personal and Professional Development of 

MICA Interns 

Dorinda L. Welle, Ph.D. 

National Development & 

Research Institutes, Inc. New 

York, NY welle@ndri.org 


History of Peer Counseling 

Innovations at 

Bronx Psychiatric Center 

• 1991-1992 NIMH Demonstration Project: “Peer 

Counselors as Members of Intensive Case 

Management Teams” 

– Employing former psychiatric patients as peer 

counselors paired with Intensive Case Managers 

– Emphasis on “experiential knowledge” of mental 

illness, hospitalization, recovery 

– Paraprofessional “control group” for comparative 

outcomes 

Findings from Peer Counseling 

Demonstration Project 

• Patients assigned a 

Peer Counselor had 

significantly higher 

perception of their 

economic situation 

and economic 

options. 

• Whether assigned a 

Paraprofessional or a 

Peer Counselor, 

patients experienced 

positive outcomes in 

many areas, including 

mental health 

aftercare, other health 

care seeking, and 

social support. 

2


Shared 

“Experiential Knowledge” 

• Since positive outcomes were evidenced 

regardless of intervention condition, were 

there “forms of experiential knowledge” 

that Mental Health Peers and “Non-Peer” 

Paraprofessionals shared? 

• In what way might both groups have 

served as “peers” for the patients? 

Shared but Unacknowledged 

Familiarity with Drug Use 

• Some peers had a history 

of substance abuse, but 

little experience in drug 

treatment or AA/NA. 

• Peers as residents of 

low-income communities 

were intimately familiar 

with drug addiction and 

its dangers. 

• Some paraprofessionals 

had a history of 

substance abuse, but 

little experience in drug 

treatment or AA/NA. 

• Paras as residents of 

low-income communities 

were intimately familiar 

with drug addiction and 

its dangers. 

• Some paras had a history 

of involvement in drug 

sales. 

Relevance of Peer/Para Drug Use 

Knowledge for Former In-Patients 

MICA Internship Program: Going 

Beyond “Experiential Knowledge” 

• Patients were encouraged to “leave drugs alone” 

after leaving the hospital. 

• Peers and paras could often spot the warning 

signs of illicit drug use in outpatients. 

• Paras sometimes warned outpatients of the 

dangers of getting involved in selling drugs or 

going to “bad areas.” 

• Money management promoted spending on 

food, utilities, other basic necessities. 

• Unlike the peer counseling approach, the MICA 

Intern training centered on a clinical approach to 

mental illness. 

• While MICA Interns brought in their own 

experiential knowledge of drug addiction and 

drug recovery, they knew little about the clinical 

features of serious mental illness. 

Different Drug Experiences, 

Different Identities 

“That’s Deep!” 

• Once on the wards, MICA Interns soon learned that 

patients’ drug use practices differed from their own. 

• MICA Interns also learned that patients had very 

different understandings of their own drug use, and 

reported different experiences of being high. 

• Interns were shocked to realize that patients were 

relatively isolated in their drug use, not part of a “street 

culture” or “drug subculture.” Drug use did not provide a 

positive or negative source of identity for patients. 

• Patients could not directly 

identify with the Interns 

on the basis of their drug 

use histories. 

• NA/AA meetings were 

outside the scope of 

patients available social 

skills and cognitive 

functioning. 

• Relationships would have 

to be built through an 

encounter with the person 

as he/she is affected by 


• Relationships could be built 

by talking about patients’ 

“scamming” or addict-like 

behavior. 

3


Identifying Mental Health “Issues” 

Among the Interns 

• Interns examined their own identifications during the 

course of the training. 

– Discussing in weekly supervision which patients they 

identified with or avoided: “favorite” vs. “difficult” 

patients. 

• Some interns experienced a “mental health epiphany” 

during the Internship. 

– E.g., some realized they had “always been 

depressed,” “depression is why I can’t recover from 

the drugs issue,” “if I don’t get some mental health 

support I could relapse.” 

• A few Interns experienced a mental health crisis or 

significant drug relapse and withdrew from the program. 

Valuing Mental Health, 

De-Stigmatizing Mental Illness 

• “Take that back to your program.” 

– The Internship encouraged Interns to seek mental 

health services at their drug treatment facilities. 

• “There’s no shame in being MICA.” 

– Interns adopted a non-stigmatizing view of mental 

illness, even among their drug recovery peers. 

• “So now you got two recoveries.” 

– Some Interns started “Double Trouble” groups on 

their wards. 

From a Culture of Conformity to a 

Community of Care and Concern 

• As Interns personalized their awareness of mental health 

issues, Interns informally supervised each others’ 

“issues” on the wards. 

– Interns at first assumed the house-managing roles 

they had held at their drug treatment facilities; keeping 

this up over time was seen as “being fake”. 

– Inappropriate or inauthentic behavior was seen as 

possibly having roots in “mental health issues you ain’t 

looked at.” 

– “You okay?” became a shared greeting among 

Interns, with expectations for a dual response 

addressing drug abstinence and emotional stability. 

“That’s Deep.” 

• As each cycle of Interns began to encounter and recognize 

their own “mental health issues,” their roles on the wards 

began to focus more on the patients’ needs for support rather 

than just focusing on impulse control and behavioral change. 

– Promoting a notion of patients as “deserving” support 

– Feeling more comfortable “just listening” 

– Attending to what patients could actually grasp 

– Stepping out of the “drug recovery lingo” and “being 

real” 

– Networking with the treatment team to advocate for 

patients 

Parallel/Process Outcomes of the 

“MICA Internship” Approach 

• In this “MICA” context, the Interns came to see drug abstinence 

as only one aspect of maintaining one’s drug recovery. 

Who are the APCIP interns? 

Where do they come from? 

Where do they stop on the way to where they are going? 

• Learning to see the complexities of the patients’ needs allowed 

the Interns to see and accept the wide range of their own 

needs. 

• For Interns largely subject to population approaches to drug 

treatment, drug recovery became a personal journey, anchored 

in the self rather than in behavior. 

Carmelo Romeo, M.S. (CRC) 

Treatment Team Leader, 

Kirby Forensic Psychiatric Center 

® 


4


MORE APCIP HISTORY 

• The Addiction Psychiatry Counseling Internship Project was 

developed as a local response at BPC to New York State Office of Mental 

Health (OMH) recognizing that co-occurring substance abuse, within the 

mentally ill population it served, was so prevalent that separate services 

for the dually diagnosed was an untenable approach to care. 

• Almost 80% of BPC’s newly admitted mentally ill clients had co-occurring 

drug/alcohol problems and it was clear that substance abuse treatment 

services needed to be available in almost all treatment venues. 

• Our core concept was to prepare individuals in advanced substance abuse 

recovery for competitive employment in the growing number of entry level 

jobs in group homes and similar community care settings, and along the 

way, have these recovering counseling students contribute to the clinical 

care teams where they trained. 

APCIP’s Message to Referring Clinicians 

• We remember a time when we had meeting after meeting 

about whether a client was ready to move to the next level of 

treatment, not about the pressure to move them out to free up 

a bed or a treatment slot for someone in worse shape. 

• We remember when we had time, to let a client go slow, so 

that we could be there for them when the hard times from the 

past made themselves felt once again, now that street 

anesthesia was out of the way. 

• We remember, but our boss is calling, our phone is ringing, 

three clients are outside our door, our beeper is going off, and 

our unopened e-mail looks like a new dictionary. 

APCIP’s Message to Program Management 

• The Addiction Psychiatry Counseling Internship Project 

( APCIP) at Bronx Psychiatric Center gives you and your client a 

choice regarding your client’s movement toward aftercare while 

maintaining intense involvement with a therapeutic system. 

• APCIP teaches your client substance abuse counseling and 

counselor self-awareness in the context of comorbid major mental 

illness and other treatment complications (trauma history, medical 

illness and disability, cognitive disability and traumatic brain injury, 

etc.) 

• Your client begins to learn about working with clients, about safety 

and risk, about how a clinical team sorts through concurrent 

illnesses, about how clinicians deal with their stress and the stress 

faced by their colleagues. 

More for Program Managers 

• Your client also faces the longing of people in treatment to go 

home, to get out of the hospital, to be in their own apartment or 

back with their family. They work with this longing no matter 

how unrealistic it is at a given moment in time, no matter how 

much damage acting out such longing can do to carefully 

planned treatment and rehabilitation efforts, no matter how 

much of a threat it poses in terms of relapse or 

decompensation. 

• If the client you are seeing will benefit from this kind of 

exposure, from looking in the mirror of working with those in 

even greater need, then consider APCIP as an alternative. If 

your client is someone who has what it takes to give something 

back as a helping professional, help us in preparing your client 

for what we all know is the difficult road ahead. 

APCIP’s Message to Recovering Candidates: 

A Career Opportunity for People in Recovery 

• The benefits of recovering role models helping others is 

not just a program concept, but a researched and 

documented successful approach to both rehabilitation 

and recovery. 

• In the Bronx Psychiatric Center Addiction Psychiatry 

Counseling Internship Project (APCIP) your 

knowledge of recovery and the dangers of relapse are 

the starting point for a program that puts you on the front 

lines of working with people who have faced the 

challenges of both mental illness and substance abuse. 

More for Recovering Candidates 

• As you may choose to learn, APCIP is a lot more than just a 

training program. It is preparation for you and the dually 

diagnosed clients you will learn to serve, to re-engage the world 

with: 

– deeper understanding of both substance abuse and mental 

illness in the context of the physical health, mental health, 

and social health issues all people face, 

– redefinition of recovery, not as something you go through, 

but as something that goes through you, something that 

moves beyond the oversimplification of using or not using 

and brings you to choices about living, learning, working, 

and playing. 

5


Still More for Recovering Candidates 

• APCIP is six months of hard work, people work, written work, 

carrying yourself like a new professional work, facing issues in 

others that frightened you in yourself work. 

• APCIP is learning the pain of illnesses that overwhelm not just 

your new skills but those of the psychiatric, medical, social 

work, nursing, psychology, rehabilitation, case management 

education, care team that treats you like a member, just like all 

the other clinical students they are helping to train. 

• APCIP is also sharing the triumphs of people finally well 

enough to go home, just as you are getting ready to finally, go 

home. 

APCIP’s Message to Vocational Counselors 

• Addiction Psychiatry Counseling Internship 

Project (APCIP) at Bronx Psychiatric Center 

confronts vocational counseling professionals with a 

difficult and sought after choice, the opportunity to 

place the high function, high potential client in a 

supportive high demand training environment that 

leads not only to employment but to careers with 

continuing growth and promotion potential. The 

difficulty is of course in whom should you choose for 

referral. 

APCIP Program Statistics to Date 

1000 

800 

600 

860 

400 

200 

0 

567 

405 

260 

Candidates 

screened 

Candidates 

Accepted 

Candidates 

Graduating 

Graduates 

Employed in 

MICA Services 

What does APCIP want from 

students? 

• Stable recovery that has included facing 

community stress and using treatment to cope, 

• Adult literacy and a willingness to tolerate 

learning from mistakes, 

• Real interest in counseling and clinical work 

that goes beyond use/ not use, and 

• Tolerance for delayed gratification and 

complexity, with minimal brittleness. 

66%,71%, 64% 

From culture shock to full integration 

into 

the therapeutic milieu: 

Addiction psychiatry interns on a psychiatric 

residency in-patient unit 

Maia Mamamtrashvili, M.D. 

• Highlights of psychological challenges at 

the beginning 

• Culture shock 

• Strong identifications due to similarities in 

life and health histories 

• Self disclosure 

• Coping skills 

6

M02: The Linkage Between Childhood Trauma and Adolescent Co-Occurring Disorders 

Gordon R. Hodas, MD 

1.5 hours Focus: Children & Adolescents 

Description: 

This workshop addresses the clear linkage between childhood trauma, especially childhood maltreatment, and 

the development of co-occurring disorders in adolescents and youth transitioning to adulthood. Successful 

youth transition requires careful attention to the trauma histories of individuals presenting with SUD and 

psychiatric disorder. A model, integrated, evidence-based program is reviewed that helps juveniles with cooccurring 

disorders transition from secure facilities back to the community. 


• Describe the circular process that contributes to the strong correlation between trauma and 

maltreatment, on the one hand, and substance use, on the other; 

• Define the term “trauma-informed care;” 

• Identify at least 3 ways that provision of this approach helps adolescents with co-occurring disorders to 

achieve greater stability of emotions and behavior; 

• Discuss at least 4 potential evidence-based components of a comprehensive, integrated program for 

adolescents with co-occurring disorders. 

NOTES:


Introduction 

THE LINKAGE BETWEEN 

CHILDHOOD TRAUMA AND 

ADOLESCENT 

CO-OCCURRING DISORDERS 

GORDON R. HODAS, M.D. 

• A common quartet of problems for 

adolescents – childhood trauma, 

psychiatric disorder, substance use 

disorder, juvenile justice involvement 

• Progression common but not inevitable 

• Focus here on nature of problem and how 

to address it. Program example involves 

juveniles with co-occurring disorders 

returning to the community 

PART 1: CHILDHOOD TRAUMA – THE 

DIMENSIONS OF THE PROBLEM 

• PREVELANCE OF CHILDHOOD TRAUMA (VARIOUS 

STUDIES): 

1. General population: 34-53% report childhood or 

sexual abuse. 

2. Public mental health clients: 90% exposed to 

trauma, most with multiple experiences. 

3. Public sector population with SMI: 51-98% reported 

trauma victimization. 

4. Adolescents in an inpatient psychiatric hospital: 

93% reported a history of trauma. Among these 

adolescents with trauma history, 32% met full criteria 

for PTSD. 

PART I: CHILDHOOD TRAUMA – THE 


• PREVELANCE OF CHILDHOOD TRAUMA (VARIOUS 

STUDIES cont.): 

5. Frequency of witnessing domestic abuse is high and 

variable: 

a. 1990’s, New Orleans: 90% of children witnessed 

violence. 

b. 1990’s, Boston, children under age 6: 47% heard 

gunshots; 10% witnessed knifing or shooting 

(Groves, Children Who See Too Much, 2002) 



• OUTCOMES OF CHILDHOOD TRAUMA: 

1. Medical and physical health consequences 

(through direct physical consequence and/or 

negative effects on lifestyle and coping): 

a. Between 20-50% of abused children have some 

degree of permanent disability, as a result of 

abuse. 

b. Childhood violence is a significant causal factor in 

10-25% of all developmental disabilities. 

c. Severe and prolonged childhood sexual abuse 

damages the developing brain. Also, produces 

hormonal and structural changes – potentially 

irreversible. 



1. Medical and physical health consequences (cont.) 

d. Possible medical consequences in childhood: head 

trauma, brain injury, sexually transmitted 

diseases/HIV, unwanted pregnancy, physical 

disabilities, pelvic pain, headaches, stomach pain, 

nausea, sleep problems, eating disorders, asthma, 

shortness of breath, muscle tension/spasms, elevated 

blood pressure. 

e. Childhood trauma linked to medical problems in 

adulthood: smoking, multiple sexual partners/sexually 

transmitted diseases, physical inactivity, severe 

obesity, ischemia, cancer, chronic lung disease 

skeletal fractures, liver disease, autoimmune 

disorders. 

1


PART 1: CHILDHOOD TRAUMA – 

THE DIMENSIONS OF THE 

PROBLEM 

1. Medical and physical health consequences (cont.) 

f. Sexual abuse predisposed to: drug and alcohol 

addiction, unprotected sex, increased sexual 

partners, prostitution, and HIV/AIDS. 

g. Many individuals with dual diagnosis (MH and 

D&A) have a history of trauma. Many also 

develop PTSD. 



2. Possible psychiatric and substance use disorders 

(may coexist with, or be a consequence of, 

trauma): 

a. Psychiatric Disorders: 

1) ODD/CD 

2) ADHD 

3) Depression 

4) BPD or Mood Disorder NOS. 

5) Intermittent Explosive Disorder 

6) PTSD 

7) Other anxiety disorder 

8) Personality Disorder – Borderline, Narcissistic, Paranoid 

9) Psychotic disorder 

10) Other 



2. Possible psychiatric and substance use disorders 

(cont.) 

b. Substance Use Disorders (SUD): 

1) Alcohol 

2) Drug use – stimulants, depressants, both. 

Hallucinogens. 

3) Mixed alcohol and drug use. 

c. Co-occurring psychiatric and substance use disorder 

– the rule, and the necessary clinical presumption. 



3. Frequency of adult psychiatric disorders, in 

individuals subjected to trauma as child/adolescent, 

compared to adults without trauma exposure: 

a. Affective disorder: almost 3 times more likely. 

b. Anxiety disorder: almost 3 times more likely. 

c. Phobia: almost 2 ½ times more likely. 

d. Panic disorder: more than 10 times more likely. 

e. Antisocial personality disorder: almost 4 times more likely. 

f. Self-harm more likely: suicide attempts, cutting, selfstarving. 

g. Auditory hallucinations and emergence of Schizophrenia 

more likely. 

h. PTSD or PTSD-related symptoms common [hyperarousal, 

re-experiencing, and avoidance] 



4. Increased substance use problems, and cooccurring 

substance use and psychiatric disorders: 

a. Substance abuse and co-occurring PTSD: 

1) Up to 67% males and females seeking SUD RX have 

PTSD – complete or partial. 

2) 40-59% of women in substance abuse treatment have 

PTSD. 

3) Rate of SUD with co-occurring PTSD 2-3 times higher 

for women than men. 

4) Among consumers receiving SUD Rx, 33% with some 

dissociative disorder. 



4. Increased substance use problems, and cooccurring 

substance use and psychiatric 

disorders (cont.): 

b. Frequency of childhood trauma in consumers with 

SUD and any psychiatric disorder: 

1) 55% of consumers at the Maine State Hospital with SUD 

and one or more psychiatric disorders reported history of 

childhood physical or sexual abuse. 

c. Lack of detection of PTSD in mental health services: 

1) Staff involved in inpatient and outpatient MH treatment 

identified 2% of consumers as having PTSD. 

2) Independent assessors of these same consumers found 

45% as having PTSD (43% more). 

3) To find out, need to ask. 

2




5. Consequences related to juvenile and criminal justice: 

a. Childhood abuse correlated with increased truancy, running 

away, homelessness. 

b. Arrest, as consequence of childhood abuse or neglect: 

1) Arrest as juvenile: 53% more likely. 

2) Arrest as young adult: 38% more likely. 

c. Violent crime leading to arrest: 38% more likely. 

d. Dangerously violent adolescents (not necessarily in “the 

system”), grades 9-12: 

1) Dangerously violent males: 3-6 times more likely witnesses and/or 

victim of high levels of violence in home, neighborhood, and 

community. 

2) Dangerously violent females: 2-7 times more likely exposed to 

violence, clinical scores for all trauma symptoms, and increased 

likelihood of suicidality. 



1. Consequences related to juvenile and criminal 

justice (cont.): 

e. Adjudicated females: 

1) Over 75% of adjudicated females had been 

sexually abused. 

2) In 1998, 92% of incarcerated females reported 

sexual, physical, or severe emotional abuse in 

childhood. 



6. Other consequences for females: 

a. Sexual abuse during childhood: 2-4 times more 

likely to be re-victimized sexually. 

b. Childhood violence: 3-4 times more likely to be 

raped. 

c. Childhood incest: twice as likely to experience 

domestic violence. 

d. Childhood trauma: 

1) High likelihood of depression and suicidality. 

2) At risk to lack empathy. 

3) Subsequent neglect or abuse of own children: 

33% of abused women (multi-generational 

cycles). 



7. Common features of children and youth subjected to 

severe trauma: 

a. Lack of trust. 

b. Anger, rage 

c. Misperceptions 

d. Poor social skills 

e. Limited “executive skills” (analyze, problem-solve, 

compromise, self-control) 



7. Common features of children and youth subjected to 

severe trauma (cont.): 

f. Academic limitations 

g. Impulsivity and startle response 

h. Urgency 

i. Lack of future orientation 

j. Materialistic concerns 

k. Hypersensitivity to being shamed, humiliated, 

“disrespected”. 

PART II: TRAUMA AND SUBSTANCE 

ABUSE USE: THE NEUROPHYSIOLOGY 

• NEUROPHYSIOLOGY OF TRAUMA: TWO 

FUNDAMENTAL RESPONSES 

(DEFENCSES) TO DANGER AND THREAT: 

1. Hyperarousal responses: “fight” or “flight”, in 

support of active mastery. 

2. Dissociation responses: passive, surrender 

response, to escape/avoid situation. 

Both responses are of adaptive benefit 

and increase the likelihood of survival. 

3



ABUSE USE: THE 

NEUROPHYSIOLOGY 

• HYPERAROUSAL RESPONSES: 

1. Include both “flight” and “flight” responses, 

enabling individual to take emergency action 

in response to fear, terror, and danger. 

a. “Fight” = self-defense. 

b. “Flight” = removing self from danger. 

2. Mediating processes: Catecholamines – 

adrenaline and noradrenalin – and 

hypothalamic pituitary axis. 




• HYPERAROUSAL RESPONSES: 

3. Physiological responses of hyperarousal: 

a. Increased heart rate. 

b. Increased blood pressure. 

c. Increased energy availability in skeletal muscles. 

4. Observable manifestations of hyperarousal: 

a. Highly focused attention 

b. Sweating 

c. Erect posture 



• DISSOCIATION RESPONSES: 

1. Dissociation involves “disengaging from stimuli in 

the external world and attending to an internal 

world” (Perry et al, 1995), in order to 

“camouflage” oneself and child and buy time. 

2. A dissociation continuum, depending on trauma 

severity and circumstances. Dissociation 

involves emotional numbing and withdrawal. 

3. Mediating processes: Increase in vagal tone, 

chemical activations, and feedback loops. 

4. Physiological responses of dissociation: 

a. Decrease in heart rate. 

b. Decrease in blood pressure. 



• DISSOCIATION RESPONSES (cont.): 

5. Observable manifestations of dissociation: 

a. Decreased movement 

b. Compliance 

c. Avoidance 

d. Restrictive affect 



• VARIABILITY OF PREFERENTIAL RESPONSES TO 

DANGER AND THREAT: 

1. Young children and females tend to dissociate. 

2. Older children and adolescents tend to become 

hyperaroused. 

3. Child and adolescent may use combinations of 

responses; responses may change over time. 



• UNDERLYING BASIS OF NEUROBIOLOGICAL 

DYSREGULATION CAUSED BY TRAUMA: 

1. Hyperarousal system as the primary source of 

dysregulation: 

a. An adaptive response becomes maladaptive: problem 

with turn-off, baseline, and reactivation. 

b. Adaptive emergency “state” becomes maladaptive 

“trait” (consistent pattern). 

c. Impaired capacity for self-regulation. 

d. Impact global: internal discomfort, impaired learning, 

problem solving, daily functioning, and lack of 

empathy. 

4





DYSREGULATION CAUSED BY TRAUMA (cont.): 

2. Dissociative symptoms vary from mild to extreme, interfere with 

attention, relationships, sense of initiative. Depression 

frequent. 

3. Affected brain structures and pathways: brain stem, right 

amygdala of limbic system, left hippocampus, prefrontal cortex, 

vermis of cerebellum, corpus collosum, left cortex, 

hypothalamic-pituitary axis (HPA axis). 

4. Affected processes: neuro-endocrine regulation, myelinization, 

neuronal migration, neuronal differentiation, synaptic 

proliferation, brain growth and functionality, connections 

between hemispheres and other internal structures. 




DYSREGULATION CAUSED BY TRAUMA (cont.): 

5. Concept of neurobiological regression (Perry) – retreat from 

cortical responses to increasingly less mature levels of brain 

functioning and behavior, in response to trauma and 

maltreatment (cortex, limbic system, midbrain, brainstem). 

6. Potential brain functions compromised by chronic trauma: 

recognition and response to danger, interpretation of stimuli, 

capacity for self-regulation, memory formation, attention, ability 

to acquire information, processing of emotional information, 

impulse control, planning, learning from experience. 



• NEUROPHYSIOLOGY OF TRAUMA AND 

RELATIONSHIP TO SUBSTANCE USE: 

1. Research ongoing, much but not all in animals. 

Findings tentative, but some patterns. 

2. Common observation: Substance use tends to follow 

or parallel traumatic exposure and development of 

PTSD. 

3. Increased substance use does not occur when 

traumatic exposure does not result in PTSD. 




RELATIONSHIP TO SUBSTANCE USE (cont.): 

4. Common pathways may reinforce substance use in 

presence of PTSD: 

a. Stress causes activation of HPA Axis, leading to 

increase in catecholamines [CRH release in 

hypothalamus, ACTH release from pituitary, 

cortisol release from adrenal glands, 

catecholamine release]. 

b. Experience of stress, plus hyperarousal due to 

catecholamines, create negative mood states, 

predisposing to substance use. 






4. Common pathways may reinforce substance use in 

presence of PTSD (cont.): 

c. Withdrawal from alcohol or cocaine elevates 

CRH, leading to catecholamine release, 

intensifying hyperarousal and dysphoric state, 

predisposing to further substance use. 

d. Pre-existing, PTSD-based hyperarousal 

exacerbated by additional hyperarousal resulting 

from drug withdrawal, further increasing risk of 

further use. 





5. Functional correlates of above – a potential traumasubstance 

abuse cycle: 

a. Dysthymia of PTSD triggers use of substances. 

b. Use of substances increases likelihood of further 

trauma and retraumatization. 

c. Retruamatization worsens PTSD symptoms, 

increasing risk of further substance abuse. 

d. Withdrawal from substances worsens PTSD, 

further predisposing to use, trauma, etc. 

5


PART III: THE CONCEPT OF TRAUMA 

INFORMED CARE 

• TRAUMA INFORMED CARE: 

1. Definition: Trauma informed care involves provision of services 

informed by an understanding of the pervasiveness of trauma 

and its consequences, involving interventions that address the 

symptoms and core deficits related to traumatic experience and 

promote the individual’s healthy functioning. 

2. Trauma informed interventions operate at two broad levels: 

a. the level of individual physiology, with particular attention to 

issues of arousal and self-regulation, and 

b. the larger social-environmental level, so that conditions that 

produce or sustain maladaptive traumatic reactions are 

mitigated. 


INFORMED CARE 

• TRAUMA INFORMED CARE (cont.): 

3. Trauma informed care based on public health 

concepts of prevention, with emphasis on primary 

and secondary prevention and promotion of 

wellness: 

a. Primary prevention – Creating culture, climate, 

knowledge base, and therapeutic relationships in 

order to avoid crisis. Wellness approaches, 

individual and group-based. 

b. Secondary prevention – Responding to crisis – 

imminent or actual crisis – to prevent escalation 

and need for restrictive procedures, including 

manual restraint, and to resolve the issue 

constructively. 


INFORMED CARE 

• TRAUMA INFORMED CARE (cont.): 

4. Trauma informed care is based on recovery 

principles and – unlike trauma specific treatment – 

does not require highly specialized treatment 

expertise. 

5. Trauma informed care is applicable to any setting, 

and any level of care. Applies to individuals and, 

groups of individuals within a setting or program. 


INFORMED CARE 

• TRAUMA INFORMED CARE (CONT.) 

6. Trauma informed care strategies – getting started: 

a. Recognize that “negative behaviors” have been 

adaptive. 

b. Determine if externally based trauma or danger 

continues. If so, address. 

PART III: THE CONCEPT OF 

TRAUMA INFORMED CARE 


6. Trauma informed care strategies – getting started 

(cont.): 

c. Embrace trauma informed beliefs: 

1) “Manipulative youth” often is feeling very out of control. 

2) Seemingly intentional behavior often is not. 

3) Youth needs developmental support and help in 

acquiring new skills. 

4) Core helping element is therapeutic relationship with the 

youth, at all levels. 

5) “Therapeutic relationship” = adult responding in ways of 

therapeutic benefit. 

6) Core consideration: avoidance of shame and 

humiliation. 


INFORMED CARE 


7. Specific trauma informed practices: 

a. Use of prevention tools, including trauma history and deescalation 

safety plan. 

b. Comprehensive evaluation, and development of clientcentered 

treatment plan. 

c. Active, ongoing engagement and relationship building by 

staff. 

d. Anticipation of needs, and early entry at sign of impending 

crises. 

e. Helping client understand own trauma history and effect on 

life – self-awareness. 

6



INFORMED CARE 

• TRAUMA INFORMED CARE (CONT.): 

7. Specific trauma informed practices (cont.): 

f. Focusing on “what you went through”, rather than 

“what’s wrong with you”. 

g. Ongoing staff support, nurturing, and modeling. 

h. Staff avoidance of intimidation, coercion, and 

violence. 

i. Promoting internal (self-management) and 

external (relating to others) skill building. 

j. Use of self to negotiate, redirect, and de-escalate, 

when indicated. 

k. Processing and learning from failures. 




8. Suggested components of gender-competent, trauma 

informed care for females: 

a. Periodic screening or assessments, not just one-time screens 

and assessments. 

b. High index of suspicion and concern regarding depression and 

potential suicidality. 

c. Referral to psychiatrist, based on signs of PTSD, depression, 

suicidality, psychosis, etc. 

d. Use of safety contracts and one-to-one staffing, if concerns 

about suicidality arise. 

e. Ensuring physical safety for the female. 

f. Ensuring that interpersonal responses by male staff are not 

threatening or demeaning. 



8. Suggested components of gender-competent, trauma 

informed care for females (cont.): 

g. Ensuring that male staff keep professional boundaries, to 

prevent sexual exploitation. 

h. Providing age-appropriate information on wellness, healthy 

living, and sexuality. 

i. Helping the female understand, links between trauma, gender, 

and current challenges. 

j. Offering opportunity for females with sexual abuse history to 

process, when ready. 

k. Helping the female maintain contact with family members and 

others she trusts. 

l. Addressing alcohol and drug-related problems and co-occurring 

disorders, as indicated. 


INFORMED CARE 

9. Indications for adjunctive use of trauma-specific 

treatment: 

a. Recent history of trauma. 

b. Amplitude of duration of acute trauma-related symptoms. 

c. Severity of trauma in terms of acute or chronic injury – 

emotional or physical. 

d. Nature of trauma (maltreatment), and the identity of 

perpetrator. 

e. Trauma associated with subsequent family 

rejection/extrusion. 


INFORMED CARE 

9. Indications for adjunctive use of trauma-specific 

treatment (cont.): 

f. Chronicity, severity, and degree of impairment caused by 

trauma-related symptoms. 

g. Suicidality. 

h. Failure of trauma informed care and appropriate 

psychotropic medication to alleviate. 

i. Cultural considerations – meaning of event, degree of 

cultural support for recovery. 

PART IV: TREATMENT – ADDRESSING 

THE NEEDS OF JUVENILES WITH CO- 

OCCURRING DISORDERS WHO 

EXPERIENCED TRAUMA 

• IDEAL COMPONENTS OF A PROGRAM ADDRESSING 

THE NEEDS OF TRAUMATIZED YOUTH WITH CO- 

OCCURRING DISORDERS: 

1. Expertise to provide integrated treatment of both mental health 

and substance use disorders. 

2. A systemic approach, involving youth within context of family and 

community. 

3. Biopsychosocial perspective and public health perspective guiding 

assessment and treatment. 

4. Assessment/evaluation of youth’s specific diagnoses and stage of 

recovery. 

5. Support for parents/guardians as caretakers and family leaders. 

6. Use of a child and family team for treatment planning, 

implementation, and monitoring. 

7






• IDEAL COMPONENTS OF A PROGRAM 

ADDRESSING THE NEEDS OF TRAUMATIZED 

YOUTH WITH CO-OCCURRING DISORDERS (cont.): 

7. Treatment interventions that involve both youth and family. 

8. Interventions to help youth remain in family home and 

community. 

9. Use of natural supports to complement professional services. 

10. Motivational strategies to engage youth and family and build on 

strengths. 

11. Provision of core components of trauma informed care. 

12. Interventions to address specific trauma-related symptoms. 





• IDEAL COMPONENTS OF A PROGRAM 

ADDRESSING THE NEEDS OF TRAUMATIZED 

YOUTH WITH CO-OCCURRING DISORDERS (cont.): 

13.Strategies to promote youth resilience and recovery. 

14.Adjunctive use of psychotropic medication, as 

clinically indicated. 

15.Provision of culturally competent care. 

16.Attention to educational/vocational needs of youth. 

17.For youth in juvenile justice system, coordination of 

care with JPO and promotion of prosocial 

functioning and peer affiliations. 





• THE WASHINGTON STATE FAMILY 

INTEGRATED TRANSITIONS (FIT) PROGRAM – 

GENERAL CHARACTERISTICS: 

1. Target population: Youth with co-occurring 

disorder within juvenile justice system, on verge 

of release from a secure juvenile facility with 

planned return back to the community. 

2. Specific eligibility requirements: 

a. Less than 17 ½ years old. 

b. Presence of a D&A problem. 





• THE WASHINGTON STATE FAMILY INTEGRATED 

TRANSITIONS (FIT) PROGRAM – GENERAL 

CHARACTERISTICS (cont.): 

c) Presence of MH problem, as manifested by at 

least one of the following: 

1) Axis 1 diagnosis other than CD. 

2) Suicidal behavior within past 3 months. 

3) Use of psychotropic medication. 

d) Youth in secure facility and due for release with at 

least 4 months of probation expected. 








3. Overview of program design: 

a. Program is systemic, with MST as core program component. 

b. FIT therapist responsible for both MH and SUD treatment. 

c. FIT therapist part of MST team, with intensive training and 

supervision. 

d. Treatment involves both youth and family. 

e. Involvement of psychiatrist, as needed. 

f. Many other program components, most evidence-based. 

g. Program typically 6 months in duration and intensive. 

h. FIT interventions begin while youth still in juvenile facility. 





• THE WASHINGTON STATE FAMILY 

INTEGRATED TRANSITIONS (FIT) PROGRAM – 

GENERAL CHARACTERISTICS (cont.): 

4. Clinical program components involve: 

a. Engagement of youth and family. 

b. Youth-specific interventions. 

c. Family interventions. 

d. Systems interventions. 

e. Peer interventions. 

f. Psychiatric interventions. 

g. Substance abuse interventions. 

h. School interventions. 

8


PART IV: TREATMENT – ADDRESSING THE 

NEEDS OF JUVENILES WITH CO-OCCURRING 

DISORDERS WHO EXPERIENCED TRAUMA 




5. Methods to maintain quality: 

a. Small caseload 

b. Team framework and support. 

c. Five day training for new staff, incorporating all 

treatment modalities. 

d. Weekly clinical supervision, and weekly consultation 

case review. 

e. On-the-job training and training boosters. 

f. Use of manual to guide interventions. 

g. Use of caregiver (parent) questionnaire, to ensure 

treatment fidelity. 





• THE FIT PROGRAM – DESCRIPTION OF CLINICAL 

PROGRAM COMPONENTS: 

1. Engagement – Via use of in-home services and 

Motivational Enhancement, including: 

a. Establishing treatment goals, including prerelease 

goals with youth and parent/guardian. 

b. Determining stage of change 

c. Decisional Balance determination (pros vs. cons 

of changing). 






PROGRAM COMPONENTS (cont.): 

d. Motivational interviewing, including use of 

“OARS” methodology: 

1) Open-ended. 

2) Affirming. 

3) Reflection. 

4) Summary 

5) Use of “change talk”. 







2. Systems interventions: 

a. Conceptualization of problem/need in terms of youth within 

multiple life contexts. 

b. Identification of current and potential supports for youth and 

family. 

c. Coordination with all involved care givers and systems. 

d. Linkage/referral, as indicated, with special attention to 

preparation for termination. 





• THE FIT PROGRAM – DESCRIPTION OF 

CLINICAL PROGRAM COMPONENTS (cont.): 

3. Youth-specific interventions: 

a. Use of Dialectical Behavior Therapy (DBT), 

with development of 4 key skills: 

1) Mindfulness. 

2) Emotional regulation. 

3) Distress tolerance. 

4) Interpersonal effectiveness. 







b. Creation and use of client-centered treatment 

plan. 

c. Individual sessions with youth. 

d. Therapy to address specific impairments caused 

by psychiatric disorders. 

e. Psychoeducation and increased self-awareness. 

9








4. Family interventions: 

a. Promotion of increased parent/caregiver 

monitoring of youth. 

b. Increasing family’s social supports. 

c. Parent skills training. 

d. Teaching DBT to family, so family can promote 

DBT skills for youth. 







5. Peer interventions: 

a. Promotion of youth socialization with prosocial 

peers. 

b. Reliance on structured time and structured 

activities. 

c. Discouragement of youth association with 

antisocial peers (in facility & community). 







6. Psychiatric/psychotropic interventions: 

a. Use of psychotropic medication, when indicated, 

monitored by psychiatrist. 

b. Continuity of medication use, following discharge. 







7. Substance abuse interventions: 

a. Addressed directly by FIT staff, not referred out. 

b. Comprehensive assessment of nature of substance use. 

c. Functional analysis of substance use. 

d. Use of D&A Decisional Balance regarding substance use. 

e. Use of workbooks to address community reinforcement and 

relapse prevention. 

f. Linkage to peer support. 







8. School interventions: 

a. Setting up community based school placement prior to 

discharge. 

b. Youth placement in appropriate school setting. 

c. Building on educational gains made while in secure setting. 

d. IEP and attention to youth transition plan. 

e. Increased communication by parent/guardian with school. 







9. Training and supervision components 

10.Quality improvement process based on outcomes. 

10






• FIT OUTCOMES: 

1. Background: 

a. Outcome study conducted by nationally recognized 

Washington State Institute for Public Policy (WSIPP), 

based on 18-month follow-up period at time of initial 

study. 

b. Cost per youth of 6-month program: $8,968.00. 

c. Program funded, bundled rate allows for integration of 

services and decrease in fragmentation. 





• FIT OUTCOMES (cont.): 

2. Recidivism outcomes: Felony recidivism reduced by 34%. 

3. Cost savings outcomes (compared with “treatment as usual” 

outpatient group), following youth’s release from juvenile 

facility: 

a. Overall cost savings determined by WSIPP to be 

$29,000.00 per youth. 

b. This takes into account the nearly $9,000.00 cost of the 

program per youth – savings of $29,000.00, after cost of 

program. 

c. Calculation based on savings from prevention of reincarceration, 

plus savings based on prevention of 

victimization of others (reduced felony rate). 

PART V: CONCLUSIONS 

PART V: CONCLUSIONS 

1. Highly challenging combination: SUD and PTSD (complete or 

partial), and other psychiatric symptoms/disorders. 

2. Even more challenging when youth with SUD and PTSD are 

also involved with juvenile justice. 

3. Need for helping adults to help, not exacerbate problem by 

stigmatizing, shaming, coercing, engaging in counteraggression. 

4. Key treatment elements include engagement and promotion of 

trust, use of comprehensive information and strengths of youth, 

commitment to prevention. 

5. Response to trauma and substance use requires trauma 

informed care and integrated approach to co-occurring 

disorders. Many evidence-based components can be 

incorporated. 

6. Programs and services need to be supervision-rich, maintain 

therapist accountability, and use of outcomes to improve 

quality. 

7. Recovery involves promotion of youth’s self-awareness, sense 

of empowerment, and capacity to make healthy choices and 

develop a positive identity. 

8. Desired outcome: being safe, living productively in community, 

enjoying meaningful relationships. Charlie Curie: 

“A life in the community for everyone – a job, a 

home, a date on the weekend.” 

11

M03: Effective Communication Training: A Bucks County Forensic Initiative 

Robert E. Kelsey, MDiv, & Dorothy J. Farr, LSW, LADC, CCDP-D 

1.5 hours Focus: Forensics Involvement 

Description: 

This workshop explores a current initiative in Bucks County designed to reduce recidivism in the criminal 

population through the use of specific communication strategies. The trainers explore the research data on 

“what works” to reduce recidivism in the offender population, review the principles of effective correctional 

interventions, and clarify how traditional mental health and drug and alcohol treatment interventions must be 

modified to reduce recidivism with this population. 


• Describe the difference between Risk Control and Risk Reduction strategies in working with the 

offender population; 

• Recognize the unique characteristics of criminal logic and how traditional treatment approaches must 

be altered to deal effectively with this population; 

• Describe basic concepts in the “What Works Research” of Andrews and Bonta; 

• Summarize the integrated approach being taken in Bucks County to more effectively intervene with 

offenders utilizing the mental health, drug and alcohol, and correctional systems. 

NOTES:


Beyond 2006: Promoting Recovery-Oriented Programs and Practices 

for Persons with Co-occurring Mental and Substance Use Disorders 

Effective Communication Training: 

A Bucks County Forensic Initiative 

May 15, 2006 

Robert E. Kelsey, M.Div 

Dorothy J. Farr, LSW, LADC, 

CCDP Diplomate 

Model we are Attempting to 

Develop in Bucks County 

• Public Safety Model 

• Focusing on Offender Risk Reduction and 

Recidivism Reduction 

• With an integration and coordination of the 

Corrections, Treatment and Community Systems 

• Using the growing body of Evidence-Based 

Principles and Practice 

• Grounded in a Basic 35-hour Training 

Experience with strong emphasis on developing 

Motivational Interviewing Skills 

So… 

If that is your plan… 

• What works…and…what does not work in 

• Reducing Offender Risk 

• Reducing Offender Recidivism and 

• Increasing Community Protection? 

What Works and Doesn’t Work 

Punitive Correctional Practices do not 

appear to have much overall deterrent 

effect on offenders or potential 

offenders. 

In fact, a purely Punitive Model of 

dealing with offenders will increase 

recidivism by 7%. 


• Evidence does not indicate that routine 

probation or parole supervision practices 

or intensive supervision models have 

significant effects on recidivism. 


• Restorative Justice programs such as 

Community Service, Restitution and 

Victim-Offender Mediation have very little 

positive effects on recidivism. 

(Although they have strong appeal in how well 

they serve the needs of victims and the 

community.) 

1



• Educational, vocational, and employment 

programs have produced positive but only 

modest reductions in recidivism 

I remember someone once saying, 

“Offenders do not come to the penitentiary because they 

can’t read and write…they come to the penitentiary 

because they can’t think!” 


• Cognitive-behavioral treatment that 

addresses the deviant thinking 

patterns (Criminal Logic of 

offenders) has consistently been 

found to be an effective 

rehabilitative strategy for both 

juveniles and adults 


• Behavioral modification programs that are 

designed to shape and maintain 

appropriate behaviors until they are 

incorporated into the habit pattern of the 

offender, have been effective in reducing 

recidivism. 


• Multi-modal programs that target a variety 

of offender criminogenic and other risk 

factors have shown that they are amongst 

the most effective at reducing recidivism. 


• Well implemented programs that deliver a 

relatively high dose of treatment tend to be 

more effective with high-risk offenders. 


• Despite the evidence that many programs 

in principle can be effective, actually 

configuring, implementing, and 

maintaining these programs is difficult. 

2


Treatment Models and Approaches 

That Are Not Research Supported 

• Targeting low risk offenders 

• Targeting non-criminogenic needs 

• Punishment sanctions only 

• Shock probation 

• Boot camps 

• Scared Straight 

• D.A.R.E. Program 

• Drug testing only 

• Home detention with electronic monitoring only 

• Encounter type program models 

• Insight-oriented psychotherapy 


That Are Research Supported 

• Treatment That Targets Criminogenic Needs 

• Targeting High Risk Offenders 

• Cognitive-Behavioral Therapies 

• Aggressive Replacement Training 

• Reasoning and Rehabilitation Program 

• Moral Reconation Therapy 

• Thinking For A Change Program 

• Cognitive Self-Change Program 

• Controlling Anger and learning to manage It (CALM 

Program) 


That Are Research Supported 

• Motivational Enhancement Therapy 

• Treating Alcohol Dependence Program 

• Pathways to Change Program 

• Interpersonal Communication Skills Training 

• Functional Family therapy (Juvenile offenders) 

• Multi-Systemic Therapy (Juvenile Offenders) 

• Community Reinforcement and Family Training 

(CRAFT) 

So…Given This, 

• How are we going to accomplish our 

goals of: 

• Reducing Offender Risk 

• Reducing Offender Recidivism and 

• Increasing Community Protection? 

Ripple Approach 

EFFECTIVE 

COMMUNICATION 

A Brief look at the components of 

the 35-Hour Training 

Designed by Ray Ferns, 

CEO of Restorative Correctional Services 

PO box 432, Stevenson, WA 98648 

(509) 427-7998 - rcogman@aol.com 

• Seven Trainers from: 

– Adult Probation, 

– Department of Corrections and 

– Behavioral Health 

• Basic Trainings two times a year for new Probation 

Officers, Parole Agents, Corrections Officers, Therapists, 

Case Managers, Social Workers, Administrators, 

Community Members, etc. 

• Annual Refresher Training each Year for those who have 

previously completed the Basic Training 

• Adult Probation and Parole also has quarterly Unit Meeting 

Refreshers and bi-monthly Management Team Refreshers 

3


List of Topics Covered 

• Risk Reduction and Risk Control – Cognitive 

Behavioral Theory, Risk Principle, Need 

Principle, Responsivity Principle, “What Works” 

• Criminal Logic 

• Social Learning Theory 

• Stages of Change 

• Motivational Interviewing 

• Basis for Evidence-Based Practice 

Risk Control: 

External focus 

Punishments 

Consequences 

Skills: Firm, Fair, Consistent 

Behavior 

Risk Reduction: 

Cognitive Structure 

Internal focus 

Skills: 

Dynamic Risk Factors 

Effective communication skills 

Anti-social attitudes and beliefs 

Reflective listening 

Elicit self motivating 

statements 

Roll with resistance 

Targets of Needs Principle 

•Changing antisocial attitudes, beliefs, feelings. 

•Reducing antisocial peer associations. 

CRIMINAL LOGIC 

•Promoting familial affection/communication. 

•Promoting pro-social associations/activities. 

•Increasing self-reflection and self-regulation and 

problem solving skills. 

•Reducing chemical dependencies. 

LOOK GOOD 

CONTROL 

Learning the Rewards of Self- 

Centered Thinking 

WIN 

FEEL GOOD 

Self- 

Centered 

Thinking 

Power 

Struggle 

Detection, 

Punishment 

Crime, 

Irresponsibility, License 

Violence 

LOSE 

POWER 

BE RIGHT 

Belittled 

Threatened 

Victim Stance 

Righteous Anger 

Taking on the Characteristics of Your 

Environment 

What do we know about the characteristics of 

criminal populations? 

• Self Centered 

• Ridged-black and white thinkers 

• Blame others 

• Avoid consequences 

• Don’t learn form prior experiences 

4


Criminal Logic Presents Itself 

As: 

• Victim Stance “I’m the victim here!” 

• Blames Others “If it weren’t for ….” 

• Uniqueness “I’m one in a million!” 

• People, Places and Things are 

“possessions” 

• Instant Gratification (What? Me learn from the past?) 

• Lies by Omission 

•etc. 

Application of Punishment 

• Does little to disengage offenders from 

patterns of thinking that re-enforce the 

logic of crime and the logic of nonaccountability 

• Criminals fail to learn from prior negative 

experiences 

Effective Communication/Motivational 

Strategies 

• Old Corrections Belief: “ 

Everyone doing this work has 

their own style of 

communication/interaction with 

offenders and all styles are okay.” 

• New Belief: 

“Communication/Interaction 

strategies have an impact on 

motivation and successful 

outcomes in the reduction of 

recidivism. It is the obligation and 

responsibility of corrections 

professionals to know when and 

how to use specific 

communication strategies to 

produce better results.” 

Social Learning Theory 


• A triangulation of dynamic factors, behavior, 

environment and “cognitive structures” each 

having potential influence over the other. 

Behavior 

Environment 

Cognitive Structure 

Tenets of Social Learning Theory 

(A Bandura, Social Learning theory, 1977) 

• Response consequences such as rewards 

or punishments influence the likelihood 

that a person will act in a certain way in a 

given situation. 

• Humans can learn by observing others. 

• Individuals are most likely to model 

behavior observed by others they identify 

with. 

5


Stages of Change 

Mastering the Stages of Change 

• Substance Use 

• Mental Illness 

• Co-Occurring 

Disorders 

• Criminal thinking 


Relapse 

Pre-contemplation 

Maintenance 

Action 

Contemplation 

Determination 

Important Assumptions 

• Change is domain specific. The individual 

may be at a different stage for different 

issues. 

• The model was developed around 

voluntary change process. 

• Each stage is time period during which 

essential tasks must be completed. 

• The process is cyclical, not linear! 

Motivational Interviewing 


• A technique used to help people recognize 

and do something about their present, or 

potential problems. 

• Particularly useful with people who are 

reluctant or ambivalent about changing. 

• It’s intended to help resolve ambivalence 

and to motivate the person to pursue 

rather than avoid change. 

6


Understanding the 

Philosophy 

• Goal-reduce rather than strengthen 

resistance. 

• Offender’s resistance is your problem. 

• Resistance is normal. 

• The PO’s approach is critical to setting 

the stage for resistance. 

• How you respond to resistance that 

makes the difference. 

Five General Principles 

• Express empathy 

• Develop discrepancies 

• Avoid argumentation 

• Roll with resistance 

• Support self-efficacy 

Five Basic Skills 

• Asking open-ended 

questions 

• Reflective listening 

• Affirmations 

• Summarizing 

• Eliciting selfmotivating 

statements 

Reflective listening-Key skill 

• Suspend your own judgment! 

• Listen to understand from the other 

person’s perspective. 

• Don’t worry about fixing-just listen to 

understand. 

Reflective Listening 

• Layers of reflective listening. 

– Repeating: The simplest reflection-repeats 

an element of what was said. 

– Rephrasing: Stays close, but substitutes 

synonyms or slightly rephrases what was 

offered. 

– Paraphrasing: More of a major statement 

in which the listener infers the meaning of 

what was said. 

– Reflections of feelings: Regarded as 

perhaps the deepest form of reflectionemphasizes 

the emotional dimensions. 

Eliciting Self-Motivating 

Statements 

• General strategy 

– Listen reflectively 

– Ask questions in specific areas of probable 

conflict or problems. 

7


Eliciting self-motivating 

statements 

• What are you listening for? 

– Problem recognition: 

– Expression of concern: 

– Intention to change: 

– Optimism about change: 

Offender Change 

Change is Not Always Easy 

• We saw our more senior Probation Officers as 

having better interviewing skills. 

– Some of them were quite resistant to the training and 

could not demonstrate the basic skills 

• This is changing in time 

– Union issues emerged 

• Managers are key and we are spending large 

amounts of time with them and with Effective 

Communication 

Treatment Agencies 

• Substance Abuse Agencies moving much 

quicker than the MH providers 

• Focus on what works with our population 

still in infancy 

• Discussion around requiring therapist to 

whom we refer to have gone through 

Basic Training 

References 

Effective Communication 

From Ray Ferns, CEO, Restorative Correctional Services, Effective 

Communication, Motivation Strategies In Assessing and 

Overcoming Resistance To Change, Co-authors, Mark Gornik and 

Deena Cheney. Ray is the consultant/trainer funded by NIC to 

conduct our training events in 2005 


From the work of Albert Bandura, Ph. D, Stanford University 

Criminal Logic 

From the work of Dr. Stanton Samenow, Ph. D, author of Inside The 

Criminal Mind (NY: Times Books/ Random House, 1984, 2004) 

References 


From the introductory work of James O. Prochaska and Carlo 

DiClemente, 1982—in intervening years applied by Prochaska , 

DiClemente and others to a variety of fields of study. 

What Works 

From the work of D.A. Andrews and James Bonta, The Psychology of 

Criminal Conduct, Anderson Publishing Co., 1994, 1998, 2003. 

From the research and work of many others, mostly out of Canada, 

who have been identified with the “What Works” movement that has 

promoted concepts such as the “Risk Principle”, including Paul 

Gendreau, Ph.D., University of New Brunswick. 

8


References 


From William R. Miller and Stephen Rollnick, Motivational Interviewing, Preparing 

People for Change, The Guilford Press, NY, London, 2002. 

Evidence Based Practice 

Our work is based on Implementing Effective Correctional management of Offenders 

in the Community: An Integrated Model, which is NIC’s pilot project for statewide 

implementation that was presented nationally through a satellite training broadcast 

by: Brad Bogue, Nancy Campbell, Elyse Clawson, et al. Crime and Justice Institute. 

Sponsored by U.S. Department of Justice, National Institute of Corrections. February, 

2004. 

Re-Engineering Probation Towards Greater Public Safety, A framework for 

Recidivism Reduction Through Evidence-Based Practice, Thomas F. White, 

Director of Operations, Court Support Services Division, State of Connecticut— 

Judicial Branch, April 2005, published National Institute of Corrections Website at: 

http://www.nicic.org/Library/021046 

9

Effective Communication and 

Motivational Strategies in 

Working with Resistant Populations 

Introduction: The following series of lesson plans were developed at the request of the 

National Institute of Corrections. The specific purpose of these lesson plans are to 

provide correctional administrators and practitioners with general information, as well as 

specific communication skills and techniques designed to reduce offender resistance, 

increase offender motivation to change, and reduce individual criminal risk. 

Agencies interested in applying for this training through technical assistance should allow 

at least 4 to 5 days to adequately deliver the training. Participants will be asked to 

complete about 30 minutes to 1 hour of work outside of the training, per day, in addition 

to the in class training time. 

Lesson Plans/Time/General purpose: 

1. Introduction to overall course: 

This is a 2- hour lesson designed to: 

• Introduce the material to be covered 

• Introduce NIC 

• Introduce one tenant of Social Learning Theory, (Early childhood 

experiences heavily influence personal attitudes and beliefs.) 

• Engage the participants in a fun, group learning exercise 

• Allow participants the opportunity to introduce themselves 

• Establish a shared learning environment 

2. Offender Management: 

This is a 1 to 2 hour lesson designed to: 

• Introduce the concepts of Risk Control and Risk Reduction 

• Describe how these strategies are a package 

• Evaluate individual and agency competencies in both strategies 

3. Social Learning Theory: 

This is a 1 to 2- hour lesson designed to: 

• Describe the origins of Social Learning Theory 

• Describe the relevance of this theory of human behavior to correctional 

practices 

• Describe the five basic tenets of Social Learning Theory 

4. Overview of “What Works” Research: 

This is a 3 to 4 hour lesson designed to: 

• Introduce the principles of Risk, Need and Responsivity 

• Describe the major risk factors associated with adult and juvenile 

offenders 

• Describe what doesn’t work 

• Identify targets for correctional programming

5. Criminal Logic: 

This is a 3- to 4 hour lesson designed to: 

• Give staff a better understanding of criminal thinking as the foundation for 

“change work” with offenders 

• Provide staff with a better understanding and appreciation for why certain 

programs have better impacts in reducing recidivism with adult and 

juvenile offenders. 

• Provide staff with a better understanding of why certain communication 

skills and techniques work better than others to reduce offender resistance 

and increase offender motivation for change. 

• Allow staff to practice skills in self-assessment, and self-adjustment in 

personal attitudes, beliefs and patterns of thinking and feeling. 

6. Introduction into Basic Communication Skills: 

This is an 8 to 12 hour lesson designed to: 

• Introduce the concept of “Stages of Change” and how this concept can 

apply to correctional practices. 

• Introduce and demonstrate competencies in five basic communication 

skills; asking open-ended questions, reflective listening (repeating, 

rephrasing, paraphrasing, reflections of emotions.), affirmations, and 

summarizations. 

• Introduce and demonstrate competency in evoking self-motivating 

statements from resistive offenders using the specific strategies of (Using 

Extremes, Looking Forward and Backward, Exploring Goals, Paradox, 

Evocative questions, Elaboration, and Decisional Balance.) 

7. Why These Skills Won’t Work For Me or My Agency: 

This is a 1- hour lesson designed to: 

• Explore staff resistance 

• Demonstrate the communication skills and techniques used to overcome 

resistance. 

8. Advanced Techniques in Overcoming Resistance: 

This is an 8- to 12 hour lesson designed to: 

• Practice and demonstrate competencies in basic communication skills used 

in specific advanced techniques such as (Simple reflections, Amplified 

reflections, Double sided reflections, Shifting focus, Emphasizing personal 

choice, and Reframing.) to overcome offender resistance.

M04: Functional Analytic Structured Systemic Treatment (FASST): An Intervention for Persons 

with Co-Occurring Mental and Substance Use Disorders 

Ralph Spiga, PhD & Amy Wells, PsyD 

1.5 hours Focus: Clinical Integrated Interventions 

Description: 

Minorities receive poorer mental health treatment and medical care than non-minorities (Surgeon General’s 

Report, 2001). The diagnosis and stigma of drug abuse, prevalent in minorities with serious mental disorders, 

further complicates such disparities. This workshop presents a state-of-the-science behavioral intervention 

that integrates methods from different behavioral treatments into a seamless whole and incorporates them 

into a treatment package compatible with the minority clinical populations typically served in an urban setting. 


• Describe the methods and challenges of examining therapeutic effectiveness in a large sample of urban 

minority patients with serious and persistent mental illness and substance use; 

• Identify individual, family and community risk factors related to treatment attendance and drug use; 

• Review potentially useful intervention techniques for reducing drug use and increasing adherence to 

treatment. 

This workshop consists of two components: a presentation and an activity. Each component contributes to the 

overarching conference goals of integrating treatment for persons with co-occurring disorders. 

NOTES:


Co- morbid Disorders 

Basic and Clinical Behavioral 

Research 

Ralph Spiga, Ph.D. 

Director 

Institute of Behavioral Research 

Associate Professor 

Collaborators and project staff were… 

J. Stahler, Ph.D.; George Rengert, Ph.D.; David A. 

Baron,M.Ed., D.O.; William Dubin, M.D. 

Therapy Supervisors: Kevin Riley, Ph.D.; 

Christopher Coombs, Ph.D.; Andrew 

Trentacoste, Ph.D. 

Interns: Amy Wells, R.N., M.A.; Mark Deskowitz, 

M.A. 

Technical Assistance: Mary Ann Aussetts, M.A.; 

Deborah Haas, M.S.; Stockton Maxwell, B.S., 

Evan Roberts, B.S. 

Thanks to attendings and social work staff.. 

Attendings: Drs Kurien, Garbley, Joy, Paul And Shack. 

Social work staff: Jay Finestone and L.J. Rossi 

Administrative staff: Kim Aponte-Smith and Doris Quiles 

Our research was financially supported by… 

This research is funded, in part, under a grant with 

the Pennsylvania Department of Health. The 

Department specifically disclaims responsibility for 

any analyses, interpretations or conclusions. 

My objectives are to… 

• Review briefly what is known about 

epidemiology and clinical features of comorbid 

mental health and substance use 

disorders. 

• Describe what is known about psychosocial 

treatments for these disorders. 

• Describe the development and clinical 

evaluation of a psychosocial treatment for 

these disorders. 

1


The Surgeon General (2001) observed… 

• “…few clinical trials have evaluated response of 

African-Americans [and other minorities] to evidencebased 

treatments.” 

• “ …few studies have examined the impact of 

treatments on African-American [and other minorities] 

delivered under the usual conditions of community 

treatment.” 

• “More remains to be learned about when and how 

treatment must be modified…” 

The Surgeon General (2001) Mental Health: Culture, Race and Ethnicity. 

U.S. Department of Health and Human Services. 

Some facts… 

• Approximately 2% substance users have mental 

health problems. 

• Of the 2% with mental health problems 

• Only 8% treated for SUD problems. 

• Only 7% treated for MH problems. 

• Of the 3% substance users with serious mental health 

problems 

• 24% treated for SUD conditional on treatment of MH 

difficulties. 

• 46% treated for MH conditional on treatment of SUD 

problems. 

Analysis of 2001-2002 National Survey of Drug Use & Health (N = 90,277; 

Harris & Edmund, 2005) 

More… 

Behavioral treatments for SUD appear effective… 

• Drug users with mental health problems and 

without health insurance most frequently are 

treated by self-help groups or in human service 

settings. 

Analysis of 1999 National Household Survey Survey on Drug Abuse (N 

= 24,282; Wu & Ringwalt, 2005) 

• All studies demonstrate that patients who remain in treatment the 

longest have the best outcomes (DATOS; Simpson et al 1997) 

• Greater frequency of individual and group counseling reduces 

relapse (McLelland et al, 1988; Fiorentine and Anglin, 1996). 

• Participation in Motivational Enhancement Therapy, Relapse 

Prevention and Community Reinforcement Approaches (voucherbased) 

are addiction therapies with demonstrated effectiveness. 

• Participating in AA/NA and other self-help improves drug use 

outcome (Project MATCH Research group, 1997). 

• Supplemental social services decrease likelihood of relapse 

(McLelland et al 1997). 

• Proper medication (Strain, 1996). 

Some current evidence-based treatments are… 

What are the features of Relapse Prevention… 

• Two decades of research has supported the idea that brief 

therapies for substance using individuals are as effective those of 

longer durations (Project MATCH, NIAAA). 

• The addictions field endeavors to describe the critical conditions 

necessary and sufficient to induce change. 

• Motivational Enhancement Therapy, Relapse Prevention 

Community Reinforcement Approaches are addiction therapies 

designed to incorporate the critical components of change into a 

brief therapeutic intervention. 

• Foster motivation for abstinence. 

• Teach coping skills: recognize high-risk situations 

and develop alternatives. 

• Train in management of urges to use. 

• Recognize situations increasing negative affect and 

provide means for managing these situations. 

• Improve interpersonal functioning and enhance 

social support. 

• Change reinforcement contingencies: alter 

lifestyle. 

2


What are the essential features of the Community 

Reinforcement Approach (CRA)… 

• Provide reinforcement for abstinence (vouchers). 

• The ABCs of behavior: functional analysis 

• Antecedents (Triggers) 

• Behaviors 

• Consequences (Positive reinforcers; Negative reinforcers; 

Positive punishers; Negative punishers) 

• Change reinforcement contingencies: alter 

lifestyle. 

• Family relationships 

• Recreational activities 

• Social networks 

• Vocational Functioning 

What are the basic principles of Motivational 

Enhancement Therapy? 

•Client-centered counseling approach. 

•Designed to help clients resolve ambivalence about 

treatment and ceasing drug use. 

•Employs strategies to evoke rapid patient directed change. 

•Patient directed change includes therapeutic tasks 

designed to accelerate patients through pre-contemplation, 

contemplation, and change phases. 

Is Motivational Enhancement Therapy effective? 

• Motivational interviewing and relapse prevention 

effective treatments for alcohol use and other substance 

use (Najativis & Weiss, 1977, PROJECT MATCH, 1977). 

• Reduces smoking in schizophrenic patients (Zeidonis, 

1997). 

• Increases post-incarceration treatment contact in drug 

abusing veterans (Davis et al., 2003). 

The results of behavior therapy trials have been 

mixed in dually diagnosed populations… 

Positive results 

• Daley et al (1998) increased 

treatment adherence among 

depressed cocaine users. 

• Martino et al. (2000) increased 

treatment attendance. 

• Swanson et al (1998) 

increased attendance at 1 st 

outpatient appointment. 

Negative results 

• Miller et al(2003) targeted 

improvement in compliance 

among inpatient & outpatient 

drug using clinical populations. 

• Donavan et al. (2001) targeted 

reduction in drug use among 

IV users. 

• Booth et al. (1998) targeted 

reduction in opioid use among 

IV users. 

• Baker et al (2002) attempted to 

increase participation in 

substance abuse inpatient 

programs. 

We designed, piloted and evaluated a treatment 

that… 

• Considers impact of cognitive impairments in attention and 

memory. 

• Focuses on the interacting consequences of mental health and 

substance abuse. 

• Utilizes a structured “decisional balance sheet” approach to 

integrate substance use, adherence and mental health symptoms. 

• Remediates social skill and problem-solving strategy deficits. 

• Engages patient through behaviorally-oriented structured 

interventions, e.g., social skill training, successive approximations. 

• Integrates housing, outpatient and social services with a 

community reentry module. 

In summary, the purposes of the clinical trial were 

to … 

• Design a multi-dimensional intervention which includes 

elements necessary for treatment of mental illness and 

substance use disorder. 

• Include elements of motivational interviewing, relapse 

prevention and skill training in the intervention. 

• Evaluate the effectiveness of these procedures in a 

primarily minority clinical population and in a typical 

clinical environment. 

3


Our basic design was a randomized, parallel group 

design… 

What were our methods? 

Referral 

CRC & Inpatient 

Units 

Consent Process 

Assessment 

Randomization 

TAU 

FASST 

Follow-up 

Assessment 

What were the inclusion criteria… 

What were the intake research assessments? 

• Axis I disorder including a Substance Use Disorder. 

• Positive urine drug screen. 

• Anticipated hospital stay of at least 3 days. 

• No serious medical condition requiring evaluation, 

hospitalization or referral. 

• Not admitted involuntarily. 

• IQ >70 

• Pre-assessments. 

• On admission. 

• SCID 

• ASI 

• SIRS 

• K-BIT/K-FAST 

• Mini-Mental Status 

• RAB 

• Drug Craving 

• GAF 

• ICCI 

• Post-assessments. 

• Immediately prior to 

discharge. 

• GAF 

• Impact Scale 

What were the follow-up assessments? 

• Assessments: 

• Outpatient attendance. 

• Rehospitalization. 

• Index of Risk. 

• Functioning: 

• Addiction Severity Index (drug use section). 

• Urine Drug Screen. 

Geographical Information Systems Analysis: 

Community, program and individual risk factors 

associated with non-attendance… 

Domiciled 

1 or more temporary housing within 0.4 

miles 

Returning Home 

Variable 

3 or more prior treatment episodes 

Bizarre behavior (presenting problem) 

2 or more liquor/beer stores within 0.4 

miles 

7 or more NA/AA meetings within 0.8 

miles 

Substance induced mood disorder 

Odds Ratio 

2.66 

2.61 

2.42 

0.18 

0.29 

0.43 

0.45 

0.48 

Significance 

.022 

.006 

.004 

.000 

.008 

.018 

.009 

.038 

UDS positive for heroin 

0.48 

.059 

Suicidal ideation 

0.49 

.023 

20% or more public assistance in census 

tract 

0.60 

. 075 

Note: Significance at p < .10 level 

Logistic regression used to predict likelihood of showing up to first outpatient appointment within 30 

days of post discharge from acute inpatient program 

4


How did we assess understanding of Informed 

Consent? The Informed Consent Comprehension 

Interview 

(ICCI) 

• Assessed after consent obtained and prior to 

therapy. 

• Misunderstandings clarified. 

• Assess: 

• Expressing choice. 

• Understanding relevant information and significance. 

• Appreciation of significance and consequences of 

alternatives. 

• Reasoning with relevant information. 

In this vulnerable population can we enhance 

comprehension of informed consent? 

• Can we enhance 

comprehension of informed 

consent? 

• Intervention: Series of cards 

with answers to FAQs. 

• Four groups: 

I. Consent-ICCI-Cards-ICCI 

II. Consent Cards-ICCI 

III. Consent-ICCI ICCI 

IV. Consent-ICCI 

• Improved understanding but 

not reasoning. 

2.5 

2 

1.5 

1 

0.5 

0 

I II III IV 

Groups 

Understanding 

Appreciation 

Reasoning 

What was Treatment-as-Usual? 

• Conducted by Unit Staff. 

• Group treatments now in place on the unit. 

• Group treatments 

• Relapse prevention 

• Denial & Acceptance 

• Coping with addiction 

• Anger & Stress Management 

What is Functional Analytic Structured & Systemic 

Therapy (FASST)… 

• Theoretically-based behavioral treatment. 

• Conducted by supervised graduate student 

assistants. 

• Combines principles and techniques of a 

Functional Analysis of Behavior, Motivational 

Interviewing Techniques and Community 

Reinforcement. 

• Five 45 minute sessions. 

• Sessions 2 per day. 

What are the characteristics of Functional Analytic 

Structured & Systemic Therapy? 

Phases 

• Engagement. 

• Assessment. 

• Motivation. 

• Behavioral Change. 

• Generalization. 

Characteristics 

• Functional analysis 

• Structured 

• Systemic 

What is the rationale for Functional Analytic 

Structured & Systemic Therapy? 

• Allocation Principle: All behavior is choice behavior and is 

allocated to alternatives of greatest benefit. 

– B = R 1 /(R 1 +R O ) 

• Mediation Principle: Other persons and social institutions 

mediate the occurrence of benefits and costs important to the 

patient. 

• Economic Principle: Price is an important determinant of 

consumption of goods and services. 

– C = LP b e -aP where C is consumption and P price. 

• Discounting Principle: Within a limited time horizons patients 

weigh costs and benefits. 

– V = A/(1+kD) V is reinforcer value, A dollar amount, D is delay and k 

discounting rate. 

• Preference Principle: We do not always know the patients 

utility curve. 

5


What were our results? 

What was our clinical sample? 

Other 

7 

Exclude 

23 

IQ


What did we find? 

•Intent-to-treat model: Patients who were 

randomized to the intervention, or TAU, 

were included in the analysis even if 

treatment was incomplete. 

•Most FASST patients who did not 

complete sessions had at least 2 sessions 

and no more than 4. 

•Patients for whom we could not obtain 

follow-up data were treated as a “no show.” 

• Nearly 64% of patients receiving the 

experimental intervention attended the first 

scheduled post-hospitalization outpatient 

appointment. 

•Nearly 36% of control patients attended 

the first scheduled appointment. 

•Likelihood Ratio (Fischer’s Exact chi – 

square) = 12.890; p < 0.001. 

% Attendance x Intervention 

70 

60 

50 

40 

30 

20 

10 

0 

FASST TAU 

Intervention 

Other findings of import… 

• Reported monthly income < $341 per month. 

• Nearly 78% reported no employment in the past 30 days. 

• Male patients engaged in high risk sexual behavior: 

• 28% report giving drugs for sex. 

• 10% report paying someone money to have sex. 

• Female patients engage in high risk sexual behavior: 

• 34% report on having sex to get drugs. 

• 26% report being paid money or drugs to have sex 

• 3% report on having unprotected sex with someone they know to have 

HIV/AIDS. 

• About 20% of males and females report being worried (moderately 

or greater) about getting HIV/AIDS. 

• 13% report they may have already been exposed to HIV/AIDS. 

Some qualitative session data… 

• Antecedents (Triggers) most frequently cited: 

• Boredom 

• Alone/lonely 

• Argument with significant other 

• Behavior (with mood): 

• Anger/argument. 

• Drug use/hallucinations 

• Consequences: 

• Feel good “real” (cocaine use). 

• Worsening relationship with C/SO. 

Some more qualitative session data… 

Impediments-potential disincentives 

• Availability 

• Hard for me to get there 

• Long wait to get appointment 

• Continuity 

• Therapist left 

• Different person all the time 

• Relevance 

• Doesn’t help 

• Just talk 

• Ambience 

• Dirty 

• Wait too long 

What have been our challenges? 

• Follow-up extremely difficult. 

• Recruiting family member or significant other, FSOCs, 

has been difficult: 

• 27 consented. 

• 5 attended at least 1 session 

• 32 phone calls from family member, significant other or 

caregiver (FSOC). 

• Alternatives: 

• Community Mentor. 

• Treatment in home (MST and FFT). 

• Phone treatment. 

• Train case mangers and staff at boarding homes etc. 

Concluding remarks… 

Social capital 

• Relationship between interpersonal trust, social 

reinforcement and social engagement. 

• Related to income inequality, health outcomes, medical 

compliance and civic engagement. 

• Determined by network of interacting formal, informal 

norms and behavior of institutions, community and 

individuals. 

Our patients live in communities with diminished 

social capital. 

7


Concluding remarks… 

Social capital 

• Relationship between interpersonal trust and social 

engagement. 

• Related to income inequality, health outcomes, medical 

compliance and civic engagement. 

• Determined by network of interacting formal, informal 

norms and behavior of institutions, community and 

individuals. 

Concluding summary… 

A well structured therapy with guided activities, 

focused on limited but well defined behavioral 

targets and incorporating 

• Motivational techniques 

• Functional analysis 

• Decision analysis 

is effective. 

8


What are our objectives? 

Functional Analytic 

Structured Systemic Therapy 

To do or not to do! 

• Understand theoretical principles of Functional Analytic Structured 

Systemic Therapy (FASST). 

• Become familiar with the activities FASST. 

• Learn the structured individual session activities. 

• Understand the application of basic and effective substance use 

treatment principles applied to patients with mentally illness and 

substance use disorders. 

What are some general principles? 

• Motion before emotion: focus is on what you do, not how 

you feel 

• Techniques: OARS and GRACE 

• Modality: Individual therapy 

• Duration: Two 45 minute sessions/day for 5 sessions 

– Session I: Assessment 

– Session II: Treatment goals 

– Session III: Decision making regarding drug use versus 

not using drugs 

– Session IV: Decision making regarding OPT versus not 

going to OPT 

– Session V: Summarize 

What is O.A.R.S.? 

• O- for Open-Ended Questions. 

Patients cannot answer with a yes or no. 

Create forward momentum. 

Moves the patient in the direction of behavior change. 

• A- for Affirmations. 

Acknowledgement of observed strengths. 

Focus on patient’s past successes with behavior change. 

Provide genuine positive feedback regarding efforts. 

Help patients feel that change is possible. 

• R- for Reflective listening. 

Provide feedback to patients about your understanding of what they said. 

Actively but gently guide the patient toward certain topics. 

Focus on and provide positive feedback for “change talk”. 

Provide negligible attention and feedback for “non-change” talk. 

• S- for Summaries. 

Pull together the information you hear, communicate interest,. 

Call attention to salient consequences. 

What is G.R.A.C.E.? 

What are the five phases of FASST? 

• G- The Gap is the distance between… 

The patient’s goals and current actions. 

• R- Roll with Resistance. 

Avoid confronting patient resistance head on. 

• A- No Arguing. 

Arguing punishes the patient’s verbal behavior. 

Increases the likelihood of emotional responses (e.g., hallucinations, 

jitteriness, feeling anxious, feeling angry 

• C- For Can do. 

Patients have intimate knowledge of what works for them, what doesn’t 

work for them, and what are their preferences. 

Assist the patient in organizing these events. 

Teach skills as necessary. 

• E- For Expressing Empathy. 

Create a reinforcing environment 

Make explicit the implicit feelings, reactions, and consequences. 

• Engagement 

• Assessment 

• Motivation 

• Behavior Change 

• Maintenance/Generalization 

1


How do we engage the patient? 

Respect is everything! 

• Establish rapport-therapist as social reinforcer: disrespect 

gets you no where 

• Providing hope: empowering the patient 

• Motivating attendance with snacks, etc 

• Set the contract: expectations, obligations, expectable 

outcomes 

• Therapist techniques and tools: GRACE, OARS and 12 

roadblocks to communication 

Ordering, threatening, giving advice, arguing, 

preaching, judging, praising, shaming, interpreting, 

consoling, probing, withdrawing 

What do we assess? 

Where I am, and where I want to be? 

• Treatment Goals Card Sort: assesses behavioral excesses, deficits 

and assets. 

• Functional Analysis: clarifies problem behaviors 

Biologic/Social/interpersonal consequences (short- & long-term). 

Social mediators of consequences-who, when, where.. 

Benefits and costs of behavior and change. 

New problems resulting from change. 

• Motivational Analysis 

Incentives/disincentives: what, who, how often 

Supports and impediments to change. 

How do we motivate for change? 

A time of reckoning. 

• Look for the Gap: what you say versus what you do. 

• Crossing the gap: clarify goals, decision analysis, and 

cost/benefits. 

• Structured techniques & tools. 

“What If” exercises. 

Decisional Balance Worksheet 

• Identify alternatives & consequences. 

• Feedback of treatment options and current strengths, 

deficits, impediments and supports. 

• Dealing with resistance: no arguing, what if? 

How do we change behavior? 

How do I get there from here? 

● Select/establish simple and achievable goals. 

• Review gap, cost/benefits, positive supports 

• Explore realistic alternatives to drug use 

• Identify simple behavioral tactics to minimize impediments and 

maximize supports. 

• Techniques & Tools 

Behavioral rehearsal 

Instruction 

• Review plan for discharge 

• Take off on a position for change: certificates, copy of treatment 

goals, positive experience in treatment. 

How do we maintain changes? 

Think of me when I’m gone! 

How do we assure the plan is achieved in the outpatient environment? 

• Coordinate aftercare: patients have option to see current FASST 

therapist for OPT 

• Empower the patient: survival bible, copies of treatment goals, 

etc. 

• Identify supportive caregivers and/or mentors 

• Train caregivers and/or mentors 

• Mobilize community/ Community interventions 

• Community education 

2

12 Roadblocks of Communication 

1 

Ordering, Directing or Commanding. Here a direction is given with the force of some authority behind it. There may be 

actual authority (as with a parent or employer), or the words may simply be phrased in an authoritarian way. Some examples: 

Don’t say that. 

You’ve got to face up to reality. 

Go right back there and tell her you’re sorry! 

Warning or threatening. These messages are similar to directing, but they also carry an overt or covert threat of impending negative 

consequences if the advice or direction is not followed. It may be a threat that the individual will carry out, or simply a prediction of a bad 

outcome if the other doesn’t comply: 

You’d better start treating him better or you’ll lose him. 

If you don’t listen to me you’ll be sorry. 

You’re really asking for trouble when you do that. 

Giving advice, making suggestions, providing solutions. Here the individual draws on her or his own store of 

knowledge and experience to recommend a course of action. These often begin with the words: 

What I would do is… 

Why don’t you… 

Have you tried… 

Persuading with logic, arguing, lecturing. The underlying assumption in these is that the person has not adequately 

reasoned it through and needs help in doing so. Such responses may begin: 

The facts are that… 

Yes, but… 

Let’s reason this through. 

Moralizing, preaching, and telling them their duty. An underlying moral code is invoked here in “should” or “ought” 

language. The implicit communication is instruction in proper morals. Such communication might start: 

You should… 

You really ought to… 

It’s your duty as a _____ to… 

Judging, criticizing, disagreeing, blaming. The common element here is an implication that there is something wrong 

with the person or with what he or she has said. Note that a simple disagreement is included in this group. 

It’s your own fault. 

You’re being too selfish. 

You’re wrong. 

Agreeing, approving, praising. Some people are surprised to find this included with the roadblocks. This kind of message 

gives a sanction or approval to what has been said. This, too, stops the communication process and may also imply an uneven 

relationship between speaker and listener. True listening is different from approving and does not require approval. 

I think you’re absolutely right. 

That’s what I would do… 

You’re a good _____. 

Shaming, ridiculing, name-calling. Here the disapproval is more overt, and is directed at the individual in hopes of shaming 

or correcting a behavior or attitude. 

That’s really stupid. 

You should be ashamed of yourself. 

How could you do such a thing? 

Interpreting, analyzing. This is a very common and tempting one for counselors: to seek out the hidden meaning for the person 

and give your own interpretation. 

You don’t really mean that. 

Do you know what your real problem is? 

You’re just trying to make me look bad. 

Reassuring, sympathizing, consoling. The intent here is usually to help a person feel better. What’s wrong with that? 

Nothing, perhaps, but it’s not listening. It meets the criterion as a roadblock because it interferes with the spontaneous flow of 

communication. Examples: 

There, there, it’s not all that bad. 

I’m sure things are going to work out all right. 

Don’t worry; you’ll look back on this in a year and laugh. 

Questioning, probing. People also mistake asking questions for good listening. Here the intent is to probe further, and find out 

more. A hidden communication from the questioner, however, is that he or she will be able to find a solution as soon as enough 

questions have been asked. Questions interfere with the spontaneous flow of communication, diverting it in directions of interest to the 

questioner but not, perhaps, to the speaker. 

What makes you feel that way? 

How are you going to do that? 

Why? 

Withdrawing, distracting, humoring, and changing the subject. Finally, this very obvious roadblock is an attempt 

to “take the person’s mind off it.” It directly diverts communication, and underneath implies that what the person was saying is not 

important or should not be pursued. 

Let’s talk about that some other time. 

That reminds me of the time… 

You think you’ve got problems, let me tell you… 

I hear it’s going to be a nice day tomorrow. 

Look on the bright side of things….

2 

O.A.R.S. 

O- for Open-Ended Questions. Open ended questions are therapist questions that patients cannot 

answer with a yes or no. Open-Ended questions create the forward momentum important to the task 

of creating an environment that will move the patient in the direction of behavior change. 

A- for Affirmations. Affirmations provide patients with positive reinforcement for observed and selfreported 

client strengths. By focusing on prior patient success with behavior change, and by providing 

genuine positive feedback regarding these efforts, the therapist builds both rapport and helps patients 

feel that change is possible. 

R- for Reflective listening. Reflective listening is actively providing feedback to patients about your 

understanding of what they are trying to convey. However, unlike traditional client-centered 

therapists, you will actively guide the patient toward certain topics. You will focus on and provide 

positive feedback for “change talk” and provide negligible attention and feedback for “non-change” 

talk. 

S- for Summaries. Summaries are a specialized form of reflective listening. They are an effective 

way to pull together the information you hear, communicate interest, build rapport, and call attention to 

salient and motivational elements of the discussion, and shift focus and direction as necessary.

3 

G.R.A.C.E. 

G- For Gap. Often our actions do not correspond with our intentions. The Gap is the space 

between what the patient desires and how they behave. In this approach, the therapist’s role is 

to listen closely and carefully to the patient’s self-report making the implicit (thoughts, feelings, 

etc) explicit (environmental and behavioral interactions), while gently directing patient attention 

toward these gaps. 

R- For Rolling with Resistance. If it seems that the conversation is not flowing and building on 

what has been said then one might conclude that the patient is avoiding or resisting the 

therapy. We avoid meeting patient resistance head on. Rather than confront, the therapist 

gently and respectfully directs patient’s attention away from topics that are inconsistent with 

treatment goals toward a constellation of target behaviors. Remember that the target 

behaviors are determined through the therapeutic partnership of patient and clinician. 

A- For no Arguing. If we find ourselves arguing with our clients in any way it is a cue for us to shift 

tactics as quickly as possible. Any sort of argumentative posture displayed by the therapist 

effectively punishes patient verbal behavior. We know that punishment has three effects: 

1. Increases the likelihood of emotional responses 

2. Increases the likelihood that the patient will avoid the interaction that produced the 

punisher 

3. And can suppress all behavior within the therapeutic context. 

C- For Can Do. Patients have intimate knowledge of what works, what doesn’t, and what their 

preferences are. Our job is to help patients recognize they have the skills necessary to make 

successful changes. Provide positive feedback for all available skills and help shape those in 

need of further practice to be built to fluency. 

E- For Expressing Empathy. It is crucial to this method for the therapist to create a reinforcing 

environment where the patient can feel comfortable going about the difficult business of 

exploring change. This requires more than superficial listening and feedback. Reflective 

listening is an important therapeutic tool used in this model to express empathy to the patient. 

Reflective listening differs from more casual listening as it requires continuous alert tracking of the 

patient’s verbal and nonverbal responses, formulation of reflections at the appropriate level of 

complexity, and ongoing adjustment of hypothesis.

4 

Drug Use Functional Analysis 

Date:________________________ 

Patient: ______________________ 

I am going to ask you some questions about your drug use. Tell me about the drugs you use 

when you are not in the hospital. It will also be helpful if you could talk about the situations in 

which you typically use, and the people with whom you often use. 

Triggers 

Before using do you usually feel … 

Angry? _____ 

Jittery? ____ 

Nervous? ____ 

Upset? ____ 

Bored? ____ 

Sad? ____ 

Lonely? ____ 

Before using I usually feel 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

What are you thinking before you use? 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

Probes: 

I want to get out of here … . I need some fun …. I need to feel good…I need to escape 

(stress) 

Tell me more. 

What events usually set off drug use? What usually happens to trigger drug use? 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

Who do you most often use with?

5 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

Probes: 

Tell me more about [name]? What do you like about using with [name]? 

Where do you like to use? 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

Probes: 

Tell me more? Why? When? Is there anything special about this place? 

Consequences 

Now we are going to talk about the problems that may have resulted from your drug use. 

(attempt to determine 7-10 costs) (short-term, long-term) 

1. What legal problems have you experienced as a result of drug use? 

_____________________________________________________________________ 

_____________________________________________________________________ 

2. What family difficulties have you experienced as a result of drug use? 

_____________________________________________________________________ 

_____________________________________________________________________ 

3. What health/medical difficulties have you experienced as a result of drug use? 

____________________________________________________________________________ 

____________________________________________________________________________ 

4. What work/employment difficulties have you experienced as a result of drug 

use?________________________________________________________________________ 

____________________________________________________________________________ 

5. What living situation difficulties have you experienced as a result of drug use? 

____________________________________________________________________________ 

____________________________________________________________________________ 

6. What financial difficulties have you experienced as a result of drug use? 

______________________________________________________________________ 

______________________________________________________________________ 

7. What other problems have you experienced as a result of drug use? 

____________________________________________________________________________ 

____________________________________________________________________________

6 

Alternatives 

What are some non-drug using activities you enjoy? 

Sports: ___________________________________________________________ 

Entertainment: _____________________________________________________ 

Games: __________________________________________________________ 

Exercise: _________________________________________________________ 

Work: ____________________________________________________________ 

School: __________________________________________________________ 

Family: __________________________________________________________ 

Which of these (activities) are you likely to do? 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

Who encourages these activities? Are (names) likely to participate in these activities with you? 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

How does (name) encourage you? 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

What gets better when you participate in these activities? (short-term, long-term) 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

What factors make it difficult for you to participate in these activities? 

1. Transportation: __________________________________________________ 

2. Money: ________________________________________________________ 

3. Childcare: ______________________________________________________ 

4. Companionship: _________________________________________________ 

5. Other impediments: _____________________________________________ 

Let’s pull together what you’ve already said:

7 

Overall, what do you gain by drug use? How does it help you? 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

Overall, in what ways do you lose out by drug use? How does it hurt you? How does drug use 

harm you? 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

Overall, what triggers your drug use? 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

Change 

Overall, what alternatives to drug use do you enjoy? 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

What can you do to change your substance use? What has worked for you in controlling drug 

use? 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

Probes: 

Tell me more? In what way/s? 

Collaboration 

What can we do to help? 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

Probes: 

Tell me more? In what way/s

8 

Treatment Attendance Functional Analysis 

form 4 

Date: ______________________ 

Patient: ______________________ 

Directions to Therapist: Try to keep the interview in a non-judgmental, conversational format. Use the 

probes to keep the flow of the conversation steady and on track. If at any time, the patient becomes 

uncomfortable checkout your impression by asking: 

“It seems you're uncomfortable, distressed. What is it about these questions that are hard for 

you?” 

We asked what you wanted to get out of treatment before. In summary, what are three things you want to 

get out of outpatient treatment? 

Probes: Tell me more 

In what ways? 

What would you like from your outpatient therapist? 

Probes: 

Good listeners? A way to get in touch when things go wrong? On time? They will help me meet my 

goals? 

Which of the following would make it easier for you to get to your outpatient appointments? 

1. Transportation: __________________________________________________________ 

2. Childcare: ______________________________________________________________ 

3. Money: ________________________________________________________________ 

4. Information: _____________________________________________________________ 

5. Other: _________________________________________________________________ 

Who would encourage your efforts to get treatment? How for each person? 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Who would help you get to outpatient treatment? 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

What could you do to make sure you get to your outpatient appointments? 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Would any of the following be helpful: 

1. Phone reminder of upcoming appointments?

9 

2. What time of day would be best for your appointments? 

3. Do you need childcare/elder care during your appointment? 

4. Would you like a copy of the bus schedule near you? 

5. Do you need help with paying bus fare to treatment? 

6. Would you like a mentor or someone who has been through similar experiences? 

What usually happens when you don’t go to treatment? 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Summary 

Let’s pull together what you’ve already said: 

Overall, in what ways will attending outpatient treatment help you? 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Overall, in what ways will not attending outpatient treatment hurt you? 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

What do you want from outpatient treatment in the long run? 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Change 

What could you do to increase your ability to attend treatment on a regular basis? 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Collaboration/Assistance 

What can we do to help you achieve your goal of attending treatment on a regular basis? 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________

10 

“What If” Exercises 

Date: _____________________ 

Patient: ____________________ 

Good things: 

1. What good things would happen if I stopped using drugs? 

2. What good things would happen if I stopped using alcohol? 

3. What good things would happen if I went to my outpatient treatment? 

4. What good things would happen if I found a job? 

5. What good things would happen if I had help with my legal difficulties? 

6. What good things would happen if I got along better with family and friends? 

7. What good things would happen if I got the health care I need? 

8. What good things would happen if I got job training or school? 

9. What good thing would happen if I took my medication?

11 

10. What good things would happen if I found a place to stay? 

Bad things 

1. What bad things would happen if I stopped using drugs? 

2. What bad things would happen if I stopped using alcohol? 

3. What bad things would happen if I went to my outpatient treatment? 

4. What bad things would happen if I found a job? 

5. What bad things would happen if I had help with my legal difficulties? 

6. What bad things would happen if I got along better with family and friends? 

7. What bad things would happen if I got the health care I need? 

8. What bad things would happen if I got job training or school? 

9. What bad things would happen if I took my medication? 

10. What bad things would happen if I found a place to stay?

12 

“What If”’ cont. 

THINGS I CAN DO 

1. Let’s list things you could do to stop using drugs. 

2. Now, let’s draw a line through the ideas that you don’t think you would ever try. 

1. Read each idea that you have not crossed off the list, and pick one idea that sounds like 

something you would like to try. What is the one idea? 

_________________________________________________________________________ 

_________________________________________________________________________ 

4. How well do you think this idea would work? In other words, what are the good things and 

bad things that could happen if you tried this idea to solve your problems? 

Good things:________________________________________________________________ 

__________________________________________________________________________ 

__________________________________________________________________________ 

Bad things:___________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________

13 

Decisional Balance for Drug Use 

Date: _____________________ 

Patient: ____________________ 

Cost = What difficulties does this behavior cause you? 

What does engaging in this/these behavior(s) cost you? 

Benefit = How does this behavior make your life better? 

In what way(s) does this behavior cause happiness? 

1. 

Behavior Costs Benefits 

To self- 

To self- 

To others- 

To others- 

2. 

To self- 

To self- 

To others- 

To others-

14 

Decision Making Summary 

Date: _____________________ 

Patient: ____________________ 

My treatment goals are: 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

When I am feeling (trigger): 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

1. I am going to stop and think of as many solutions as I can. 

2. I am going to think about their consequences. 

3. Solutions I might try: 

a. ____________________________________________________ 

b. ____________________________________________________ 

c. ____________________________________________________ 

If I try it, what can happen next? 

My best solution is: ___________________________________________________________ 

And my plan for solving the problem is that I will: 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Next time I might: 

___________________________________________________________________________________

15 

____________________________________________________________________________________ 

___________________________________________________________________________________

16 

Therapist Data Summary Sheet 

Date:________________________ 

Patient: ______________________ 

Summary of Session 1 

Drug of Choice: 

Drugs most frequently used: 

1. _______________________________ 

2. _______________________________ 

People you use with: 

1. ________________________________________ 

2. ________________________________________ 

3. ________________________________________ 

Psychosocial Problems: 

1. Employment: ___________________________________________________ 

2. Family Relationships:__________________________________________________ 

3. Relationships with peers:______________________________________________ 

4. Living arrangements:___________________________________________________ 

5. Medical problems:_____________________________________________________ 

6. Legal difficulties ___________________________________________________ 

Summary statement of difficulties (use wording from GAG/CGI) 

Summary of Session 2

17 

Drug use: Antecedents, Consequences and Alternatives 

Triggers for drug use: 

Feelings: 

Persons: 

1. _____________________ 1. _______________________ 

2. _____________________ 2. _______________________ 

Thoughts: 

Places: 

1. _____________________ 1. _______________________ 

2. _____________________ 2. _______________________ 

Events: 

1. _____________________ 

2. _____________________ 

Consequences of drug use: 

Benefits 

Feelings: 

Thoughts: 

1. ______________________ 1. _______________________ 

2. ______________________ 2. _______________________ 

Events: 

Relationships: 

1. ______________________ 1. _______________________ 

2. ______________________ 2. _______________________ 

Employment: 

Legal: 

1. ______________________ 1. ________________________ 

2. ______________________ 2. ________________________ 

Medical: 

1. ______________________ 

2. ______________________ 

Costs 

Feelings: 

Thoughts: 

1. ______________________ 1. ________________________ 

2. ______________________ 2. ________________________ 

Events: 

Relationships: 

1. ______________________ 1. _______________________ 

2. ______________________ 2. _______________________ 

Employment: 

Legal: 

1. _______________________ 1. _______________________ 

2. _______________________ 2. _______________________ 

Medical: 

1. _______________________ 

2. _______________________

18 

Alternatives to drug use: 

Things I can do instead of using drugs: 

1. _____________________________________ 

2. _____________________________________ 

3. _____________________________________ 

Support for alternatives: 

Persons: 

1. _____________________________________ 

2. _____________________________________ 

Impediments to alternatives: 

□ Financial □ Childcare □ Transportation □ Other _______________ 

Consequences of alternatives: 

1. _________________________________ 

2. _________________________________ 

3. _________________________________ 

Treatment Attendance 

Since your last hospitalization you have attended treatment at least: 

□ Once per week □ Once per month □ At least once □ Never 

You want help achieving the following goals: 

1. _____________________________________________ 

2. _____________________________________________ 

3.______________________________________________ 

You want an outpatient therapist who: 

1. ______________________________________________ 

2. ______________________________________________ 

3. ______________________________________________ 

People who can help you get to outpatient treatment: 

1. _______________________________________________ 

2. _______________________________________________ 

Impediments to attending outpatient treatment: 

□ Financial □ Childcare □ Transportation □ Other _______________ 

Things I can do to get to treatment: 

1. _________________________________________________ 

2. _________________________________________________

Certificate of Achievement 

Temple University 

Episcopal Hospital 

Ricky 

In recognition of successful completion of Therapy 

Amy Wells, MA 

February 2006 

Ralph Spiga, Ph D 

February 2006 

Temple University

M05: Challenges and Opportunities for Promoting Integrated Treatment and Support Services 

for Co-Occurring Disorder Members in Managed Behavioral Healthcare 

James E. Bechtel, PhD, CCDP-D, & J. Andrew Burkins, MD 

1.5 hours Focus: Systems Integration 

Description: 

Clinical care management and coordination within Pennsylvania’s HealthChoices Managed Behavioral 

Healthcare network provide a unique opportunity to promote and ensure integrated and evidence-based 

recovery and support options for Co-Occurring Disorder (COD) members. Magellan’s clinical care management 

protocol will be detailed with review of all phases of member program service engagement and 

Magellan/County COD programs described. Collaboration with County-based mobile and residential services, 

forensic-based services and with physical health providers and special needs units is reviewed. 


• Describe the unique role of Magellan/HealthChoices clinical care management in addressing treatment 

requirements of Co-Occurring Disorder members; 

• Identify the evaluation and monitoring protocols that are used by Magellan/HealthChoices clinical care 

management staff to ensure integrated treatment for each COD member; 

• Review various recovery and support alternatives recommended and coordinated by 

Magellan/HealthChoices clinical care management to promote and ensure continuity of care for COD 

members. 

NOTES:



2006 

Promoting Integrated Treatment 

and Support Services in Managed 

Behavioral Healthcare 


• James E. Bechtel, PhD, CCDP-D 

• J. Andrew Burkins, MD 

• Magellan Behavioral Health – Health 

Choices 


MISSION: 

• To ensure evidenced based and 

innovative solutions are delivered to our 

members, and to collaborate with our 

providers to positively influence the 

individuals’ total health and well-being in 

support of their recovery process 


PHILOSOPHY 

• Anyone who needs treatment will receive 

treatment at the appropriate level of care 

according to the guidelines of medical necessity 

established by the state in the Health Choices 

criteria 

• Under Health Choices all levels of care are 

available, unlike most commercial health plans 


• MBH currently coordinates Mental Health 

& Drug and Alcohol services for 5 counties 

– Bucks (34,423 covered lives) 

– Delaware (61,552 covered lives) 

– Lehigh (42,883 covered lives) 

– Montgomery (39,367 covered lives) 

– Northampton (26,136 covered lives) 


• On a typical day – such as 4/4/06 – there 

were a total of 335 members covered in 

“residential” COD and /or D&A treatment 

facilities from those 5 counties 

1



• We consider RECOVERY as the priority with the 

following perspectives: 

– RECOVERY is a long-term process of internal 

change and it is recognized that internal change 

proceeds through various stages (TIP 42) 

– RECOVERY is the process through which severe 

alcohol and other drug problems are resolved in 

tandem with the development of physical, emotional, 

ontological (spiritual, life-meaning), relational and 

occupational health (White W & Kurtz E 2005) 


– RECOVERY is a self determined and holistic 

journey that people undertake to heal and 

grow. RECOVERY is facilitated by 

relationships and environments that provide 

hope, empowerment, choices and 

opportunities that promote people reaching 

their full potential as individuals and 

community members (OMHSAS 2005) 


• High rate of psychiatric co-morbidity in alcohol 

dependence 

– 78% of male alcoholics have a coexisting lifetime 

history of psychiatric disorder 

– 86% of female alcoholics have a coexisting lifetime 

history of psychiatric disorder (ASAM 2006) 

– Individuals with psychiatric illness and addiction 

compose at least half of the patients in most mental 

health treatment systems (Ziedonis, D. M. 2004) 


• At point of initial treatment encounter 

– Individuals with a psychiatric disorder 

• 22% have co-occurring alcohol disorder 

• 15% have a co-occurring drug disorder 

– Individuals with an alcohol disorder 

• 37% have a co-occurring psychiatric disorder 

– Individuals with a drug disorder 

• 53% have a co-occurring psychiatric disorder 


• Clinical Care Managers “talk-up” available 

COD resources with program and county 

staff—which may include 

– Behavioral Health Recovery Management 

Project www.bhrm.org 

– Co-Occurring Center for Excellence (COCE -- 

www.coce.samhsa.gov 

– Northeast Addiction Technology Transfer 

Center www.neattc.org 


– www.PA-Co-Occurring.org (IRETA/NeATTC 

website) 

– TIP 42 – Substance Abuse Treatment for 

Persons with Co-Occurring Disorders 

– TIP 43 – Medication Assisted Treatment for 

Opioid Addiction in Opioid Treatment 

Programs 

2



• Clinical Care Managers also discuss, and 

promote, with agency and program staff 

the Certified Co-Occurring Disorders 

Professional (CCDP) Certificate 

(www.pacertboard.org) and the recent Co- 

Occurring Disorder Competency Program 

approval criteria and guidelines (DPW 

Bulletin-2/10/06) 


• Mental Health RECOVERY Principles 

– Based on the needs of the individual 

– Empower individuals by encouraging them to 

have control over their lives 

• Set their own goals 

• Decide what services they will receive 

• Help to plan and implement the delivery of service 

– Allow individuals to move in and out of the 

system as needed 


• Mental Health RECOVERY Principles (cont) 

– Strengths based to help individuals maintain 

their sense of identity, self esteem and dignity 

– Meet the special needs of individuals with 

mental illness who are also affected by old 

age, substance abuse/addiction, physical 

disability, mental retardation, homelessness, 

and/or involvement in the criminal justice 

system 


• Mental Health RECOVERY Principles (cont) 

– Be coordinated through linkages with affected 

individuals and support/families at the local 

and state level 


• Alcoholism and Other Drug Dependency 

(AODD) RECOVERY Principles 

– Recognize AODD as primary diseases 

– AODD are responsive to treatment and are 

complex behavioral disabilities having chronic 

medical, social and psychological 

components 

– RECOVERY process is lifelong 

– Denial is a central characteristic of AODD 



(AODD) RECOVERY Principles (cont) 

– There is NO single “one size fits all” recovery 

approach that is effective for all individuals 

– RECOVERY is individual specific and guided 

by an individualized recovery plan based on a 

face to face comprehensive biopsychosocial 

assessment of the individual and, if possible, 

the individual’s support systems 

3





– Direction of recovery is based on individual 

assessment criteria, the individual’s response to 

treatment and the individual’s history of previous 

treatments and responses to recovery principles 

– RECOVERY is a continuum comprised of specialized 

service components that may include any, or all, of 

the following 

• Detoxification 

• Residential treatment and rehabilitation 

• Partial hospitalization/intensive outpatient programs 

• Outpatient therapy, counseling, psychiatric treatment 




– Individual assignment to particular levels and 

types of recovery programs are based on 

specified standards and criteria utilized by 

appropriately trained or credentialed 

professionals 

– Self help groups (AA, NA, Double Trouble) 

are essential adjuncts to the recovery process 


• Clinical staff are acutely aware of the 

ramifications of alcohol/drug dependence 

– There exists significant thinking that 

substance dependence results in “systematic 

deconstruction” of the personality 

– This is characterized by a loss of interest in 

life, feelings of guilt and self resentment and 

anger towards self and others (Latcouich, 

M.A. 2003) 


• CLINICAL CARE MANAGERS 

– In the HealthChoices program Clinical Care 

Managers assume a critical role in coordinating 

services for COD members beyond merely 

“approving” services (we are not just “The Insurance 

Company”) 

– Licensed Clinical Care Managers along with medical 

and supervisory staff frequently collaborate with 

agency & program staff to identify and/or establish a 

“best-fit” treatment protocol for the member 


– Intake Clinical Care Managers receive service 

requests from either the member directly or 

form individuals at assorted sites including 

ERs, Crisis Centers, Medical Facilities or 

Forensic Staff 

– Whatever the source for the request, the 

Clinical Care Manage considers the case with 

a comprehensive perspective rather than 

through a strict Mental Health or Drug and 

Alcohol “lens” 


– This comprehensive perspective focuses on 

Integrated Treatment with the member 

entering the “right door” for treatment 

initiation. 

– Results of the Pennsylvania Client Placement 

Criteria (PCPC) or the ASAM (PPC-2R) for 

adolescents, as well as the current mental 

status, drives the process for actual program 

selection and assignment 

• All background and clinical information is reviewed 

and included in the treatment assignment process 

4



– Clinical Care Managers possess a detailed 

knowledge of services within and beyond the 

provider network to address COD member’s 

recovery needs 

– The Clinical Care Managers possess 

extensive information regarding each 

outpatient and residential (including hospital 

level/medically managed) program and 

coordinates with the member, the referral 

contact and the program to optimize treatment 

engagement. 


– For a comprehensive and individualized approach the 

clinical care manager is in a pivotal role to coordinate 

services beyond residential care - with most of the 

available services established in joint MBH-County 

projects. 

– From the Managed Behavioral HealthCare 

perspective, we consider co-occurring disorders (and 

addiction) to be chronic illnesses (White, W.L. 2005). 

For too long we have over emphasized the early 

stages of intervention with neglect of the long term 

course of the syndrome. 


• Case Review Process 

– In the case review process there is focus on 

early and ongoing assessment for cooccurring 

disorders and discussion with 

program staff about determining “Quadrants 

of Care” (TIP 42) 

– In May 2006 nearly all members identified in 

Quadrants II and IV can be involved in 

integrated intervention within a residential 

D&A facility and have a meaningful treatment 

episode 


– In the case review process there is discussion 

with program contacts regarding consensus 

and evidence-based intervention strategies in 

addressing PCPC dimensions 3, 4, 5, and 6 

– Throughout the residential treatment episode 

there is a pronounced focus in the review 

process on “Readiness for Change” and on 

Relapse Prevention Therapy (McGovern, 

M.P. et al 2005) 


– The MBH/HealthChoices approach (or 

paradigm) emphasizes critical 

discharge/transition planning to ensure 

continuity of care 

– The Clinical Care Manager may be the most 

knowledgeable person about the individual in 

treatment and may be the one “most involved” 

in collaborating on the case during the 

transition planning phase 


– MBH/HealthChoices continues to coordinate a 

continuum of support services within each county for 

COD members to further promote successful 

community re-integration (“success” often rests on 

availability of community support) 

– MBH/HealthChoices coordinates a High Risk member 

group in each county (Intensive Support 

Network/IMPACT Programs) with specialized 

monitoring and follow-up protocols 

• Members with COD syndromes comprise 48-60% of these 

groups 

5



• Intervention and support services for COD 

members coordinated with county offices 

– Mobile Engagement Services (MES) 

– PACT - Team MAST - Team 

– CTT - Services Project Reach 

– Bridge - Transition Team COD - CRRs 

– Supervised Recovery House (Village of Hope) 

– Women’s Recovery Center (& Recovery House) 

– D&A Intensive Case Management 

– MICA - Intensive Case Management 

– Program for Integrated Recovery (PIR-IOP) 


• QUESTIONS? 

6

M06: An Overview: Co-Occurring Disorders Professional Certification & Preparing for the CCDP 

Written Exam 

Mary Jo Mather, PCB Executive Director 


Description: 

This workshop provides an overview of the certification for the Certified Co-Occurring Disorders Professional, 

including employment, supervision, education and documentation of all requirements. The written 

examination structure is reviewed along with helpful hints for exam preparation and useful handouts. A brief 

history of the Pennsylvania Certification Board itself, its mission, purpose and functioning, is also provided. 


• Define the mission and functions of the PA Certification Board; 

• List requirements for the Certified Co-Occurring Disorders Professional certification; 

• Describe the written examination and means of preparing, including available supports. 

NOTES:

Important Information 

1. This credential is known as the Certified Co-Occurring Disorders Professional (CCDP). The master’s level CCDP is 

known as the Certified Co-Occurring Disorders Professional Diplomate (CCDP Diplomate). 

2. An official college transcript is required and should be sent directly from the college or university to the PCB Office. 

3. If there are problems with your application, you will be notified in writing. 

4. This application may be photocopied. 

5. When application is approved, applicant will be notified of the written exam dates and locations. 

6. Application fee is non-refundable. 

7. Use the Checklist in this application to ensure all required materials are included prior to mailing application to the 

PCB Office. 

8. Questions regarding this application and the CCDP process should be directed to the PCB Office at (717) 540-4455 or 

email your question to info@pacertboard.org. 

If you have a credential with PCB of any kind, see Easy Pass information for 

quick, easy application instructions! 

1

Requirements for CCDP 

Employment 

CCDP: 

• Three years (6000 hours) of documented work experience must have been obtained over the past 7 years. 

• One year (2000 hours) of documented work experience must be providing integrated services to clients with cooccurring 

disorders. 

• Supervised work experience is defined as paid professional experience in the delivery of counseling services to 

individuals, families, or groups with mental illness, substance abuse disorders, or co-occurring disorders or delivery of 

supervision to those providing said counseling services. 

CCDP Diplomate: 

• Same as above. Applicants with a relevant college internship/practicum or a relevant state issued license and 

specialized credential need only document 2 years (4000 hours) of said employment. 

Supervision 

• 300 hours of on-the-job supervision received in the CCDP performance domains. A minimum of 10 hours of 

supervision must be received in each domain. 

• Supervision is broadly defined as the administrative, clinical, and evaluative process of monitoring, assessing, and 

enhancing one’s performance. 

Education 

CCDP: 

• A minimum of a bachelor’s degree from an accredited college or university that is recognized by the US Department of 

Education or the Council on Higher Education Accreditation or a CAC, CAC II, CAC Diplomate, CCS, CPS, CCJP, 

CCSM, CCRM, or CCMS plus 110 hours of relevant education including 6 in ethics, 6 in cultural competency, and 6 in 

communicable diseases, i.e. hepatitis, HIV/AIDS, TB, STDs. 

• Within the 110 hours of education, 35 must be integrated and specifically related to the knowledge and skills necessary 

to perform the tasks within the Co-Occurring Disorders Professional performance domains. These domains are: 

screening and assessment, crisis management, treatment planning, counseling, case management, person, family & 

community education, and professional responsibility. 

• Applicants with a relevant college internship/practicum or a relevant state issued license and specialized credential are 

exempt from all of the 110 hours of education. 

• Three college credits are equivalent to 45 clock hours. 

• Education is defined as formal, structured instruction in the form of workshops, seminars, institutes, in-services, 

college/university credit courses and PCB approved distance education. Education must be specifically related to the 

knowledge and skills necessary to perform the tasks within the CCDP performance domains. 

• Education, as defined above, that applicant provides to others may also be used, with letter of verification from 

sponsoring provider. 

CCDP Diplomate: 

• A minimum of a master’s degree from an accredited college or university that is recognized by the US Department of 

Education or the Council on Higher Education Accreditation plus 110 hours of relevant education including 6 in ethics, 

6 in cultural competency, and 6 in communicable diseases. 

• Within the 110 hours of education, 35 must be integrated and specifically related to the knowledge and skills necessary 

to perform the tasks within the Co-Occurring Disorders Professional performance domains. These domains are: 

screening and assessment, crisis management, treatment planning, counseling, case management, person, family & 

community education, professional responsibility, clinical supervision, research design & application. 

• Applicants with a relevant college internship/practicum or a relevant state issued license and specialized credential are 

exempt from all of the 110 hours of education. 

2

• Three college credits are equivalent to 45 clock hours. 

• Education is defined as formal, structured instruction in the form of workshops, seminars, institutes, in-services, 

college/university credit courses and PCB approved distance education. Education must be specifically related to the 

knowledge and skills necessary to perform the tasks within the CCDP performance domains. 

• Education, as defined above, that applicant provides to others may also be used, with letter of verification from 

sponsoring provider. 

Examination 

A written examination is required. 

Other 

• Signed Code of Ethical Conduct 

• Signed, dated and notarized Release 

• Official college transcript 

• Documentation of all other education (certificates of attendance) 

• Copy of license and specialized credential, if applicable 

Out of State Applicants 

Applicants living and/or working in other states are welcome to apply for the CCDP. Applicant must either have a bachelor’s 

degree for the CCDP, or a master’s degree for the CCDP Diplomate, or a reciprocal IC&RC credential, which must first be 

reciprocated into PA. 

Fees 

Fee $200.00 CCDP Recertification Fee $150.00 

(fee must accompany application and materials) 

(due every 2 years) 

CCDP Diplomate Recertification Fee $200.00 

(due every 2 years) 

Retest Fee $100.00 

Exam Cancellation Fee $100.00 

Certification Time Period 

PCB certification encompasses 2 calendar years commencing on the date of successful completion of the written examination. 

Two dates, date of issue and valid through, will appear on the certificate along with a certification number. 

Appeal Process 

The purpose of appeal is to determine if PCB accurately, adequately and fairly reviewed applicant's file. A letter requesting an 

appeal must be made to PCB in writing within 30 days of the notification of the board's action. A person shall be considered 

notified 3 days after the relevant date of mailing. The written appeal will be sent to the Executive Committee who in turn will 

thoroughly review the entire application and materials to determine whether or not applicant should have been denied approval. 

Applicant will be notified in writing as to the findings of the Executive Committee. 

Recertification 

To maintain the high standards of this professional practice and to assure continuing awareness of new knowledge in the field, 

PCB requires recertification every 2 years. 

To be recertified as a CCDP, an individual must: 

1. Hold a current and valid certificate issued by PCB; 

2. Submit 50 PCB approved hours of education including 3 in professional ethics and responsibilities received within the 2 year 

recertification cycle (PCB approved education listed on pacertboard.org); 

3. Endorse by signature and uphold by practice the PCB Code of Ethical Conduct for professional behavior; 

4. Complete an application, notarized and signed by applicant and pay recertification fee. 

To be recertified as a CCDP Diplomate, an individual must: 

1. Hold a current and valid certificate issued by PCB; 

2. Submit 40 PCB approved hours of education including 3 in professional ethics and responsibilities received within the 2 year 

3

ecertification cycle (PCB approved education listed on pacertboard.org); 

3. Endorse by signature and uphold by practice the PCB Code of Ethical Conduct for professional behavior; 

4. Complete an application, notarized and signed by applicant and pay recertification fee. 

Lapsed Certification 

The completed recertification application should be received at PCB prior to the expiration date. If the application is incomplete, 

applicant will be notified by mail. 

There is no grace period, so if the recertification is not completed by the expiration date, the individual will no longer hold an a 

active credential and no further use of the credential is permitted until the individual has recertified. 

The individual may regain their credential by submitting a completed recertification application, the recertification fee, plus a $10 

per month late fee for each month past the expiration date. This process is effective for 23 months from the date of expiration. 

After 23 months, the individual must complete all phases of the initial certification process to regain the credential. 

Retest of Examination 

In the case of an unsuccessful written examination, applicant may: 

Retest - Applicants failing the written exam may retest. Send a written request for retest to PCB within 30 days of receipt of 

notification that he/she did not successfully complete the exam. PCB will notify applicant of the next exam date. Applicant must 

notify PCB in writing of his/her intent to be seated for that exam or desire to be rescheduled. Applicant will be required to pay a 

retest fee of $100 prior to being rescheduled for exam. Applicant must take the exam within 1 year or 4 exam dates to keep 

application active. 

4

Application for CCDP 

LIST OTHER PCB CREDENTIALS YOU HOLD: _____________________________(see Easy Pass for easy, quick 

application instructions) 

APPLICATION FOR CCDP ________ OR CCDP DIPLOMATE __________ 

NAME: ________________________________________________________________________________________________ 

HOME ADDRESS: _______________________________________________________________________________________ 

________________________________________________________________________________________________________ 

(city) (state) (zip) (email) 

COUNTY: ____________________________________________ GENDER: (Please circle) MALE FEMALE 

HOME PHONE: ( )_______________________________ SOCIAL SECURITY # ___________________________ 

EMPLOYER: _________________________________________ 

DATE OF BIRTH: _______________________________ 

EMPLOYER ADDRESS: ______________________________________________________ ZIP CODE:_________________ 

COUNTY: ________________________________________ EMPLOYER PHONE: ( )_________________________ 

EMAIL: __________________________________________ 

HIGHEST DEGREE EARNED:_________________________ NAME OF COLLEGE/UNIVERSITY:______________ 

NAME ON YOUR TRANSCRIPT, if different than listed above (i.e. maiden name) ____________________________________ 

DATE YOU REQUESTED TRANSCRIPT SENT TO PCB: __________________________ (include copy of request) 

If the following is applicable, please complete this part and include a verification letter from agency where internship/practicum 

was performed and copies of license(s) and specialized credential(s). 

AGENCY WHERE INTERNSHIP/PRACTICUM WAS PERFORMED: ____________________________________________ 

LIST RELEVANT STATE ISSUED LICENSE(S): _____________________________________________________________ 

LIST SPECIALIZED CREDENTIALS: ______________________________________________________________________ 

Fee of $200 can be paid using one of the following: 

Check or Money Order to PCB 

( ) Check $__________ Credit Card ___________ - __________ - ___________ - ___________ 

( ) Money Order $__________ 3-Digit Security Code ______ Expiration Date: _____ /_____ 

( ) Visa/Mastercard $__________ Signature___________________________________________________ 

5

Work Experience Verification 

Applicant’s Name_________________________________________________ Title____________________________________ 

Supervisor’s Name________________________________________________ Title___________________________________ 

Employer________________________________________________________________________________________________ 

Supervisor’s Telephone # ( 

)_____________________________________ 

Applicant’s dates of employment in counseling From:_____/_____/_____ To:_____/_____/_____ 

Month Day Year Month Day Year 

Applicant’s dates of employment providing integrated From:_____/_____/_____ To:_____/_____/_____ 

services to clients with co-occurring disorders Month Day Year Month Day Year 

Number of hours worked weekly: ____________ 

Please give a detailed description of the applicant’s job duties in counseling and integrated services to clients with co-occurring 

disorders during the above dates of employment. 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

_____________________________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Signature of Supervisor___________________________________________________ 

Date________________________ 

NOTE: If more than one employer must document current and relevant previous employment, photocopy this page for 

each employer. 

6

Supervision 

To Supervisor: Please complete this form indicating applicant's on-the-job supervision in performing CCDP functions. This form 

is not intended to document applicant's total number of hours worked but rather the hours of on-the-job supervision you have 

provided the applicant. 

Applicant's Name ________________________________________________________________________________________ 

I hereby attest that a minimum of 300 hours of supervision have been attained by the above-named applicant. At least 10 hours 

in each of the CCDP performance domains have been provided to the applicant. 

CCDP PERFORMANCE DOMAINS 

# HOURS RECEIVED IN EACH 

1. Screening & Assessment _________________ 

2. Crisis Management _________________ 

3. Treatment Planning _________________ 

4. Counseling _________________ 

5. Case Management _________________ 

6. Person, Family, & Community Education _________________ 

7. Professional Responsibility _________________ 

Please also include the following for CCDP Diplomate applicant: 

8. Clinical Supervision _________________ 

9. Research Design & Application _________________ 

TOTAL MUST BE AT LEAST 300 HOURS 

_________________ 

____________________________________________ 

Supervisor's Signature 

____________________________________________ 

Date 

7

Code of Ethical Conduct 

UNLAWFUL CONDUCT 

Rule 1.1 Once certified, a certified professional shall not be convicted for any misdemeanor or felony relating to the individual’s 

ability to provide substance abuse and other behavioral health services as determined by PCB. 

Rule 1.2 A certified professional shall not be convicted of any crime that involves the use of any controlled or psychoactive substance. 

SEXUAL MISCONDUCT 

Rule 2.1 A certified professional shall, under no circumstances, engage in sexual activities or sexual contact with clients, whether such 

contact is consensual or forced. 

Rule 2.2 A certified professional shall not engage in sexual activities or sexual contact with clients’ relatives or other individuals with 

whom clients maintain a close personal relationship when there is a risk of exploitation or potential harm to the client. 

Rule 2.3 A certified professional shall not engage in sexual activities or sexual contact with former clients because of the potential 

harm to the client. 

Rule 2.4 A certified professional shall not provide clinical services to individuals with whom they have had a prior sexual 

relationship. 

FRAUD-RELATED CONDUCT 

Rule 3.1 A certified professional shall not: 

1. present or cause to be presented a false or fraudulent claim, or any proof in support of such 

claim, to be paid under any contract or certificate of insurance; 

2. prepare, make, or subscribe to a false or fraudulent account, certificate, affidavit, proof of loss, or 

other document or writing, with knowledge that the same may be presented or used in support 

of a claim for payment under a policy of insurance; or 

3. present or cause to be presented a false or fraudulent claim or benefit application, or any false or 

fraudulent proof in support of such a claim or benefit application, or false or fraudulent 

information, which would affect a future claim or benefit application, or be paid under any 

employee benefit program; 

4. seek to have an employee commit fraud or assist in an act of commission or omission to aid 

fraud related behavior. 

Rule 3.2 An individual shall not use misrepresentation in the procurement of certification or recertification, or assist another in the 

preparation or procurement of certification or recertification through misrepresentation. The term "misrepresentation" 

includes but is not limited to the misrepresentation of professional qualifications, education, certification, accreditation, 

affiliations, employment experience, the plagiarism of application and recertification materials, or the falsification of 

references. 

Rule 3.3 An individual shall not use a title designation, credential or license, firm name, letterhead, publication, term, title, or 

document which states or implies an ability, relationship, or qualification that does not exist and to which they are not 

entitled. 

Rule 3.4 A certified professional shall not provide service under a false name or a name other than the name under which his or her 

certification or license is held. 

Rule 3.5 A certified professional shall not sign or issue, in their professional capacity, a document or a statement that the professional 

knows or should have known to contain a false or misleading statement. 

Rule 3.6 A certified professional shall not produce, publish, create, or partake in the creation of any false, fraudulent, deceptive, or 

misleading advertisement. 

Rule 3.7 A certified professional who participates in the writing, editing, or publication of professional papers, videos/films, 

pamphlets or books must act to preserve the integrity of the profession by acknowledging and documenting any materials 

8

and/or techniques or people (i.e. co-authors, researchers, etc.) used in creating their opinions/papers, books, etc. 

Additionally, any work that is photocopied prior to receipt of approval by the author is discouraged. Whenever and 

wherever possible, the certified professional should seek permission from the author/creator of such materials. The use 

of copyrighted materials without first receiving author approval is against the law and, therefore, in violation of the Code of 

Ethical Conduct. 

EXPLOITATION OF CLIENTS 

Rule 4.1 A certified professional shall not develop, implement, or maintain exploitative relationships with clients and/or family 

members of clients. 

Rule 4.2 A certified professional shall not misappropriate property from clients and/or family members of clients. 

Rule 4.3 A certified professional shall not enter into a relationship with a client which involves financial gain to the certified 

professional or a third party resulting from the promotion or the sale of services unrelated to the provision of services or of 

goods, property, or any psychoactive substance. 

Rule 4.4 A certified professional shall not promote to a client for their personal gain any treatment, procedure, product, or service. 

Rule 4.5 A certified professional shall not ask for nor accept gifts or favors from clients and/or family members of client. 

Rule 4.6 A certified professional shall not offer, give, or receive commissions, rebates, or any other forms of remuneration for a client 

referral. 

Rule 4.7 A certified professional shall not accept fees or gratuities for professional work from a person who is entitled to such services 

through an institution and/or agency by which the certified professional is employed. 

PROFESSIONAL STANDARDS 

Rule 5.1 A certified professional shall not in any way participate in discrimination on the basis of race, color, sex, sexual orientation, 

age, religion, national origin, socio-economic status, political belief, psychiatric or psychological impairment, or physical 

disability. 

Rule 5.2 A certified professional who fails to seek therapy for any psychoactive substance abuse or dependence, psychiatric or 

psychological impairment, emotional distress, or for any other physical health related adversity that interferes with their 

professional functioning shall be in violation of this rule. Where any such conditions exist and impede their ability to 

function competently, a certified professional must request inactive status of their PCB credential for medical reasons for as 

long as necessary. 

Rule 5.3 A certified professional shall meet and comply with all terms, conditions, or limitations of a certification or license. 

Rule 5.4 A certified professional shall not engage in conduct that does not meet the generally accepted standards of practice. 

Rule 5.5 A certified professional shall not perform services outside of their area of training, expertise, competence, or scope of 

practice. 

Rule 5.6 A certified professional shall not reveal confidential information obtained as the result of a professional relationship, without 

the prior written consent from the recipient of services, except as authorized or required by law. 

Rule 5.7 The certified professional shall not permit publication of photographs, disclosure of client names or records, or the nature of 

services being provided without securing all requisite releases from the client, or parents or legal guardians of the clients. 

Rule 5.8 The certified professional shall not discontinue professional services to a client nor shall they abandon the client without 

facilitating an appropriate closure of professional services for the client. 

Rule 5.9 A certified professional shall not fail to obtain an appropriate consultation or make an appropriate referral when the 

client's problem is beyond their area of training, expertise, competence, or scope of service. 

SAFETY & WELFARE 

Rule 6.1 A certified professional shall not administer to himself or herself any psychoactive substance to the extent or in such manner 

as to be dangerous or injurious to a recipient of services, to any other person, or to the extent that such use of any 

9

psychoactive substance impairs the ability of the professional to safely and competently provide services. 

Rule 6.2 All certified professionals are mandated child abuse reporters. 

RECORD KEEPING 

Rule 7.1 A certified professional shall not falsify, amend, or knowingly make incorrect entries or fail to make timely essential entries 

into the client record. 

ASSISTING UNQUALIFIED/UNLICENSED PRACTICE 

Rule 8.1 A certified professional shall not refer a client to a person that he/she knows or should have known is not qualified by 

training, experience, certification, or license to perform the delegated professional responsibility. 

COOPERATION WITH THE BOARD 

Rule 9.1 A certified professional shall cooperate in any investigation conducted pursuant to this Code of Ethical Conduct and shall not 

interfere with an investigation or a disciplinary proceeding or attempt to prevent a disciplinary proceeding or other legal 

action from being filed, prosecuted, or completed. Interference attempts may include but are not limited to: 

Rule 9.2 A certified professional shall: 

1. the willful misrepresentation of facts before the disciplining authority or its authorized 

representative; 

2. the use of threats or harassment against, or an inducement to, any client or witness in an effort to 

prevent them from providing evidence in a disciplinary proceeding or any other legal action; 

3. the use of threats or harassment against, or an inducement to, any person in an effort to prevent or 

attempt to prevent a disciplinary proceeding or other legal action from being filed, prosecuted or 

completed; 

4. refusing to accept and/or respond to a letter of complaint, allowing a credential to lapse while an 

ethics complaint is pending, or attempting to resign a credential while an ethics complaint is 

pending. Violation of this rule under these circumstances will result in the immediate and 

indefinite suspension of the certified professional’s credential until the ethical complaint is 

resolved. 

1. not make a false statement to the PCB or any other disciplinary authority; 

2. promptly alert colleagues informally to potentially unethical behavior so said colleague could take 

corrective action; 

3. report violations of professional conduct of other certified professionals to the appropriate 

licensing/disciplinary authority when he/she knows or should have known that another certified 

professional has violated ethical standards and has failed to take corrective action after informal 

intervention. 

Rule 9.3 A certified professional shall report any uncorrected violation of the Code of Ethical Conduct within 90 days of alleged 

violation. Failure to report a violation may be grounds for discipline. 

Rule 9.4 A certified professional with firsthand knowledge of the actions of a respondent or a complainant shall cooperate with the 

PCB investigation or disciplinary proceeding. Failure or an unwillingness to cooperate in the PCB investigation or 

disciplinary proceeding shall be grounds for disciplinary action. 

Rule 9.5 A certified professional shall not file a complaint or provide information to the PCB, which he/she knows or should have 

known, is false or misleading. 

Rule 9.6 In submitting information to PCB, a certified professional shall comply with any requirements pertaining to the disclosure of 

client information established by the federal or state government. 

Signature:__________________________________________________________Date:_________________________________ 

10

Release 

I hereby request that the Pennsylvania Certification Board grant the credential to me based on the following assurances and 

documentation: 

I subscribe to and commit myself to professional conduct in keeping with the PCB Code of Ethical Conduct; 

I hereby certify that the information given herein is true and complete to the best of my knowledge and belief. I also authorize 

any necessary investigation and the release of manuscripts and other personal information relative to my certification. 

Falsification of any records or documents in my application will nullify this application and will result in denial or revocation of 

certification; 

I consent to the release of information contained in my application and any other pertinent data submitted to or collected by PCB 

to officers, members, and staff of the aforementioned Board; 

I consent to authorize PCB to gather information from third parties regarding continuing education and employment and 

understand that such communication shall be treated as confidential; 

Allegations of ethical misconduct reported to PCB before, during, or after application for certification is made will be 

investigated by PCB and could result in the nullification of the application or denial or revocation of certification. 

Signature:________________________________________________________ Date:__________________________________ 

Please print your name as it should appear on your certificate. 

_______________________________________________________________________ 

THIS APPLICATION PAGE MUST BE NOTARIZED IN THE SPACE BELOW. 

11

Easy Pass for PCB credentialed professionals! 

If you hold a CAC, CAC II, CAC Diplomate, CCJP or CPS: 

1. Send application, CCDP supervision form, and fee. 

2. You do not need to verify counseling employment on work verification form, just the employment providing 

integrated services to clients with co-occurring disorders (exception: CPS must document both counseling and 

integrated services). 

3. Send notarized release unless you have recertified or submitted another application (with notarized release) within 

1 year of CCDP application. Notarized releases older than 1 year in your PCB file cannot be used towards the 

CCDP application. 

4. Send signed Code of Ethical Conduct unless you have recertified or submitted another application within 1 year of 

CCDP application. Code of Ethical Conducts older than 1 year in your PCB file cannot be used towards the 


5. You will not need to send your official transcript. 

6. Your education requirement is 35 hours integrated and specifically related to clients with co-occurring disorders, 

including 6 in cultural competency. It can be training you’ve already submitted for past applications, but you do 

need to send proof of attendance. Applicants with a relevant college internship/practicum or a relevant state 

issued license and specialized credential are exempt from all of the 110 hours of education. 

If you hold a CCSM, CCRM, or CCMS: 








4. You do not need to send your official transcript. 

5. Your education requirement is 35 hours integrated and specifically related to clients with co-occurring disorders. 

It can be training you’ve already taken, but you do need to send proof of attendance. Applicants with a relevant 

college internship/practicum or a relevant state issued license and specialized credential are exempt from all of the 

110 hours of education. 

If you hold any Associate level credential or a CAAP: 








4. You will need to have your official transcript sent unless there is one already on file. 

5. Your education requirement is 35 hours integrated and specifically related to clients with co-occurring disorders, 6 

in ethics, 6 in cultural competency, and 6 in communicable diseases. It can be training you’ve already submitted 

for past applications, but you do need to send proof of attendance. (APS I requires 60 hours, CAAP requires 35 

hours including 6 in cultural competency). Applicants with a relevant college internship/practicum or a relevant 

state issued license and specialized credential are exempt from all of the 110 hours of education. 

12

CCDP Checklist for applicants new to PCB 

The following should be included in the CCDP Application: 

________1. Completed application 

________2. Experience Verification Form(s) 

________3. Signed Code of Ethical Conduct 

________4. Completed and notarized Release Form 

________5. 110 hours of documented education, if applicable, including 

______ 6 in ethics 

______ 6 in cultural competency 

______ 6 in communicable diseases 

________6. Supervision Form completed by supervisor 

________7. Copy of license and specialized credential, if applicable; you are exempt from education requirements 

________8. Documentation of college internship/practicum, if applicable (letter from agency); you are exempt from education 

requirements 

________9. $200.00 non-refundable fee payable to PCB 

To be sent separately: 

________10. Official college transcript 

Photocopy entire application for your records. Send original application, all required documentation, and payment to: 

PCB 

298 S. Progress Avenue 

Harrisburg, PA 17109 

(717) 540-4455 

(717) 540-4458 – fax 

email: info@pacertboard.org 

website: pacertboard.org 

13

CCDP Checklist for applicants with a current PCB credential 



________2. Integrated Services Experience Verification Form(s) only - (counseling employment verification not necessary) 

________3. Signed Code of Ethical Conduct (if no other has been sent within the past year) 

________4. Completed and notarized Release Form (if no other has been sent within the past year) 

________5. 35 hours of documented education integrated and specifically related to clients with co-occurring disorders, 

including 6 in cultural competency 

CCSM, CCRM, CCMS only need send 35 hours of education integrated and specifically related to clients with 

co-occurring disorders 


________7. Copy of license and specialized credential, if applicable; (you are exempt from all education requirements) 

________8. Documentation of college internship/practicum, if applicable (letter from agency); (you are exempt from all 

education requirements) 



PCB 



(717) 540-4455 

(717) 540-4458 – fax 


website: www.pacertboard.org 

14

CCDP Checklist 

for applicants with 

a current Associate level 

credential or CAAP 



________2. Experience Verification Form(s) 

________3. Signed Code of Ethical Conduct (if no other has been sent within the past year) 

________4. Completed and notarized Release Form (if no other has been sent within the past year) 

________5. 35 hours of documented education integrated and specifically related to clients with co-occurring disorders, 

including 6 in ethics, 6 in cultural competency and 6 in communicable diseases. CAAPs do not need to send ethics 

and communicable diseases education. 


________7. Copy of license and specialized credential, if applicable; (you are exempt from all education requirements) 

________8. Documentation of college internship/practicum, if applicable (letter from agency); (you are exempt from all 

education requirements) 



PCB 



(717) 540-4455 

(717) 540-4458 – fax 


website: www.pacertboard.org 

15

TABLE OF CONTENTS 

Purpose of the Candidate Guide....................2 

Examination Content...............................2 

Domains........................................2-24 

Sample Questions..............................24-28 

Sample Examination Schedule......................28 

Taking the Examination...........................29 

Examination Rules................................29 

Special Administrations..........................30 

Admission to the Examination.....................30 

Examination Dates................................30 

Scoring..........................................30 

Test Disclosure..................................31 

References....................................32-37

PURPOSE OF THE CANDIDATE GUIDE 

The Written Examination for Certified Co-Occurring Disorders 

Professional (CCDP) is an examination that tests knowledge and 

skills about co-occurring disorders. This exam has been developed 

by the PA Certification Board (PCB) and a panel of content experts 

from the alcohol and other drug abuse field and the mental health 

field from across the Commonwealth. The exam is based on current 

practice in the field. 

The purpose of the Candidate Guide is to provide you with guidance 

for the CCDP/Diplomate written examination process. By providing 

you with background information on examination domains and sample 

questions, your preparation for the exam can be enhanced. 

EXAMINATION CONTENT 

The 2004 PCB Role Delineation Study for Co-Occurring Disorders 

Professionals identified seven performance domains with two 

additional domains for the master’s level credential. Within each 

performance domain there are several identified task statements, 

knowledge, and skill areas that provide the basis for questions in 

the examination. This Candidate Guide contains detailed 

information on the domains, tasks, knowledge, and skill areas. The 

following is a list of the performance domains for the examination 

and the number of test questions in each. 

CCDP DOMAINS 

NUMBER OF QUESTIONS 

Screening & Assessment 23 

Crisis Management 20 

Treatment Planning 19 

Counseling 36 

Case Management 21 

Person, Family & Community Education 14 

Professional Responsibility 17 

CCDP DIPLOMATE DOMAINS 

Includes the 7 domains above plus: 

Clinical Supervision 15 

Research Design & Application 8 

SCREENING AND ASSESSMENT 

Task 1 – Engage client and establish rapport. 

Knowledge of: 

1. Stages of change and recovery process. 

2. Empathetic and active listening. 

3. Interview process including objectives and techniques 

(e.g., motivational interviewing). 

4. Federal, state, and local laws related to 

2

confidentiality in substance abuse and mental health. 

5. Ethical principles of human services. 

6. Institutional, class, culture, language, and other 

culturally based considerations in order to better 

facilitate access and service utilization. 

7. Theories and principles concerning human behavior, 

development, and biopsychosocial approaches as they 

relate to diverse cultural and ethnic groups. 

Skill in: 

1. Sharing compassion, empathy, respect, flexibility, and 

hope to all individuals, regardless of their degree of 

impairment, stage of (non)recovery, or level of 

acceptance in the treatment and recovery process. 

2. Maintaining professional boundaries through objective, 

empathic detachment and managing personal biases with a 

non-judgmental, non-punitive demeanor and approach. 

3. Demonstrating sensitivity to, and respect for, persons 

with different disorders, characteristics, and cultural 

backgrounds (e.g., ethnic, racial, gender, sexual 

orientation, and socio-economic class). 

4. Matching the communication styles of persons from 

different cultural backgrounds using a variety of 

verbal and non-verbal responses and strategies. 

5. Facilitating the participation of support persons, 

family members, and other service providers and to 

welcome them as collaborators. 

6. Demonstrating a desire and willingness to elicit the 

individual’s viewpoint and to recognize and validate 

the daily courage needed to survive the changes of 

multiple no-fault persistent and relapsing disorders. 

7. Demonstrating patience, persistence, and optimism in 

helping to establish and maintain the individual’s 

motivation. 

8. Communicating clearly and concisely, both verbally and 

in writing. 

9. Engaging and establishing rapport with individuals from 

different cultural groups, using socially and 

culturally appropriate conventions. 

10. Communicating and applying confidentiality rules and 

regulations. 

Task 2 – Gather and document client information. 

Knowledge of: 

1. Risk assessment process. 

2. Appropriate intervention strategies including emergency 

procedures. 

3. Obtaining accurate information and biopsychosocial 

history including collateral information. 

4. Psychosocial stressors and traumas particular to 

different ethnic, cultural, and other groups. 

3

Skill in: 

1. Identifying and understanding non-verbal behaviors. 

2. Discerning the relevance of information obtained from 

the client, family, and other collateral sources. 

3. Organizing and summarizing client data and clinical 

impressions including cultural strengths. 

4. Documenting information in an objective manner. 

5. Recognizing special client needs. 

6. Writing clear, concise reports and summaries. 

7. Assessing risk behaviors and initiating appropriate 

interventions and referrals. 

8. Utilizing the biopsychosocial components of assessment, 

including the spiritual dimension, when assessing both 

psychiatric and substance-related disorders. 

Task 3 – Recognize signs and symptoms of substance use disorders. 

Knowledge of: 

1. Conceptual models of addiction. 

2. Current Diagnostic & Statistical Manual for Mental 

Health Disorders (DSM) criteria for substance-related 

disorders. 

3. Classes of chemicals including their basic actions in 

the body and brain, their intoxication and withdrawal 

symptoms, and their potential combined interactions. 

4. New psychoactive chemicals (prescription, nonprescription, 

and street drugs). 

5. Signs and symptoms of potentially high-risk medical 

complications associated with detoxification. 

6. The relationship between psychoactive substance use and 

trauma, including but not limited to physical, 

emotional, and sexual abuse. 


complications associated with detoxification. 

8. Behavioral manifestations of intoxication. 

9. Legal limits of blood alcohol content. 

10. Significance of diagnostic reports from laboratory 

tests. 

11. Individual, family, and cultural belief system 

regarding substance use. 

Skill in: 

1. Identifying the various conceptual models of addiction. 

2. Recognizing signs and symptoms of intoxication, 

tolerance, and withdrawal. 

3. Assessing severity of intoxication and risk for 

withdrawal. 

4. Utilizing laboratory data. 

5. Identifying medical conditions associated with 

psychoactive substance use and making appropriate 

referrals. 

6. Recognizing the cultural difference with regard to 

substance use among different groups. 

4

Task 4 – Recognize signs and symptoms of psychiatric disorders. 

Knowledge of: 

1. Conceptual models of psychiatric disorders. 

2. Current DSM criteria for mental disorders. 

3. Current DSM multiaxial diagnostic system. 

4. Components and terminology of the mental status 

examination. 

5. Basic tenants of psychopharmacology. 

6. Differences in the thresholds of psychiatric distress 

and symptom expression in persons from different 

cultures. 

Skill in: 

1. Identifying the various conceptual models of 

psychiatric disorders. 

2. Utilizing the mental status examination. 

3. Conducting a culturally appropriate assessment 

4. Effectively communicating therapeutic concepts. 

5. Using established DSM criteria for assessing acuity of 

symptoms and service intensity needs. 

6. Applying information derived from the multiaxial 

diagnostic system. 

7. Identifying various classes of basic psychotropic 

medication and recognizing relevant side effects. 

8. Recognizing the cultural difference with regard to 

psychopathology among different groups. 

Task 5 – Recognize interactions between co-existing mental, 

substance-related, and medical disorders. 

Knowledge of: 

1. Physical, mental, and cultural issues that may 

complicate the identification of substance use 

disorders. 

2. Physical, mental, and substance use disorders that may 

require more extensive evaluation. 

3. The potential interactions between substance use and 

other mental disorders. 

4. The relationship between substance use and physical, 

emotional, and sexual trauma throughout the life cycle. 

5. Cultural influences on medical, psychiatric, and 


6. The interaction between general medical disorders, 

prescribed medications, and substances of abuse. 

Skill in: 

1. Accurately assessing substance use in the presence of 

symptoms of co-occurring physical and/or mental 

disorders within the person’s cultural context. 

2. Accurately assessing mental disorders in the presence 

of symptoms of co-occurring substance use or medical 

5

problems within the person’s cultural context. 

3. Identifying conditions that present high-risk for 

harmful behaviors or physical deterioration and 

facilitating appropriate referrals. 

4. Responding to cultural influences on substance use and 

mental disorders and their treatment. 

5. Exploring and identifying interactions between general 

medical disorders, prescribed medications, and 

substances of abuse. 

6. Addressing issues related to traumatic experiences in a 

sensitive and informed manner. 

Task 6 – Utilize relevant assessment instruments. 

Knowledge of: 

1. Valid and reliable screening and assessment tools. 

2. Applications and limitations of screening and 

assessment tools. 

3. Screening and assessment tools with persons from 

different ethnic and cultural backgrounds. 

4. Standardized level of care placement criteria 

instruments. 

Skill in: 

1. Selecting and applying appropriate assessment 

instruments. 

2. Explaining the rationale for the use of specific 

assessment and placement tools. 

3. Interpreting the results of substance and mental 

disorders instruments. 

4. Explaining the results of substance and mental 

disorders instruments to clients and others. 

Task 7 – Develop diagnostic impressions and communicate results. 

Knowledge of: 

1. A holistic perspective of the biopsychosocial-spiritual 

dimensions of any disorder. 

2. Culturally normative patterns of behaviors to be 

differentiated from psychopathology. 

3. Interactions between substance use, mental, and other 

physical disorders. 

4. DSM criteria and rule-out procedures for the presenting 

symptoms. 

5. Techniques for synthesizing assessment data and 

formulating diagnostic impressions. 

Skill in: 

1. Organizing and summarizing relevant client data and 

clinical impressions. 

2. Writing clear, concise, objective reports and 

summaries. 

3. Formulating diagnostic impressions that reflect the 

6

individual’s needs and circumstances. 

4. Identifying culturally normative behaviors that may be 

misinterpreted as psychopathology. 

5. Recognizing special client needs (e.g., learning 

disabilities, developmental disabilities and mental 

retardation, physical limitations, etc.). 

CRISIS MANAGEMENT 

Task 1 - Conduct an immediate risk assessment to determine the 

existence of an emergency or crisis situation. 

Knowledge of: 

1. Indicators of serious threat of harm to self or others. 

2. Signs and symptoms of delirium and other serious 

medical conditions. 

3. DSM Decision Trees for identifying medical, substance 

use, psychiatric, environmental, and cultural 

stressors. 


complications (e.g., withdrawal, lithium toxicity, 

heroin overdose, etc.). 

5. Individual and cultural differences that can contribute 

to adverse drug reactions and crisis situations. 

6. High risk for suicide and violence in persons with 

combined mental and substance-related disorders. 

Skill in: 

1. Gathering relevant information using all available 

resources. 

2. Assessing acute levels of dangerousness. 

3. Engaging and communicating clearly and concisely with 

the person/significant others. 

4. Applying the DSM Decision Trees to determine the 

presence and extent of an emergency or crisis 

situation. 

Task 2 - Evaluate the nature and level of risk in a client's crisis 

situation by analyzing the elements of the crisis in order to 

implement and provide an appropriate intervention. 

Knowledge of: 

1. The effects on functioning and degree of disability 

related to mental and substance-related disorders, both 

separately and combined. 

2. The classes of psychotropic medications, their actions, 

medical risks’ side effects, possible interactions with 

other substances, and addictive potential. 

3. Potential differences and the way in which different 

ethnic, cultural, gender, and age groups respond to 

substances including psychotropic medications. 

4. Current DSM Axis IV coding for stressors. 

5. Specific risk assessments instruments. 

7

6. Relapse symptoms and stages for both mental and 

substance-related disorders and their implications for 

current functioning. 

7. One’s own personal and cultural biases and professional 

limitations in assessing a crisis situation. 

Skill in: 

1. Recognizing established indicators for assessing acuity 

of symptoms and service intensity needs. 

2. Using risk assessment procedures and instruments 

appropriate to the type of crisis. 

3. Conveying empathy, respect, and hope to all 

individuals, regardless of their degree of impairment, 

stage of (non)recovery, or level of cooperation, 

managing personal biases, and maintaining a nonjudgmental, 

non-punitive demeanor and approach. 

4. Displaying sensitivity to, and respect for, persons 

with different disorders, characteristics, and cultural 

backgrounds (e.g., ethnic, racial, gender, sexual 

orientation, and socio-economic class). 

5. Engaging individuals, family members, and 

traditional/alternative service providers from diverse 

backgrounds and welcoming them as collaborators. 

6. Seeking supervision and consultation when necessary. 

Task 3 - Implement an immediate course of action appropriate to 

the crisis. 

Knowledge of: 

1. Duty to warn/protect rulings, related regulations, and 

policies. 

2. Community resources including ethnic and cultural 

resources that can aid in resolving a person’s crisis. 

3. Current crisis resolution theory and techniques. 

4. Current theories of motivational enhancement. 

Skill in: 

1. Prioritizing immediate needs and identifying existing 

strengths and resources. 

2. Taking immediate action regarding duty to warn/protect 

while maintaining engagement with person/family. 

3. Identifying other immediately needed clinical/medical 

supports. 

4. Developing culturally relevant and appropriate goals 

based on a person’s choices. 

5. Involving the person and families in active choices, 

goal setting, use of therapeutic contracting, and other 

activities, which support the person’s capacity to 

envision a positive personal future. 

6. Developing, writing, communicating, and monitoring a 

crisis plan in collaboration with client and other 

involved parties. 

7. Negotiating, advocating, and acquiring needed clinical 

8

and community resources and services while integrating 

the client’s natural support system. 

8. Using current intervention techniques (e.g., 

motivational enhancements, behavioral contracting, 

empathic confrontation, cognitive-behavioral 

approaches, and culturally specific enhancements). 

Task 4 - Conduct a postvention debriefing with all parties 

involved in the crisis. 

Knowledge of: 

1. Rationale and methods for facilitating a postvention 

debriefing process. 

2. Determining the effectiveness of the crisis 

intervention. 

3. The need for and content of crisis documentation. 

4. Crisis situations as potential opportunities for 

acquiring new knowledge and skills. 

Skill in: 

1. Determining how, when, and with whom to conduct a 

postvention session. 

2. Identifying and evaluating the causes of and solution 

to the crisis situation. 

3. Developing proactive strategies for avoiding similar 

crises in the future. 

4. Maintaining engagement with and soliciting feedback 

from client, family members, service providers, and 

others as collaborators. 

5. Documenting the nature of the crisis, interventions 

used, and outcomes. 

Task 5 - Develop and implement an individualized follow-up plan. 

Knowledge of: 

1. Client’s current strengths, resources, diagnoses, 

clinical support, and needs. 

2. Peer support and empowerment groups, both those aimed 

at dual recovery and those that support the person in a 

specific acute area of need (e.g., drop-in centers, 

clubhouses, Alcoholics Anonymous/Narcotics 

Anonymous/Dual Recovery groups). 

3. Various individual and family supports compatible with 

different cultures. 

4. Integrated relapse prevention strategies. 

5. The interrelationship between the postvention 

debriefing results and the comprehensive individual 

treatment plan. 

6. The need for timely verbal and written data to the 

referral source. 

Skill in: 

1. Identifying and accessing a full range of treatment and 

9

support services, including peer supports and those in 

the natural support system. 

2. Engaging family members and offer various supports on 

an individual and group basis (e.g., education, peer 

support, referrals for needed social services, family 

psychoeducation or therapy) where indicated and 

desired. 

3. Referring to external supports (e.g., PA Recovery 

Organizations Alliance, PA Mental Health Consumers’ 

Association, National Alliance for the Mentally Ill 

including its family education and support group 

affiliates). 

4. Identifying and integrating the results of the 

postvention debriefing process into a comprehensive 

individual treatment plan. 

5. Advocating for needed services and supports. 

TREATMENT PLANNING 

Task 1 – Interpret and evaluate clinically relevant data received 

from individual, significant others, assessments, and prior 

treatment sources to determine treatment needs. 

Knowledge of: 

1. The application of diagnostic reports (e.g., laboratory 

tests, neuropsychological evaluations, etc.). 

2. Mental health and drug and alcohol symptomology, a 

comprehensive understanding of their interrelationship, 

and their effects on functioning and 

degree of disability. 

3. Categories within, and application of, the current 

edition of the DSM as a means of reviewing diagnostic 

criteria and related features. 

4. Integrated models of assessment, intervention, and 

recovery for persons having both substance-related and 

other mental disorders. 

5. The effects of culture on the individual’s beliefs and 

choices related to treatment. 

Skill in: 

1. Synthesizing data to determine treatment needs. 

2. Consulting with other professionals to interpret 

findings. 

3. Organizing and summarizing relevant client data and 

clinical impressions to determine treatment needs. 

Task 2 – Engage the individual and others in a comprehensive 

treatment planning process. 

Knowledge of: 

1. Confidentiality and other ethical issues. 

2. Cross-cultural family structures, dynamics, 

communication styles, and techniques. 

10

3. Social supports and networks for individuals using 

services. 

4. Methods of engagement and maintaining relationships. 

5. Stages of Change Theory and motivational interviewing. 

Skill in: 

1. Communicating and applying laws, regulations, and 

ethical principles including professional boundaries. 

2. Facilitating cross-cultural communication while 

engaging diverse individuals, families, and social 

networks. 

3. Demonstrating sensitivity to, and respect for, 

individual differences. 

4. Creating and integrating collaborative relationships. 

5. Matching interviewing techniques to an individual’s 

stage of change. 

Task 3 – Review data with the individual and others to 

collaboratively identify and prioritize treatment needs. 

Knowledge of: 

1. Strategies for clearly and effectively presenting the 

assessment data. 

2. The relevance of specific tests and assessments in 

evaluating symptom severity. 

3. Means of managing feelings and other responses to the 

data. 

4. Negotiation techniques, needs, and priorities 

consensus. 

Skill in: 

1. Presenting assessment data clearly and sensitively. 

2. Evaluating the comprehension and level of acceptance of 

the data presented. 

3. Communicating, both verbally and non-verbally, with 

diverse populations. 

4. Negotiating to identify and prioritize needs. 

Task 4 – Develop integrated treatment goals and measurable 

objectives with the individual and others. 

Knowledge of: 

1. Models of assessment, intervention, and recovery for 

individuals having both substance-related and other 

mental disorders. 

2. Interventions and other services that address needs and 

stages of change. 

3. The treatment plan as a working contract between all 

parties. 

4. Existing resources and barriers to service integration. 

Skill in: 

1. Collaboratively developing an integrated treatment 

11

plan. 

2. Recruiting and collaborating with community groups, 

individuals in recovery, and other natural support 

groups in the development and design of recovery and 

self-help service models. 

3. Building consensus. 

4. Identifying resources for, and overcoming barriers to, 

achieve the goals. 

Task 5 – Identify specific and measurable steps to achieve goals, 

utilizing the individual’s strengths and resources. 

Knowledge of: 

1. Methods of task analysis. 

2. Strengths-based approach. 

3. Individual strengths and needs related to a specific 

goal. 

4. Resources available. 

5. Therapeutic contracting. 

Skill in: 

1. Formulating tasks in a clearly understandable and 

logical sequence. 

2. Facilitating active choice in setting goals and 

selecting steps for achievement. 

3. Identifying and matching strengths to goals and steps. 

4. Accessing resources needed to accomplish the steps. 

5. Writing clearly and concisely, using client-centered 

language. 

6. Negotiating a contract that encourages movement toward 

the goal. 

7. Identifying responsibilities and timelines for 

achievement of steps. 

Task 6 – Monitor and document individual’s progress in achieving 

treatment goals, and modifying the treatment plan as necessary. 

Knowledge of: 

1. Review strategies as part of the treatment plan. 

2. Progress note format, rationale, and regulations. 

3. Treatment plan revision procedures and format. 

4. The stages of change and phases of treatment. 

5. Internal and external contributors to relapse. 

6. Circumstances that may necessitate a change in the 

course of treatment. 

7. Assessment as an ongoing process. 

Skill in: 

1. Conducting regular assessments of treatment 

interventions in order to evaluate effectiveness. 

2. Negotiating adjustments to the treatment plan. 

3. Writing clear, brief notes that track individual’s 

progress. 

12

COUNSELING 

Task 1 - Provide a safe, empathic environment in order to 

facilitate a collaborative relationship with the person and 

significant other(s). 

Knowledge of: 

1. Communication styles, strategies, and supports that 

facilitate rapport with persons from different cultural 

backgrounds. 

2. Environmental factors that support or inhibit the 

collaborative relationship. 

Skill in: 

1. Involving persons and family members as collaborators. 

2. Demonstrating sensitivity to, and respect for, persons 

with multiple disorders. 

3. Building rapport across different cultural backgrounds. 

4. Identifying and addressing intrapersonal attitudes, 

values, and beliefs that may impede the development of 

a collaborative relationship. 

Task 2 - Develop an ongoing therapeutic alliance. 

Knowledge of: 

1. Boundary issues. 

2. The importance of relationship skills. 

3. The effects on functioning and degree of disability 

related to mental and substance use disorders. 

4. The importance of monitoring the person’s perception of 

the relationship. 

Skill in: 

1. Maintaining one’s professional boundaries with 

objectivity and empathic detachment. 

2. Demonstrating compassion, empathy, respect, 

flexibility, and hope to all individuals. 

3. Communicating with integrity and honesty. 

4. Establishing and maintaining the person’s motivation to 

remain engaged in the therapeutic process. 

5. Interacting with persons displaying symptoms of 

multiple disorders. 

Task 3 - Utilize appropriate integrated counseling strategies and 

techniques. 

Knowledge of: 

1. Integrated models of assessment, intervention, and 

recovery. 

2. The interactive effects of multiple disorders. 

3. Counseling theories and techniques. 

4. Change theory, motivational strategies, and strengths- 

13

ased practice. 

Skill in: 

1. Using assessment results to individualize strategies. 

2. Matching integrative strategies and theoretical 

approaches to the person’s strengths, needs, cultural 

background, and motivational level. 

3. Matching interventions to the person’s level of 

involvement and responsibility. 

4. Using Stage of Change theory and strengths-based 

interviewing. 

Task 4 - Evaluate the effectiveness of counseling interventions 

and strategies. 

Knowledge of: 

1. Program and individual outcomes. 

2. Performance measures that demonstrate movement toward 

goals. 

3. Implications of relapse on the counseling process. 

4. Those involved in the counseling process having varying 

and/or different perceptions. 

Skill in: 

1. Renegotiating goals and/or action steps. 

2. Adapting integrative approaches to the person’s 

diagnoses, cognitive abilities, and stages of recovery. 

3. Adjusting strategies based on information obtained from 

various sources. 

4. Documenting progress in reference to the treatment plan 

for ongoing review with the person and others. 

Task 5 – Develop integrative discharge and aftercare plans. 

Knowledge of: 

1. The discharge planning process. 

2. The full range of entitlement programs, natural 

community, cultural supports, and other services. 

3. The legalities and confidentiality requirements related 

to the referral process. 

4. Relapse prevention theories related to mental and 


5. The need to advocate and negotiate. 

Skill in: 

1. Evaluating a person’s relapse triggers, their strengths 

and supports for managing recovery, and barriers to 

recovery. 

2. Identifying and accessing services and supports to meet 

the person’s specific needs. 

3. Advocating and negotiating for needed services and 

supports. 

4. Obtaining and documenting the necessary releases of 

14

CASE MANAGEMENT 

information. 

Task 1 – Collaborate with the individual and others to identify 

and prioritize strengths and needs and match to appropriate 

services. 

Knowledge of: 

1. Array of available services. 

2. Variety of integrative programs and therapeutic models. 

3. Strengths-based and motivational approaches. 

4. Factors relevant to level of care determinations. 

5. Various criteria utilized for matching service needs 

and/or need for additional evaluation. 

6. Culturally-based strengths and resources. 

Skill in: 

1. Applying placement criteria. 

2. Helping individuals recognize and use personal 

strengths and resources. 

3. Recognizing current needs and capabilities and matching 

to appropriate services. 

4. Involving the person in active choices, goal setting, 

use of therapeutic contracting, and other activities. 

5. Using a person’s personal and cultural strengths and 

resources to support the recovery process. 

Task 2 – Develop treatment and service options in a collaborative 

manner. 

Knowledge of: 

1. Available treatment and support services in the 

integrated and discrete mental health/alcohol and other 

drug abuse systems. 

2. The full range of entitlement programs, existing 

services, and community and cultural supports for 

individual and significant others. 

3. Principles of recovery from both substance use and 

mental health disorders. 

4. The empowerment model as it relates to the individual’s 

responsibility in directing his/her own recovery. 

Skill in: 

1. Demonstrating the ability to use engagement and 

motivational techniques. 

2. Demonstrating the ability to use culturally competent 

interventions. 

3. Explaining options and promoting the person’s choice. 

Task 3 – Access, coordinate, and facilitate referrals, community, 

peer, and natural support systems to maximize treatment and 

recovery opportunities as identified in the comprehensive, 

15

integrated treatment plan. 

Knowledge of: 

1. Agency referral processes. 

2. Funding sources and entitlements and procedures for 

accessing them. 

3. Continuity of care principles. 

4. The need to negotiate and advocate to overcome barriers 

to treatment. 

5. Peer support, empowerment groups (e.g., clubhouses, 

drop-in centers, self-help groups) and natural support 

systems. 

6. The need to coordinate services with multiple systems 

including family, education, rehabilitation, criminal 

and juvenile justice, medical and other social 

services. 

Skill in: 

1. Negotiating, coordinating, and advocating for client to 

obtain needed services. 

2. Advocating against discriminatory practices identified 

throughout the service continuum. 

3. Developing and maintaining positive working 

relationships. 

4. Managing service transitions in a manner that ensures 

continuity of care. 

5. Identifying and navigating barriers to treatment. 

Task 4 – Monitor and evaluate the delivery and coordination of 

services. 

Knowledge of: 

1. Expected outcomes related to treatment service 

provisions. 

2. Current confidentiality laws and regulations including 

transmission of information. 

3. Strengths, limitations, and protocols for information 

exchange with service providers. 

4. Person’s response to treatment and available 

alternatives. 

5. The need for active follow-up strategies especially for 

persons at higher risk of relapse. 

Skill in: 

1. Using monitoring and evaluation techniques for 

assessing outcome focused services. 

2. Complying with current confidentiality laws and 

regulations. 

3. Communicating relevant information from/to current 

providers. 

4. Utilizing new information to facilitate the 

modification of the treatment plan. 

5. Developing an individualized follow-up strategy to 

16

ensure continuity of care whenever possible. 

PERSON, FAMILY & COMMUNITY EDUCATION 

Task 1 - Educate the person and family about the symptoms of 

specific disorders, their interactive effects, and the 

relationship between symptoms and stressors. 

Knowledge of: 

1. DSM. 

2. Substance use and mental health disorders as primary 

co-occurring disorders. 

3. Health issues associated with substance abuse and 

mental health disorders. 

4. Effects of co-occurring disorders on the person and 

family. 

5. Drug types, actions, interactions, and side effects. 

6. Major life stressors, their impact, and management. 

7. Psychoeducational approaches that are appropriately 

matched to families from different ethnic, cultural, 

and socioeconomic backgrounds. 

Skill in: 

1. Using applicable learning theories and teaching 

techniques. 

2. Tailoring the education to the person and family. 

3. Accessing and utilizing educational resources. 

4. Promoting hope and self-efficacy. 

5. Teaching stress management. 

Task 2 - Educate the person and family about the recovery 

process. 

Knowledge of: 

1. Recovery models related to substance use disorders 

2. Recovery models related to mental health disorders. 

3. Integrated recovery models related to co-occurring 

disorders. 

Skill in: 

1. Outlining the recovery process. 

2. Engaging the person and family in the recovery process. 

3. Promoting hope and self-efficacy. 

Task 3 - Educate the person and family about self-help and peer 

groups in the recovery process. 

Knowledge of: 

1. Support and recovery groups in the local community. 

2. Alternative support resources. 

3. The history, value, and philosophy of specific selfhelp 

and peer groups. 

17

Skill in: 

1. Communicating, active listening, and negotiating. 

2. Describing the group, their norms, and their purposes. 

3. Reviewing the potential benefits and risks of available 

groups. 

4. Assisting in the selection of a group(s) that best 

meets their needs. 

5. Teaching behaviors for effective group participation. 

Task 4 - Educate the person and family about self-advocacy. 

Knowledge of: 

1. Personal rights and responsibilities. 

2. Pertinent laws and regulations. 

3. Negotiation strategies. 

4. Assertiveness training techniques. 

5. Barriers and discriminatory practices related to the 

recovery process. 

6. Service systems and resources. 

Skill in: 

1. Role-playing and skills teaching. 

2. Connecting people with resources and navigating 

systems. 

3. Encouraging empowerment. 

4. Promoting confidence and self-efficacy. 

Task 5 - Educate the community about co-occurring disorders, the 

impact on the individual, family, and community, and the efficacy 

of treatment. 

Knowledge of: 

1. Psychological, physiological, social, and emotional 

effects of discrimination on individuals. 

2. Stigma and discrimination related to co-occurring 

disorders. 

3. Co-occurring disorders and integrated treatment. 

4. Value and effectiveness of treatment. 

5. Cost analysis of treatment delivery. 

6. Current research regarding treatment efficacy. 

7. Prevailing community and political structure. 

Skill in: 

1. Assessing and synthesizing current literature and 

research. 

2. Organizing and presenting materials. 

3. Communicating effectively and persuasively with the 

community. 

4. Mediation and negotiation. 

PROFESSIONAL RESPONSIBILITY 

Task 1 - Behave in an ethical manner by adhering to multi- 

18

disciplinary codes of ethics and standards of practice. 

Knowledge of: 

1. Professional codes of ethics pertaining to agency, 

discipline, and/or scope of practice. 

2. Client rights and consequences of violations. 

3. Consequences of violating codes of ethics. 

4. Professional standards of practice. 

5. Cross-cultural competencies for mental health and 

substance abuse providers. 

6. Overt and subtle forms of discrimination. 

Skill in: 

1. Translating professional codes of ethics into 

appropriate behavior. 

2. Effective written and oral communication. 

3. Applying professional standards of practice in a 

culturally competent manner. 

4. Assessing personal and system bias. 

Task 2 - Follow appropriate policies and procedures by adhering 

to federal, state, and agency regulations regarding substance use 

and mental health treatment as they relate to integrated care. 

Knowledge of: 

1. Mandatory reporting requirements. 

2. Statutory and regulatory legalities. 

3. State and federal confidentiality regulations and 

consequences of non-compliance. 

4. Grievance processes. 

5. Anti-discrimination guidelines. 

Skill in: 

1. Interpreting and integrating policies, procedures, and 

regulations. 

2. Applying confidentiality regulations. 

3. Communicating relevant statutes, regulations, and 

grievance procedures to the client. 

4. Applying anti-discrimination guidelines. 

Task 3 - Recognize and maintain professional and personal 

boundaries. 

Knowledge of: 

1. Personal and professional strengths and limitations. 

2. Transference/countertransference. 

3. The importance of utilizing supervision and peer 

feedback. 

Skill in: 

1. Identifying, evaluating, and managing boundary issues. 

2. Eliciting and utilizing feedback from supervisors and 

peers. 

19

Task 4 - Engage in continuing professional development based on 

an ongoing assessment of needs. 

Knowledge of: 

1. Methods for evaluating personal training needs. 

2. Certification and credentialing requirements. 

3. Current professional literature and resources on 

substance use, mental health, and co-occurring 

disorders. 

4. Resources for education and training in substance use, 

mental health, and integrated treatment. 

Skill in: 

1. Assessing training needs. 

2. Selecting and accessing training programs. 

3. Interpreting professional literature. 

4. Applying practical and professional knowledge and 

experience. 

Task 5 - Participate in clinical and administrative supervision 

and consultation. 

Knowledge of: 

1. The importance of ongoing assessment of professional 

skills and development. 

2. Professional competency in substance use, mental 

health, and co-occurring disorders. 

3. Resources for clinical supervision and consultation. 

4. The function and need for clinical consultation and 

technical assistance. 

Skill in: 

1. Recognizing one’s own professional capabilities and 

limitations in providing integrated treatment. 

2. Recognizing and communicating the need for consultation 

and supervision. 

3. Reviewing and consulting on client cases. 

4. Using both constructive criticism and positive 

feedback. 

Task 6 - Advocate for public policy and resource development in 

support of quality services. 

Knowledge of: 

1. Public relation techniques and their value. 

2. Community organizations. 

3. The importance of interagency and community 

collaboration. 

4. Government entities and political leaders. 

Skill in: 

1. Communicating effectively. 

20

2. Effective public relations techniques. 

3. Identifying common interests and areas of potential 

conflict between stakeholders. 

CLINICAL SUPERVISION 

Task 1: Establish a supervisory relationship with supervisee that 

promotes professionalism and personal satisfaction. 

Knowledge of: 

1. Power and authority issues. 

2. Effective listening and communication techniques. 

3. Management techniques. 

4. Conflict resolution strategies. 

5. Personality styles. 

6. Ethnicity and diversity issues. 

7. 

8. 

Empowerment strategies. 

Boundary and ethical issues. 

9. Stress management techniques. 

Skill in: 

1. Providing constructive feedback. 

2. Respecting individual differences. 

3. Mediating and negotiating. 

4. Delegating authority and responsibility. 

5. Applying a strengths-based approach to supervision. 

6. Maintaining professional boundaries and ethics. 

7. Applying stress management techniques. 

Task 2: Assess the strengths and needs of a supervisee as related 

to their provision of integrated clinical services. 

Knowledge of: 

1. Core competencies and job responsibilities. 

2. Communication strategies and techniques. 

3. Performance evaluation and assessment techniques. 

4. Models of clinical supervision. 

5. Counseling theories and standards of clinical practice. 

6. Ethnicity and diversity as it relates to supervision. 

Skill in: 

1. Communicating effectively 

2. Thinking critically. 

3. Encouraging self-assessment. 

4. Assessing abilities to perform specific job 

responsibilities. 

5. Assessing and addressing diversity in supervision. 

Task 3: Design and modify a supervisee’s individual development 

plan. 

Knowledge of: 

21

1. Career development strategies. 

2. Core competencies and job responsibilities. 

3. Problem solving methods. 

4. Clinical supervision models. 

5. Learning styles. 

6. Models of evaluation techniques. 

7. Agency policies and procedures and professional 

responsibilities. 

Skill in: 

1. Formulating and documenting goals and objectives. 

2. Developing objective indicators toward the achievement 

of goals. 

3. Monitoring and documenting the supervisee’s 

development. 

4. Engaging the supervisee in the process of selfassessment. 

5. Adapting supervisory techniques to the supervisee’s 

learning style. 

Task 4: Provide effective individual and group supervision with 

ongoing educational opportunities. 

Knowledge of: 

1. Teaching, modeling, coaching, and counseling 

techniques. 

2. Supervisee’s essential job functions. 

3. Boundary issues as they apply to supervision. 

4. Clinical supervision models and techniques. 

5. Appropriate continuing education opportunities. 

Skill in: 

1. Applying various evaluation techniques. 

2. Providing constructive feedback. 

3. Adapting style of supervision to meet supervisee’s 

needs. 

4. Demonstrating alternative clinical techniques and 

approaches. 

5. Matching appropriate continuing education 

opportunities. 

6. Maintaining professional boundaries. 

Task 5: Evaluate the effectiveness of the supervisory process. 

Knowledge of: 

1. Self-evaluation techniques. 

2. Methods of obtaining accurate feedback from various 

sources. 

3. Boundary and ethical issues and their affect. 

4. Personal biases. 

Skill in: 

1. Overcoming biases. 

22

2. Eliciting accurate evaluation data. 

3. Interpreting evaluation data. 

4. Applying feedback for self-correction and growth. 

5. Monitoring the correction of identified problems. 

6. Maintaining professional boundaries and ethics. 

RESEARCH DESIGN AND APPLICATION 

Task 1: Review current evidence-based practices for specific 

disorders and for integrated treatment supported by clinical trials 

and/or outcomes-based research. 

Knowledge of: 

1. Research design and analytical methods. 

2. Current practice guidelines for integrated treatment. 

3. Study limitations, limits of inference, and researcher 

and reader bias. 

4. Population disparities in studies related to subgroup 

diversity and ethnicity. 

5. Relevant research resources, literature, and current 

debates. 

Skill in: 

1. Critically analyzing research findings. 

2. Summarizing research studies, verbally and in writing. 

3. Adapting current evidence-based practices for 

integrated treatment. 

4. Recognizing bias in reporting and/or interpreting 

research findings. 

5. Using current technology and resources to conduct 

literature reviews. 

Task 2: Conduct clinical practice and program related studies, 

following accepted performance improvement procedures, in order 

to examine treatment outcomes. 

Knowledge of: 

1. Evidence-based research regarding specific disorders 

and integrated treatment practices. 

2. Continuous quality improvement processes. 

3. Research design and methodology. 

4. Current technology for gathering and analyzing internal 

data. 

5. Limits and biases affecting quality of data used in the 

study. 

Skill in: 

1. Using current technology and resources in conducting 

studies. 

2. Developing and implementing continuous quality 

improvement studies. 

3. Gathering and documenting study related data. 

23

Task 3: Analyze and apply the findings of clinical research and 

local continuous quality improvement efforts. 

Knowledge of: 

1. Methods of data analysis and arriving at conclusions. 

2. Data presentation strategies for informed decisionmaking. 

3. Individual and systems change theory. 

4. Community and agency priorities, operational 

capabilities, and limitations. 

Skill in: 

1. Analyzing data and arriving at conclusions. 

2. Preparing data summary to communicate findings, 

recommendations, and limitations. 

3. Selecting change strategies based on priorities, local 

culture, and recommendations. 

4. Implementing and monitoring specific change processes. 

SAMPLE QUESTIONS 

The questions on the CCDP/Diplomate examination were developed from 

the domains identified in the 2004 Role Delineation Study. 

Multiple sources were utilized in the development of questions for 

these exams. Each question is linked to one of the knowledge and 

skill areas identified in each domain. 

The following is taken from the instructions that will be read to 

you prior to taking the examination: 

The questions in the examination are multiple choice with four (4) 

choices: A, B, C, and D. There is only one correct choice for each 

question. Carefully read each question and all the choices before 

making a selection. Choose the single best answer. Mark only one 

answer for each question. You will not be given credit for any 

question for which you indicate more than one answer. It is 

advisable to answer every question, since the number of questions 

answered correctly will determine your final score. There is no 

penalty for guessing. 

Following are sample questions that are similar to those you will 

find in the CCDP/Diplomate exam. 

1. There have been numerous studies documenting the high 

prevalence of what personality disorder among substance 

abusers? 

a. Antisocial personality disorder 

b. Paranoid personality disorder 

c. Schizoid personality disorder 

d. Schizotypal personality disorder 

24

2. There are seven elements in the referral process. Which of 

the following is not an example of an element of the 

referral process? 

a. Arranging referrals to other professionals, agencies, or 

programs to meet the client's needs 

b. Evaluating the outcome of the referral 

c. Occasional assessment of referral services to determine 

appropriateness 

d. Explaining to the client, in clear language, the 

necessity of the referral 

3. All assessment tools listed below are multi-dimensional 

except: 

a. RAATE. 

b. MAST. 

c. DUSI. 

d. ASI. 

4. Counselors are at great risk to behave in a racist manner 

without being aware of it when they: 

a. were raised in a family environment marked with racial 

bias. 

b. lack cultural diversity in their personal life. 

c. are representative of a majority culture and working 

with a client from a minority culture. 

d. assert that color makes no difference at all in the 

assessment, goal setting, treatment planning, and/or 

client communication. 

5. The organization founded as an alternative to programs with 

spiritual overtones, whose publication is called the "The 

Small Book" is: 

a. Secular Organization for Sobriety. 

b. Rational Recovery. 

c. Al-Anon. 

d. Dual Recovery Anonymous. 

6. In order to treat dual diagnosis disorders most effectively, 

interventions must be adapted to client's: 

a. stage of treatment 

b. degree of impairment. 

c. relapse plan. 

d. motivation for change. 

7. According to the DSM-IV-R, to make a diagnosis of Attention 

Deficit/Hyperactivity Disorder, some hyperactive, impulsive, 

or inattentive symptoms must be present before the age of: 

a. seven. 

b. twenty-one. 

c. sixteen. 

d. eighteen. 

8. According to Carl Rogers, "Accurate Emphatic Understanding" 

25

efers to the therapist's ability to: 

a. objectively understand the dynamics of the client's 

behavior. 

b. accurately diagnose the client's central problem. 

c. sense the inner world of the client's subjective 

experience. 

d. like and care for the client regardless of their 

behavior. 

9. In terms of treatment planning, a critical problem of dual 

disordered clients is that they are typically in a 

___________ regarding their substance abuse. 

a. motivational state 

b. premotivational state 

c. high motivational state 

d. moderate motivational state 

10. Crises may present useful opportunities for engaging people 

with service/treatment providers by first demonstrating: 

a. their need for active substance use and mental health 

treatment. 

b. that their way of managing doesn't work and that their 

skills are deficient. 

c. that help with obtaining basic needs (e.g., housing, 

money) can be obtained from treatment providers. 

d. that treatment providers are empathic and trustworthy. 

11. Professionals have an obligation to deal with colleagues 

when they suspect unethical conduct. Generally, if you 

suspect a violation you should begin with: 

a. reporting to a professional board. 

b. telling your supervisor or their supervisor. 

c. informally dealing with the person. 

d. bringing it up at a staff meeting. 

12. In contrast to 12-step groups, such as AA, NA, CA, Rational 

Recovery does not require: 

a. assuming responsibility for one's own behavior. 

b. an abstinence goal. 

c. challenging self-defeating and irrational beliefs. 

d. an awareness of how alcohol and drugs can interfere with 

achieving personal goals. 

13. The postvention debriefing of a crisis should be guided by 

what standards? Please identify the most relevant point. 

a. Supervisee welfare 

b. Relevant legal and ethical standards 

c. Program and/or agency service and administrative needs 

d. The good judgment of the debriefing leader 

14. If family members are involved when identifying goals and 

steps to reaching them, it is generally useful to: 

a. avoid direct involvement/contact until a trusting 

26

elationship is established with the client. 

b. wait until goals are identified and include family 

members in how they can be helpful in supporting their 

member to achieve the goals. 

c. carefully assess the potential for the family's 

contribution to possible relapse. 

d. engage the family early in the assessment and planning 

processes, working collaboratively with them, the 

client, and any others actively involved. 

Extended exam questions for CCDP Diplomate: 

15. Which of the following is not consistent with the 

assumptions made in a Blended Model of supervision? 

a. Modeling and reinforcement are basic skills 

b. Change is constant and inevitable 

c. There are many correct ways to view the world 

d. People do not always know what is best for them 

16. Another way to describe attributes in research studies or in 

the experiment are: 

a. descriptive statistics and dichotomous data. 

b. effect size and P value. 

c. independent and dependent variables. 

d. nominal and ordinal. 

17. An individualized supervision plan will not: 

a. define strengths as well as deficits. 

b. develop standards for state, local, and facility 

training for various levels of staff. 

c. identify areas of greatest need. 

d. define a training plan with a timetable and components. 

18. Nominal, ordinal, interval, and ratio are all terms used to 

describe: 

a. how data is measured. 

b. the Body Mass Index (BMI) of persons. 

c. research design and methodology. 

d. a one-way analysis of variance. 

No. Answer Domain 

1. A Counseling 

2. C Case Management 

3. 

4. 

B 

D 

Screening & Assessment 

Professional Responsibility 

5. B Person, Family, & Community Education 

6. D Case Management 

7. A Screening & Assessment 

8. C Counseling 

27

9. 

10. 

B 

C 

Treatment Planning 

Crisis Management 

11. C Professional Responsibility 

12. B Person, Family, & Community Education 

13. B Crisis Management 

14. D Treatment Planning 

Extended Exam 

15. A Clinical Supervision 

16. C Research Design & Application 

17. B Clinical Supervision 

18. A Research Design & Application 

SAMPLE EXAMINATION SCHEDULE 

The CCDP examination consists of 150 multiple-choice questions and 

the CCDP Diplomate examination consists of 175 multiple-choice 

questions. Three hours and thirty minutes (3 and 1/2 hours) will 

be provided for completion of the written examination. 

Schedule 

Activity 

8:30 - 8:45 a.m. Admit and register candidates 

8:45 a.m. All candidates are seated 

8:45 – 9:00 a.m. Give instructions 

Distribute materials 

9:00 a.m. Begin examination 

12:30 p.m. End examination 

Collect materials 

TAKING THE EXAMINATION 

The CCDP/Diplomate examination follows a 4-option multiple-choice 

format. Questions of this type begin with a stem, the premise 

statement, and are followed by four options. In answering the 

questions, candidates should read the stem and options carefully. 

They should then select the one best answer and fill in the letter 

on the answer sheet that corresponds to the best answer for the 

question. 

The test measures the seven or nine major Performance Domains in 

co-occurring disorders. Test questions are designed to assess 

knowledge as well as the candidate's ability to assess typical cooccurring 

disorders clients and apply sound principles. Successful 

candidates will draw on knowledge, analysis, and application to 

identify the one best option. 

28

In taking the test, you may find it helpful to eliminate obviously 

incorrect responses after the first reading so as to increase the 

probability of selecting the best response. If you determine that 

there are two or more reasonable options, you should select the 

most plausible choice. There is no penalty in the scoring formula 

for guessing. 

1. 

2. 

3. 

4. 

5. 

The questions in the examination are multiple choice with four 

(4) choices marked A, B, C, and D. There is only one correct 

choice for each question. Carefully read each question and 

all of the choices before making a selection. Choose the 

single best answer. Mark your answer on the answer sheet by 

blackening the circle under the letter of your choice. 

Mark only one answer for each question. You will not be given 

credit for any question for which you indicate more than one 

answer. Be certain to mark your answer on the correct line 

and in the correct column for the question you are working on. 

Read each question carefully. Choose the best answer for each 

question. If you change your answer, make sure that you 

completely erase your previous answer. 

It is advisable to answer every question since the number of 

questions answered correctly will determine your final score. 

There is no penalty for guessing. 

You may bring a watch in order to budget your time. 

EXAMINATION RULES 

No books, papers, or other reference materials may be taken into 

the examination room. 

No examination materials, documents, or memoranda of any type may 

be taken from the room by any candidate. 

The examination will be given only on the date and time noted on 

the Admission Letter. If an emergency arises and you are unable to 

take the examination as scheduled, you may call the PCB Office. 

No questions concerning the content of the examination may be asked 

during the examination period. The candidate should listen 

carefully to the directions given by the Proctor and read the 

directions carefully in the examination booklet. 

SPECIAL ADMINISTRATIONS 

Individuals with disabilities and/or religious obligations that 

require modifications in test administration, may request specific 

procedure changes, in writing, to PCB, no fewer than 60 days prior 

to the scheduled test date. With the written request, the 

29

candidate must provide official documentation of the disability or 

religious issue. Candidates should contact PCB on what constitutes 

official documentation. PCB will offer appropriate modifications 

to its procedures when documentation supports the need for them. 

ADMISSION TO THE EXAMINATION 

Upon fulfillment of the appropriate eligibility requirements and 

completion of the application process for CCDP/Diplomate, you will 

be seated for the examination. PCB will send you an Admission 

Letter confirming your enrollment approximately two (2) weeks prior 

to the examination date. This Admission Letter will also contain 

the reporting time, test time, location, contact person, and other 

relevant information. 

Your Admission Letter and a PICTURE IDENTIFICATION CARD (Student 

ID, Driver's License, etc.) must be presented for entrance to the 

examination. 

EXAMINATION DATES 

The CCDP/Diplomate examination may be administered up to four times 

per year in March, June, September, and December. The exact date, 

time, and location of the examination will be provided to you after 

your CCDP application has been submitted to and approved by PCB. 

SCORING 

PCB will score all examinations and mail score reports to 

candidates. Scores will be broken down by category so that 

candidates can see areas of strength and weakness. This process 

takes approximately three to four weeks. 

The passing point is fixed to assure that all candidates must 

achieve the same score to be granted certification. To achieve a 

passing score, CCDP candidates must correctly answer 100 questions 

out of 150 total questions and CCDP Diplomate candidates must 

correctly answer 100 questions out of 175 total questions. 

TEST DISCLOSURE 

If candidates wish to appeal their score on the written test, they 

must submit a written request to PCB within 30 days of the postmark 

on the test score report. Candidates should be aware that test 

security and item banking procedures do not permit candidate’s 

access to test questions, answer keys, or other secure materials. 

30

REFERENCES 

The following resources were used as the basis for most of the 

questions on the CCDP/Diplomate examination. Consulting these 

references may be beneficial to you as you prepare for the exam. 

Please note that not all questions on the exam came from these 

references. 

Alcoholics Anonymous. Alcoholics Anonymous Big Book. 4th Ed. 

Alcoholics Anonymous World Services, 2000. 

American Psychiatric Association. Diagnostic and Statistical 

Manual of Mental Disorders. 4th Ed., revised. (DSM-IV-TR), 2000. 

Antai-Otong, D. Psychiatric Emergencies: How to Accurately Assess 

and Manage the Patient in Crisis. Pesi Healthcare, 2001. 

Barlow, D. & Durand, V.M. Abnormal Psychology: An Integrative 

Approach. 3rd Ed. Wadsworth Publishing Company, 2002. 

Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. 

Cognitive Therapy of Substance Abuse. Guilford Press, 1993. 

Berghuis, D. J. & Jongsma, A. E. The Severe and Persistent Mental 

Illness Treatment Planner. Wiley & Sons, 2000. 

Bissell, L. & Royce, J. Ethics for Addiction Professionals. 

Hazelden, 1994. 

Black, T. Doing Quantitative Research in the Social Sciences : An 

Integrated Approach to Research Design, Measurement and 

Statistics. Sage, 2002. 

Cohen, B. Theory and Practice of Psychiatry. Oxford Press, 2003. 

Commonwealth of PA. PA Bulletin, Volume 15, #42; 42CFR Part 2, 

1985, 1992. 

Commonwealth of PA. PA Confidentiality Guidelines, 28 PA Code - 

Section 709.28, Chapter 255.5, 1998. 

Corey, G. Theory and Practice of Counseling and Psychotherapy. 

6th Ed. Brooks/Cole, 2000. 

Corey, G., Corey M.S. & Callahan, P. Issues and Ethics in the 

Helping Professions. 6th Ed. Brooks/Cole, 2003. 

Creswell, J. Research Design: Qualitative, Quantitative, and 

Mixed Methods Approaches. Sage, 2002. 

Daley, D. C. & Moss, H. B. Dual Disorders: Counseling Clients 

with Chemical Dependency and Mental Illness. 3rd Ed. Hazelden, 

2002. 

31

Daley, D. C. A Family Guide to Dual Disorders. 3rd Ed. Hazelden, 

2003. 

Daley, D. C. Dual Diagnosis Workbook: Recovery Strategies for 

Addiction and Mental Health Problems. Herald House, 1994. 

Daley, D. C., & Roth, L. When Symptoms Return: A Guide to Relapse 

Prevention in Psychiatric Illness. Revised Ed. Learning 

Publications, 2001. 

Denning, P. Practicing Harm Reduction Psychotherapy. Guilford 

Press, 2000. 

Dennison, S. Handbook of the Dually Diagnosed Patient. 

Lippincott, 2003. 

Doweiko, H.E. Concepts of Chemical Dependency. 5th Ed. 

Brooks/Cole, 2001. 

Evans, K. & Sullivan, J. M. Dual Diagnosis: Counseling the 

Mentally Ill Substance Abuser. 2nd Ed. Guilford Press, 2001. 

Fallot, R. D. Spirituality and Religion in Recovery from Mental 

Illness (New Directions for Mental Health Services, #80). Jossey 

Bass Publishers, 1998. 

First, M. & Frances, A. DSM-IV Handbook of Differential 

Diagnosis. American Psychiatric Publishing, 1995. 

Frames, R. & Miller, S. Clinical Textbook of Addictive Disorders. 

Guilford Press, 1995 

Galanter, M. & Kleber, H. Textbook of Substance Abuse Treatment. 

3rd Ed. American Psychiatric Association, 2004. 

Gay and Lesbian Medical Association. Healthy People 2010 - 

Companion Document for LGBT Health. GLMA, 2001. 

Hamilton, T. & Samples, P. The 12 Steps and Dual Disorders. 


Haynes, R., Corey, G., & Moulton, P. Clinical Supervision in the 

Helping Professions: A Practical Guide. Wadsworth, 2002. 

Hester, R. K. & Miller, W. R. Handbook of Alcoholism Treatment 

Approaches: Effective Alternatives. 2nd Ed. Allyn & Bacon, 1995. 

Huch, S. & Cormier, H. Reading Statistics and Research. Harper 

Collins, 1996. 

International Certification and Reciprocity Consortium. Study 

Guide for the Certification Examination for Advanced Alcohol and 

32

Other Drug Abuse Counselors. Columbia Assessment Services, 2002. 


Guide for the Certification Examination for Alcohol and Other 

Drug Abuse Counselors. Columbia Assessment Services, 2002. 


Guide for the Certification Examination for Clinical Supervisors. 

Columbia Assessment Services, 2002. 

James, J.K. & Gilliland, B.E. Crisis Intervention Strategies. 4th 

Ed. Brooks/Cole, 2001. 

Johnson, J. & Preston, J. D. Clinical Psychopharmacology Made 

Ridiculously Simple. 5th Ed. MedMaster, 2003. 

Keltner, N. & Folks, D. Psychotropic Drugs. 3rd Ed. Mosby 

Publishing, 2001. 

Kennedy, J. Fundamentals of Psychiatric Treatment Planning. 

American Psychiatric Publishing, 2003. 

Lee, W. M. L. Multicultural Counseling. Accelerated Development, 

1999. 

Legal Action Center. Confidentiality: A Guide to Federal Law and 

Regulations. Legal Action Center, 1995. 

McArthur, J. & Selnes, O. AIDS and the Nervous System. 2nd Ed. 

Lippincott Raven, 1997. 

McGuire, S. Subtle Boundary Dilemmas. Hazelden, 1996. 

Miller, N. S. Treating Coexisting Psychiatric and Addictive 

Disorders: A Practical Guide. Hazelden, 1994. 

Miller, W. Combined Behavioral Interventions Theory Manual. 

Pending Publications, 2001. 

Miller, W. R. & Rollnick, S. Motivational Interviewing: Preparing 

People for Change. 2nd Ed. Guilford Press, 2002. 

Montrose, K. & Daley, D. Celebrating Small Victories: A Primer of 

Approaches & Attitudes for Helping Clients with Dual Disorders. 


Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. Integrated 

Treatment for Dual Disorders: A Guide to Effective Practice. 

Guilford Press, 2003. 

NAADAC. Basics of Addiction Counseling: Desk Reference and Study 

Guide. The Association For Addiction Professionals, 2003. 

33

National Institute of Drug Abuse (NIDA). How Good is Your Drug 

Abuse Program. National Institute of Health, 1993. 

National Institute of Drug Abuse (NIDA). NACDA Clinical Report 

Series: Mental Health Assessment & Diagnosis of Substance Abuse. 

BKD 148, 1994. 

Nuckols, C. The Dual Diagnosis Recovery Book. Hazelden, 1993. 

O’Connell, D. F. & Beyer, E. P. Managing the Dually Diagnosed 

Patient: Current Issues and Clinical Approaches. Haworth Press, 

2002. 

O’Neal, J. H., Talaga, M. C., & Preston, J. D. Handbook of 

Clinical Psychopharmacology for Therapists. 3rd Ed. New 

Harbinger, 2002. 

Onken, L., Blaine, J., Gensen, S., & Horton, A. Treatment of 

Drug-Dependent Individuals with Comorbid Mental Disorders. NIDA 

Research Monograph #172. National Institute on Drug Abuse, 1997. 

PA Act 126 regarding the release of drug and alcohol treatment 

records or related information for children. (Pg. 21). 1998. 

PA Department of Health, Bureau of Drug & Alcohol Programs. 1999 

Confidentiality Protocol & 2002 Protocol for Sharing Information. 

PA Department of Health. Pennsylvania Client Placement Criteria. 

2nd Ed. PA Department of Health, 1999. 

Pennsylvania Certification Board, Certified Co-Occurring 

Disorders Professional Grandfathering Application. Pennsylvania 

Certification Board, 2004. 

Perkinson, R. & Jongome, A. The Chemical Dependence Treatment 

Planner. Wiley, 1998. 

Powell, D. Clinical Supervision in Alcohol and Drug Abuse 

Counseling: Principles, Models, Methods. Jossey-Bass Publishers, 

1999. 

Santrock, J. Lifespan Development. 6th Ed. William Brown 

Communications, 1997. 

Shader, R. Manual of Psychiatric Therapeutics. 3rd Ed. Lippincott 

Williams & Wilkins, 2003. 

Shea, S. C. The Practical Art of Suicidal Assessment: A Guide for 

Mental Health Professionals and Substance Abuse Counselors. 

Wiley, 1999. 

Sperry, L., Carlson, J., & Kjos, S. Becoming an Effective 

Therapist. Allyn & Bacon, 2003. 

34

Stern, T., Herman, J., & Slavin, P. The MGH Guide to Psychiatry 

in Primary Care. McGraw-Hill, 1998. 

Thompson, Brooks, Cole. Codes of Ethics for the Helping 

Professions. 2nd Ed. Patterson Printing Co., 2004. 

Tims, F. M., Leukefeld, C. G., & Platt, J. J. Relapse and 

Recovery in Addictions. Yale University Press, 2001. 

United States Dept. of Health & Human Services, Substance Abuse & 

Mental Health Services Administration, Center for Substance Abuse 

Treatment. A Providers Introduction to Substance Abuse Treatment 

for LGBT Individuals. Publication #OCP1, 2001. 



Treatment. Assessment and Treatment of Patients with Coexisting 

Mental Illness and Alcohol and Other Drug Abuse. TIP #9. 1995. 



Treatment. Brief Interventions and Brief Therapies for Substance 

Abuse. TIP #34. 1999. 



Treatment. Comprehensive Case Management for Substance Abuse 

Treatment. TIP #27. 1998. 



Treatment. Confidentiality of Patient Records for Alcohol and 

Other Drug Treatment. TAP #13. 1994. 



Treatment. Enhancing Motivation for Change in Substance Abuse 

Treatment. TIP #35. 1999. 



Treatment. Substance Abuse Treatment for Persons with HIV/AIDS. 

TIP #37. 2002. 



Treatment. Substance Use Disorder Treatment for People with 

Physical and Cognitive Disabilities. TIP #29. 1998. 



Treatment. Guidelines for the Use of Antiretroviral Agents in 

35

HIV-Infected Adults and Adolescents. 

http://aidsinfo.nih.gov/guidelines/adult/AA-102904.pdf, 2000. 


Mental Health Services Administration. Report to Congress on the 

Prevention and Treatment of Co-Occurring Substance Abuse and 

Mental Disorders. 2002. 


Mental Health Services Administration. Strategies for Developing 

Treatment Programs for People with Co-Occurring Substance Abuse 

and Mental Disorders. SAMHSA Publication #3782. 2003. 

Westermeyer, J. J., Weiss, R. D., & Ziedonis, D. M. Integrated 

Treatment for Mood and Substance Use Disorders. John Hopkins 

University Press, 2003. 

Zukerman, E.L. Clinician's Thesaurus. 5th Ed. Guilford Press, 

2000. 

36

2004 PA Certification Board (PCB). All rights reserved. No part 

of this document may be disclosed or reproduced in any form without 

written authorization of PCB. For more information, write to PCB, 

298 S. Progress Avenue, Harrisburg, PA 17109. 

37

M07: Moody Blues: Co-occurring Substance Use and Mood Disorders 

Pasquale Russoniello, MA 


Description: 

Research demonstrates that there is often a strong link between mood disorders and substance use. 

Historically, however, treatment has not been effectively integrated in treating these disorders. This workshop 

explores research about the prevalence of these co-occurring disorders, as well as gender issues and effective 

treatment approaches. 


• Describe mood disorders in the DSM-IV-TR and their risk factors for substance use disorders; 

• Review gender issues both in assessment and treatment; 

• Discuss evidence-based treatment components across treatment settings for these co-occurring 

disorders. 

NOTES:


Moody Blues: Co-occurring 

Substance Use and Mood 

Disorders 

Pasquale Russoniello 

Epidemiology: Major Depression 

(DSM-IV, 1994) 

• Depression is estimated to become 

the second leading cause of disability 

worldwide 

• An estimated 17% of adults will have 

an episode of major depression in 

their lifetime 

– 5% of these episodes will last more than 

one year 

Epidemiology: Major Depression 

• 5-10% of adult primary care clients 

suffer from major depression 

– 8% of primary care clients may have 

dysthymia 

– Higher rates in institutions 

– Increased risk of Alcohol Dependence in 

adult first-degree relatives 

• 50%-60% with one episode of Major 

Depression are likely to have others 

National Survey of Major 

Depression (NESARC, 2001-2002) 

• Increased likelihood of current or lifetime 

MDD: 

– Middle age – mean age of onset about age 30 

– Native American race 

– Female gender 

– Low income 

– Separation, divorced or widowhood 

• Nearly one-half wanted to die, one-third 

considered suicide and 8.8 % reported one 

attempt 

NESARC Findings for MDD and 

SUDs 

• 14% of current MDD persons have a Alcohol use 

disorder (AUD) and 4.6 had a drug use disorder 

• (higher rates among persons with lifetime MDD – 

40% had AUD & 17% had experienced drug 

disorder. 

• Strong relationship - MDD to substance dependence 

and a weak relationship to substance abuse 

• Coexisting substance dependence disorder and 

MDD predict poor outcome among clinic patients 

• Integrated treatment becoming common practice 

Epidemiology: Bipolar Disorder 

(DSM IV, 1994) 

• Lifetime=0.8 to 1.6 percent of the general 

population 

• Lifetime incidence = 1.6% 

• Males and Females equally affected by 

Bipolar I Disorder 

– Bipolar II is more common in females 

• 25-50% attempt suicide 

– 11 % die by suicide. 

1


Under-recognition and Undertreatment 

of Depression 

• Depression 

– 45% untreated 

– 44% under treated 

– 11% treated appropriately 

Hirschfeld et al., 1997 

Underrecognition and 

Undertreatment: Bipolar Disorder 

• More than half do not seek treatment 5 

years after first experiencing symptoms. 

• 36 percent did not seek treatment after 10 

years. 

• The correct diagnosis was not made until 

an average of 8 years after first seeking 

treatment (NDMDA survey). 

Undertreatment: Provider Factors 

(Hirschfeld,et al,1997) 

• Poor education about the disorders 

• Limited training in interpersonal skills 

•Stigma 

• Inadequate time to evaluate and treat 

• Failure to consider psychotherapeutic 

approaches 

• Inadequate doses of medication for 

inadequate durations 

DSM-IV Mood Disorders 

• Major Depressive Disorder 

• Dysthymic Disorder 

• Depressive Disorder NOS 

• Bipolar I Disorder 

• Bipolar II Disorder 

• Mood Disorder Due to a General Medical Condition 

• Substance-Induced Mood Disorder 

• Mood Disorder NOS 

Comorbidity is Common 

(Kessler et al,1996) 

• Most people with 1 mental disorder suffer 

from 1 or more other disorders 

• Mood disorders are risk factors for medical 

illness 

• Both psychiatric and medical comorbidities 

are especially common in those with 

bipolar disorder 

Some Comorbid Conditions 

• Substance related disorders 

– Alcohol abuse/dependence most common 

• Anxiety disorders 

• Impulse Control Disorders (Bipolar 

disorder) 

– Pathological Gambling and Kleptomania 

most common 

• Eating Disorders (Bipolar disorder) 

• Personality Disorders 

2


Causes of Mood Disorders 

• Biological diseases 

• Caused by changes in brain chemistry 

• No single cause of changes in brain 

chemistry 

– Episodes occur as a result of genetic, 

biological, and psychological influences 

combined with life stresses 

Common Pathway Hypothesis 

(Reinecke & Davison, 2002) 

• Interactive model 

• Behavioral manifestation of a new 

psychobiological state 

• Various interlocking processes at the: 

– Neurophysiological & 

– Biochemical & 

– Experiential & 

– Behavioral levels 

Common Pathway Hypothesis (con’t) 

BIOPSYCHOSOCIAL-SPIRITUAL MODEL 

(Adapted from Sands, 1991) 

BIOLOGICAL 

• Affects the limbic-diencephalic-prefrontal 

cortex connection 

• Builds over many years 

• Weaving together of biological, social and 

psychological factors 

PSYCHOLOGICAL 

Genetics 


Neurophysiology 

Cognition 

Emotions 

Behaviors 

Interactions 

Transactions 

SPIRITUAL 

SOCIAL 

Factors Considered in the 

Common Pathway Hypothesis 

• Genetic vulnerability 

• Predisposing temperament 

• Character traits 

• Age and gender 

• Physical illness 

Factors Considered in the Common 

Pathway Hypothesis (con’t) 

• Aging 

• Developmental events 

• Socio-cultural context 

• Major trauma (single event or 

ongoing traumatic events) 

3


Expression of Mood Disorders 

According to CFP Hypothesis 

• Major genetic vulnerability with or without 

‘abnormal’ major environmental stress 

• Predisposing parameters in the absence 

of genetic or biological vulnerability 

• Severe traumatic event with minimal 

vulnerability 

SEE STRESS DIATHESIS MODEL 

STRESS-DIATHESIS MODEL 

Psychobiological 

vulnerability 

Protective factors 

Social support 

Skill building 

Transitional programs 

Medication 

Socioenvironmental 

stressors 

Impairments Dysfunction Disabilities 

Disability 

Good 

Rehabilitation Outcomes 

Poor 

(Adapted from Anthony, W.A. & Liberman, R.P., 1994) 

Major Depressive Episode 

(DSM-IV): Criterion A 

• Essential Feature: 

–A period of at least 2 weeks 

during which there is either 

depressed mood or the lost of 

interest or pleasure in nearly all 

activities 

DSM-IV Criteria for Major 

Depressive Episode: Criterion A 

•4 or more of: 

–Appetite changes (usually weight 

loss) 

–Insomnia or hypersomnia 

–Motor agitation or retardation 

–Fatigue/loss of energy 

DSM-IV Major Depressive Episode: 

Criterion A (Cont’d) 

–Feelings of worthlessness or 

excessive guilt 

–Diminished ability to think or 

concentrate or indecisiveness 

–Recurrent thoughts of death or 

suicidal ideation without a plan, or a 

suicide attempt or a specific plan for 

committing suicide 

Physical Symptoms in Depression 

That Can also be Due to SUDs 

• Tiredness, fatigue 

• Sleep disturbance 

• Headaches 

• Psychomotor retardation/agitation 

• GI disturbances 

• Appetite changes 

• Body aches and pains 

4


DSM-IV Criterion B & C 

B. The symptoms do not meet criteria 

for a Mixed Episode 

C. Symptoms cause clinically 

significant distress or impairment in 

social, occupational, or other 

important areas of functioning 

Differential Diagnosis: DSM-IV 

Criteria D & E 

• D- Symptoms not due to direct effects 

of a substance (drug of abuse, a 

medication) 

• Substance –Induced Mood Disorder 

– or a general medical condition 

• Mood Disorder Due to a General 

Medical Condition 

• E- symptoms not better accounted for 

by bereavement 

Rule Out Medications/Drugs That 

Can Cause Depression 

• Sedative-hypnotic agents 

• Antidepressive meds (may worsen 

depression; increase suicidal ideation/beh. 

especially in children, adolescents) 

• Anti-inflammatory agents and analgesics 

• Steroids/ Hormones 

• Antihypertensives/Cardiovascular agents 

• Others, e.g.interpheron 

Clinical Interview 

• Start with chief complaint 

• Explore past history 

• Explore current symptoms 

– Look for critical criteria for depression 

and/or mania 

• Assess risk of suicide 

• Assess need for immediate 

hospitalization 

Suicidality: Key Points to Assess 

(CME,Inc.,2003) 

• Depressed mood, regardless of diagnosis 

• Hopelessness 

– Beck Hopelessness Scale 

• Changes in social supports, finances or 

health 

• Family hx or recent exposure to events 

• Presence of alcohol and/or drug use 

• Changes in substance abuse 

Suicidality (Cont’d) 

– History and seriousness of previous 

attempts 

– Presence of suicidal or homicidal ideation, 

intent, or plans 

– Access to means for suicide and the 

lethality of those means 

– Presence of psychotic symptoms, command 

hallucinations, or severe anxiety (could be 

related to drug intoxication or withdrawal) 

5


DSM-IV Criteria 

Dysthymic Disorder 

• Depressed mood for most of the day 

on more days than not, lasting for two 

years 

• When depressed, two or more of: 

– Poor appetite or overeating 

– Insomnia or hypersomnia 

– Low energy or fatigue 

DSM-IV Criteria for Dysthymia 

– Low self-esteem 

– Poor concentration of indecisiveness 

– Feelings of hopelessness 

• Causes significant distress or impaired 

social or occupational functioning 

• Can never be without symptoms longer 

than two months 

• Lifetime prevalence is 6% 

Bipolar Disorders 

• Bipolar I 

– Meets criteria for major depression and mania 

• Bipolar II 

– Meets criteria for major depression and 

hypomania 

• Cyclothymic 

– Minor depression and hypomania 

• Bipolar Disorder NOS 

DSM-IV Criteria For Manic Episode 

• Distinct period of abnormally and 

persistently elevated, expansive, or 

irritable mood lasting at least 1 week 

– Or any duration if hospitalized 

•3 or more: 

– Inflated self-esteem or grandiosity 

– Decreased need for sleep 

DSM-IV Criteria For Manic Episode 

• Behaviors (Cont’d) 

– More talkative than usual or pressure to keep 

talking 

– Flight or ideas or subjective experience that 

thoughts are racing 

– Distractibility 

– Increase in goal-directed activity 

– Excessive involvement in pleasurable activity 

Some Medical Conditions That Can 

Cause Mania (Preston,2002) 

• Central nervous system trauma 

–Post-stroke 

• Metabolic disorders 

– Hyperthyroidism 

• Infectious diseases 

– Encephalitis 

• Seizure disorder 

• Central nervous system tumor 

6


Some Medications That Can Cause 

Mania (Benner,2002) 

• Stimulants (amphetamines) 

• Antidepressants (especially tricyclics) 

• SAM-e 

• Antihypertensives 

• Corticosteroids in higher doses 

• Anticholinergics (Cogentin®) 

• Thyroid hormones 

Treatment Options : Mania 

• Medication 

• Psychosocial/environmental 

approaches 

• Hospitalization for stabilization 

Bipolar 1: Diagnosis 

• Characterized by one or more manic episodes 

or mixed episodes 

• Often, one or more major depressive episodes 

• Cannot be related to drug-induced behaviors or 

a medical condition 

• Significant impairment 

Rule Out: 

Symptoms due to medical condition, medication, 

or substance abuse; and 

• Schizoaffective disorder 

• Anxiety disorder 

Bipolar II Disorder 

• Characterized by hypomanic and 

depressive episodes 

• More difficult to recognize 

– Hypomania may seem normal 

• Usually seek treatment only for depression 

Misdiagnosis in Mood Disorders 

• As many as 69% are misdiagnosed 

– For every 10 people with a diagnosis of 

depression, as many as 3 may have a bipolar 

disorder 

– Often misdiagnosed as unipolar depression 

• If agitated or restless, may be diagnosed 

with anxiety disorder 

– Many diagnosed with Borderline personality 

disorder may have Bipolar disorder 

Consequences of Misdiagnosis 

( Kahn, et al., 2000) 

• Diagnose as SUD only vs COD 

– More than 50% abuse alcohol or drugs 

during manic phase of the illness 

• Treatment difficulties 

– Episodes may become more frequent and 

harder to treat 

– 23% developed new or accelerated rapid 

cycling (Kindling) 

• Suicide 

– 1 out of 5 will die from suicide 

7


Suicide : Bipolar Disorder 

• Lifetime risk = 15xs higher in bipolar 

disorder than in general population 

– Highest risk = young men in early phase of 

illness who have made previous attempts or 

who abuse alcohol 

– Risk increased if psychotic and depressed 

concurrent with mania 

– Increased risk if abusing substances 

• 10-19% commit suicide 

– 79% of these suicides occurred while 

depressed 

Substance Induced Mood 

Disorders 

A disturbance in mood characterized by 

either (or both) of the following: 1) 

depressed mood r diminished interest and 

pleasure in activities; or 2)elevated, 

expansive or irritable mood. 

Alcohol 

inhalant 

amphetamine opioid 

cocaine 

hallucinogen 

phencyclidine 

Other e.g. ecstasy, 

Marijuana 

Substance- Related Disorders 

(Kessler et al. 1996) 

• More than 60% of individuals with bipolar 

disorder meet lifetime criteria for a 

substance-related disorder 

– Greater than in any other Axis 1 disorder 

• 34-67% rate of major depression in 

alcohol abusers 

Substance Abuse Disorders 

Cont’d 

• It is one of the major factors in medication 

noncompliance and suicidality. 

• Symptoms of the disorders mimic each 

other 

• These individuals have a more difficult 

course of illness and are the most 

treatment resistant. 

Substance Abuse Disorders 

Cont’d 

• In around 10% of persons with co-occurring 

disorders the depression persists after acquiring 

sobriety (Nunes et al.1993) 

• Both disorders can exist independently of each 

other in the same individual and treatment of the 

mood disorder yields improvement in both 

conditions (Zickler, 2000; Grant, 1999) 

• Those persons with co-occurring disorders are 

much more likely to seek treatment with resulting 

higher costs (Druss & Rosenheck, 2000) 

General Treatment Approaches 

• Use evidence-based guidelines and 

management tools for treating 

• Medication 

• Psychotherapy 

– Integrated for co-occurring, including 

individual and group 

– Intensive outpatient 

• Psychoeducation 

• Self-help, including 12 step and Dual 

Recovery 

8


Examples of Psychotherapy 

Options (Kahn et al,2000) (Klerman et al,1984) 

• Cognitive Therapy 

• Behavior Therapy 

• Interpersonal Therapy 

• Group therapy incorporating above 

Psychoeducational Issues 

(Keltner,2003) 

• Focus on wellness 

– Learn to minimize stress 

– Balance sleep and activity patterns 

– Adverse effects of medication and/or substances 

• Genetic risks 

• Avoid alcohol or illicit drugs 

– Identify triggers 

– Problem solving and harm reduction strategies 

• Advance directives 

Psychosocial Issues (Cont’d) 

Example of Treatment Phases and Goals 

For Depression (APA, 2002) 

• Improve coping skills 

– Enlist family and friends 

• Acceptance of illness 

• Signals of relapse 

– Learn to recognize “early warning signs” of 

new mood episode 

Phase 

Acute 

Continuation 

Length 

6-12 (16) 

weeks 

4-9 (12) 

months 

Tx Goal 

Achieve 

Remission 

Prevent 

Relapse 

Maintenance 

Varies 

Protect 

against 

Recurrence 

Depression: Evidence-Based 

Beneficial Interventions 

• Cognitive therapy (in mild to moderate 

depression) 

• Continuation treatment with 

antidepressant drugs (reduces risk of 

relapse in mild to moderate depression) 

• Electrconvulsive therapy severe 

depression) 

• Prescription antidepressant drugs for all 

levels of severity 

9

Moody Blues: Co-occurring Substance Use and Mood Disorders 

Bibliography 

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders Forth 

Edition, Text Revision. Washington, DC. 

American Psychiatric Association. (2000). Practice guidelines for the treatment of patients with 

major depressive disorder (2 nd ed.). Washington, D.C.: Author. 

Beck, A. T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. 

N.Y.: Guilford Press. 

Clinical Tools (2003) Introduction to screening, diagnosis and treatment of depression in 

primary care. Retrieved from http://cme.depressionclinic.com on January 22, 2004. 

Frances, A.J. (1993). An introduction to dysthymia. Psychiatric Annals. 23, 607-608. 

Goodwin, F.K. & Jamison, K.R. (1990). Manic-Depressive Illness, N.Y.:Oxford University 

Press. 

Hilty, D.M., Brady T.B., & Hales, R.E. (1999). A review of bipolar disorder among adults. 

Psychiatric Services, 50(12), 201-213. 

Hirschfeld RMA. The comorbidity of major depression and anxiety disorders: Recognition and 

management in primary care. Primary Care Companion J Clin Psychiatry, 

2001;3(6):244-254. 

Irvine, E.A., Silver, R.C., & Waitzkin, H. (2000). Trauma and the risk of psychiatric disorder. 

Archives of Family Medicine. September, 2000. 

Kessler, R.C., Nelson, C.B., & McGonagle, K.A. (1996). The epidemiology of co-occurring 

addictive and mental disorders: Implications for prevention and service utilization. 

American Journal of Orthopsychiatry. 66, 17-31. 

Klerman, G.L., Weissman, M.M., Rounsaville B.J., & Chevron, E.S. (1984). Interpersonal 

psychotherapy of depression. N.Y.: Basic Books. 

MacArthur Foundation. MacArthur initiative depression toolkit (2001). Retrieved from 

www.depression-primarycare.org/clinicians/toolkits. on February 16,2004 

Miller, W.R. & Rollnick, S. (1991). Motivational Interviewing: Preparing people to change 

addictive behavior. N.Y.: Guilford Press. 

NIH News. (2005). National survey sharpens picture of Major Depression among U.S. adults. 

Retreived April 3, 2006 from: http://www.nih.gov/news/pr/oct2005/niaaa-03a.htm

Prochaska, J.O. & DiClemente, C.C., (1992). Stages of change in the modification of problem 

behaviors. American Journal of Psychology. 28, 183-218. 

Reinecke, M.A. & Davison M.R. (Eds.). (2003). Comparative treatments of depression. Springer 

(www.spriingerpub.com). 

Shea, M.T., Glass, D.R., Pilkonis, P.A., Watkins, J., & Docherty, J. P. (1990). Personality 

disorders and treatment outcome in the NIMH Treatment of Depression Collaborative 

Research Program. American Journal of Psychiatry. 147, 711-718. 

Shea, M.T., Glass, D.R., Pilkonis, P.A., Watkins, J., & Docherty, J.P. (Frequency and 

implications of personality disorders in a sample of depressed outpatients. Journal of 

Personality Disorders. 1, 27-42 

Shea MT, Glass DR, Pilkonis PA, Watkins J & Docherty JP (1990). Personality disorders and 

treatment outcome in The NIMH Treatment of Depression Collaborative Research 

Program. Am, J Psychiatry:147: 711-718 

Strakowski Sm, Del Bello JP. (2000). The co-0ccurrence of bipolar and substance abuse 

disorders. Clinical Psychology Review 20: 191-206

M11: Lessons Learned From Early Systems Integration Grants: Wesley Spectrum Services 

Co-occurring Disorders Program 

Carolyn Baird, MBA, Med, CARN-AP, CCDP-D & Lorraine Shipley, MEd, LPN 


Description: 

Much learning has occurred through the implementation of the first MISA Grants in Pennsylvania. Now the 

Washington Wesley Spectrum Co-Occurring Disorders Program, this early “experiment” in integrated services 

has a thriving, growing adult COD program with a full spectrum of services; a new family component; an 

Adolescent IOP; and an in-house Case Manager. This presentation will examine the “growing pains” and 

discuss the lessons learned. 


• Compare and contrast the requirements for mental health and substance use outpatient treatment 

programs; 

• Describe the barriers to be overcome in implementing integrated treatment programs; 

• Discuss the benefits of an integrated approach in treating individuals with co-occurring disorders; 

• Evaluate the need for integrated services in their own treatment area. 

NOTES:


LESSONS LEARNED FROM EARLY 

SYSTEMS INTEGRATION GRANTS: 

LESSONS LEARNED 

FROM EARLY SYSTEMS INTEGRATION 

GRANTS: 

CO-OCCURRING 

DISORDERS 

PROGRAM 

WSS CO-OCCURRING DISORDERS PROGRAM 

Carolyn Baird, MBA, MEd, CARN-AP, CCDP-P 

Lorraine Shipley, MEd, LPN 

Background 

• Establishment of MISA Consortium 1997- 

sponsored by PA Department of Public Welfare 

Office of Mental Health and Substance Abuse 

Services (OMHSAS) and Department of Health 

Bureau of Drug and Alcohol Programs (BDAP) 

• Purpose-examine integrated approaches to 

treatment of co-occurring disorders of mental 

illness and substance abuse 

Background 

• MISA Consortium issued a formal report in 1999 

• Courses and core competencies were 

established 

• OMHSAS and BDAP issued a request for 

counties to express interest in establishing MISA 

services and systems 

• 29 counties expressed their interest 

Background 

• April 2001-interested MH administrators and SCA 

directors received a solicitation for MISA pilot 

projects 

• 18 proposals were received and reviewed 

• 5 counties were awarded pilot projects 

• One child and adolescent project was funded in 

Berks County 

• Four adult projects were funded Beaver, Blair, 

Mercer and Washington 

Overview 

• MH and D/A funds allocated for two years 

• A third year was used for evaluation by the 

Center for Mental Health Policy and Services 

Research (CMHPSR) University of PA 

• Data collection was ongoing for the first two 

years with individualized pilot outcomes 

• SIIP (Screening Interview for Initial Placement) 

concurrent pilot 

1


Purpose 

• Create best practice models of systems 

integration 

• Test the theory that integrated services have 

better outcomes for MISA consumers 

• Support the potential of integrated systems as a 

cost-effective alternative to traditional services 

General MISA Pilot Facts 

• Dually licensed (MH & D/A) providers 

• Policies and procedures that demonstrate MISA 

philosophy 

• SIIP used as screening tool 

• MISA Intensive Case Management available 

• MISA Core Competency training for staff 

Washington County Philosophy 

• Any client wishing services for either mental 

health or substance abuse issues has the right to 

barrier free access to the service/services of 

his/her choice. 

• A variety of service settings and intensities have 

been provided in order to facilitate client choice. 

Washington County Features 

• Multiple MISA screening points 

• Mobile MISA assessments 

• MISA intensive case management 

• Establishment of a MISA Oversight Committee 

Washington County Features 

• Development of a MISA Halfway House, MISA 

therapeutic community housing, and mobile 

crisis services 

• Community committee to promote MISA 

awareness and supports 

• Enhancements to the dually licensed continuum 

of care 

Multiple MISA Screening Points 

• All treatment providers, not just MISA providers, were 

trained in the SIIP (Screening Interview for Initial 

Placement) 

• Individuals could be assessed at one of three base 

service units Centerville, Washington Communities or 

SPHS Behavioral Health 

• Contracted substance abuse treatment agencies could 

complete assessments 

• Washington Drug and Alcohol provided assessments, 

onsite or mobile, through their Assessment Unit 

2


MISA Intensive Case Management 

• Intensive Case Management (ICM) services are offered 

by the Single County Authority (SCA) Washington Drug 

and Alcohol Commission 

• Each of the BSUs has an ICM unit 

• Any MISA client may be followed by ICM at any site 

based on the client’s point of entry 

• ICMs receive MISA Core Competency training 

MISA Intensive Case Management Continued 

• Future, the SCA and each BSU will have 

identified MISA ICMs 

• Clients will be assigned their ICM based on their 

point of entry to MISA services 

• All MISA ICMs will meet monthly, as a unit, to 

staff clients 

MISA Oversight Committee 

Composed of: 

• MH Administrator 

• MH Program Specialist 

• SCA Director 

• D/A Program Specialist 

• Participating agencies’ assigned staff 

• Fiscal personnel 

MISA Oversight Committee Continued 

• Met weekly at the beginning 

• Held issue focused meetings 

• Identified as a quarterly meeting 

Purpose was to: 

• problem solve 

• address complaint and grievance issues 

MISA Halfway House 

• Greenbriar opened the Lighthouse for Women 

in September of 2001 

• It is dually licensed 

• It holds up to 24 women 

MISA Housing 

Plan was for a Therapeutic Community: 

• Focused on issues of substance use, MISA, 

homelessness and incarceration 

• Life skills program associated with it 

• Staffed 16 hours a day 

• Referrals to treatment and ancillary services 

3


Mobile Crisis Services 

• A request for proposal was extended in the fall 

of 2001 – due date November 1 st 

• One agency responded 

• Washington County MH/MR met with this 

agency to develop the services 

• Hoped for start-up was October 2002 

• Unable to develop 

MISA Community Committee 

Goals: 

• Review status of MISA programming 

• Provide ongoing input as to how to improve 

services 

MISA Community Committee Continued 

Action steps: 

• Provide general guidance, review and input 

• Assist in the continuous quality improvement 

(CQI) process 

• Function as an early warning system 

• Maintain an up to date knowledge base 

• Advocate for increased resources 

MISA Community Committee Continued 

MISA Task Force has been asked to serve 

• Established in 1995 

• One of the Washington County SHIP (State Health 

Improvement Planning Process) task forces 

• Member of Washington County Health Partners, Inc. 

• Sponsored trainings that educated 500 individuals 

• Supported the start-up of Dual Recovery Anonymous in 

Washington County 

l 

Continuum of Care Enhancements 

• All Washington County treatment agencies 

have staff trained to use the SIIP 

• Most WC agencies have staff who have or are 

receiving MISA training in the core 

competencies 

• Centerville Clinic (BSU) was working toward 

dual licensure 

• Catholic Charities (D/A) was researching dual 

licensure 

HIGHLIGHTS 

• MISA Continuum of Care from Inpatient 

through support programs 

• Uniform screening tool, the SIIP (Screening 

Interview for Initial Placement) 

• Administrative Oversight team 

• Specialized data collection system 

• Active community committee 

4


MISA Continuum of Care 

MISA 

• Greenbriar 

Assessments 

Inpatient Rehabilitation 

Women’s Halfway House 

• SPHS-Behavioral Health 

Assessments 

Partial 

Outpatient 

ENHANCED DUAL 

Partial 

Outpatient 


MISA ENHANCED DUAL 

• Spectrum Family Network 

Assessments 

Outpatient 

Partial (proposed) 

• Catholic Charities 

Assessments 

• SPHS-CARE 

Assessments 


MISA ENHANCED DUAL 

• Washington Communities 

Assessments 

• Centerville Clinics 

Assessments 

• Turning Point Outpatient 

Outpatient (new) 


Goals and Objectives of Original Proposal 

Goal 1 

Develop and implement an integrated 

assessment and case management program 

for MISA consumers 

Goal I Objectives 

1. Hire and train identified MISA Assessment 

Staff in the use of the SIIP and PCPC 

All MH/MR and D&A agencies and the SCA in 

Washington County have staff trained in the 

SIIP and PCPC 


2. Assure that Assessment Staff meet core 

competencies for MISA Assessment Staff 

Most agencies have a core of staff with the MISA 

Core Competency trainings 

5



3. Hire and train identified MISA Intensive Case 

Management staff 

Existing staff being identified as (MISA) COD 

Funding became available for resource case 

management staff to be hired by COD 

agencies 


4. Assure that ICM Staff meet the core 

competencies for MISA Case Management 

staff 

Training has been ongoing 


5. Develop and implement a training program for 

all MISA Assessment, Treatment and Case 

Management staff 

Ken Montrose, Training Director for Greenbriar, is 

being utilized as a resource for advanced, 

continuing education and cross training 

Training program in place 


6. Locate MISA Assessment and Case 

Management staff within a centralized location 

overseen by GTC 

Washington County Single County Authority 

has maintained control of this 


7. Develop a county-wide Mobile Crisis Team 

that is trained in MISA Core Competencies 

MH/MR Administration decided 

against this because of cost 


8. Develop an informational outline for all 

county D&A and MH/MR provider agencies 

Brochures and information 

sheets are available 

6




Goal II 

Enhance the current MISA treatment 

and aftercare services within 


Goal II Objectives 

1. Increase the number of qualified MISA 

treatment staff in the two existing dually 

licensed MISA treatment facilities in 


The CARE Center relinquished their mental 

health license prior to awarding of grant 

New providers were recruited to become 

dually licensed providers 


2. Assist in developing a full continuum of nonresidential 

adolescent MISA treatment 

services 

This goal was put on hold but 

is currently being reactivated 


3. Develop referral agreements with residential 

and hospital based adolescent programs, to 

facilitate access to all levels of care for MISA 

adolescents 

Contracts are in place to refer to out of county 

providers with adolescent dual tracks 


4. Develop MISA assessment positions for both 

adolescent and adult MISA consumers 

All assessment staff at the SCA have had the 

(MISA) COD core competency training 


5. Develop information technology resources 

specifically for MISA services 

Only county wide data collection is available 

7



6. Assist GTC in the development of dually 

licensed MISA halfway house services for 

women/men 

The women’s halfway house was 

established in September 2001 

The men’s halfway house is on indefinite hold 


7. Increase utilization of current community 

aftercare/support programs 

Unchanged 


8. Develop a MISA program/services monitoring 

tool 

Program review and chart review 

part of the regulatory audits 


9. Assist in the development of post treatment 

housing 

Unchanged 


10. Develop mobile crisis services 

for MISA consumers 

Initiative canceled 



Goal III 

Develop MISA community 

Support services 

8


Goal III Objectives 

1. MISA Intensive Case Management staff will 

conduct monthly case management staff 

meetings 

MISA Case Management plan 

was never initiated 

Some providers have Resource 

Case Managers 


2. Quarterly meetings will be held to review the 

status of MISA programming and provide 

ongoing input as to how to improve services 

MISA Task Force completed 

the goals it had set for itself 


3. Enhance the Consumer Support Team to 

provide specific feedback regarding MISA 

services 

Still pending 


4. Quarterly meetings will be held with SCA, 

MH/MR Administrators and MISA providers to 

identify specific barriers and implement a plan 

of action 

COD Provider Meetings are held 

This group sponsors in county COD trainings 


Goals and Objectives 

May 2003 

Goal IV 

Educate and provide supportive 

services for family members and 

children of MISA consumers 

Goal IV Objectives 

1. Enhance current educational/support 

programs for parents of MISA consumers by 

adding a MISA component to current 

programming 

Pending 

9


Goal IV Objectives 

2. Develop a MISA family member workbook 

3. Develop a workbook for children 

of MISA consumers 

Greenbriar has a training website with 

educational materials available 

Provider Status as of July 2002 

• One inpatient & two outpatient providers were 

dually licensed 

• Three providers were evaluating the impact of 


• All providers were screening individuals 

requesting assessments 

• All clients with potential to be MISA were given a 

SIIP and offered MISA services 

Client Status as of July 2002 

Services began April 1, 2002 

The pilot has served 

• 37 inpatient rehab clients 

• 9 women are at the Lighthouse 

• 21 clients are active at Spectrum with the 

potential to double census by months end 

• 16 clients are in outpatient at SPHS BH & 

3 clients are in partial 

Training Status as of July 2002 

• Nine agencies received SIIP training (30-40 

individuals) 

• Community and provider agencies have been 

sending staff to the MISA Core Competencies 

• Providers have identified approximately 40 staff 

still in need of core competency training 

Focus for July/August 2002 

• Establish monthly MISA provider meetings 

• Identify at least one ICM per BSU/SCA as a 

MISA ICM 

• Establish monthly MISA ICM Team Meetings 

• Assist providers in the process of obtaining 


• Assist in the development of a men’s MISA 

Halfway House 

What We Learned 

2002 Overall 

Average MISA client characteristics 

• 34-37 years of age 

• Caucasian 

• Drug use disorder/mood disorder dxs 

• Co-occurring medical problems 

• Receiving psychotropic medication 

• Criminal justice system involvement 

10



2002 Overall 

Only Mercer County mandated MISA Case 

Management services. 

Only Mercer County had preliminary adult MISA 

client outcomes. 

• 33% arrested and 39% incarcerated 

• 67% admitted to ER (75% for MH & 83% for 

Medication) 

• 92% still engaged in treatment 


2002 Washington County 

Barriers 

• Need for two licenses (MH and D/A) 

• Two regulatory bodies at the state level 

• Two different sets of licensing regulations 

• Two different sets of confidentiality laws 



Barriers 

• Separate county administrative bodies 

• Two funding streams 

• Lack of program staff and administrators with 

MISA expertise and commitment to integrated 

programming 



Barriers 

• Concern for ‘turf’ 

• Concern for census 

• Lack of Case Management services for coordination 

of care 



Benefits 

• Clients could go to one location for assessment 

and treatment 

• Clients became cohesive as a group 

• Clients began to advocate for what they needed 



Recommendations 

• Administration needs to consider MISA 

services the primary option for clients 

• Providers should be required by regulation and 

contract to assess for dual disorders and refer 

to integrated treatment 

11





• Administrative staff working to integrate 

programming should have MISA 

backgrounds and commitment to integration 

• Program staff must be trained in both MH 

and D&A and have ongoing MISA training 




• Integrated Case Management services must 

be an integral part of treatment 

• Community services to support recovery are 

needed 


2005 Spectrum Family Network 

Status of Program 

• Assessments are available at all possible 

points of entry 

• Referrals can be made by anyone 

• On site Resource Case Management 

• Off site Intensive Case Management 




Services consist of 

• Adult, Adolescent, Child Mental Health 

Outpatient 

• Drug & Alcohol/COD Partial (20 clients) 

• Drug & Alcohol/COD Intensive Outpatient (20) 

• Drug and Alcohol/COD Outpatient (80) 




Recent enhancements 

• Participation in Drug Court 

• Family & Parenting Groups 

• Adolescent Intensive Outpatient 

• Dual Recovery Anonymous Meetings 



Challenges 

The need to be comfortable with integrating two 

sets of regulations 

• Maintaining dual licenses 

• Coordinating two regulatory bodies 

• Maintaining confidentiality 

12




Challenges 

Recruiting experienced COD administrators and 

line staff: 

• Initially, there were very few individuals 

available with experience in both fields 

• Training requirements were/are high for D/A 

and COD regulations 

• Social service salaries are usually low 



Challenges 

Once established COD program grew rapidly: 

• Out stripped available staff 

• Volume and intensity ‘burned’ staff out 

• Constant ‘turn over’ of clients and staff 

frustrating to continuity 

• New ‘musts’ constantly being identified 



Challenges 




Programs are ‘fee for service’: 

• Some services are not reimbursable under 

current system 

• Reimbursements often don’t cover cost 

• Simplify the regulatory process 

• Simplify funding 

• Continue to train and credential staff 





• Reduce caseloads according to severity levels 

and intensity of program 

• Streamline paperwork 

• Continue to develop ancillary and support 

services 

QUESTIONS? 

13

Lessons Learned From Early Systems Integration Grants: 

WESLEY SPECTRUM SERVICES COD PROGRAM 

Bibliography 

Commonwealth of Pennsylvania - Department of Health 

Annex A, Title 28. Health and Safety 

Part V. Drug and Alcohol Facilities and Services 

Chapter 701 

Chapter 704 

Chapter 709, Subchapters A, C, H, I 

Revised 3/2004 

Commonwealth of Pennsylvania – Department of Public Welfare 

Pennsylvania Code, Title 55. Public Welfare 

Chapter 20. Licensure or Approval of Facilities and Agencies 

Chapter 1153. Outpatient Psychiatric Services 

Chapter 5100. Mental health Procedures 

August 12, 2000 

Bulletin – Commonwealth of Pennsylvania – OMHSAS-06-03 

Department of Health – Department of Public Welfare 

Co-Occurring Disorder Competency Approval Criteria 

Issued February 10, 2006 

Department of Health – Department of Public Welfare 

Draft recommendations from the Co-Occurring Disorders Advisory 

Committee (Co-Dac) 

August 30, 2005 

University of Pennsylvania, Center for MH Policy & Services Research 

‘Pennsylvania Pilot Integrated Mental health and Substance Abuse Project 

for Persons with Co-Occurring Disorders Final Report 2003-2004’ 

July 26, 2004

M12: An Overview of Adolescents and Co-Occurring Disorders (continued as M22) 

Gregg Benson, MA, LCADC 

3 hours Focus: Children and Adolescents 

Description: 

This double workshop presents an overview of working with adolescents with co-occurring disorders including: 

discussion of prevention and early intervention factors; effective assessment and individualized treatment 

strategies; and follow-up considerations that focus on relapse prevention. Specific combinations of disorders 

with greater prevalence are highlighted. 

Educational Objectives: By the end of this workshop, participants will be able to: 

• Identify some biologic and environmental factors that support resiliency and that create risks for 

children regarding co-occurring disorders; 

• Distinguish DSM-IV disorders which are more prevalent in adolescents who develop substance use 

disorders; 

• formulate areas for assessment and planning integrated treatment interventions; 

• Design strategies for fully engaging youth and promoting recovery and wellness; 

• Evaluate continuing care needs and strategize means of incorporating community supports into relapse 

prevention plans and strategies. 

NOTES:


An Overview of Adolescents 

& 

Co-Occurring Disorders 

Presented By: 

Gregg Benson, MA, LCADC 

Consultation Associates 

20 Community Pl. 4 th Fl. 

Morristown, New Jersey 07960 

(973) 539-1980 

Fax: (973) 539-3687 

E-mail: gregg_benson@verizon.net 

COURSE OBJECTIVES 

• To understand the uniqueness of adolescence as a 

developmental process and differentiate it from and 

adults 

• To differentiate “normal” adolescence from 

“pathological” adolescence 

• Examine risk factors, etiologies and other possible 

relationships between SUD and other co-occurring 

psychiatric and associated disorders. 

Objectives, cont. 

• Explore and discuss the role, function and efficacy of 

DSM IV and Diagnosis 

• Discuss and demystify the role of medication(s) in the 

treatment tool box 

• Identify both current evidence-based treatments for 

SUD/MDs and promising alternative therapeutic 

strategies. 

• Identify and discuss challenges to providing integrated 

care 

• To Facilitate Paradigm Shifting 

Why Focus On Co-Occurring Disorders? 

• Substance Use Disorders are the most common and 

clinically significant comorbid disorders among adults with 


• Psychiatric and Other Associated Disorders are most 

common in persons with Substance Use Disorder(s) 

• Co-occurring disorders are associated with a variety of 

negative outcomes. 

• Outcomes improve when the SUD is well managed 

• Outcomes improve when mental health disorders are well 

managed 

• Parallel but separate MH and SUD treatment systems 

deliver fragmented and ineffective care – especially with 

adolescents. 

1


Why Focus on Co-Occurring Disorders -Cont. 

• A CMHS (2001)national health services study indicated 

that 43% of adolescents receiving mental health services 

had been diagnosed with a co-occurring SUD. 

• SAMSHA 1994-96 National Household Survey found 

13% of adolescents with significant emotional and 

behavior problems reported alcohol and drug 

dependence. 

• SAMSHA/CSAT 1997-2002 study found 62% of 

adolescent males and 82% of adolescent females 

entering SUD treatment had a significant co-occurring 

emotional/psychiatric disorder. 

Comorbidity is the Norm 

• Estimates suggest that >75% have a psychiatric disorder 

• Behavioral disorders e.g., Conduct Disorder (CD) = most common (50- 

80%) 

– negatively correlated with treatment success 

• Mood Disorders, esp. Depression= prevalent (24-50%) 

• Anxiety Disorders (7-40%) 

• High rates of exposure to childhood abuse and other potentially 

traumatic events is correlated with substance use 

• Many have multiple disorders 

– Depression, substance use and conduct disorders 

• Acute and chronic effects of psychoactive substances can exacerbate 

preexisting psychopathology 

Psychiatric Symptom Severity, Youths in 

Residential Drug Treatment in New Jersey 

60 

50 

40 

30 

20 

10 

0 

35 

12.2 15.6 33.7 30.9 

22.7 

33 

15.4 

28 

51 

13.3 

24.3 

Depression Anxiety ADD/ADHD Conduct 

Disorder 

Acute High Clinical 

Source: Hawke, Survey of Adolescent Drug Treatment Programs in New Jersey, 2002 

What does Integration mean? 

(Drake R., 2001) 

• Cross-trained multi-disciplinary staff 

• Integrated assessment, treatment planning and 

case management 

• Coordination with outside caregivers, residential 

settings and families 

• Continuing psychopharmacologic monitoring 

• Utilization of peer recovery supports 

• Dual recovery philosophy 

Some Basic Assumptions 

(Adapted from Minkoff, 2000) 

• Heterogeneous population 

• Application of Developmental Biopsychosocial 

framework 

• Complex assessment occurs over time and 

begins with need to engagement as many as 

possible 

• Frequent occurrence of multiple problems and 

mental and physical disorders 

• Effective interventions and treatment programs 

are flexible and occur in stages 

Additional Assumptions 

• The adolescent sitting before you has a history 

before the onset of their presenting symptoms. 

• The adolescent’s early developmental history 

holds essential information regarding resiliencies 

& islands of competencies as well areas of 

challenge, deficit and risk potential 

G. Benson - 2005 

2


Adolescents with SUD. . . 

• Have been adjudicated delinquent 

• Are overrepresented in the Juvenile Justice Sysytem 

• Are largely undiagnosed or misdiagnosed psychiatrically 

• Have histories of child abuse, neglect and sexual abuse; 

• Have high co-morbidity with psychiatric conditions; 

• Have high co-morbidity of ADHD and Learning Disorders – 

Usually Undiagnosed 

• Distributed across diverse health & social service systems 

Characteristic Behaviors 

and Attitudes In Normal Adolescence 

• Experimenting 

• Practicing 

• Questioning and challenging 

• Peer bonding 

• Here and now focus 

• Sense of invulnerability 

Challenges to “Normal” Adolescent 

Development 

Challenges to “Normal” Adolescent 

Development 

• Genetic Vulnerabilities / Predispositions 

‣family history of Substance Use Disorders 

‣family history of Psychiatric and other Associated Disorders 

‣family history of medical illness 

• Learning and Attentional Disorders 

• Other Physical Cognitive Disabilities 

• Parental / Family / Caretaker Dysfunction 

• Medical Illness 

• Trauma (Sexual, Emotional, Physical) 

• Active Addiction and/or Psychiatric Disturbance 

• Community and Environment 

• Single Parent Homes 

• Poverty 

• Wealth 

Characteristics of “Normal”, Substance Abusing & Antisocial Adolescents 

Domain 

“Normal” Adolescent 

Substance Abusing Adolescent “Antisocial” Adolescent 

Purposes of Assessment 

Affect 

Moodiness 

Drastic Mood Swings – 

Angry and Controlling – Or 

Guilty Anger 

Calm, Cool and Charming 

Worldview 

“I should be able to do anything I want 

to.” “ I feel like I am not as good at 

things as I would like to be.” “If I steal I 

“I’ve done some bad things and I 

feel guilty.” If I don’t stay on top of 

things, people will find out I’m 

“I’m cool – you don’t matter 

unless you have something I 

want.” “It’s not bad unless you 

• Establish a working relationship 

might get caught, then people would 

bad.” “I have steal to get money – 

get caught.” “You're a fool and 

Presenting 

know I am a thief!” 

Moodiness, Feeling Insecure, Not 

besides, all of my friends do.” 

School problems, family conflict, 

deserve to be ripped off!” 

Violent behavior, violent crimes, 

• Engage the adolescent 

Problem. 

Liked, Don’t Fit In 

change of friends, drastic mood 

swings, lying, legal problems: theft, 

B&E, etc. 

rageful outbursts, Families & 

others injured and the like 

wreckage following the trail of 

the antisocial. 

• Demystify the process 

Social 

Functioning 

Good achievement, positive peer 

group, Interests and/or outside 

involvement 

Current problems and other things 

grow progressively worse 

Excellent functioning, i.e. Class 

President, in charge of 

everything, smooth talker- Or- 

Poor functioning, numerous legal 

• Engage Parents / Guardians 

Motivation 

Autonomy – Peer Identification 

To avoid further problems, return 

to previous positive functioning, 

regain acceptance & trust of family 

and peers 

violations, volatile relationships 

To “Win”; Be right; Control; Seek 

Stimulation & Excitement; 

Immediate Gratification, Ends 

Justify the Means 

• Assess Competencies, Capacities & 

Resiliencies 

Defenses 

Isolation, Minimizing, Externalizing 

Lying, Manipulation, 

Con, Split off Affect, 

Rationalization & Increased Use of 

Intellectualizing, Rage 

Thinking Errors 

&Intimidation 

3

G. Benson, 2004 

G. Benson 2004 


Perspective of Assessors & Providers 

BELIEF SYSTEMS 

THEORETICAL UNDERPINNING & ORIENTATION 

PHILOSOPHICAL ORIENTATION 

KNOWLEDGE COMPETENCY 

SKILLS COMPETENCY 

ATTITUDINAL POSITIONS 

LANGUAGE 

COMMITMENT 

PURPOSE 

CURIOSITY 

HUMILITY 

Assessment for ALL Disorders 

is Needed Because. . . 

• Having one disorder increases the risk of 

developing another disorder; 

• The presence of a second disorder makes 

treatment of the first more complicated; 

• Treating one disorder does NOT lead to effective 

management of the other(s); 

• Treatment outcomes are poorer when co-occurring 

disorders are present. 

Gender Differences 

Latimer, 2002, Robbins, 2002 

Males 

• More common overall 

• Disruptive disorders 

• Acting Out 

•Poly SD 

Females 

• Higher rates of 

depression 

• Acting In 

• One drug 

THE INTEGRATED DIAGNOSTIC FORMULATION/SUMMARY 

• INTERPRETATION OF COLLECTED DATA – HOW DO YOU UNDERSTAND THE 

DATA AND BRING MEANING? 

• ARTICULATES THE SEVERITY OF ILLNESS PROBLEMS ACROSS THE SIX 

DIMENSIONS INCLUSIVE OF INTERACTIONS BETWEEN DIMENSIONS 

• IMPRESSIONS, SUSPICIONS & CURIOSITY REGARDING COLLECTED DATA 

• IDENTIFICATION AND ANALYSIS OF RESILIENCIES, STRENGTHS AND 

EXECUTIVE EGO FUNCTIONS 

• IDENTIFICATION AND ANALYSIS OF DEFICITS, RESISTANCES, DEFENSES 

AND/OR OTHER POTENTIAL INTERFERENCES WITH TREATMENT (E.G., 

MULTIPLE TREATMENT EPISODES, MULTIPLE RELAPSE HISTORY, 

TRAUMA/ABUSE ISSUES, CO-OCCURRING/ASSOCIATED DISORDERS, ETC) 

• PRIORITIZATION OF IDENTIFIED DIMENSIONAL PROBLEMS BY 

ASSESSED/EVALUATED SEVERITY OF ILLNESS AND IN CONSIDERATION OF 

POTENTIAL TREATMENT INTERFERENCES/RISKS THEY MAY POSE 

• ASAM LEVEL OF CARE PLACEMENT IS DETERMINATION BY SEVERITY OF 

ILLNESS AND “DOSE/INTENSITY” OF SERVICES) REQUIRED IN ACCORDANCE 

WITH PPC-2R CRITERIA 

ASAM PPC-2R - Levels of Care 

• Level .05 - Early Intervention 

• Level I - Outpatient Treatment 

• Level II.1- Intensive Outpatient (IOP) 

• Level II.5 - Partial Hospitalization (PHP) 

• Level III.1- Clinically Managed Low Intensity Residential TX 

• Level III.5 - Clinically Managed Med. Intensity Residential TX 

• Level III.7 - Medically Monitored High Intensity Res./IP TX 

• Level III.7D - Medically Managed Sub-Acute Detox Res./IP TX 

• Level IV - Medically Managed Intensive Inpatient TX/Detox 

ASAM PPC 2R - Dimensions 

• Dimension 1 - Acute Intoxication/Withdrawal Potential 

• Dimension 2 - Biomedical Conditions and Complications 

• Dimension 3 Emotional, Behavioral or Cognitive Conditions 

and Complications 

– Co-morbidity 

» Dangerousness 

» Interference with addiction recovery 

» Social functioning 

» Ability for self-care 

» Course of illness 

• Dimension 4 – Readiness to Change 

• Dimension 5 – Relapse, Continued Use or Continued Problem Potential 

• Dimension 6 - Recovery Environment 

4


Summary of Data For Determining 

Treatment Needs 

• Co-Occurring / Co-Morbid Disorder Diagnosis 

• Severity of Illness & Imminence of Risk 

• Intensity / Dose of Service Appropriate 

• Stage of Change/Motivation (ASAM Dim. 4) 

– (e.g. pre-contemplation, contemplation, etc.) 

• Utilization Management Criteria 

– Monitoring of treatment process for change 

Summary of Data, Cont. 

• Determination of Multidisciplinary Treatment Team and 

Support Systems Resources Needs 

– (e.g.: case manager, peer supports, family, etc.) 

• Individual capacities, strengths, resources, and interests 

and appropriate modifications & accommodations 

necessary to meet individual needs 

• Involvement & Case Management of Collaborative / 

Collateral Systems 

– (e.g.: juvenile justice, child protective system, school, etc.) 

5


Neurological & Neurotoxic Effects 

of Substance Use 

Substance Use & Psychiatric / Mental 

Health Disorders 

• Interference & Changes in Brain Function 

• Physiological Effects – Short & Long Term 

Dangerous Dance 

Partners 

• Affect & Mood Impairment 

• Tolerance & Progression 

Adolescent Patterns of Use 

• Adolescent use patterns are different than adults 

• Developmental/legal issues affect use patterns 

• Adolescents who use substances tend to use 

specific classes of substances from early to late 

teens 

• It is helpful to compare an individual’s usage 

pattern with those that are “usual” 

ADHD 

• 3 SUBTYPES 

– Predominantly inattentive type 

– Predominantly hyperactive/impulsive type 

– Combined 

• Diagnostic Features 

– Persistent pattern of inattention and/ or hyperactivityimpulsivity 

– Characteristics present before 7 years old 

– Some impairment from the symptoms must be 

evident in two settings 

– Symptoms clearly interfere with functioning 

– Symptoms not attributed to other conditions 

Learning Disorders 

Learning Disorders, cont. 

• Learning disorders are conditions of the 

brain that affect a person’s ability to: 

– Receive language or information 

– Process language or information 

– Express language or information 

• May manifest in an 

imperfect ability to: 

–Listen 

– Think 

– Speak 

– Read 

–Write 

–Spell 

– Do mathematical 

operations 

1


Learning Disorders, cont. 

• Four Major Categories 

– Reading Disorders 

– Mathematics Disorders 

– Disorders of Written Expression 

–LD –NOS 

• LD’s are neither intelligence based nor 

impairments of the senses 

Oppositional Defiant Disorder 

(adapted from DSM IV-TR, 2000) 

• Diagnostic Features: 

– A recurrent pattern of negativistic, hostile & 

defiant behavior 

– lasting 6 months or more 

– Disturbance in behavior causes clinically 

significant impairment in: 

–Social 

– Academic or 

– Occupational functioning 

Conduct Disorder 

• May have prior diagnosis of Oppositional 

Defiant Disorder (ODD) 

• Early onset of Substance Use 

– increased risk of continued SU 

– continuation of and potential increase in 

antisocial behavior 

– profit driven drug dealing 

– more substance-related symptoms 

Conduct Disorder, cont. 

• Aggression 

– High correlation to substance abuse 

• Polysubstance abuse, males 

– Direct pharmacological effects of the 

substances 

– Disinhibition 

– Other co-existing disorders, e.g. bipolar 

disorder 

• Over 18 may consider Anti-Social PD 

Most Commonly Diagnosed Cooccurring 

Mental Disorders Include: 

• Oppositional Defiant Disorder 

• Conduct Disorder 

• Mood Disorders 

• Specific Anxiety Disorders 

• Attention-Deficit / Hyperactivity Disorder 

• Learning Disorders* 

Relationship between 

Conduct Disorder, ADHD, SUD 

• Impulsivity may produce poorer social 

choices 

– Behavior 

– Deviant peers 

• Self-medication 

• Reflect type of brain functioning with high 

reinforcement from certain psychoactive 

agents 

2


Mood Disorders 

Anxiety Disorders 

• Major depressive disorder most common 

• Later onset than substance abuse 

• Bipolar Disorder 

• Prominent mood liability and dyscontrol 

• Onset of psychopathology preceded or 

coincided with SU for other disorders 

• Most common – Post Traumatic Stress 

Disorder (PTSD) 

• More commonly identified in females 

• Males tend to be more hidden 

• Usually associated with Child Abuse & Neglect and 

Sexual Abuse 

• High Incidence of Self Medicating 

Recommendations for Practice 

(Riggs, 2003) 

• Strengths-based perspective 

– Notice all positive statements and behaviors 

• Empathy, respect, non-judgmental stance 

• Joining rather than “expert” model 

• Offer of, and peer group support availability for 

family (beyond 12-step) 

• Data-based information/education 

• Engender hope & focus on competence 

• Keep an “over time” perspective 

Research-Based Interventions 

for SUD in Adolescents (Riggs, 2003) 

• Behavioral/Psychosocial 

• Motivational enhancement therapy 

• Family-based interventions 

• Behavioral therapy approaches 

• Cognitive-behavioral therapy 

• Community reinforcement therapy 

• Pharmacological – not enough research 

Effective Treatment 

Service Characteristics 

• Has well trained multidisciplinary staff with 

population age specific competencies 

• Has intensive and sufficient duration to achieve 

attitude and behavior changes 

• Provides continuing next level of care services 

or strong community based services linkages to 

provide adequate transition and continuity to 

reinforce changes 

• Has flexibility of approaches within multiple domains of 

young person’s life 

(Bukstein, 1995; Fleisch, 1991; Friedman & Beschner,1985) 

Effective Treatment 

Service Characteristics – Cont. 

• Sensitive to cultural and socioeconomic realities 

of family, child, community 

• Encourages family involvement 

– working with families to improve 

communication, parenting skills, issues of 

parental substance use disorders 

• Uses wide range of social services to help 

youth and family prepare for drug-free life 

3


Characteristics of Culturally Competent 


(Gains Center: Working Together for Change, 2001) 

• Family (as defined by culture) seen as primary 

support system 

• Clinical decisions culturally driven 

• Dynamics within cross-cultural interactions 

discussed explicitly & accepted 

• Cultural knowledge build into all practice, 

programming & policy decisions 

• Providers explore youth’s level of 

assimilation/acculturation 

Characteristics of Culturally Competent 

Treatment Programs 

(Gains Center: Working Together for Change, 2001) 

• Respect for cultural differences 

• Creative outreach services to underserved 

• Awareness of different cultural views of 

treatment/help-seeking behaviors 

• Program staff work collaboratively with community 

support system 

• Treatment approaches build on cultural strengths & 

values of minorities 

• Ongoing diversity training for all staff 

• Providers are similar to youth of color served 

Motivational Enhancement Therapy 

• Stand-alone brief interventions OR 

• Integrated with other modalities 

• Client-centered approach for resolving 

ambivalence and planning for change 

• Demonstrates improved treatment 

commitment and reduction of substance 

use and risky behaviors 

• Developmentally appropriate with 

adolescents 

Family-Based Interventions 

• Structural-Strategic Family Therapy 

• Parent Management Training (PMT) 

• Functional Family Therapy (FFT) 

• Multi-systemic Therapy (MST) 

• Multidimensional Family Therapy (MDFT) 

– All based on: 

• Family systems theory 

• Use of functional analysis for interventions that restructure 

interactions 

• Teaching parents behavioral principles and better monitoring 

skills to increase the adolescent’s pro-social behaviors, 

decrease substance use, improve family functioning, and 

hold treatment gains 

Behavioral Therapy Approaches 

• Based on operant behavioral principles 

– Reward behaviors incompatible with drug use 

– Withhold rewards or apply sanctions for use or other 

negative behaviors targeted 

– Use of physical monitoring (urines, etc.) for close link 

of consequences 

• Use of individual approach and family 

involvement 

• Has demonstrated positive results for a number 

of problem areas 

Community Reinforcement Therapy 

• Combines principles & techniques derived 

from others (behavioral, CBT, MET, and 

family therapy) 

• Uses incentives to enhance treatment 

outcomes 

4


Cognitive-Behavioral Therapy 

Alternative Therapeutic 

Intervention Strategies 

• Based on learning theory 

• Has individual and group applicability 

• Has a number of manualized approaches 

• Uses MET 

• Uses functional analysis to target areas 

• Teaches coping strategies, problem-solving & 

communication skills (practice & homework) 

• Uses relapse-prevention and alternative 

activities strategies for avoiding substance use 

• Yoga & meditation 

• Music therapy 

• Art therapy 

• Dance & movement 

therapy 

• Adventure based 

elements courses 

• Multimedia 

• Clinical journaling 

• Poetry and short story 

writing 

• Peer teaching 

• Script writing & 

theatrical production 

• Therapy animals 

Alternative Therapeutic 

Intervention Strategies - Cont. 

• Recreation therapy 

• Drumming 

• Instrumental music 

• Movie making 

• Bibliotherapy 

• Community service initiatives 

5 Steps to an Integrated Treatment Process 

(Adapted from Riggs, 2003) 

1. Meetings with adolescent and family to engage them 

in collaborative negotiations to establish goals and 

develop strategies for reducing or eliminating barriers 

to goal achievement. 

2. Entire treatment team case conference 

3. Implement treatment strategies which may include: 

– Individual and/or group therapies 

– Family-based treatment/education 

– 12-step or other supports (peer, etc.) 

– Medication for psychiatric disorder 

– Urine screens, self-report, medication monitoring, physical 

observation 

5 Steps to Integrated TX. 

(Adapted from Riggs, 2003) 

4. Continual monitoring of all disorders, symptoms, 

treatment strategies, movement toward/away from 

goals, and the relationship between all parties 

5. Collaborative Discharge / Continuing Care Planning 

ROLE AND OBLIGATION 

OF THE 

PROFFESSIONAL 

• ATTUNEMENT 

• CURIOSITY & CREATIVITY 

• PARADIGM SHIFTING 

• EVALUATION OF WHAT YOU “SEE” AND 

WHAT IT “MEANS” 

• ACCOMODATION & MODIFICATION 

• RESPONSIBILITY FOR “RESPONSE-ABILITY” 

5


ROLE AND OBLIGATION 

OF THE 

PROFFESSIONAL – CONT. 

In order to fulfill our professional responsibilities 

and obligations to provide the highest quality care 

possible, we must have: 

MULTI-DISCIPLINARY FLUENCY 

MULTI-SYSTEMIC FLUENCY 

MULTI-LINGUISTIC FLUENCY 

MOST IMPORTANTLY IT IS ESSENTIAL TO 

REMEMBER: 

• ALWAYS KEEP A SENSE OF HUMOR 

• TAKE WHAT YOU DO SERIOUSLY AND YOURSELF 

WITH A GRAIN OF SALT! 

• IMAGINE THE POSSIBILITIES AND THE POSSIBILITIES 

ARE ENDLESS! 

• IT’S KIND OF FUN DOING THE 

IMPOSSIBLE! 

6

M13: Tri-Recovery Process: Improving Performance Measures for fhe Mental Health, 

Substance Use And The Criminal Justice-Involved Individual 

(continued as M23) 

Richard S. Takacs, MA, CEAP, CCFC, CPRP, CCJP, CCDP 

3 Hours Focus: Clinical Integrated Interventions & Criminal Justice 

Description: 

Workshop participants are presented with a working model of a Tri-Recovery approach spanning the 

continuum of ambulatory behavioral health services for the mental health, substance use, and criminal justice 

involved individual. The focus is on the development and implementation of an integrated model of Tri- 

Recovery that places emphasis on increasing engagement and retention. The Tri-Recovery process builds on 

similarities rather than differences in negotiating a plan of change for the individual to improve performance 

outcomes. 


• Cite the prevalence of mental health and substance use disorders in the criminal justice involved 

individual; 

• Specify stage wise interventions for the mental health, substance use, and criminal justice involved 

individual; 

• Formulate integrated service plans; 

• Identify performance measures; 

• Apply and integrate Tri-Recovery principles into daily work with the mental health, substance use, 

and criminal justice involved individual. 

NOTES:


The Tri-Recovery Process: 

Improving Performance Measures For The 

Mental Health, Substance Use, And The 

Criminal Justice Involved Individual 

Richard S. Takacs, M.A., CEAP, 

CCFC, CPRP, CCJP, CCDP 

Mercy Behavioral Health 

Pittsburgh, PA 

Learning Objectives: 

• Recognize the prevalence of mental health and 

substance use disorders in the criminal justice 

involved individual. 

• Apply and integrate Tri-Recovery principles into 

daily work with the mental health, substance 

use, and criminal justice involved individual. 

• Specify stage wise interventions for the mental 

health, substance use, and criminal justice 

involved individual. 

• Formulate integrated service plans. 

• Identify performance measures. 

What is Tri-Recovery? 

• Recovery 

• Dual Recovery 

• Tri-Recovery 

Scope of the Problem 

• Questions 

– Are individuals with mental illness and 

substance abuse more likely to be violent 

towards others than individuals without mental 

illness and substance abuse? 

– Are individuals who have committed violent 

acts against others more likely to be mentally 

ill substance abusers? 

Public Perceptions 

• 17% thought a “troubled” person might be 

dangerous. 

• 33% thought a depressed individual might 

be dangerous. 

• 60% thought a schizophrenic individual 

might be dangerous. (Pescosolido et al., American J. Public 

Health, 1999) 

Epidemiologic Studies 

• Men with schizophrenia and no history of 

alcoholism, were 3.6 times more likely to 

commit a violent crime. 

• Men with schizophrenia and a history of 

alcoholism were 25.2 times more likely to 

commit a violent crime. (Rasanen et. al.., 1998) 

1


Prison Populations 

• Schizophrenia without alcoholism - 7.2% 

• Schizophrenia with alcoholism - 17.2% 

• Schizophrenia with earlier homicide-25.8% 

• In 1997, more than 2.5 million arrests were 

made for alcohol offenses and more than 1.5 

million arrests for drug offenses. 

• At least half of the adults arrested for major 

crimes (homicide, theft, assault), and more than 

eight in ten arrested for drug offenses, tested 

positive for drugs at the time of their arrest. 

• About half of the state prison inmates and 

40% of federal prisoners incarcerated for 

committing violent crimes report that they 

were under the influence of alcohol or 

drugs at the time of their offense. 

• Three-quarters of all prisoners in 1997 

were involved with alcohol or other drug 

abuse in someway during the time leading 

up to their current offense. 

• In one-half to two-thirds of homicides and 

serious assaults alcohol was present in 

the offender, the victim or both. 

• Alcohol and other drugs are often involved 

in rape and other sexual assaults. 

• It is estimated that up to 60% of sexual 

offenders were under the influence at the 

time of their offense. 

• From 1985 to 1995, the proportion of drug 

offenders in state prisons increased from 

9% to 23%. 

• Drug offenders have accounted for more 

than one-third of the growth in the state 

prison population and more than 80% of 

the increase in the number of federal 

prison inmates since 1985. 

2


• Estimates are between 25% to 50% of 

drug dependent individuals have a lifetime 

comorbid psychiatric disorder. 

• While the comorbidity rates for major 

psychiatric disorders are significant for 

non-institutionalized drug dependent 

individuals, they are even higher for 

individuals in treatment programs and 

even higher for prison inmates. 

• National Epidemiologic Studies that 

included a sample of prison inmates, 

found a comorbidity rate of 90% for 

antisocial personality, schizophrenia, and 

bipolar disorder among inmates 

dependent on alcohol or other drugs. (Regier et 

al, 1990) 

• A national survey of adults on probation 

conducted by the Bureau of Justice 

Statistics (BJS) indicated that while 41% of 

all adult probationers had substance 

abuse treatment as a condition of 

probation, only 7% were required to have 

psychiatric or psychological counseling. 

(BJS,1997) 

Commonalities of Lifestyles 

• Strong sense of non-accountability 

• Most clearly evident in situations where 

the individual is confronted by the negative 

consequences of his or her drug use and 

criminal behavior. 

• Individuals lack confidence in their ability 

to get their wants and desires met without 

drugs or crime; they seem more confident 

in the lifestyle than they are themselves. 

3


• Belief systems are habitually rigid and 

simplistic, with dichotomous “black and 

white” thinking. 

• Both lifestyles presume weak social 

cohesion or sense of community. 

Core Lifestyle Elements 

• Responsibility 

• Confidence 

• Meaning 

Responsibility 

• Use life lessons to encourage behavior change. 

• Natural consequences of our actions hold the 

greatest promise of stimulating change. 

• From consequences we learn to modify behavior 

in order to achieve more satisfying outcomes. 

• Community 

• Natural learning experiences are often 

referred to as “life lessons”. 

• “Life lessons” are more potent initiators of 

change than anything else created by 

staff. 

• Short term effects of use and criminal 

thinking are highly reinforcing and central 

to the lifestyle. 

• Negative long-term effects are more 

important in facilitating change. 

4


Discourage Enabling Behaviors 

• Naturally occurring “life lessons” can help 

to teach individuals to pay closer attention 

to the long-term negative consequences of 

their lifestyle with an eventual goal of 

achieving greater balance in their 

anticipation of the possible short and long 

term outcomes of their actions. 

• To enable is to prevent people from 

experiencing the natural negative 

consequences of their actions. 

• Enabling inhibits the corrective 

experiences and life lessons that foster 

change. 

• Enabling constricts the individual’s 

opportunities for change. 

• Stress personal responsibility for the 

choices they have made in their life. 

• Outside circumstances, and internal processes, 

may limit an individual’s options but they do not 

determine an individual’s choices. 

• Knowing that they have a choice can be highly 

empowering to individuals who for the most part 

accept on faith the premise that their actions are 

compelled by influences outside their control. 

Meaning 

• Self-efficacy is important in preparing 

individuals for the high risk situations they 

will likely encounter. 

• Avoid labeling 

• Often derogatory and dehumanizing 

• Limit categorization to the lifestyle and 

gauging where the individual stands 

relative to that lifestyle 

5


Challenge Cognitive Simplicity 

• Reductionism has a role in science. 

• Individuals involved in drug/criminal lifestyle also 

engage in extensive reductionism. 

• Reduce objects and events to dichotomized 

categories while trying to construe the world 

through “black and white lenses. 

• Challenge an individual’s most cherished 

assumption by adopting a contrary position 

(devil’s advocate) 

• Forming a collaborative relationship (Socratic 

method). 

• Contrasting an idea with its opposite to achieve 

a new idea or synthesis (dialectic method) 

Community 

Social Support 

• “Community” encompasses an individual’s 

social commitments, obligations, and 

involvements. 

• Social support, unlike enabling, infers 

acceptance of the individual rather than 

acceptance of the individual’s behavior. 

• Without social supports the odds that 

change will take root are substantially 

reduced. 

Encourage The Individual’s Sense 

Of Connection 

• Community means perceiving one’s connection 

with the surrounding environment. 

• The ability to move beyond the current situation 

and life status. 

• Seek sense of connection to something outside 

him or herself. 

Motivation/Engagement 

• Coercion 

•Persuasion 

• Constructive Confrontation 

• External Contingencies (threats) 

• Bribe/Incentive 

•Beg 

6


Six Stages of Change 

• Precontemplation 

• Contemplation 

• Preparation 

•Action 

• Maintenance 

• Termination 

Ready, Willing, Able 

• Ready: A matter of priorities 

• Willing: The importance of change 

• Able: Confidence for change 

Precontemplation 

• Individual is unaware or under aware of 

their problem(s) 

• There is no intention to change behavior in 

the foreseeable future. 

Contemplation 

• Individual is aware that a problem(s) exists 

and is considering overcoming it. 

• Individual has NOT made a commitment. 

• Individual is ambivalent and in the process 

of evaluation whether to do anything about 

it. 

Preparation 

• Individual is planning to take action in the 

near future. 

• Individual has unsuccessfully taken action 

in the recent past. 

Action 

• Individual is actively changing behavior, 

experiences, or environment in order to 

overcome their problem(s). 

7


Maintenance 

• Individual works to prevent relapse and 

consolidates what they have gained from 

taking and maintaining action(s). 

Interventions for Stages 


– Raise doubt 

– Increase the individual’s perception of the 

risks and problems with their current behavior. 


– Tip the balance 

– Evoke reasons to change/risks of not 

changing 

– Strengthen the person’s self-efficacy (change 

talk) for change of current behaviors. 


– Help the individual to determine the best 

course of action to take in seeking change 

•Action 

– Help the individual continue to take steps 

toward change 


– Help the individual identify and use strategies 

to prevent relapse 

8


Principles of Engagement 

• Avoid argumentation 

• Express empathy 

• Support self-efficacy 

• Roll with resistance 

• Develop discrepancy 

Avoid Argumentation 

• Do not utilize argumentation to confront 

the individual’s denial or minimization of 

the problem(s) 

• Heavy confrontation causes most 

individuals to feel attacked; participate less 

fully; resist interventions; and argue the 

opposite point of view 

Express Empathy 

• Hostile confrontation of individuals has 

been shown to increase dropout and 

relapse 

• Do not try to “break through” denial, but 

attempt to work around it. 

• Build up, rather than tear down 

• If the individual feels understood they are 

more able to open up to their own 

experiences and to share 

• Become more comfortable to examining 

their ambivalence about change 

Support Change Talk 

• An individual’s belief that change is 

possible is an important motivator to 

succeeding in making change 

• Help the individual develop a belief that 

they can make a change 

Roll with Resistance 

• Do not fight resistance -- “roll” with it 

• Statements demonstrating resistance are 

not challenged. Utilize individual’s 

momentum to further explore their view. 

Resistance tends to be decreased rather 

than increased. 

9


Develop Discrepancy 

• Individuals are encouraged to develop 

their own solutions to problems that they 

themselves have developed 

• Individual can be invited to examine new 

perspectives 

• “Motivation for change occurs when 

people perceive a discrepancy between 

where they are and where they want to be” 

(Miller, Zweben, DiClemente, & Rychtarik, 1992, p. 9) 

• Help individuals examine their current 

behavior and future goals 

Ambivalence 

• Conflict between two courses of action 

• Normal, acceptable, and understandable 

• Must be resolved to move forward with 

change 

• Pressuring produces resistance 

Tri-Recovery Process 

• Psychiatric/Substance 

Abuse/Dependence 

• Housing 

• Employment 

• Family 

• Peers 

• Recreation 

Primary Goals 

• Reducing use of illicit drugs 

• Reducing the commission of crimes to 

finance addiction 

• Improved psychological and physical wellbeing 

• Improved social productivity and family 

functioning 

• Achieve and maintain a drug-free lifestyle 

Goals 

• Restore functioning to optimal states of 

constructive life activity 

• Eliminate or compensate for functional 

deficits 

• Restore ability for independent living, 

community integration 

10


• Restore optimal state of work activity 

• Eliminate or compensate for functional 

deficits which lead to competitive or 

supported employment 

• Maximize individual involvement, 

preference and choice 

• Strengths focus 

• Skills training 

• Partnership with family/supports 

Elements of a Successful Tri- 

Recovery Program 

• Longitudinal, stage wise, motivational 

approach 

• Comprehensive, fully integrated services 

• Continuum of treatment interventions 

• Comprehensive Case Management 

• Provision and integration of continuing 

social supports 

Case Management 

• Coordinated approach to the delivery of… 

– Health 

– Substance Abuse 

– Mental Health 

– Social Services 

– …Linking individuals with appropriate services 

to address specific needs and to achieve 

stated goals 

Stage-Wise Treatment 

• Focus on engagement and retention in 

treatment using stages-wise approach 

• Use an individualized, flexible, long-term, 

individual centered approach 

• Comprehensive assessment, service 

planning and coordination 

• Facilitate movement along treatment 

continuum, moving toward recovery 

• Stage 1: Engagement 

• Stage 2: Persuasion 

• Stage 3: Active Treatment 

• Stage 4: Relapse Prevention 

11


Engagement 

• Reach out to the individual --proactive 

• Identify and fulfill individual’s immediate 

needs (often basic survival needs) 

• Offer easily accessible, crisis assistance 

• Utilize empathic, motivational statements 

• Begin basic education about addiction and 

mental illness 

• Make a commitment to developing a 

therapeutic alliance 

• Form a alliance with family/supports 

• Coordinate benefits, referrals, etc. 

• Reduce administrative barriers to facilitate 

access to services 

Persuasion 

• Therapeutic working alliance is 

established 

• Prepare for active change strategies 

• Individual goals development 

• Explore barriers for achieving the goals 

• Ambivalence is part of the process 

• Stabilize psychiatric disorders 

• Start social skills training 

• Begin to help the individual change 

various aspects of their lives (cognitions, 

beliefs, habits, behaviors, friends, living 

situation, etc.) 

• Begin creating a hopeful attitude and 

motivation for change 

Active Treatment 

• Abstinence from substances and recovery 

from mental illness are primary goals 

• Monitor substance use and prescribed 

medication use 

• Targeted psychotherapy (individual, group, 

family) 

• Structured schedule of activities 

• Re-introduce self-help group networks 

• Psychiatric Rehabilitation 

• Vocational Rehabilitation 

• Supported employment 

12



• Reinforce behavior changes 

• Active self-help group participation 

• Active psychiatric/vocational rehabilitation 

• Improve family/other relationships 

• Continued support/advocacy/skills training 

• Case Management interventions are most 

successful if utilized in the context of a 

multidisciplinary team approach 

Rehabilitation 

• Improving Adherence to Psychiatric and 

Vocational Rehabilitation Programs 

• Maximize individual involvement, 

preference and choice 

• Strengths focus 

• Extensive skills training 

• Partnership with family/other supports 

Integrating Systems 

• View the offender’s problems as the 

responsibility of all systems and the offender’s 

successes as benefiting all systems 

• Initiate joint case staffings 

• Cross-train/Cross-practice staff 

• Community treatment providers should establish 

contact with offenders before they are relapsed - 

- trust & rapport 

• Keep treatment plans flexible enough to 

respond to offender’s needs 

Issues To Consider 

• Offender clients who are newly released from 

incarceration may be seen as noncompliant, 

when they are actually confused about 

expectations in a new setting 

• Offenders may not have much recent practice in 

personal accountability or decision making 

13


Personal Living Skills 

• A major part of the jail and prison culture is 

“working the system” -- be aware 

• Offenders need to learn basic life skills 

– Budgeting 

– Using public transportation 

– Seeking and maintaining employment 

– Training to enhance interpersonal skills in both family 

and relationships with peers 

– Anger management skills 

• Personal hygiene and grooming 

• Management of sleep/wake cycles 

• Dressing, taking care of clothing 

• Preparing basic meals or obtaining a 

nutritious diet 

• Money management 

• Orientation/sensitivity to time 

Social and Interpersonal 

• Conversational skills 

• Respect and concern for others 

• Appropriateness in varied social settings 

• Attachments, ability to form and sustain 

friendships and relationships 

• Constructive leisure and recreational activities 

• Anger and conflict management 

• Impulse management 

Service Procurement Skills 

• Ability to obtain and follow through on 

medical services 

• Ability to apply for benefits 

• Ability to obtain and maintain safe housing 

• Skill in utilizing social service agencies 

Prevocational/Vocational 

• Basic reading and writing skills 

• Skills to follow instructions 

• Transportation skills 

• Manner of dealing with supervisor 

• Timeliness/punctuality 

• Telephone skills 

Summary 

• Prevalence of mental illness, substance 

abuse/dependence in the criminal justice 

involved individual 

• Change and Adherence Theory 

• Resistance Techniques 

• Stage-Wise Approaches & Interventions 

• Goals for the Recovery Process 

14

M14: Trauma History and Risk Assessment in the Co-occurring Disorder Program Planning 

Model: Case-based Implications for Treatment, Rehabilitation, and Recovery (continued as M24) 

Stefan Larkin, EdD, Kristina Muenzenmaier, MD & Gregory Sathananthan, MD 

3 hours Focus: Clinical Integrated Interventions 

Description: 

Presentation participants will engage in guided assessment, treatment, rehabilitation, and recovery program 

planning for persons with COD, using the varying severity of co-occurring mental illness and substance abuse 

disorders as presented in SAMHSA’s QUAD IV, as adapted from the New York COD Model, the Level of 

Function and Maturation/Progression dimensions of the original New York Model, and new Trauma History and 

Risk dimensions, aiding clinicians in critical service decisions with persons having co-occurring disorders. 


• Identify the key severity and context dimensions of the Co-Occurring Disorders Program Planning 

Model; 

• Describe some of their cases and review key clinical decisions using the COD Program Planning Model; 

• Discuss possible interactions of co-occurring disorders of varying severity and their possible impact on 

treatment, rehabilitation, and recovery. 

NOTES:


Trauma History and Risk Assessment in the 

Co-occurring Disorder Program Planning Model: 

Case-based Implications for Treatment, Rehabilitation, and Recovery. 

Trauma History and Risk Assessment 

in the Co-occurring Disorder Program Planning Model: 


Hershey, Pennsylvania 


Gregory Sathananthan, M.D. 

Kristina Muenzenmaier, M.D. 

Linda L. Hawkins, M.D. 

May, 2006 

® 


® 


Trauma History and Risk Assessment in the 

Co-occurring Disorder Program Planning Model: 


I. Brief History and Core Concepts 

II. QUAD IV 

III. Dual Diagnosis Program Planning Grid 

IV. Case Exercise I 

V. Stages of Change, Symptom Severity and Time 

VI. Trauma and time 

VII. Risk and Program Planning 

VIII. Case Exercise II 

IX. Questions and Discussion 

Brief History and Core Concepts 

1. The original New York Model (Larkin, 1987) grew out of a problem in 

communicating about CoD clients: staff from different agencies and service 

systems talking about their CoD clients would share and ultimately defend (on 

the beaches, in the hills, on the landing grounds, never surrendering) the 

policies and practices they knew to work, even though they and nobody else in 

the room were talking about clients who were closely similar to one another. 

The first New York model was the simple 2 X 2 grid seen below. 

New York Model (Fall 1987) 

HI 

MI 

HI -LO 

HI -HI 

LO -LO LO -HI 

LO 

LO SA 

HI 

® 


® 


3. Before QUAD IV used the earliest version of the New York Model as a basis for 

matching mental illness and substance abuse disorder symptom severity to 

service systems and providers, the New York Model, what was then known as 

the Dual Diagnosis Program Planning Grid, had already grown two additional 

dimensions. 

In 1988, Linda Hawkins, M.D., then leading a dual diagnosis day program at 

Buffalo Psychiatric Center and on the New York MICA Training Task Force, 

suggested adding Level of Function as an additional dimension to the model, 

noting she had clients within the same quadrant of the first 2 X 2 version of the 

New York Model, who if served together would relate as predator and prey. 

The easiest way to understand this is to imagine that at this very moment there 

is a CEO of a Fortune 500 company within 100 miles of here who has Bipolar 

Affective Disorder and has been an alcoholic for more than 20 years and when 

his depressive symptoms become severe and he increases his alcohol intake, 

the corporate aircraft quickly brings the necessary psychiatrists to intervene. 

Not far from the corporate headquarters there is a homeless shelter and in that 

shelter is a person with schizophrenia who abuses crack. Both clients fit in the 

same HI-Hi region of the New York Model pre Dr. Hawkins and QUAD IV. One 

might expect the service systems for the two clients to be somewhat different. 

In that same 1988 meeting, in literally the same breath five minutes later, Dr. 

Hawkins and I said “and we have to add time as well. We need to know how old 

was the person when they got each illness and how long have they been sick 

with each illness? In 2000 Dr. Sathananthan detailed the time dimension to 

include age of onset for each illness, and progression of each illness and up 

until today the New York you will see on the next slide has been what we have 

been using. Before we propose some changes we want to try using it with you. 

Hi 

® 


® 


1


Case Exercise I 

Progression of Both Illnesses and 

Maturation of the Person over time 

Hi 

Lo 

Level 

of 

Function 

Hi 

M I S 

e l e 

n l v 

t n e 

a e r 

l s i 

s t 

y 

Lo 

Lo 

Substance 

Abuse 

Severity 

® 


2

M15: TIP 42 Treatment for Persons with Co-Occurring Disorders 

(continued as M25) 


3 hours Focus: Systems Integration & Clinical Integrated Interventions 

Description: 

This double workshop provides an overview of the Treatment Improvement Protocol #42, Substance Abuse 

Treatment for Persons with Co-Occurring Disorders. Material is presented that describes historical 

developments, definitions, screening and assessment, evidence-based practices, services integration and 

building a system of care. The final segment reviews recent developments in integrating research with 

practice, and discusses some emerging findings on means of effecting change in programs and clinical 

practice. 


• List basic contents of TIP #42; 

• Describe the role of screening and assessment for CODs in the clinical planning process; 

• Define similarities and differences of evidence- and consensus-based practices: 

• Identify the building blocks of a system of care for persons with CODs; 

• Discuss some emerging findings for means of effecting change in programs and clinical practice. 

NOTES:


TIP 42 (and Beyond) — 

Substance Treatment for 

Persons with Co-Occurring 

Disorders 

Stanley Sacks, Ph.D., Expert Leader 

SAMHSA’s Co-Occurring Center for Excellence 

(COCE) 


Table of Contents: Chapters 

Chapter 1—Introduction 

Chapter 2—Definitions, Terms, and Classification Systems for 


Chapter 3—Keys to Successful Programming 

Chapter 4—Assessment 

Chapter 5—Strategies for Working With Clients With Co- 

Occurring Disorders 

Chapter 6—Traditional Settings and Models 

Chapter 7—Special Settings and Special Populations 

Chapter 8—A Brief Overview of Specific Mental Disorders 

Chapter 9—Substance-Induced Disorders 

Table of Contents: Appendices 

Appendix A – Bibliography 

Appendix B – Acronyms 

Appendix C – Glossary 

Appendix D – Specific Mental Disorders: Additional Guidance for the 

Counselor 

Appendix E – Emerging Models 

Appendix F – Common Medications for Disorders 

Appendix G – Screening and Assessment Instruments 

Appendix H – Screening Instruments 

Appendix I – Selected Sources of Training 

Appendix J – Dual Recovery Mutual Self-Help Programs and Other 

Resources for Consumers & Providers 

Appendix K – Confidentiality 

Appendix L – Resource Panel 

Appendix M – Cultural Competency and Diversity Network Participants 

Appendix N – Field Reviewers 

SAMHSA’s Definition of 


The term refers to co-occurring substance use 

(abuse or dependence) and mental disorders. 

Clients said to have co-occurring disorders have 

one or more mental disorders as well as one or 

more disorders relating to the use of alcohol and/or 

other drugs. 

Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005b) 

COD & Treatment Outcomes 

COD clients have poorer outcomes, 

such as higher rates of HIV infection, 

relapse, rehospitalization, depression 

and suicide risk. 

COD clients have better outcomes 

with treatment designed for their 

special needs. 


Woody & 

Blaine 

Substance 

Abuse & 

Depression 

COD Advances Timeline 

1979 1981 1989 1993 

Pepper 

Chronic 

Young Adult 

Minkoff 

Integrated 

Treatment 

Ries 

TIP 9 

Mid 

1990’s 1996-7 Late 1998 1999 

Sacks & 

De Leon 

MTC 

DATOS 

Studies 

Evidenced- 

Based 

Practices 

for SMI 

NASADAD 

NASMPHD 

Four 

Quadrants 

Early 1990’s 

Kessler 

National 

Comorbidity 

Survey 

2000- 

2003 

Research on 

Strategies & 

Models 

Mid 1990’s 

Drake 

ACT 

2002- 

2004 

RTC 

COCE 

COSIG 

NREP 

NFI 

Policy Academy 

Toolkit 

COD TIP 

1


Prevalence of Co-Occurring 

Disorders 

mental health programs 1 

clients with 

substance use disorder 

20% — 50% 

Facilities Offering Special 

Programs for Clients with COD 

Number of Facilities 

COD Special Programs 

drug treatment facilities 1 50% — 75% 

clients with 

mental disorder 

General Population 

of those with 

lifetime addictive disorder 

of those with 

lifetime mental illness disorder 

(National Comorbidity Survey 2 ) 

50% 

50% 

have mental 

disorder 

have substance 

use disorder 

4 million with serious mental disorders 3 

Source: 1 Sacks et al. 1997; 2 Kessler, R. et al. 1994; 3 Grant et al. 2004; SAMHSA, 2004 

20000 

15000 

10000 

5000 

0 

8,736 

1995 

3,295 

15,239 

13,428 13,720 

10,860 

6,818 6,696 6,696 

5,255 

1997 1999 2000 2002 


Advances in Treatment 

“No wrong door” policy 

Mutual self-help for people with COD 

Integrated care as a priority for people 

with severe and persistent mental illness 

Development of effective approaches, 

models, and strategies 

Pharmacological 

Adapted from 

advances 

Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005b) 

Four Quadrants 

Service Coordination by Severity 

Quadrant III 

Less severe mental 

disorder 

More severe 

substance disorder 

Quadrant I 

Less severe 


Less severe substance 

disorder 


Quadrant IV 

More severe 


More severe 


Quadrant II 

More severe 


Less severe 


Integrated Treatment 

Integrated treatment refers broadly to any 

mechanism by which treatment interventions 

for COD are combined within the context of a 

primary treatment or service setting. 

Integrated treatment is a means of 

coordinating substance abuse and mental 

health interventions to treat the whole 

person more effectively. 


Levels of Program Capacity in 

COD 

Beginning 

Addiction Only Tx 

Intermediate 

COD Capable 

Advanced 

COD Enhanced 

Substance 

Abuse Tx 

More Tx for Mental Disorders 


COD Integrated 

COD Enhanced 

Advanced 

Intermediate 

COD Capable 

Mental Health Only Tx 

Beginning 

Mental 

Health Tx 

More Tx for Substance Abuse Disorders 


2


The Clinical Planning Process 

COD TIP Definition: Screening 

Screening 

Person 


(referral or provision) 

Developing Treatment 

Resources 

Assessment 

Individualized 

Treatment Plan 

Diagnosis 

A formal process of testing to determine whether a 

client does or does not warrant further attention at the 

current time in regard to a particular disorder and, in 

this context, the possibility of a co-occurring substance 

or mental disorder. 

The screening process for co-occurring disorders 

(COD) seeks to answer a “yes” or “no” question: Does 

the substance abuse [or mental health] client being 

screened show signs of a possible mental health [or 

substance abuse] problem? 

Note that the screening process does not necessarily 

identify what kind of problem the person might have, or 

how serious it might be, but determines whether or not 

further assessment is warranted. 


The Goal: Universal Screening 

All individuals presenting for treatment 

of a substance use disorder should 

undergo at a minimum screening for any 

co-occurring mental disorders. 

All individuals presenting for treatment 

of a mental disorder should undergo at a 

minimum screening for any cooccurring 


Features of Screening 

Instruments 

High sensitivity (but not high 

specificity) 

Brief 

Low cost and no cost 

Minimal staff training required 


Consumer friendly 


Measures of Precision Defined 

Sensitivity: the probability that the screening test is positive 

given that the person has the disorder. This is also know as the 

true positive rate. A large sensitivity means that a negative test 

can rule out the disorder. 

Specificity: the probability that the screening test is negative 

given that the person does not have the disorder. This is also 

known as true negative rate . A large specificity means that a 

positive test can rule in the disorder. 

Overall Accuracy: is the combination of sensitivity and 

specificity – the probability that the screening test is positive 

given that the person has the disorder combined with the 

probability that the screening test is negative given that the 

person does not have the disorder. 

Screening Protocol and 

Processes 

Screening processes always should define a protocol for 

determining which clients screen positive and for ensuring 

that those clients receive a thorough assessment. 

Screening process establishes precisely how any screening 

tools or questions are to be scored and indicated what 

constitutes scoring positive for a particular possible problem 

(often called “establishing cut-ff scores”). 

The screening protocol details exactly what takes place after a 

client scores in the positive range and provides the necessary 

standard forms to be used to document both the results of all 

later assessments and that each staff member has carried out 

his or her responsibilities in the process. 


3


Counselor Role in Screening 

All counselors can be trained to screen for cooccurring 

substance use and mental disorders. 

Screening often entails having a client respond to 

a specific set of questions, evaluating the 

response, and then taking the next “yes” or “no” 

step in the process depending on the results and 

the design of the screening process. 

In substance abuse or mental health treatment 

settings, every counselor or clinician who 

conducts intake should be able to screen for the 

most common COD and know how to implement 

the protocol for obtaining COD assessment 

information and recommendations. 


COCE Full Matrix for Evaluating Screening Instruments 

DIS 

* 

COCE Full Matrix for Evaluating Screening Instruments continued 

MINI- 

GAI TCUD 

INSTRUMENT A DA SSI- CAG MHS MIN Screen 

N-Q S 

AD DAS SAD RD 

K10 

NAME 

SI LI SA E F-III I (modified 

S T D 

S 

) 

Purpose 

Screening 

Assessment 

Clinical utility: 

Diagnosis 


Placement 



Clinical Utility: 

Outcome 

Severity Measure 

Reporting 

Methodological 

Considerations 

Norms available 

Reliability on readministration 

Internal consistency 

(with alpha) 

Validity 

*The DIS is not a screening instrument. It was evaluated because of its overall importance. 

Overall accuracy 

Effects of 

demographics or 

background on 

lidit 

MINI- GAI TCUD 

INSTRUMENT A DA SSI- CAG MHSF MI 

Screen N-Q S 

AD DAS SAD RD 

K10 

NAME 

SI LI SA E -III NI 

S T D 

S 

(modified) 

Administration 

Tech. support 

available and free 

Tech. support 

available at 

minimal cost 

Computer admin. 

Computer scoring 

Interpretive 

Time taken for 

admin. 

Complexity of 

scoring 

Required skill level 

Intensity of 

required training 

Reviewer's 

*The DIS is not a screening instrument. It was evaluated because of its overall importance. 

Comments 

(Summary) 

DIS 

* 

Screening Instruments for COD – 

COCE/COSIG Findings 

Mental Health 

Mental Health Screening Form-III (MHSF)-III 

Mini International Neuropsychiatric Interview 

(MINI) Screen - Modified 

Substance Abuse 

Simple Screening Instrument for Substance 

Abuse (SSI-SA) 

Dartmouth Assessment of Lifestyle (DALI) - 

Modified 

Both 

Global Appraisal of Individual Needs (GAIN) 

Combination of above especially MINI and 

DALI 

Stan Sacks: 

(MHSF)-III “user friendly” in 

SA settings; MINI Screen 

Modified-best with SMI and 

low motivation, important 

validation studies completed; 

SSI-SA-better with strong 

rapport and/or strong desire 

to look at AOD use: DALImodified 

form best as MD 

screener in SA settings; 

GAIN-good for both SA and 

MH screening and in settings 

that can streamline data 

collection - i.e., screening, 

assessment, treatment 

planning, outcome 

evaluation. 

List of Screening Instruments 

Mental Disorder Screening Instruments: 

Diagnostic Interview Schedule (DIS-IV) 

The Mental Health Screening Form-III (MHSF)-III 

Mini-International Neuropsychiatric Interview (M.I.N.I.) 

M.I.N.I. Screen Modified 

National Center for Health Statistics - 10 Questions (K10) 

Referral Decision Scale (RDS) 

Substance Abuse Disorder Screening Instruments 

Addiction Severity Index (ASI) 

CAGE Questionnaire Adapted to Include Drugs (CAGE-AID) 

Dartmouth Assessment of Lifestyle (DALI) 

DALI Screen Modified (NYS) 

Drug Abuse Screening Test (DAST) 

Short Alcohol Dependence Data Questionnaire (SADD) 

Simple Screening Instrument for Substance Abuse (SSI-SA) 

TCU-Drug Screen II (TCUDS) 

Substance Abuse and Mental Disorder Screening Instrument 

Alcohol Dependence Scale (ADS) 


GAIN - Quick (GAIN-Q) 

Integrated Screening 

Integrated screening addresses both 

mental health and substance abuse, each 

in the context of the other disorder. 

A comprehensive screening process also 

includes exploration of a variety of related 

service needs including medical, housing, 

victimization, trauma and so on. 

Center for Substance Abuse Treatment. (2005c) 

4


Screening Instruments are Needed for 

Specialized Populations 

For 

Example: 

Adolescent: 

Juvenile 

Justice: 

Adult Criminal 

Justice: 

Global Appraisal of Individual 

Needs (GAIN) 

The Massachusetts Youth 

Screening 

Instrument (MAYSI) 

Criminal Justice-Co-occurring 

Disorder Screening Instrument 

(CJ-CODSI) 

The Content of the Screening will 

Vary Upon the Setting 

Substance abuse screening in mental health 

settings should: 

Screen for substance use, substance 

related problems, and substance-related 

disorders (this report presents 

recommended instruments for this purpose) 

Screen for acute safety risk related to 

serious intoxication or withdrawal (this 

report recommends the inclusion of this in 

the screening process) 


The Content of the Screening will 

Vary Upon the Setting continued 

COCE Recommendations for a Selection Process 

Mental Health Screening has three major components in substance abuse 

treatment settings: 

Screen for mental health symptoms and mental disorders 

(this report presents recommended instruments for this 

purpose) 

Screen for acute safety risk: suicide, violence, inability to 

care for oneself, HIV and hepatitis C virus risky behaviors, 

and danger of physical or sexual victimization (this report 

recommends the inclusion of this in the screening process) 

Regardless of the setting, all clients should be screened for 

past and present victimization and trauma (this report 

recommends the inclusion of this in the screening process) 


1. Screening Instruments in the Matrix review are all acceptable. 

2. Decide if you want a screening instrument for substance use disorder, a 

screening instrument for mental disorders or both. 

3. If the latter, either use a combination of SA and MH screening 

instruments (for example, MINI Screen Modified/DALI) or use the GAIN. 

4. COCE recognizes that the use of other instruments may be desirable in 

a particular circumstance and that there are other viable options 

available. 

5. Consider customizing your instrument with additional items selected 

from the comprehensive list of instruments. 

6. Involve stakeholders and users in the instruments selection process. 

7. Begin parallel development of coordinated assessment instruments, 

placement determination, treatment planning and treatment resources. 

Screening: 

Future Instrument Development 

The Clinical Planning Process 

Validation Studies of Current Instruments 

Screening 

Assessment 

Diagnosis 

New Instruments for Special Populations 

Criminal Justice 

Children and Adolescents 

Elderly 

Person 


(referral or provision) 

Individualized 

Treatment Plan 

New Instruments for BOTH Substance Abuse 

Center for Substance Abuse Treatment, (2005a) 

and Mental Disorders 

Developing Treatment 

Resources 

5


COD TIP Definition: Assessment 

A basic assessment consists of gathering key 

information and engaging in a process with the client 

that enables the counselor/therapist to understand 

the client’s readiness for change, problem areas, 

COD diagnosis, disabilities, and strengths. 

An assessment typically involves a clinical 

examination of the functioning and well-being of the 

client and includes a number of tests and written and 

oral exercises. The COD diagnosis is established by 

referral to a psychiatrist or clinical psychologist. 

Assessment of the COD client is an ongoing process 

that should be repeated over time to capture the 

changing nature of the client’s status. 


Basic Assessment Consists of: 

Background 

Substance use 

Psychiatric problems 

Integrated assessment 


Domains of Assessment 

Acute Safety 

Needs 

Quadrant 

Assignment 

Level of Care 

Diagnosis 

Disability 

Strengths and 

Skills 

Recovery Support 

Cultural Context 

Problem Domains 

Phase of 

Recovery/ Stage of 

Change 


List of Selected Assessment Instruments 


Addiction Severity Index (ASI) 


Individual Assessment Profile (IAP) 

Mental Health 

Beck Depression Inventory–II (BDI–II) 

Beck Hopelessness Scale (BHS) 

Brief Psychiatric Rating Scale (BPRS) 

Brief Symptom Inventory (BSI) 

General Behavioral Inventory (GBI) 

Referral Decision Scale (RDS) 

Trauma Informed 

Post-traumatic Stress Symptom Scale Self Report (PSS-SR) 

Trauma History Questionnaire (THQ) 

List of Selected Assessment Instruments Continued 

General Health 

— Medical Outcomes Study Short Form (SF-36) 

Some Discussion Issues 

Diagnostic 

— Diagnostic Interview Schedule (DIS-IV) 

— Structured Clinical Interview for DSM-IV Disorders (SCID) 

Motivation and Readiness to Change 

— Circumstances, Motivation, and Readiness Scales (CMR Scales) 

— Readiness to Change Questionnaire 

— Stages of Change, Readiness and Treatment Eagerness Scale 

(SOCRATES) 

— University of Rhode Island Change Assessment (URICA) 

— Recovery Attitude and Treatment Evaluator (RAATE) 

Level of Care 

— Level of Care Utilization System (LOCUS) 

Structured Instruments and Clinical 

Processes/Judgment 

Population & Setting 

Agency & System 

Amount of Information/Use of 

Information 

6


High Severity 

Alcohol and other drug abuse 

Low Severity 

The Four Quadrants 

III 


disorder/more severe 

substance abuse 

disorder 

I 


disorder/less severe 


disorder 

Mental Illness 

IV 

More severe mental 

disorder/more severe 


disorder 

II 

More severe mental 

disorder/less severe 


disorder 

High Severity 


Assessment Steps 

Assessment Step 1: Engage the Client 

Assessment Step 2: Identify and Contact Collaterals 

Assessment Step 3: Detect Acute Conditions Associated with 


Assessment Step 4: Determine Quadrant and Locus of Responsibility 

Assessment Step 5: Determine Level of Care – SA [ASAM PPC-2R 

Dimensions] 

Assessment Step 6: Determine Level of Care – MH LOCUS Dimensions 

Assessment Step 7: Determine Diagnosis: Principles 

Assessment Step 8: Identify Strengths and Supports 

Assessment Step 9: Identify Cultural and Linguistic Needs and Supports 

Assessment Step 10: Identify Problem Domains 

Assessment Step 11: Determine Stage of Change/Stage of Treatment 

Assessment Step 12: Plan Treatment 

Additional Considerations 

Assessment should be a clinical driven processinvolves 

clinician making connection with the 

client. 

Consider the client in a context (i.e. setting) and 

fit assessment process to the setting. 

Take into account the system of care the person 

is in – think of systems available so you can do 

treatment planning. 

Integrated Assessment 

Integrated assessment consists of: 

cross walk between MH and SA; 

establishing times when client did well; 

determining stage of change by 

problem; and 

stage-specific assessment and 


Center for Substance Abuse Treatment, (2005c) 

Advice to the Counselor: 

Do’s and Don’ts of Assessment for COD 

Do keep in mind that assessment is about getting to know a person with 

complex and individual needs. Do not rely on tools alone for a comprehensive 

assessment. 

Do always make every effort to contact all involved parties. 

Don’t allow preconceptions about addiction to interfere with learning about 

what the client really needs. 

Do become familiar with the diagnostic criteria for common mental disorders, 

including personality disorders, and with the names and indications of 

common psychiatric medications. 

Don’t assume that there is one correct treatment approach or program for any 

type of COD. 

Do become familiar with the specific role that your program or setting plays in 

delivering services related to COD in the wider context of the system of care. 

Don’t be afraid to admit when you don’t know, either to the client or yourself. 

Most important, do remember that empathy and hope are the most valuable 

components of your work with a client. 

Conclusions 

Screening, Assessment and Treatment Planning are the 

foundation of good service to COD clients. 

The need exists for the further empirical validation of existing 

screening Instruments and for the development of new 

instruments that address co-occurring disorders simultaneously. 

There should be equivalent attention to and resources for 

Screening & Assessment, and for the parallel development of 

consensus- and evidence-based treatment services. 



7


What is an Evidence-Based Practice? 

In the area of COD treatment, EBP is defined by COCE 

primarily as the use of current and best research evidence in 

making clinical and programmatic decisions about services to 

client[s). The research considerations involved in 

determining what constitutes an evidence-based practice 

include not only the robustness of the study findings but also 

the type of design employed and the methodological rigor of 

the procedures. 

A broader definition of EBP also includes taking into account 

clinician expertise and patient values, as indicated by the 

Institute of Medicine (2000) and more recently by the American 

Psychological Association (2005). 

What is a Consensus-Based Practice? 

Consensus-based practice (CBP) in the field of co-occurring 

substance use and mental disorder treatment is defined as 

agreements regarding treatment practice that are achieved 

through the general concurrence of treatment practitioners, 

researchers, clients and other experts in the field. 

Concurrence may be actively sought, such as through the 

development of a Treatment Improvement Protocol 

wherein clinicians and clinical researchers join forces to 

agree on appropriate practice[s], or through the use of 

constituent service organizations, such as the American 

Society for Addiction Medicine, to develop standards for 

service providers. 

Center for Substance Abuse Treatment. (2005a) 


Levels of Research Evidence 

The Co-Occurring Center for Excellence 

has developed a pyramid to capture the 

level or strength of research evidence (see 

next slide). 


Consensus- and Evidence-Based Practices for COD 




Essential 

Programming 


Working with Clients 

with COD (with evidence 

based in substance abuse 

treatment) 

Models 


for the Severely 

Mentally Ill 


Perspective 


Viewpoint 

Develop a Phased Approach 

to Treatment 

Screening, Assessment, 

and Referral 



Prescribing 




Motivational 

Enhancement 

Contingency 

Management 

Techniques 


Therapeutic Techniques 


Assertive 

Community 

Treatment 

Modified 

Therapeutic 

Community 

Collaborative 






Consensus – Based 

Practices 


Problems Early in Treatment 


Classes 




Treatment 



Impairments 


(Onsite) 


Mutual Self-Help Groups 


Treatment (Substance Use and 

Mental Illness) 


Maintain and Extend 

Treatment Effectiveness 


Self-Help Groups (Offsite) 


Management 

Adapted from Substance Abuse Treatment for Persons With Co- 

Occurring Disorders TIP, 2005b 

8


Six Guiding Principles 

1. Employ a recovery perspective. 

2. Adopt a multi-problem viewpoint. 

3. Develop a phased approach to treatment. 

4. Address specific real-life problems early in 

treatment. 

5. Plan for the client’s cognitive and functional 

impairments. 

6. Use support systems to maintain and extend 

treatment effectiveness. 

Essential Programming for 

Clients With COD 

screening, assessment, and referral 

psychiatric and mental health consultation 

prescribing onsite psychiatrist 

medication and medication monitoring 

psycho-educational classes 

double trouble groups (onsite) 

dual recovery mutual self-help groups (offsite) 

intensive case management (ICM)* 

Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders TIP, 2005b 

*Can be seen either as an element of a program or as a full program model. 

Adapted from Substance Abuse Treatment for Persons 

With Co-Occurring Disorders TIP, 2005b 

Evidence-Based 

Practices 

(from Substance Abuse 

Fields) 

Techniques for Working With 


Provide motivational enhancement to increase 

motivation for treatment. 

Design contingency management techniques to 

address specific target behaviors. 

Use cognitive–behavioral therapeutic techniques to 

address maladaptive thinking & behavior. 

Employ relapse prevention techniques to reduce 

psychiatric and substance use symptoms. 

Apply repetition and skills-building to address deficits 

in functioning. 

Facilitate client participation in mutual self-help group. 


Nine Essential Features of ACT 

Evidence–Based 

Models for 

Persons with COD 

1. Services provided in the community, most frequently in 

the client’s living environment. 

2. Assertive engagement with active outreach. 

3. High intensity of services. 

4. Small caseloads. 

5. Continuous 24-hour responsibility. 

6. Team approach (the full team takes responsibility for all 

clients on the caseload). 

7. Multidisciplinary team, reflecting integration of services. 

8. Close work with support systems. 

9. Continuity of staffing. 


9


Controlled Act Research 

Fidelity Improves Outcomes 

20 

ACT better than Standard 

ACT not better than Standard 

*** If current & subsequent points = 1 then the current score = 1 

Assessment Figure Points 1. Percent Baseline of 6 Participants mo. 12 mo. in Stable 18 mo. Remission 24 mo. 30 for mo. High-Fidelity 36 mo. ACT 

Hi-Fidelity Programs (E; 0n=61) 19.67vs. Low-Fidelity 26.23 29.51 ACT Programs 37.7 42.62 (G; n=26). 55.74 

Low-Fidelity 0 3.85 3.85 7.69 7.69 15.38 15.38 

60 

17 

50 

15 

Number of Studies 

10 

5 

0 

6 

Time in 

Hospital 

8 

3 

Housing 

Stability 

7 7 

5 

Quality of 

Life 

Client 

Satisfaction 

1 

Percent inRemission 

40 

30 

20 

10 

0 

Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo. 

Sacks, S. & Osher, F. 2003. [original reference to follow] 

McHugo, et al., 1999 

Advice to Counselors and Administrators: 

Treatment Principles From ACT 

Provide intensive outreach activities. 

Use active and continued engagement techniques with clients. 

Employ a multidisciplinary team with expertise in substance abuse 

treatment and mental health. 

Provide practical assistance in life management (e.g., housing) as well 

as direct treatment. 

Emphasize shared decision making with the client. 

Provide close monitoring (e.g., medication management). 

Maintain the capacity to intensify services as needed (including 24-hour 

on-call, multiple visits per week). 

Foster team cohesion and communication; ensure that all members of 

the team are familiar with all clients on the caseload. 

Use treatment strategies that are related to the client’s motivation and 

readiness for treatment, and provide motivational enhancements as 

needed. 


to structure 

more flexible activities 

shorter meetings & 

activities 

more staff guidance 

more staff 

responsibility as role 

models 

Modified TC 

Key Modifications 

to process 

fewer sanctions 

engagement 

emphasis 

individually paced 

progress in program 

flexible criteria for 

moving to next stage 

live-out re-entry 

(aftercare) essential 

to elements 

accent on orientation & 

instruction 

individualized task 

assignments 

engagement emphasis 

throughout 

activities proceed at a 

slower pace 

counseling to assist use 

of community 

Summary 

The Modified TC is 

more flexible 

less intense 

more individualized 

The quintessential elements remain 

peer self-help 

community-as-method 


Outcomes baseline vs 2-year 

follow-up 

3.5 

3 

2.5 

2 

1.5 

1 

0.5 

0 

Drug 

Use 

De Leon, G., Sacks, S., et al. 2000. 

Modified TC 2 

Alcohol 

# of 

Drugs 

Employment 

Drug 

Use 

Alcohol 

TAU 

# of 

Drugs 

Employment 

baseline 

2-year 

follow-up 

10


Modified TC Program in 

Criminal Justice Settings 

Psycho-educational 

Classes 

Cognitive-behavioral 

Elements 

Therapeutic 

Interventions 

50 

40 

30 

20 

10 

0 

MICA Offender 12 Month Outcomes 

33% 

MH 

reincarceration 

rates 

16% 

TC only 

TC + 

aftercare 

5% 

Total n= 139 n=64 n=32 n=43 


Sacks, S., Sacks, J., et al. 2004 

Advice to Counselors & Administrators: 

Recommended Treatment and Services From the 

MTC Model 

Treat the whole person. 

Provide a highly structured daily regimen. 

Use peers to help one another. 

Rely on a network or community for both support and healing. 

Regard all interactions as opportunities for change. 

Foster positive growth and development. 

Promote change in behavior, attitudes, values, and lifestyle. 

Teach, honor, and respect cultural values, beliefs, and differences. 

Evidence–Based Practices 

for Persons with 

Severe Mental Disorders 


Evidence–Based Practices for Persons 

with Severe Mental Disorders 

Collaborative Psychopharmacology 



Illness Management and Recovery Skills 

Assertive Community Treatment 

Integrated Dual Disorder Treatment (Substance Use 

and Mental Illness) 

Co-Occurring Center for Excellence (COCE) Change Model 

Inputs 

(Advances in 

the field) 

Resources 

Available 

SAMHSA 

Initiatives 

NIH 

Research 

Change 

Agents 

Adapted from Mueser, K., Torrey, W.C., Lynde, D., Singer, P. & Drake, R.E. (2003) and from the Substance Abuse Treatment for Persons With Co- 

Occurring Disorders TIP (2005b) 

CO- 

OCCURRING 

DISORDERS 

CENTER 

National Steering 

Council 

Project 

Management Team 

Project Staff 

Subcontractors 

Consultants 

Technology 

Transfer 

Approach 

Principles: 

• Relevance 

• Credibility 

• Clarity 

• Feasibility 

• Psychosocial 

factors 

Practices: 

• Matching goals to 

readiness 

• Interpersonal 

Strategies 

• Organizational 

support 

• Use of: 

–Translators 

– Early adopters 

–Champions 

• Peer networking 

• Follow-up and 

support 

Targets of 

Change 

Norms and 

Culture of 

Practice 

Legislative 

Regulatory 

Context 

COSIG and 

non-COSIG States 

Sub-State Entities 

(Cities, Counties, 

Tribes, and 

Tribal Organizations) 

Providers 

(community-based, 

educational 

establishments, 

homelessness 

system, criminal 

justice, other 

social and 

public health) 

Clinical 

Practice 

Outcomes 

Short Term 

Long Term 

Willingness to 

Science and practice 

challenge 

viewed as coequal 

traditional 

partners in advancing 

assumptions 

patient outcomes 

Incentives for 

change 

Removal of 

barriers 

Support of and 

resources for 

innovation 

Interagency 

communication, 

cooperation 

Cross 

competence 

Readiness for 

organizational 

change and 

development 

Support of clinical 

innovation 

Readiness 

for/adoption of 

innovation 

Institutionalization of 

evidence-based 

practices through 

reimbursement, 

licensing, etc. 

Evidence-based 

practices as 

strategic goals 

Capacity 

development 

No wrong door 

Integrated 

systems 

System 

sustainability 


practices as 


norm 


practices as 

standard of care 

11


Conclusion 

There are a variety of treatment 

strategies and models ready for 

infusion into clinical practice. There is 

the need to develop new application 

approaches based on the principles 

and practices of technology transfer. 

CSAT 2005b. 

Services Integration 

Services integration refers to both: 

– The process of merging previously separate 

clinical services into a seamless and 

harmonious framework of practices at the 

level of the individual. 

– The delivery of integrated treatment for clients 

with co-occurring disorders (COD) utilizing 

various techniques. 


Any process by which mental health and 

substance abuse services are appropriately 

integrated or combined at either the level of 

direct contact with the individual client with 

COD or between providers or programs 

serving these individuals. Integrated services 

can be provided by an individual clinician, a 

clinical team that assumes responsibility for 

providing integrated services to the client, or 

an organized program that provides 

appropriately integrated services by all 

Center for Substance 

clinicians 

Abuse Treatment, (2005d) 

or teams to all clients. 

CSAT 2005b. 

Who Provides Services 

Integration? 

Services Integration may include 

integrated clinical treatment by an 

individual treatment provider or clinical 

team, or COD program development by 

a particular treatment program. 

CSAT 2005b. 

Services Integration: Co- 

Location 

Co-location of mental health and 

substance abuse programs or clinicians 

may facilitate the provision of integrated 

services, but is neither necessary, nor 

sufficient for services integration. 

Systems Integration 

The process by which individual systems 

or collaborating systems organize 

themselves to implement services 

integration to clients and families with 

COD as a routine practice that is 

supported by system infrastructure and is 

a core function of system design. 

Center for Substance Abuse Treatment, (2005d) 

12


Integrated Systems 

A model for bringing the mental health and substance abuse treatment 

systems (and other systems, potentially) into an integrated planning 

process. 

The entire system is organized in ways consistent with the assumption 

that COD is highly prevalent and requires specialized interventions. 

This includes system-level policies and financing, the design of all 

programs, clinical practices throughout the system, and basic clinical 

competencies for all clinicians. 

For example, Comprehensive Continuous Integrated System of Care 

(Minkoff, 2001); and various Co-Occurring State Incentive Grants 

(COSIG) and other State Initiatives. 

CSAT 2005a. TIP 42. 

Services Integration and 

Other Forms of Integration 

Providing Integrated 

Treatment to Clients is 

Fundamental 

Without this, Integrated 

Programs and Systems 

Integration have no purpose 

COD CLIENT 

Integrated 

Treatment 

Integrated Programs 

can facilitate 



Systems Integration 

Integrated 

Programs 

Systems Integration can facilitate Integrated 

Treatment and Integrated Programs 

Center for Substance Abuse Treatment, (2005d) 

Principles That Guide Systems 

Of Care For People With COD 

Principles that Guide 

Systems of Care for 

People with COD 

Co-Occurring Disorders (COD) are to be expected. 

COD are to be expected in all behavioral health 

settings and system planning must address this in 

all policies, regulation, and programming. 

Center for Substance Abuse Treatment. 2005b 

Principles That Guide Systems Of Care For People 

With COD Continued 

Develop Improved Systems of Care and 

Move toward Integrated Systems. A fully 

integrated system of mental health and 

addiction services that emphasizes 

continuity and quality is in the best 

interest of consumers, providers, 

programs, and systems. 



Integrated treatment refers broadly to 

any mechanism by which treatment 

interventions for COD are combined 

within the context of a primary 

treatment or service setting. 


coordinating substance abuse and 

mental health interventions to treat 

the whole person more effectively. 

Adapted from CSAT, 2005a. Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP 42 

13


Levels of Program Capacity in 

COD 



Beginning 

Addiction Only Tx 

Intermediate 

COD Capable 

Advanced 

COD Enhanced 

Substance 

Abuse Tx 

More Tx for Mental Disorders 


COD Integrated 

COD Enhanced 

Advanced 

Intermediate 

COD Capable 

Mental Health Only Tx 

Beginning 

Mental Health 

Tx 

More Tx for Substance Abuse Disorders 

There are many points of entry. The 

system of care must be accessible from 

multiple portals of entry (i.e., have “no 

wrong door”) and be perceived as 

welcoming by the consumer. 





The system of care for COD should 

not be limited to a single “correct” 

model or approach. 



The system of care must reflect the 

importance of the partnership between 

science and service, and support both 

the application of evidence- and 

consensus-based practices for persons 

with COD and evaluation efforts of 

existing programs and services. 





Behavioral health systems must collaborate with 

professionals in primary care, human services, 

housing, and related fields in order to meet the 

complex needs of persons with COD. 

Principles that Guide 

Provider Activity For 

People With COD 


14


Principles That Guide Provider 

Activity For People With COD 

Principles That Guide Provider Activity For People With COD Continued 

Co-occurring disorders must be expected and 

treatment approaches should incorporate this 

assumption in all screening, assessment and 


Within the treatment context, both cooccurring 

disorders are considered of 

equal importance 1 . 



1 Adapted from original 

Principles That Guide Provider Activity For People With 

COD Continued 

Empathy, respect, and the belief in the 

individual’s capacity for change are 

fundamental provider attitudes. 

Principles That Guide Provider Activity For People With 

COD Continued 

Treatment should be individualized to 

accommodate the specific needs and 

personal goals of unique individuals in 

different stages of change. 



Other Guiding Principles 

Employ a recovery perspective. 

Adopt a multi-problem viewpoint. 

Develop a phased approach to treatment. 

Address specific real-life problems early in 

treatment. 

Use support systems to maintain and extend 



Essential Programming for 










15


Building Blocks for Constructing a 

Co-Occurring Treatment System 

Clinical Capacity 

Evaluation and Monitoring 

Evidence and Consensus- Based 

Practices 

Workforce Development and 

Training 

Screening, Assessment, & 


Definitions, Terminology, 

Classification 

Infrastructure 

Information Sharing 

Certification and 

Licensure 

Financing Mechanisms 

Systems Change 


Service & System Change 

Co-Occurring Center of Excellence 

(COCE) 

Type 

Higher Intensity 

Technical 

Assistance 

Main Outcome 

Service & 

System Change 

Areas Of Emphasis 

Services & Services 


Systems 

Evaluation and 


Evidence 

Monitoring 

and 


Consensus- Based 

Workforce 

Licensure 

Practices 

Development and Financing Mechanisms 

Screening, 

Training 

Assessment, & 


Definitions, 


Terminology, 



Approach 

comprehensive 

collaborative 

proactive 

longitudinal 


CRITICAL INPUTS 

Mental Health, SAMHSA’s 

Substance Mission & 

Abuse,& COD Priorities 

Research 

State/Local 

Experience & 

Federal 

Innovation 

Policy 

Consumer 

State 

Needs And 

Policy Perspectives 

THE COD SERVICE SYSTEM 

SAMHSA’s COCE 

COCE: 

Transmit Guide Foster 

COCE GOALS 

CLARIFYING AND 

ESTABLISHING 

Definitions 

Nosology 

Measurement 

Evidence & Consensus-Based 

Practices 

Unified Approach to 

Treatment 

AGENDA SETTING 

Professional Education 

Practice Improvement 

Research 

Policy 


RESOURCE TO SAMHSA 

Logistical/Operational 

Execution/Implementation 

Informational 

WORK OF THE COCE 

PRODUCTS 

Overview Papers 

Templates for Product 

Development 

Technical Reports 

Articles 

Literature Reviews 

ACTIVITIES 

Training 

Diffusion of Innovation 

Field Application and Study 

Technical Assistance 

Training of Trainers 

Institutes 

Coordination with other 

SAMHSA Centers 

Conclusion 

Much has been accomplished in the field of COD in the last 10 

years, and the knowledge acquired is ready for broader 

dissemination and application. 

The importance of the transfer and application of knowledge 

and technology has likewise become better understood. 

New government initiatives (for example, COSIG, COCE, and 

MHT) are underway that improve services by promoting 

innovative technology transfer strategies using material that 

reflect the recent advances in the field. 

Source: Center for Substance Abuse Treatment. 2005b 

http://coce.samhsa.gov/ 

References 

References (continued) 

American Association of Community Psychiatrists (AACP). AACP Principles for the Care and Treatment of 

Persons with Co-Occurring Psychiatric and Substance Disorders. Pittsburgh, PA: AACP, 2000. 

Center for Mental Health Services. Co-Occurring Disorders: Integrated Dual Disorders Treatment, 

Implementation Resource Kit. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2002. 

Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-Occurring 

Disorders. Treatment Improvement Protocol (TIP) Series, Number 42. DHHS Pub. No. (SMA) 05-39920. 

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005a. 

Center for Substance Abuse Treatment. Treatment, Volume 1: Overarching Principles in the Planning, 

Implementation, and Delivery of Service for Persons with Co-Occurring Disorders. COCE Overview Paper. 

Rockville, MD: Substance Abuse and Mental Health Services Administration. 2005b. 

Center for Substance Abuse Treatment. Treatment, Volume 1: The Use of Evidence- and Consensus-Based 

Practices in Treating Persons With Co-Occurring Disorders. COCE Overview Paper No. 4. Rockville, MD: 

Substance Abuse and Mental Health Services Administration. 2005c. 

Center for Substance Abuse Treatment. Treatment, Volume 1: Screening, Assessment, and Treatment 

Planning for Persons with Co-Occurring Disorders. COCE Overview Paper No. 2. Rockville, MD: 

Substance Abuse and Mental Health Services Administration. 2005d. 

Grant, B.F., Stinson, F.S., Dawson, D.A., Chou, S.P., Dufour, M.C., Comptom, W., Pickering, R.P. & Kaplan, K. 

Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders. 

Archives of General Psychiatry, 61, 807–816, 2004. 

Kessler, R.C., McGonagle, K., Zhao, S., Nelson, C.D., Hughes, M., Eshleman, S., Wittchen, H., and Kendler, 

K. Lifetime and 12-month prevalence of DSM-IIIR psychiatric disorders in the United States: Results from 

the National Comorbidity Survey. Archives of General Psychiatry 51:8–19, 1994. 

Miller, W.S. and Rollnick, S. Motivational Interviewing: Preparing People for Change. 2nd Edition. 

New York: Guilford Press, 2002. 

Minkoff, K. and Cline, C. Comprehensive, continuous, integrated systems of care. Psychiatric Clinics 

of North America, In press. 

Osher, F.C. A vision for the future: A service system responsive to the needs of persons with cooccurring 

mental and addictive disorders. American Journal of Orthopsychiatry 66(1):71–76, 

1996. 

Osher, F.C. Managing scarce community mental health resources, APA Synapse, October, 1996. 

Osher, F.C. & Kofoed, L.L. Treatment of patients with psychiatric and psychoactive substance use 

disorders. Hospital and Community Psychiatry 40:1025–1030, 1989. 

Prochaska, J.O. and DiClemente, C.C. The Transtheoretical Approach: Crossing the Traditional 

Boundaries of Psychotherapy. Homewood, IL; Dow-Jones/Irwin, 1984. 

Sacks, S., Sacks. J.Y., De Leon, G., Bernhardt, A.I. & Staines. G.L. Modified therapeutic community 

for mentally Ill chemical abusers: Background; influences: Program description: Preliminary 

findings. Substance Use and Misuse, 32(9), 1217-1259, 1997. 

Substance Abuse and Mental Health Services Administration. Principles for Systems of Managed 

Care, 1996. http://www.mentalhealth.org/publications/allpubs/MC96-61 [Accessed December 28, 

2005]. 

Substance Abuse & Mental Health Administration. (2004) Results from the 2003 National Survey on 

Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies. 

16


Additional References 

Additional References (continued) 

Addiction Technology Transfer Center (ATTC). 2000. The Change Book: A Blueprint for Technology 

Transfer. University of Missouri-Kansas City. CSAT: SAMHSA. 

Alexander, M.J., Sussman, S., & Teleki, A. (2004) Trauma-Informed Screening and Assessment for 

Women with Co occurring Mental Health and Substance Abuse Problems in Correctional 

Settings. Center for the Study of Issues in Public Mental Health Nathan Kline Institute for 

Psychiatric Research Orangeburg, NY 10960. 

Backer, T. 1991. Drug Abuse Technology Transfer, Rockville, MD: NIDA. 

Backer, T., David, S.L. & Saucy, G. (eds.) 1995. Reviewing the behavioral science knowledge base on 

technology transfer. NIDA Research Monograph 155. Rockville, MD: National Institute on Drug Abuse. 

Carroll, J.F.X, & McGinley, J.J (2004) Guidelines for Using the Mental Health Screening Form III. 

Presentation to the Screening & Assessment COCE/COSIG Workgroup. 

De Leon, G., Sacks, S., Staines, G., & McKendrick, K. 2000. Modified therapeutic community for homeless 

MICAs: Treatment Outcomes. American Journal of Drug and Alcohol Abuse, 26(3), 461-480. 

Dennis, M.L., White, M.K. & Titus, J.C (2001) Common measures that have been used for both 

clinical and research purposes with Adolescent Substance Abusers. Chestnut Health Systems, 

Bloomington, IL Drake, R.E., Mueser, K.T. Brunette, M.F. & McHugo, G.J. (2004). A review of 

treatments for people with severe mental illnesses and co-occurring substance use disorders. 

Psychiatric Rehabilitation 27(4), 360-374. 

Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. 2005. Implementation 

Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la 

Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI 

Publication #231). 

Grant, B.F., Stinson, F.S., Dawson, D.A., Chou, S.P., Dufour, M.C., Comptom, W., Pickering, R.P. & 

Kaplan, K. (2004) Prevalence and co-occurrence of substance use disorders and independent 

mood and anxiety disorders. Archives of General Psychiatry, 61, 807–816. 

Institute of Medicine 2000. Crossing the quality chasm: A new health system for the 21st century. 

Washington, DC: National Academy Press. 

Jeffery, D.P., Ley, A., McLaren, S. & Siegfried, N. 2000. Psychosocial treatment programmes for 

people with both severe mental illness and substance misuse. The Cochrane Database of 

Systematic Reviews 2000, Issue 2. Art. No.: CD001088. DOI: 10.1002/14651858.CD001088. 

NASMHPD and NASADAD (1999). National dialogue on co-occurring mental health and substance use 

disorders. Washington, DC. 


Lamb, S., Greenlick, M.R. & McCarty, D. (eds.) 1998. Bridging the gap between practice and 

research. Washington, DC: National Academy Press. 

McLellan, A.T., Lewis, D.C., O’Brien, C.P., Kleber, H.D. 2000. Drug Dependence, a chronic medical 

illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American 

Medical Association, 284(13), 1689-1695.McHugo, G.J., Drake, R.E., Teague, G.B. & Xie, H. 1999. 

Fidelity to assertive community treatment and client outcomes in the New Hampshire dual 

disorders study. Psychiatric Services, 50(6), 818-824. 

Minkoff, K. 2001. Service Planning Guidelines: Co-occurring psychiatric and substance disorders. 

Fayetteville, IL: University of Chicago, Center for Psychiatric Rehabilitation, Behavioral Health 

Recovery Management. Online [retrieved 11-10-04] at 

http://www.bhrm.org/guidelines/ddguidelines.htm 

Mueser, K.T., Torrey, W.C., Lynde, D., Singer, P., & Drake, R.E. 2003. Implementing evidence-based 

practices for people with severe mental illness. Behavior Modification, 27(3), 387-411. 

Office of the Surgeon General. 1999. Report on Mental Health. Publication #017-024-01653-5, 

Superintendent of Documents, Washington, DC. 

Rogers, E.M. 1995a. Diffusion of innovations. 4th Edition. New York, NY: Free Press. 

Rogers, E.M. 1995b. Lessons for guidelines from the diffusion of innovations. Joint Commission 

Journal on Quality Improvement, 21(7): 324-328. 


Sackett, D.L., Rosenberg, M.C., Muir Gray, J.A., et al. 1996. Evidence-based medicine: What it 

is and what it isn’t. British Medical Journal, 312, 71-72. 

Sacks, S. 2000. Co-occurring mental & substance abuse disorders—Promising approaches & 

research issues. Journal of Substance Use & Misuse 35(12-14), 2061-2093. 

Sacks, S., Sacks. J.Y., De Leon, G., Bernhardt, A.I. & Staines. G.L. 1997. Modified therapeutic 

community for mentally Ill chemical abusers: Background; influences: Program description: 

Preliminary findings. Substance Use and Misuse, 32(9), 1217-1259.Sacks, S. & Osher, F. 

2003. Evidence- and Consensus-Based Practices for Clinical Capacity Building. Presented 

at the COSIG New Grantee Meeting, Washington, DC. 

Sacks, S., Sacks, J.Y., McKendrick, K., Banks, S., & Stommel, J. 2004. Modified TC for MICA 

Offenders: Crime Outcomes. Behavioral Sciences & The Law, 22, 477-501. 

Sacks, S. Melnick, G. & Coen, C. (2006) Co-Occurring Disorders Screening Instrument for 

Criminal Justice Populations (CJ-CODSI). GAINS Annual Conference, Boston, MA. 

Substance Abuse and Mental Health Services Administration. 2002.Report to Congress on the 

Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental 

Disorders. Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Substance Abuse & Mental Health Administration. (2004). Results from the 2003 National 

Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied 

Studies. 

Simpson, D.D. 2002. A conceptual framework for transferring research to practice. Journal of 

Substance Abuse Treatment, 22, 171-182. 









tel 212.845.4429 fax 212.845.4650 


17

M16: Housing Implications for the OMHSAS Blueprint for Recovery: Recommendations from the 

OMHSAS Adult Advisory Committee Housing Workgroup 

John Ames 

1.5 hours Focus: Systems Integration & Recovery Supports 

Description: 

The purpose of the OMHSAS Housing Workgroup was to draft a set of housing and service goals, priorities and 

strategies for expanding recovery-oriented housing options for consumers with serious mental disorders 

and/or co-occurring substance use disorders as a next step in Pennsylvania’s "A Call for Change: Towards a 

Recovery-Oriented Mental Health Service System for Adults." These recommendations are presented for 

identification and discussion. 


• describe the role of housing in a recovery oriented system of care; 

• identify the philosophy and practical aspects of the concept of separating housing from services; 

• use information from this workshop to share with colleagues. 

NOTES:

Revised: 2/20/06 

DRAFT definition of supportive/supported housing to be used in all data collection and for all 

other purposes by DPW-OMHSAS. 

Definition: 

Supportive housing is a successful, cost-effective combination of affordable housing with services 

that helps people live more stable, productive lives. Supportive housing works well for people 

who face the most complex challenges—individuals and families who have very low incomes and 

serious, persistent issues that may include substance use, mental illness, and HIV/AIDS; and 

may also be homeless, or at risk of homelessness. 

A supportive housing unit is: 

• Available to, and intended for a person or family whose head of household is experiencing 

mental illness, other chronic health conditions including substance use issues, and/or multiple 

barriers to employment and housing stability; and my also be homeless or at risk of 

homelessness; 

• Where the tenant pays no more than 30%-50% of household income towards rent, and ideally 

no more than 30%; 

• is associated with a flexible array of comprehensive services, including medical and wellness, 

mental health, substance use management and recovery, vocational and employment, money 

management, coordinated support (case management), life skills, household establishment, 

and tenant advocacy; 

• Where use of services or programs is not a condition of ongoing tenancy; 

• Where the tenant has a lease or similar form of occupancy agreement and there are not limits 

on a person’s length of tenancy as long as they abide by the conditions of the lease or 

agreement; and 

• Where there is a working partnership that includes ongoing communication between 

supportive services providers, property owners or managers, and/or housing subsidy 

programs. 

Supportive Housing is: 

1. Safe and Secure 

2. Affordable to consumers 

3. Permanent, as long as the consumer pays the rent and honors the conditions of the lease. 

Supportive Housing is linked to support services that are: 

1. Flexible. Individualized services are available when the consumer needs them, and 

where the consumer lives. 

2. Optional. People are not required to participate in services to keep their housing, 

although they are encourage to use services.

DRAFT – Community Based and Recovery oriented Housing Options for individuals with 

Serious Mental Illness or co-occuring disorders. 

Need – to provide housing to individuals with mental illness in their own home communities, 

through application of flexible and creative housing strategies which support and enhance 

Recovery. 

Issues 

• Stable, affordable safe, decent and sanitary housing is a major component of a successful 

recovery for individuals suffering from a serious mental illness (SMI) or a co-occurring 

mental illness and substance abuse disorder (COD) . There is a great need for the Office 

of Mental Health and Substance Abuse Services (OMHSAS) to concentrate simply on 

housing issues for the population of persons in the state who are affected by serious 

mental illness, or co-occurring disorders of serious mental illness and substance abuse. 

Studies have shown that persons who are satisfied with their housing and have a stable 

secure place of their own are more compliant with therapy, tend to have fewer and shorter 

inpatient stays and generally have more successful recovery. 

• Housing is an issue because it is expensive, and most persons with SMI or COD have 

limited incomes. Recently many if not most persons with a disability who rely on SSI 

have been priced out of the private rental market in many areas. Safe decent affordable 

housing for low-income persons, a group which includes many disabled individuals, is 

disappearing in areas with strong economies, and in which the rental subsidies offered by 

the government have not kept pace with real rental costs. 

-Concept - Housing should be separated from services. This concept requires that we develop 

a new focus on: how we provide housing services to individuals with SMI and COD; the process 

we use to move persons out of mental hospitals into community residential settings; and also 

how we use residential services in the community to prevent long-term hospitalization. This new 

focus demands that we complete a full paradigm shift from the 1970's oriented protective, 

custodial view of housing and services for persons with SMI or COD; to a concept of 

recovery and informed consumer choice, of both housing options and supportive services. 

-Background – Residential services, in the Community Residential Rehabilitation Services 

(CRRS) and Long Term Structured Residences (LTSR’s) funded and licensed by the OMHSAS, 

are attached to specific housing sites, and are ranked according to the staffing needs presented by 

the level of severity of the consumer’s illness and the need to provide care and supervision. 

Most of the residential services funded through the OMHSAS, including CRRS and LTSR’s, 

have not traditionally been considered permanent housing for the individual. The housing sites 

are meant to be transitional residences, in which training, rehabilitation and supportive services 

are offered on site and in connection or coordination with other community treatment services 

that are included in the individual’s mental health treatment plan. Where a mental health 

consumer lives is based on what level of staffing and support he needs, similar to the state 

1

hospital. The CRRS and LTSR’s were developed to be short term (1-3 years) treatment and 

housing, in which staff worked with individuals placed there to assist in the recovery process, 

help with community integration and prepare residents to move in a timely fashion from the 

staffed setting into more independent and permanent housing. 

-Problems with the current CRRS and LTSR services – Consumer perspective 

• Moving, changing residences is very difficult for people, as is the lack of a feel of 

permanency when frequent moves are required. Persons with serious mental 

illness are subject to great stress as a direct result of the upheaval associated with 

a change of residence, which can occur as treatment needs change, and persons 

must be transferred to a new location. Some of the persons living in CRR’s form 

attachments with their housemates, and want to be able to call home the actual 

CRR site where they have been placed. Nevertheless they may be required to 

move to a new site and develop relationships with new housemates as their need 

for treatment intensity changes. 

• The current linear CRRS, LTSR model fails to provide housing choices for 

individuals with serious mental illness. If a person needs the services and 

supports that accompany or are interwoven into the residence, the person must 

live where the County MH/MR Program and it’s provider agencies have located 

the residences, in the CRR which provides the level of service most needed for 

that person. Some consumers really don’t want to live with other persons with 

mental illness, but would prefer to choose their own roommates or housemates; 

and some don’t want to live with anyone, but are happier and more productive 

when living alone. 

-Problems with the current CRRS and LTSR services – Administrative concerns 

• The current model only works when individuals can continue to move to the least 

restrictive housing alternative, from state hospital through the levels of CRRS (or 

LTSR’s), into supported or totally independent living (linear progression). Many 

consumers who are ready to move from residential treatment facilities to their 

own private housing frequently must remain in CRRS with minimum to moderate 

levels of staffing, not because they still require the level of service/support 

offered in the CRRS, but because there is no available affordable safe decent 

sanitary housing available in the community into which the resident can move. Or 

if housing is available, the necessary supports which make community housing a 

viable alternative, such as crisis residential services, mobile psych rehab and 

dedicated housing support caseworkers are not readily available within the 

County's service array. In effect, some residents continue to receive a level of 

staff support which is not needed, but must be provided due to the treatment 

model of the CRRS, in order to continue to be housed. 

• In other instances persons are placed in residential settings including CRRS and 

LTSR’s because some level of staff supervision is guaranteed. Such placements 

2

are perceived as necessary for state hospital discharge, even though individuals 

might have done very well being discharged into their own apartments or other 

residential settings of their own choosing had the necessary service supports 

and evidence based treatment practices been available. 

• The state requires the provider of CRRS and LTSR facilities (whether the county 

operates the program or sub-contracts to a provider agency), to own the property, 

and be the landlord to the residents. The costs associated only with housing 

(rent/mortgage, taxes, utilities, etc.) are built into the contracts or budgets for 

CRRS and LTSR’s operated by Counties and their contracted provider agencies. 

The money for this kind of program is allocated by the state to the county 

MH/MR program, and thus community housing for persons with a serious mental 

illness living in “group homes” is paid for by the state. Because staffing and 

support services are integrated into the CRRS program and are site based, the 

flexibility to separate housing from service components is not currently easy to 

do, limiting opportunities for creative change. 

• In the group home model, CRRS and LTSR’s are frequently perceived as the only 

choice for moving consumers from state hospitals to the community. In order to 

serve newly released persons at the top of the residential services pipeline the 

bottom must be free and clear. This means that individuals must continue to 

move into less restrictive settings at all levels of the program, so that new persons 

needing residential services can be placed, according to the level of supervision 

and staffing deemed appropriate, into an available “slot”. When the pipeline is 

clogged, i.e., no movement is occurring at the least restrictive staffed level, the 

whole system backs up, and is in effect static rather than dynamic. Hence, when 

persons are due to be moved from state hospitals into the community, new 

funding to develop additional CRRS must be appropriated and allocated. 

• Overall, the desire to serve persons with mental illness effectively in the 

community through a recovery oriented flexible system that can adapt to meet 

changing circumstances is hampered by the constraints of the most prevalent 

current residential model, which combines housing and treatment in one bundled 

service; and by failure in the system to support or encourage counties to develop 

appropriate recovery oriented supports and effective local housing options for 

consumers with mental disabilities. 

Re-thinking housing options - what can the OMHSAS do differently? 

The OMHSAS has promoted the development of alternatives to CRRS and LTSR’s for 

almost a decade, and a variety of local housing options, including supported housing have 

successfully been built. 

OMHSAS must: 

• Promote the concept that consumers should have choices, within reasonable 

funding constraints to live where they please in the community. 

3

• Un-bundle the community residential rehabilitation service model, and separate 

housing from staff support. 

• Develop flexible, creative and effective consensus based best service practices 

which facilitate recovery, supported by affordable community housing options. 

Work with other responsible entities, such as local housing and redevelopment 

authorities; non-profit housing developers; community based housing consortiums 

and advocacy groups to provide housing opportunities for persons with serious 


• Develop mobile recovery oriented service delivery models which bring the 

housing supports to the consumer, if needed to promote housing stability. 

• Under the assumption that one size does not fit all, the state should recognize the 

positive aspects of the CRRS and LTSR’s, and attempt to revitalize some of them 

to be viable short term options for some consumers. Needed changes should be 

made to assure that persons move through the group homes fairly quickly into 

permanent secure housing in the community. CRRS and LTSR’s should be a part 

of a community housing continuum, rather than the only option recognized and 

promoted by OMHSAS, the state hospitals and the County MH/MR Programs. 

What direction should the planning for creating better housing options take? 

Everything we do to enable, facilitate and support persons with SMI to live in the community 

should be based on the philosophy of the recovery process, and included in that process is the 

concept of informed consumer choice. Service system planning should also be based on the 

recovery concept, and, therefore, consumers should be included and actively participate in the 

planning process. 

There is also a housing philosophy, which supports the concept of recovery. 

The National Association of State Mental Health Program Directors “Position Statement 

on Housing and Supports for People With Psychiatric Disabilities” is that conceptual 

model. The statement reads: 

Housing Options 

It should be possible for all people with psychiatric disabilities to have the option to live 

in decent, stable, affordable and safe housing that reflects consumer choice and 

available resources. These are settings that maximize opportunities for participation in 

the life of the community and promote self-care, wellness and citizenship. Housing 

options should not require time limits for moving to another housing option. People 

should not be required to change living situations or lose their place of residence if 

they are hospitalized. People should choose their housing arrangements from among 

those living environments available to the general public. State mental health 

authorities have the obligation to exercise leadership in the housing area, addressing 

housing and support needs and expanding affordable housing stock. This is a 

4

esponsibility shared with consumers and one that requires coordination and 

negotiation of mutual roles of mental health authorities, public assistance and housing 

authorities, and the private sector. 

Provision of Services 

Necessary supports, including case management, on-site crisis interventions, and 

rehabilitation services, should be available at appropriate levels and for as long as 

needed by persons with psychiatric disabilities regardless of their choices of living 

arrangements. Services should be flexible, individualized and promote respect and 

dignity. Advocacy, community education and resource development should be 

continuous. 

Need – to provide an array of housing opportunities to individuals with mental illness in their 

own communities, through application of flexible and creative housing strategies. 

Many Counties have developed local housing options over the past 10 years which are 

designed to meet local needs, using local resources. Those housing options have 

included working closely with housing authorities to obtain public housing units and 

section 8 program vouchers; and there are other models of supported housing that have 

worked well in parts of the state. 

In many Counties part of the MH County allocation goes to fund supported housing 

models that involve rent subsidies, in which the provider agency rents an apartment and 

sub-lets to eligible MH consumers; or the rent subsidy directly supports consumers in 

lease based landlord tenant rental options. Staff can be available on-site in a flexible 

delivery model, where staff interactions with tenants can vary both in intensity and 

frequency, based on need. The supported living model still requires state money, through 

County MH allocations to partially support the housing costs of the consumer; and some 

of the same problems occur when the consumer is ready for a more independent living 

situation, but still requires a housing rental subsidy. 

The successful development of good local housing options can translate into a practice or 

process that has the overt support of the state and which is portable to other counties. 

What is needed is a new statewide focus on effectively utilizing available resources, with 

an eye towards creating flexible service delivery models offering consumers a choice 

through a coordinated continuum of local housing options, which in the long run will 

move the state more into the business of offering treatment and less into the business of 

funding housing. 

• Ideally, a new focus would promote the concept that persons leaving state 

hospitals and persons in the community with SMI who are in need of should have 

secure housing of their own, which is affordable, decent, and permanent; a place 

that can be called home. Agencies that are funded to provide housing and rent 

support to low income individuals should be utilized to the fullest extent 

possible to meet the housing needs of MH consumers. 

5

• A new construct recognizes housing as a necessity which should not be available 

based on whether persons are compliant with treatment and medication plans; but 

that the housing is still their own, unaffected by treatment expectations. The 

inherent risks involved with consumer housing choice are consistent with current 

practices and philosophy of the recovery model. 

• Some consumers may continue to need residential support services that require 

staff to be present at various times in their homes during certain periods of the 

day, to insure that recovery continues, and that the skills necessary to function 

independently in the community are developed or rediscovered. New service 

delivery systems should be developed for support staff to go to the consumer 

at his or her residence, rather than forcing the consumer to reside in the 

treatment or rehab site of the support staff. 

• Some CRRS and LTSR’s should be revitalized and used as originally intended, 

for short term intensive community re-habilitation, after which the consumer 

moves into permanent housing of his choice in the community. 

• Most of the rest of the CRRS should be phased out via a strategic planning 

process; the housing component should be separated, and the money spent 

on the CRRS should be used to develop treatment and rehabilitative services 

that are recovery oriented evidence based practices and which support 

consumer choice housing. The CRRS and LTSR’s must become options in a 

local continuum, rather than the primary or only choice for housing consumers. 

What advantages would this change in focus have? 

• It gives the consumer the choice of where to live; with whom to live, (if anyone); 

and how independent to be. Housing options could include renting an apartment; 

renting a room; sharing the rent on an apartment; owning a home, buying a home 

with friends; living with friends or relatives, living in a room and board facility; 

or in domiciliary care. 

• Housing authority programs funded by HUD are designed to meet the needs of 

persons with low income, and offer housing options which include living in 

public housing units; in private rental units available to the general public, aided 

by a section 8 housing rental subsidy; and in subsidized supported living 

arrangements. It is probable that the housing costs associated with residential 

treatment services could be funded by local housing authorities for a portion of 

the consumers served by the OMHSAS, who need housing in the community and 

can qualify for housing support under HUD guidelines. 

• If supportive services are not bundled with housing, new and creative community 

support models can be created. Staffing of the current residential components of 

traditional CRRS can be converted to mobile psych rehab or mobile medication 

support, or to mobile housing support services, provided in the consumer’s home 

6

or provided at other rehab programs attended by the consumer outside of the 

home. As recovery progresses for the consumer and the need for staff to be 

present in the consumer’s home diminishes, staff can be withdrawn, and hours cut 

back and eventually eliminated. Consumers can continue to live in their own 

homes, no longer required to physically move to a new location just because they 

no longer need as much staff support! 

• “Clogs in the pipeline” of moving persons from state hospitals into the 

CRRS/LTSR system will no longer be a problem, as there will be no pipeline. 

The constraints on moving persons to less restrictive alternatives in the 

community will be: the availability of supported housing options; and the 

availability of mobile support staff. 

• HUD will provide funds for the cost of some of the housing of low-income 

individuals, rather than the state bearing all of the housing costs through state 

allocation for residential services. OMHSAS will be allocating more money to the 

County MH/MR Programs for treatment, services and supports, and less for 

housing. 

Planning Resources available to help with the transition of individuals from State Hospitals 

to the Community. 

Un-bundled housing options – Other models for the community housing array 

The OMHSAS has promoted the development of alternatives to CRRS for almost a decade, and a 

variety of local housing options, including supported housing have successfully been built. 

There are many examples in this state of collaboration between MH/MR Programs and 

community housing and service providers that allow communities to offer housing with 

subsidized rental support, usually through HUD funding to individuals with SMI, where the 

housing is separate from support services. Un-bundled housing simply means that the individual 

chooses where and with whom to live, and that services relating to his or her SMI are offered to 

that individual in the community at site based locations, and also at the individual’s home when 

needed to help preserve the housing and maintain the integrity and viability of the housing 

choice. 

Un-bundled housing can include: 

• Living with relatives 

• Renting an apartment, either alone or with roommates 

• Buying a house 

• Living in a rooming house 

• Congregate living with other persons with SMI (such as a Fairweather Lodge) 

• Any SRO (single Room Occupancy Environment) 

Service models that effectively support independent consumer housing choice include: 

• Intensive Case Management and Targeted Case Management 

• Supportive Housing case management staff 

• Mobile Psych Rehab units 

7

• Community Treatment Teams 

• Resource Coordination 

What will OMHSAS do to promote the change from a protective, custodial model of care to 

one of recovery, in regard to un-bundling housing and services? 

- OMHSAS will continue to support the creation of Local Housing Option Teams 

(LHOT's), which address the creation of housing options for disabled individuals at the 

county/local level, through collaboration among county MH Offices; local Housing Authorities; 

provider agencies and other interested parties. The intent of LHOTS is to actualize the concepts 

of separation of housing venues from service options, and create a true housing continuum for 

persons with SMI and COD, and for other populations with limiting disabilities. More than 600 

new housing opportunities have been created in the last three years of operation and development 

of LHOTs in 27 Counties. 

OMHSAS will continue to support development of Fairweather Lodges, through a contract 

with Stairways Behavioral Health, Inc., of Erie Pa. The Lodges, while not appropriate for 

everyone with a SMI or COD, are a long standing housing option that fully supports recovery 

for the Lodge members. Fairweather Lodge is considered to be an Evidence Based Practice. 

Lodges are consumer run and staffed; all lodge rules and decisions are made through 

democratically run daily meetings. 

Lodges are eventually economically self-sufficient, and most persons applying to become lodge 

members cite the opportunity to be successfully employed as the main reason they wish to join 

the lodge. Stairways has several employment venues in the lodges, but the primary source of 

income is through a commercially viable and competitive janitorial service, with sufficient 

contracts to require the services of several Lodge crews. 

Stairways, Inc. has demonstrated that lodges and other supportive housing models will work 

effectively for consumers in a "service rich" continuum of recovery oriented services and 

supports. 

OMHSAS will continue to craft a philosophy of housing for persons with a Serious Mental 

Illness that is consistent with and congruent with the concept and practices involved in the 

promotion of recovery for our consumers. So far, the workgroup has made the determination 

that housing is more related to each person having an informed CHOICE of housing options, 

which are separate from support services; that allow a consumer to create a HOME. 

OMHSAS will promote supportive/supported housing, as a preference for all future 

OMHSAS supported housing development, according to the following description and 

definition: 

DRAFT definition of supportive/supported housing to be used in all data collection and for all 

other purposes by DPW-OMHSAS. 

Definition: 

8

Supportive housing is a successful, cost-effective combination of affordable housing with 

services that helps people live more stable, productive lives. Supportive housing works well for 

people who face the most complex challenges—individuals and families who have very low 

incomes and serious, persistent issues that may include substance use, mental illness, and 

HIV/AIDS; and may also be homeless, or at risk of homelessness. 

A supportive housing unit is: 

• Available to, and intended for a person or family whose head of household is 

experiencing mental illness, other chronic health conditions including substance use 

issues, and/or multiple barriers to employment and housing stability; and my also be 

homeless or at risk of homelessness; 

• Where the tenant pays no more than 30%-50% of household income towards rent, and 

ideally no more than 30%; 

• is associated with a flexible array of comprehensive services, including medical and 

wellness, mental health, substance use management and recovery, vocational and 

employment, money management, coordinated support (case management), life skills, 

household establishment, and tenant advocacy; 

• Where use of services or programs is not a condition of ongoing tenancy; 

• Where the tenant has a lease or similar form of occupancy agreement and there are 

not limits on a person’s length of tenancy as long as they abide by the conditions of 

the lease or agreement; and 

• Where there is a working partnership that includes ongoing communication between 

supportive services providers, property owners or managers, and/or housing subsidy 

programs. 

Supportive Housing is: 

1. Safe and Secure 

2. Affordable to consumers 

3. Permanent, as long as the consumer pays the rent and honors the conditions of the 

lease. 

Supportive Housing is linked to support services that are: 

1. Flexible. Individualized services are available when the consumer needs them, and 

where the consumer lives. 

2. Optional. People are not required to participate in services to keep their housing, 

although they are encourage to use services. 

9

M17: Living on the Edge: Substance Use Disorders and Borderline Personality Disorder 

Pasquale Russoniello, MA & Veronica O. Bowlan, MSW, LSW 


Description: 

Emotional dysregulation and impulsive, reckless behaviors are the hallmarks of Borderline Personality Disorder 

(BPD). This workshop discusses how individuals with BPD often turn to drugs and alcohol. While substance use 

is an attempt to manage difficult emotions, it also fuels self-destructive, impulsive behaviors. We examine how 

to assess and treat some triggers for substance use, such as PTSD symptoms, interpersonal conflict and 

abandonment issues. 


• discuss the DSM-IV-TR criteria for BPD; 

• examine the link between the symptoms of BPD and substance use; 

• evaluate the behavioral and emotional triggers for substance use; 

• apply a self-assessment tool for emotional dysregulation. 

NOTES:


Living on the Edge: Substance 

Use Disorders & Borderline 

Personality Disorder 

Pasquale Russoniello, MA 

& 

Veronica O. Bowlan, MSW, LSW 

Borderline Personality As A 

Diagnosis (PBD) 

• DSM-IV-TR Personality Disorder: Axis II in 

the DSM multi-axial assessment system 

• Is a Cluster B Personality disorder 

• Is over represented in all treatment 

modalities, e.g. inpatient, outpatient, crisis 

and Emergency Room services 

• Is often co-morbid with other Axis I and 

Axis II DSM disorders. 

1 

2 

Other DSM-TR Co-occurring 

Axis I and Axis II Disorders 

• Substance Use Disorders (SUD) 


• Brief Psychotic Episodes 

• Dissociative identity Disorder 

• Antisocial Personality Disorder 

• Anxiety Disorders, including Panic D/O, 

OCD, & PTSD 

3 

Controversies/Problems 

With The BPD Diagnosis 

• Is evolving diagnosis 

• High degree of heterogeneity among 

persons diagnosed with the disorder 

• Is highly sensitive to sociocultural factors 

• Often confounded with features of other 

disorders 

• Different views of etiology 

• Stigma of diagnosis affects consumer and 

practitioner 

• Limited research on effective treatment 

• Highly stressful for practitioners to treat. 

4 

Epidemiology (APA, 2001) 

• Borderline Personality Disorder is the 

most common personality disorder in 

clinical settings. 

– 10% seen in outpatient settings 

– 15-20% seen in psychiatric inpatient settings 

– 30%-60% of clinical populations with 

personality disorders 

– 2% of general population 

Epidemiology (cont’d) 

(APA, 2001) 

– Diagnosed predominately in womenratio 

3-1 

– Present in cultures around the world 

– 5 times more common in first degree 

biological relatives 

– Greater familial risk for substancerelated 

disorders, antisocial personality 

disorder, and mood disorders 

5 

6 

1


DSM-IV-TR 

Diagnostic Criteria for 

301.83 Borderline Personality Disorder: 

A pervasive pattern of instability of 

interpersonal relationships, self-image, 

and affects, and marked impulsivity 

beginning by early adulthood and present 

in a variety of contexts, as indicated by 

five (or more) of the following (CRITERIA): 

7 

DSM-IV-TR Criteria for BPD 

1. FRANTIC EFFORTS TO AVOID REAL OR 

IMAGINED ABANDONMENT 

2. A PATTERN OF UNSTABLE AND INTENSE 

INTERPERSONAL RELATIONSHIPS 

3. IDENTITY DISTURBANCE OR PROBLEMS 

WITH SELF-IMAGE OR SENSE OF SELF 

4. IMPULSIVITY THAT IS POTENTIALLY SELF- 

DAMAGING 

5. RECURRENT SUICIDAL BEHAVIOR OR 

PARA-SUICIDAL BEHAVIOR 

8 

DSM-IV-TR Criteria for BPD 

(CON’T) 

6. AFFECTIVE INSTABILITY 

7. CHRONIC FEELINGS OF EMPTINESS 

8. INAPPROPRIATE INTENSE OR 

UNCONTROLLABLE ANGER 

9. TRANSIENT,STRESS-RELATED 

PARANOID IDEATIONS OR SEVERE 

DISSOCIATIVE SYMPTOMS 

9 

BPD and SUD (Rosenthal, 2006) 

• May share common etiological and 

maintaining factors: 

– Difficulties with the regulation of emotional 

experience and expression 

– Impulsivity 

• Those with BPD and SUD, compared to 

those with BPD only, may show more 

severe psychopathology 

– Greater anxiety 

– More suicide attempts 

• Attachment problems, e.g. to treatment 

10 

Vulnerability Factors That May 

Contribute to BPD-SUD 

• Acute physical 

distress 

• Chronic illness 

• Deterioration of 

health/strength 

• Anger 

• Fatigue 

• Loneliness 

• Major life loss 

• Chronic pain 

• Poor problem solving 

ability 

• Poor impulse control 

• New life 

circumstances 

• Co-morbid disorders 

such as PTSD 

• Fear of changing 

• Limited motivation 

11 

Dialectical Behavior Therapy 

Theory of BPD 

(Linehan, 1993) 

• What is Dialectical Behavior 

Therapy? 

• A modification of standard 

cognitive-behavioral therapy which 

was designed for treatment of 

parasuicidal consumers with 

borderline personality disorder 

12 

2


BPD is a Pervasive Disorder 

of the Emotion Regulation 

System 

Emotion Dysregulation 

Emotional Vulnerability 

BPD criterion behaviors function 

to regulate emotions or 

are a natural consequence of 

emotion dysregulation 


13 

Inability to 

Modulate Emotions 

14 

DBT’S Reorganization of DSM-IV 

Criteria for BPD (Linehan, 1993) 

1. Emotional Dyregulation : Criteria 6 & 8 

2. Interpersonal Dysregulation: Criteria 1 

& 2 

3. Behavioral Dysregulation: Criteria 4 & 

5 

4. Cognitive Dysregulation: Criterion 9 

5. Dysregulation of the self: Criteria 3 & 7 

DBT as a Dialectical Approach: 


• Stresses that to fully understand a 

person’s behavior it must be 

placed in its behavioral and 

environmental context 

(interrelatedness) 

15 

16 

Invalidating Environment 

Pervasively negates or 

dismisses behavior 

independent of 

the actual validity 

of the behavior 

Biosocial Theory of BPD 

Biological Dysfunction in the 

Emotion Regulation System 

Invalidating 

Environment 

17 

Pervasive Emotion Dysregulation 

18 

3



and 


= 

Child with some emotional 

problems already 

Major TRAUMA 

• Sexual Abuse 

• Physical Abuse 

• Emotional Abuse 

NOW…………… ADD 

19 

• Severe Neglect 

20 

BPD 

1. AVOID ABANDONMENT 

2. INTENSE RELATIONSHIPS 

3. PROBLEMS WITH SELF- 

IMAGE 

4. IMPULSIVITY IN SELF- 

DAMAGING AREAS 

5. RECURRENT SUICIDAL 

PARASUICIDAL BEHAVIOR 


7. FEELINGS OF EMPTINESS 

8. INTENSE ANGER 

9. DISSOCIATIVE 

SYMPTOMS 

BPD and PTSD 

PTSD 

1. EXPOSURE TO TRAUMA 

INVOLVING INTENSE 

FEAR 

2. RE-EXPERIENCING 

TRAUMA 

3. AVOID STIMULI 

ASSOCIATED WITH 

TRAUMA 

4. NUMBING OF 

RESPONSES 

5. INCREASED AROUSAL 

6. SYMPTOMS LAST 

LONGER THAN 1 MONTH 

7. IMPAIRS IMPORTANT 

Comorbidity of BPD and 

PTSD (Freeman, 1998) 

• 1/3 of persons with BPD fulfill criteria for PTSD 

• 75% of whom are women 

• Hx of physical or sexual abuse in the 

developmental background of 60%-75% of 

persons with BPD 

• Women with BPD who report Hx of sexual abuse 

engage in more lethal self-injurious behavior 

than women not reporting abuse 

AREAS OF FUNCTIONING 21 

22 

Substance Abuse and Trauma 

• PTSD –5 times likelihood of alcohol abuse 

& dependence 

• PTSD and veterans - 75% met criteria for 

alcohol abuse 

• 60% women & 20% men in alcohol 

recovery programs – sexual abuse as 

child 

• 80% men and women report physical 

abuse as children in above recovery 

Complex Posttraumatic 

Syndrome (Van der Kolk, 1994) 

Conglomeration of syndrome tends to 

occur together: 

• Chronic affect dysregulation 

• Destructive behavior against self and 

others 

• Learning disabilities 

• Dissociative problems 

• Somatization/physical complaints 

program • Distortions in concepts of self and others 

23 

24 

4


A New Diagnosis: 

Complex Posttraumatic Stress 

Disorder (Herman, 1992) 

Complex Posttraumatic Stress 

Disorder (Cont’d) (Herman, 1992) 

• Alterations in perception of 

perpetrator 

(preoccupation with perpetrator, 

acceptance of beliefs of perpetrator, etc.) 

• Alterations in relations with others 

(isolation, distrust, searching for rescuer, 

failures at self-protection, etc.) 

• Somatization (unexplained or 

exacerbated physical complaints) 

• Alterations in system of meaning 

(sense of hopelessness and despair, etc) 

A history of subjection to totalitarian 

control over a prolonged period ( e.g. 

survivors of childhood sexual abuse) 

• Alterations in affect or impulse 

regulation (chronic suicidal ideation, selfinjury, 

explosive anger, etc.) 

• Alterations in consciousness or 

attention (dissociative episodes, reliving 

trauma, depersonalization, etc.) 

• Alterations in self-perception (selfblame; 

sense of helplessness, etc.) 

25 

26 

Multi-Dimensional 

Biopsychosocial Assessment 

• Mental Health 

• Substance Use 


• Medical 

• Developmental 

Examples Of Assessment 

Domains (APA, 2001) 

• Presence of risk-taking & impulsive 

behaviors 

• Mood disturbance and reactivity 

• Risk of suicide 

• Risk of violence to persons or property 

• Substance abuse 

27 

28 

Assessment Domains (cont’d) 

(APA, 2001) 

• Ability to care for self or others (e.g. 

children, aging parent) 

• Achievements, skills 

• Financial resources 

• Psychosocial stressors and supports 

• Motivation and readiness for treatment 

29 

Engagement 

Start where the person is, including 

developmentally 

Balance client-centered expectations, 

goals regarding behavioral change with 

therapist goals of balancing safety issues 

and placing responsibility on the individual 

Maintain a dialectical abstinence approach 

Complete and total emphasis on abstinence 

on one hand with on other hand a planned 

approach for lapses that mitigates harm and 

increases resumption of abstinence 

30 

5


Essential Components of 

Treatment (Paris, 1993) 

1. Providing a stable treatment framework 

2. Having highly active/involving therapists 

3. Establishing a connection between the 

person’s actions (e.g. substance use) and 

feelings in the present 

4. Identifying adverse effects of self-destructive 

behaviors, including substance use that 

interferes with quality of life 

5. Paying careful attention to countertransference 

feelings 

6. Referring to 12 step programs 

31 

Subjective Units of Distress Scale 

[SUDS] For Self-Management 

• “On as stress scale of 0 to 10, with 0 as a 

neutral and 10 is the maximum emotional or 

physical discomfort you can imagine, where 

are you right now?” 

• 0 – 3 GREEN ZONE 

• 4 – 6 YELLOW ZONE 

• 7 – 10 RED ZONE 

• Can also be combined with Chain 

Analysis of substance use behavior 

32 

Hierarchy of Treatment 

Priorities (APA, 2001) 

• Suicidal and self-destructive 

behaviors 

• Behaviors interfering with therapy 

• Behaviors interfering with quality 

of life 

33 

Parasuicidal Behaviors 


• Nonfatal acts in which an individual deliberately 

causes self-injury or ingests a substance in 

excess of an prescribed or generally recognized 

dose. 

• ¾ of BPD individuals have committed at least 

one parasuicidal act. 

• Parasuicidal acts are never accepted as 

therapeutic choice. 

34 

Skill Building in Therapy with 

Persons with BPD 

Information can be offered that helps the 

understanding of events, feelings, 

behaviors etc. and validates the individual. 

Learning skills: interpersonal; distress 

tolerance; mindfulness; problem solving 

and social skills are helpful and can be 

accomplished by persons with BPD. 

35 

Effective Supervision 

• Since a team approach is recommended 

to treat persons with BPD, team 

supervision meetings are recommended to 

provide mutual support, problem solving 

and to renew “HOPE” for the team 

members 

• Therapists need regular consultation,and 

peer support to manage their own 

transference and intense feelings which 

arise 

36 

6

Living on the Edge: Substance Use and Borderline Personality Disorder 

Bibliography 

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental 

disorders Forth Edition, Text Revision. Washington, DC. 

American Psychiatric Association. (2001). Practice guideline for the treatment of 

patients with Borderline personality disorder. Available at www.psch.org 

Freeman, A. (1998, April). Creative approaches to the short-term 

treatment of borderline personality disorder. Presentation. Sponsored by the 

Institute for Behavioral Healthcare, Portola Valley California, Philadelphia, PA 

Herman, J.L. (1992). Trauma and recovery. New York, NY: Basic Books. 

Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline 

personality disorder. New York, NY: Guilford Press. 

Paris, J. (1996). Cultural factors in the emergence of borderline pathology. 

Psychiatry, 59, 185-192 

Paris, J. (Ed.). (1993) Borderline personality disorder: Etiology and 

treatment. Washington, DC: American Psychiatric Press, Inc. 

Recommended reading list: General books for the basics of DBT. 

Sharetrain: The Behavioral Technology Transfer Group. Seattle, WA. 

http://www.behavioraltech.com 

Rosenthal, Z. (2006). Dialectical Behavior Therapy for Patients Dually 

Diagnosed With Borderline Personality Disorder and Substance Use Disorders. 

Psychiatric Times, January, 2006, volume XXV, issue 1. Retrieved April 3, 2006 

from http://www.psychiatrictimes.com/showArticle.jhtml?articleID=177101045 

van der Kolk, B., (1994). The body keeps the score: Memory and the 

evolving psychobiology of posttraumatic stress. Retrieved 7/14/2005 from 

http://www.trauma-pages.com/articles.htm 

van der Kolk, B., McFarlane, A., Weisaeth, L., (Eds) (1996). Traumatic 

stress: The effects of overwhelming experience on mind, body, and society. The 

Guilford Press: New York.

M21: Creating and Sustaining Integrated Dual Disorders Treatment Programs: 

Lessons from the Field in Ohio 

Patrick E. Boyle, LISW, LICDC 


Description: 

The workshop focuses on the implementation of the Integrated Dual Diagnosis Treatment (IDDT) model. Data 

and observations collected over the 2.5-year period of Ohio’s participation in the national Implementing 

Evidence-Based Practices Project, and over subsequent years, is presented. Implementation process 

facilitators, and barriers to successful program establishment and maintenance in community treatment 

centers and state hospitals, are discussed. 


• Describe core components of the IDDT model and its accompanying fidelity scale; 

• List key strategies observed from 50 Ohio IDDT site implementation processes; 

• Summarize the implications for utilizing key strategies regarding assessing organizational readiness and 

achieving desirable IDDT fidelity levels 

NOTES:


Creating and Sustaining IDDT Programs: 

Lessons from the Field in Ohio 

Patrick E. Boyle, MSSA, LISW, LICDC 

Center for EBPs 

Ohio SAMI CCOE Ohio SE CCOE 

Case Western Reserve University 

Cleveland, Ohio 

May 15, 2006 

2006 Pennsylvania COSIG 

Promoting Recovery-Oriented 

Programs & Practices 

Learning Objectives 

1. Describe core components of the IDDT 

model and its accompanying fidelity 

scale. 

2. List key strategies observed from 50 

Ohio IDDT site implementation 

processes. 

3. Summarize the implications for 

utilizing key strategies regarding 

assessing organizational readiness 

and achieving desirable IDDT fidelity 

levels 











1


What we know about EBPs… 

• Practice interventions 

• Supported by evidence that they 

are effective 

• We all want to do what is known to 

work best for the consumers with 

whom we work 

• EBP implementation – easier said 

than done? 



…moving EBPs into routine care 

is more challenging than inventing 

them! 

It is one thing to say with the prophet 

Amos, “Let justice roll down like 

mighty waters,” and quite another to 

work out the irrigation system. 



William Sloane Coffin 

What we know so far about 

implementation science 

• Fixsen, et al. synthesis of literature (2005) 

– Searched 9 academic databases for “implementation” 

since 1970 

– Across multiple domains (e.g. agriculture, business, child welfare, 

engineering, health, juvenile justice, manufacturing, medicine, mental health, 

nursing, and social services) 

– Reviewed 1,054 

– Cut to 734 deemed “significant” 

– Only 22 reported results of studies or meta analyses of 

implementation variables 



What’s Common? 

Despite tremendous variability in 

content and context, across 

domains: 

• They have similar implementation 

problems 

• They showed similar implementation 

solutions 



“Problem” themes 

• No clear pathways to implementation yet 

• What is implemented 

– is often not used with high fidelity and good 

effect 

– disappears with time and staff turnover 

• “Usability” has little to do with the weight 

of the evidence re: program outcomes 

– Evidence on effectiveness helps us select what 

we want to implement 

– Evidence on outcomes does not help us 

implement the program 



“Solutions” themes 

(Facilitators to implementation) 

• “Buy-in” and champions 

• Adequate time for “exploration” 

• Perceived benefit & manageable risk 

• Reduction of systems and policy barriers 

• Right resources at the right time 

• Implementation teams with clear change 

leadership 

• Organizational change 



2


“Solutions” themes 

(Facilitators to implementation) 

• Effective strategies to change adult 

behavior (e.g. front line staff, supervisors) 

• Effective strategies to change program 

operations (e.g. H.R., scheduling) 

• Access to knowledgeable people 

(“purveyors”) 

• Trusting relationship with purveyors 

• Fidelity and outcomes measures 



How do we know an 

implementation is successful? 

• Intervention Outcomes 

• Implementation 

Outcomes 






–The “Evidence” in EBPs 

–Collection of intervention outcomes 

in every application 

• Implementation Outcomes 






– The “Evidence” in EBPs 

– Collection of intervention outcomes -every 

application 

• Implementation Outcomes 

– Fidelity scales measure the success of the 

implementation effort 

– Presence or absence of key elements 

– Scores allow us to attribute changes in 

intervention outcomes (consumer, etc.) to the 

EBP 



The research on EBPs tells us: 

Effective intervention practices 

+ Effective implementation 

practices 

Good outcomes for consumers 

No other combination of factors reliably 

produces desired outcomes for consumers. 



What have we found in Ohio? 

• Numerous factors appear to influence the 

success of IDDT implementation 

• These factors and strategies can be 

described 

so can begin to measure their presence or 

absence 

• Observations support some themes in the 

literature about core implementation 

components 



3


How does the Center learn 

about these factors in Ohio? 

• Fidelity assessments & consultation - 

since 2000 

• CCOE Evaluation surveys 

• Data collection 

– SAMHSA National Implementing Evidence 

Based Practices Project: IDDT and IMR (2002 

– 2004) with 9 teams (+ 52 cmh teams + 9 

state hospitals) 

– SAMHSA 2 nd Wave Implementation Project: 

SE (2004-2006) with 10 sites 

– ODMH funded SE Outcomes Research 


Project (2005-2007) 


Case studies: 

IDDT Implementation Methods 

• All sites use the IDDT Toolkit (enhanced) 

• All sites receive intensive and ongoing 

technical support from an expert 

Consultant/Trainer 

• Success of the implementation at each 

site was measured using the General 

Organizational Index and the IDDT Fidelity 

Scale 



What do we know about those 

factors? 

Integrated Dual Disorders 

Treatment (IDDT) 

State of the art in implementation 

science is: 

– Identifying the factors that appear to be 

important – components of the 

implementation process 

– Gathering empirical support for 

importance of key components 

– Beginning to describe the 

factors/components so that they can be 

measured 



• Developed for persons with co-occurring 

severe and persistent mental illness and 

substance use disorders 

• Emphasis is on treatment of both 

disorders by the same team of clinicians 

in the same location at the same time 

• Treatment is most often delivered in 

mental health centers or integrated 



mental health and SA treatment centers 

Substance abuse common 

in people with mental illness 

Combination and levels of 

illness 

• Over 50% of people with schizophrenia, 

bipolar disorder and other severe mood 

disorders have a substance use disorder 

at some time in their life 

• About one third of people with anxiety and 

depressive disorders have a substance 

use disorder at some time in their life 

Mild to moderate I 

Mental illness symptoms 

Low to moderate 

substance use disorder 

Mild to moderate III 

Mental illness symptoms 

Severe substance use 

disorder 

Severe 

II 

mental illness symptoms 

Low to moderate 

Substance use disorder 

Severe 

IV 

mental illness symptoms 

Severe substance use 

disorder 





4


Status 

NHDD 10 years Status 

250 

200 

150 

100 

50 

0 

0 1 2 3 4 5 6 7 8 9 10 

Year 

Remission 

No-Remission 

Dropout 

Not_Rated 

Dead 

Course of dual disorders 

• Both disorders are chronic, wax & wane 

• Recovery from mental illness or substance 

abuse occurs in stages over time 

– Precontemplation 

– Contemplation 

– Preparation/Determination 

–Action 

– Relapse prevention 

» Prochaska and DiClemente, Miller and Rollnick 1991 







Dual disorders - worse outcomes than 

singular 

• Relapse of mental illness 

• Treatment problems and hospitalization 

• Violence, victimization, and suicidal 

behavior 

• Homelessness and Incarceration 

• Medical problems, HIV & Hepatitis risk 

behaviors and infection 

• Family problems 

• Increase service use and cost 



Why integrated treatment of 

dual disorders? 

• More effective than separate treatment 

• 26 studies show integrated treatment is 

more effective than traditional separate 

treatment 



Abstinence leads to 

improvements in other 

outcomes 

• Reduce institutionalization 

• Reduce symptoms, suicide 

• Reduce violence, victimization, legal 

problems 

• Better physical health 

• Improve function, work 

• Improve relationships and family 



5


60 

50 

40 

30 

IDDT fidelity to model 

improves abstinence 


Assessment Figure Points 1. Percent Baseline of Participants 6 mo. in Stable 12 mo. Remission 18 mo. for High-Fidelity 24 mo. 30 ACT mo. 36 mo. 

Hi-Fidelity Programs ( E n=61) 19.67 Low-Fidelity 26.23 ACT 29.51 Programs 42.62 ; n=26). 55.74 

; 0 vs. 37.7 ( G 

Low-Fidelity 0 3.85 3.85 7.69 7.69 15.38 15.38 

How do people obtain 

remission 

from dual disorders? 

• Stable housing 

• Sober support network/family 

• Regular meaningful activity 

• Trusting clinical relationship 

20 

10 

– Alverson et al, Com MHJ, 2000 

0 

Baseline 6 mo. 12 Promoting mo. Recovery-Oriented 

18 mo. 24 mo. 30 mo. 36 mo. Promoting Recovery-Oriented 



Traditional treatment 

• Treating each disorder separately 

– Parallel—occurs in the same time frame but 

at separate agencies or programs 

– Sequential—occurs at different times, in the 

same or separate agencies/programs 

– Typically treated by different staff, who have 

differing types of training 

• Separate treatment is far less effective 





Integrated Dual Disorders 

Treatment - IDDT: What is it? 

• The New Hampshire-Dartmouth Model 

• Robert Drake, MD and colleagues 

• Treatment of substance use disorder and 

mental illness together 

– Same team 

– Same location 

– Same time frame 

Ten Treatment Principles 

of IDDT 

1. Integration of substance 

abuse & mental health 

treatments 

•Same clinicians within program or 

agency 

•Supports cross training 

Source: Mercer-McFadden, C., Drake, R.E., Clark, R.E., Verven, N., Noordsy, D.L., Fox, T.S. (1998). 

Substance Abuse Treatment for people with Severe Mental Disorders: a program manager’s guide. 

New Hampshire-Dartmouth Psychiatric Research Center. 





6



of IDDT 

2. Flexibility & specialization 

of clinicians 

•Cross-trained staff 

3. Assertive outreach 


of IDDT 

4. Recognition of client 

preferences 

• Client-centeredness 

• Cultural competence 

5. Close Monitoring 

6. Comprehensive Services 






of IDDT 

7. Range of Stable Living Situations 

The Basic Change Paradigm 

8. The Long-term Perspective 

9. Stage-wise Treatment 

10. Optimism 



• Why change? 

– What is in it for me as a stakeholder? 

• How to change? 

– How is the practice implemented? 

• How to sustain the practice? 

– What structures need to be modified? 



No one has 

It goes We don’t 

Our consumers are 

tried it in our against have the staff 

different 

state 

our 

They are 

tradition 

too 

We aren't 

doing it 

It needs more 

entrenched 

wrong now 

thought We have 

tried that 

I'm all 

This is 

It is too 

before 

for it, 

just a fad 

but... ambitious 

We 

We don't 

There's We have 

weren't 

have the 

not 

always done trained to 

I don't have 

resources 

enough it this way do it this 

the 

time 

way 

authority 

We didn't 

It 

There's 

budget for It's not our takes 

no money Everyone 

We have too this 

problem too 

for it else isn't 

many crises 

long 

doing it 

to do this 

It won't 

work in 

this 

There is no 

agency 

clear mandate 

for this 

No se puede 

It's not 

We don't 

important to 

have a clear 

I am not 

everyone 

consensus 

sure my 

It is a system 

boss will 

problem, not 

Me falta animo 

like it 

ours 

How many times do we hear these reactions to change? 

There are numerous reasons not to change. 

And one overpowering reason to change. 

To improve the lives of adults with severe mental illness. 

Evidence-Based Practices, worth the change. 



Measuring Fidelity 

to the IDDT Model 

IDDT Fidelity Index 

• Subscale I. Organizational Characteristics 

• Total of 12 components 

• Subscale II. Treatment Characteristics 

• Total of 14 components 



7


Part I: 

Organizational Characteristics 



Items 

01: Program Philosophy 

02: Eligibility and Identification 

03: Penetration 

04: Assessment 

05: Treatment Planning 

06: Treatment 



Part I: 

Organizational Characteristics 

Part II: 

Treatment Characteristics 

Items 

07: Training 

08: Supervision 

09: Process Monitoring 

010: Outcome Monitoring 

011: Quality Improvement 

Items 

T1a: Multidisciplinary Team 

T1b: Integrated SA Specialist 

T2: Stage-Wise Interventions 

T3: Comprehensive DD Service 

Access 

T4: Time-unlimited Services 

012: Client Choice 




T5: Outreach Programs & Practices 

Part II: 

Treatment Characteristics 

Part I: Organizational Characteristics 


Items 

T8: Group DD Treatment 

T9: Family Psychoeducation on 

DD 

T10: Participation in Self-help 

Groups 

T11: Pharmacological Treatment 


T12: Interventions Programs & Practices to Promote 

H 

lth 

• Definition 

–Committed to clearly 

articulated philosophy 

consistent with IDDT 

(outreach, long term, 

stagewise, integrated 

MH&SA, comprehensive) 



8



1. What are the next steps towards achieving this 

standard? 

a. 

b. 

c. 

2. Who is responsible for this next step? 

3. When will we accomplish this next step? 



02: Eligibility/Client Identificati 


–All SMI clients screened using 

standardized tools/admission 

criteria for already active 

clients & new admissions 

–Routine & systematic eligibility 

tracking 



03: Penetration 

04: Assessment 


–All consumers who could 

benefit have access to IDDT 




–All clients receive high quality, 

standardized, comprehensive & 

timely, assessments; that are 

individualized, staged, with risk 

factors; updated annually 

targeting domains for 

intervention 



05: Treatment Plan 

06: Treatment 


–Explicit (i.e, treatment plans 

that identify the target of 

intervention, the intervention 

designed to address problem; 

and how it will bring about 

change) individualized plan for 

all IDDT consumers; updated 

every 3 mo. 




–All IDDT clients receive 

unique IDDT treatment 

consistent with their 

individualized treatment plan 



9


07: Training 

08: Supervision 


–All new practitioners receive 

standardized training in IDDT 

(2-day equivalent); existing 

staff receive annual refresher 

training (1-day equivalent) 

w/in 2 months of hire 




–Staff receive structured, 

weekly client- specific 

supervision (individual or 

group) from an experienced 

IDDT clinician; sessions 

explicitly address clinical 

application of IDDT model 



09: Process Monitoring 

010: Outcome Monitoring 


–Supervisors and program 

leaders monitor 

implementation semiannually 

and use relevant data in a 

systematic approach to 

improve program 




–Leaders monitor standardized 

client outcomes quarterly and 

share data with practitioners 

to improve services 



011: Quality Improvement 

012: Client Choice 


–The agency’s QI committee has 

an explicit plan to review IDDT 

components and progress 

semiannually 




–All clients receiving IDDT 

services are offered choices; 

staff consider and abide by 

client preferences when 

offering and providing 

services 



10


Part II: Treatment Characteristics 

T1a: Multidisciplinary Team 

T1b: Integrated SA Specialist 


–Substance abuse specialist, 

case managers, psychiatrist, 

nurse, counselors, and other 

ancillary providers work 

collaboratively on the team 


–Substance abuse specialist 

with at least 2 years 

experience works 

collaboratively with team 





T2: Stage-Wise Interventions 

T3: Access to 

Comprehensive DD Services 


–All interventions (including 

ancillary) are consistent with 

and determined by client’s 

stage of treatment/recovery 




–Consumers have access to a 

range of services [residential, 

supported (competitive) 

employment, family 

psychoeducation, ACT/ICM 

(15:1, 24 hr care; 50%+ in 

community), illness 



management]; ancillary 

T4: Time-Unlimited Services 


–Clients with DD are treated 

on a time unlimited basis 

with intensity modified 

according to need 

T5: Outreach 


–All clients (esp. engagement 

stage) provided with assertive 

outreach (practical assistance 

in natural living environments) 





11


T6:Motivational Interventions 

T7: Substance Abuse Counseling 


–All practitioners understand 

and base interventions on a 

motivational approach 




–Practitioners demonstrate 

understanding of basic 

substance abuse principles and 

provide to clients in active 

treatment and relapse 

prevention stage 



T8: Group DD Treatment 

T9: Family DD Treatment 


–All clients are offered 

integrated stage-wise group 

treatment and 2/3 regularly 

attend 


–Practitioners always attempt to 

involve family/ support network 

to give DD psychoeducation 

and promote collaboration with 

treatment team 





T10: Self-Help Participation 

T11: Pharmacological Treatment 


–Practitioners connect clients in 

active treatment or relapse 

prevention stages with 

substance abuse self-help 

programs 




–Prescribers are trained in DD 

treatment; derive input from 

client and team to increase 

appropriate medication 

adherence; no medication 

prohibition; offer medication 

known to decrease use; avoid 



addictive meds 

12


T12: Interventions to Promote 

Health 

T13: Secondary Interventions 

- for Non-Responders 


–Clients receive a 

comprehensive, structured, 

basic education on how to 

promote health; all staff are 

well-versed in such techniques 




–Program utilizes a specific plan 

to identify, evaluate, and link 

non-responders to more 

intensive interventions (e.g., 

supervised housing, 

payeeship, changing meds, 

etc.) 



Implementation Plan for 

Agencies 

Phases: 

‣ Enabling/Motivating 

‣ Planning/Implementation 

‣ Sustaining 





Enabling/Motivation 

Phase 

Implementation Phase 

‣Readiness Assessment 

• Steering Committees 

•Gather stakeholders 

• Consultation 

• Consensus building 



• Agency Baseline Measure 

• One day activity 

• Written report 

• Action plan 

• Steering Committee 

– Determines priorities & plans action 

• Training 

– for the entire treatment team 



• Clinical and Programmatic Consultation 

13


Sustaining Phase 

• Implementation Monitoring 

– Ongoing Consultation & Booster 

Training 

– Regular (annual) Fidelity Assessments 

– Feedback 

– Steering Committee 


– Service Improvements 








• Action 

• Maintenance/Relapse Prevention 

Prochaska and DeClementi, Miller and Rollnick 1991 

Stage of Change - 


• No intention to change behavior - may “wish” - 

“want to want to change” 

• Unaware/lack awareness of problems 

• Others are aware of problem 

• Present for help under pressure 

• May demonstrate change under pressure - 

though then return to behavior 

• Hallmark = resistant to change 





Stage of Change - Contemplation 

• Aware of problem & seriously thinking about 

overcoming it 

• No commitment to take action 

• May remain “stuck” here for many years 

• Knowing where one wants to go yet “not quite 

ready” 

• Weighing pro’s and con’s of problem/solution 

• Hallmark = ambivalence 

Stage of Change - Preparation 

(Determination) 

• Intend to take action soon (perhaps 

again), may have done so in the past 

• Some reduction in problem behavior 

• Decision-making stage 

• Hallmark = small steps toward action 





14


Stage of Change - Action 

• Individuals modify behavior, experiences, or 

environment to overcome problems 

• Requires considerable commitment of time 

and energy 

• Change is visible and recognized 

• Action does not = change (6 months) 

• Hallmark = visible modification of behavior 

Stage of Change 

Relapse 

Prevention/Maintenance 

• Work to consolidate gains attained 

• A continuation (not absence) of change 

• From 6-12 months - indeterminate 

• Hallmark = stabilizing behavior change 

& avoiding relapse 





What we have learned…. 

“…the challenges and complexities of 

implementation far outweigh the efforts of 

developing the practices and programs 

themselves.” 

Fixsen, D., Naoom, S.F., Blasé, K.A., 

Friedman, R.M. & Wallace, F. (2005). 





Desirable Practitioner 

Characteristics 

• The IDDT Toolkit draft version 

(SAMHSA, 2003) 

offered no specific team member or team 

leader 

profile 

• In general, a well-developed IDDT 

practitioner profile 

had not been developed at the sites prior to 

staffing 

the positions 



•More explicit criteria were in evidence where 

Professional abilities: Team 

Member 

• Credentials, educational backgrounds, 

knowledge about and exposure to the 

IDDT population varied widely 

• Level of experience and exposure 

varied widely 



15


Professional abilities: Team 

Member 

• Experience seemed to be more 

important than familiarity with the 

model 

• Team members’ lack of credentials, 

skills, and experience appeared to be 

ameliorated by intelligence, 

enthusiasm, and strong supervision 



Professional abilities: Team Leader 

• Excellent clinical supervisory skills - 

pivotal especially where team 

members’ levels of skills and 

experience were low 

• Capacities for promoting team 

cohesiveness and engaging important 

community stakeholders in the 

implementation were important 





• Managerial and leadership 

capabilities played an important 

part in Team Leaders’ real and 

perceived effectiveness 

– in general, those skills had not been 

adequately considered during the 

selection process 

• Strong administrative 

support/supervision and expert 

coaching from the CCOE combined 

to compensate for missing 

managerial skills 





Professional Attitudes 

• Degree to which practitioners were 

– motivated, enthusiastic, open to change, 

and otherwise receptive to the practice 

changes asked of them 

– had notable influence on the uptake of 

the training 

Professional Attitudes 

• After 6 months, one agency scrapped its 

originally designated team and recruited 

internally for new team members 

“I was sucked into it.” 

Agency Practitioner 

• Although experience and skills were 

important for 

Promoting 

implementation 

Recovery-Oriented 

success 


– a willingness to take on IDDT was 



16


Elements of the Selection Process 


• Characteristics relevant to IDDT were 

not initially well understood 

• Hirers with a greater understanding of 

IDDT tended to select practitioners 

whose clinical skills “fit” the model 

• Despite an understanding of IDDT, 

hirers tended to overlook the “hidden” 

characteristics that would be required 

for implementing the model 



• Identifying the pool of prospective 

practitioners was the most important 

aspect of the selection process 

• Where existing staff comprised the 

pool of prospective IDDT 

practitioners, recruitment was 

superior to assignment 




• Internal recruitment presented 

challenges, including agency’s 

political climate and perceptions of 

favoritism 

“You’d be seen as a traitor if you came onto 

this team…some programs were de-funded 

in order for this team to be built and they 

think that [IDDT] staff are getting all this 

special training, lower caseloads, 

attention…” 




• Early or pre-training for the purpose of 

screening prospective practitioners was 

demonstrated as useful 

• The wisdom of training for depth and 

transferability with an eye to inevitable staff 

turnover was clear 

• “Selecting” additional staff to attend training 

emerged as a cost-effective means of providing 

a cushion against turnover. 




• Selection of skilled and talented 

practitioners for the Team Leader - not 

sufficient without provision of adequate 

supports for the role 

• The stresses of an implementation vs. 

practice as usual were not initially well 

understood 

“You could have the right person for the job 

…being asked to do seventeen other 

jobs…and not able to do it well.” 



Interaction of Staff Selection, Staff 

Training, and Staff Supervision 

• The selection process observed to be 

functionally intertwined with other core 

implementation components 

• Elements of selection could impact other 

components - negatively or positively 

• Elements of staff training and supervision 

observed to compensate for deficits in 

staff selection process 



17


Training 

“We now have thousands of 

experiments across the country 

which have proven that in mental 

health training is not enough to 

create change.” 

--Dr. Robert Drake/Dartmouth PRC 



• Factors 

– Multiple methods 

– Quality and 

structure of 

supervision 

• Link training and supervision 

– Policies and 

standards 

• Strategies 

– Integrate & intersperse didactic 

& applied learning 

– Provide ongoing monitoring & in 

vivo clinical supervision for skill 

maintenance 

– Address productivity policies & 

standards that pose obstacles to 

skill development & 

maintenance 



Interaction of Staff Selection, Staff 

Training, and Staff Supervision 

• Training staff with fewer skills required 

more intensive sessions initially - left no 

room for anything but ongoing and expert 

supervision from the Team Leader 

• Failing to accurately assess practitioners’ 

attitudes about the model and the 

population as well as their openness to 

change proved even more costly 



Supervision 

• Factors • Strategies 

– Recruitment 

– Match supervisors to IDDT 

approach and 

philosophy 

philosophical stance – Facilitate meeting structure and 

opportunity for in vivo 

– Supervision structure 

monitoring 

– Supervisor support – Provide supervisors with access 

–Time 

to training, consultation, and 

– Consultation support peer networking 

– Administrative 

support 



– Evaluate feasibility of program 

leadership role 

Study finding: 

Conclusions from Case Study 

Findings 

The process of developing the skills 

required to deliver IDDT well occurs over 

time, in context of clinical application and 

with consistent and expert supervision 

and mentoring. 

• Practitioner characteristics are variably 

important 

• Professional experience and skills did not 

compensate for unwillingness to change 

• Expert supervision and training appeared 

• Skills Training and Supervision 

to compensate for deficits in experience 

cannot be separated 

and skill level where motivation to 

• Both are necessary for success change was present 





18


Some overarching themes… 

• Each agency has areas of strength and 

vulnerability 

• No two local Boards or Agencies are alike 

• Agency cultures are heterogeneous 

• Change occurs in stages and takes time 

• Key stakeholders must “have a stake” in the 


• An infrastructure for external technical support is 

salient 



Implementation strategies: 

Training 

Participants often cited training – at all levels - as 

the 

most critical factor in building programs and 

systems of 

care. 

Strategies for Developing Treatment Programs for People 

With Co- 

Occurring Substance Abuse and Mental Disorders. 2003. 

U.S. 

Substance Abuse and Mental Health Services 

Administration 

(SAMHSA) 10 



Training As Usual 

• “It may be a waste of time, energy, and 

financial resources to continue to train 

staff in this manner without first addressing 

the changes that are necessary in the 

systems within which they work to enable 

them to implement these interventions.” 

» Fadden, 1997 

Some effective training strategies… 

Intensive, Comprehensive, Targeted 

Training 

- Both didactic and applied learning 

– Ongoing in vivo supervision 

– Attention to work environment 

– Staff support 

– Advocacy to remove barriers to using newly 

learned practice skills 





What We Are Learning About 

Practitioners….. 

• Longtime personal and professional belief 

systems take time to change 

• Intellectual acceptance of a new approach does 

not immediately translate into changed practice 

• Practitioners who have had previous exposure 

to innovation find it easier to adopt change 


Practitioners, cont’d….. 

• Practitioners tend to become more 

enthusiastic about a new practice when 

they begin to see results 

• Once they’re “sold,” they feel empowered 

and are more likely to continue to develop 

their skills 





19


Implementation Strategies: 

Support for Agency Leadership 

Implementation Strategies: 

Support for Agency Leadership 

What we observed: 

What we observed, cont’d: 

• Agency leadership often under-estimate the 

complexity of implementing an EBP 

• Directors and program leaders often believe 

existing services adhere more closely to the 

model than they actually do 



• CMHCs tend to cite lack of cooperative Mental 

Health Authorities as a major reason for not 

implementing or successfully sustaining EBP 

programs 

• Care is often not taken to develop a shared 


vision and understanding Programs & Practices of how the new EBP 

Some effective leadership 

strategies: 

• Pave the way for an EBP by 

building an agency culture that is 

open to change 

• Accurately assess staff’s readiness 

to “buy in” to a new philosophy 

• Accurately assess the knowledge 

and skills level of agency staff 



Leadership strategies, cont’d… 

• Recruit vs assign practitioners to a 

new team 

• Build in and communicate 

administrative support for program 

managers 

• Ensure that EBP training and 

supervision are part of staff job 



descriptions and not an additional 

Leadership strategies, cont’d… 


Agency Administrators….. 

• Engage multiple stakeholders 

around planning, implementing, 

and sustaining the EBP program 

• Track outcomes specific to the 

EBP program and acknowledge 

successes 

• Make maximum use of external 



technical expertise and support 

• Longtime personal and professional 

belief systems take time to change 

• Intellectual acceptance of a new 

approach does not immediately 

translate into changed administrative 

styles and skills 

• Administrators who actively monitor 



the outcomes of the EBP program are 

20



Administrators, cont’d….. 

• Administrators who have had previous 

exposure to innovations find it easier to 

adopt EBPs and to be patient with 

incremental change 

• Administrators who value the input of 

other stakeholders cultivate a broader 

base of people with a “stake” in their 

program 



Study finding: 

Agencies whose leadership was receptive 

to 

ongoing technical support, including: 

• consultation, 

• training, and 

• regular evaluation and feedback, 

were better able to develop strategies that 

created and sustained viable EBP programs. 



Systems Issues… 

– Structural challenges to integrated treatment 

– Organizational stages of implementation: 

motivating, enacting, and sustaining 

– Each stage 6 mo - 1 year 

– Multiple levels of organizational change: 

(1) Health authority 

(2) Program leadership 

(3) Clinician/supervisor 

(4) Family 

(5) Consumer 



Some effective strategies for policy 

makers: 

• Building consensus for the vision of 

integrated dual disorder services 

• Conjoint planning 

• Clear definition of standards 

• Structural, regulatory, reimbursement, and 

contracting mechanisms 

• Demonstration projects 

• Sponsorship of training and monitoring 



Ohio SAMI CCOE Mission…to promote the 

development and maintenance of integrated treatment 

for people with mental and substance use disorders in 

Ohio 

CCOE Staff 

Goals 

1. provide clinical training and consultation for 

service delivery 

2. disseminate information about evidence based 

practices and the problems and needs of this 

special population 

3. consult on program development, design, and 


4. conduct research assessing program fidelity, 

model adaptations, and outcomes for consumers 

and their families 



• Co-Directors & Director of Implementation 

Services 

• Directors of Consultation & Training (IDDT & 

SE) 

• Consultant & Trainers (IDDT & Supported 

Employment) 

• Peer Specialist 

• Medical Consultant 

• Director & Assistant Dir of Research & 

Evaluation 

Di f C i i 



21


Ohio SAMI CCOE Services 

References 

• Training and Education 

– Intensive On-site, Regional, Annual Conference, 

Videoconferences 

• Programmatic Consultation 

– During all Stages of Implementation 

• Clinical Consultation 

• Research and Evaluation 

– Fidelity Reviews and Feedback 

– Client and Programmatic Promoting Recovery-Oriented Outcomes 


• Communications Newsletter & Website ☺ 

• Integrated Treatment for Dual Disorders: 

A Comprehensive Guide to Effective 

Practice (2003). Mueser, Noordsy, Drake, 

Fox. NY: Guilford Press 

• Websites: 

– www.mentalhealthpractices.org 

– www.samhsa.gov 

– www.ohiosamiccoe.case.edu 

– www.nirn.fmhi.usf.edu 

– www.tacinc.org/index/viewPage.cfm?pageId=114 



Conclusions 

Contact 

Patrick E. Boyle, MSSA, LISW, LICDC 

1. Evaluation is informing, shaping, and 

reinforcing implementation strategies 

for Ohio 

2. Learning challenges and facilitators for 

stage-wise implementation cross all 

levels of an organization and system 

3. Achieving desirable outcomes is 

possible with assistance and a 

sustained effort 



Center for Evidence Based Practices at Case 

Ohio SAMI CCOE - Ohio SE CCOE 

c/o Northcoast Behavioral Healthcare 

1756 Sagamore Road, Admin Bldg 7, Room 304 

Northfield, OH 44067-1086 

Ph: 330-468-8663 Fax: 330-468-8723 

Patrick.boyle@case.edu 

www.ohiosamiccoe.case.edu 



22

M26: Dual Recovery: 12-Step Programs for Co-Occurring Disorders 

Susan Caldwell, MEd, CAC 

1.5 hours Focus: Recovery Supports 

Description: 

Peer Support has existed for many years in 12-step circles. In the Philadelphia area, the first groups for 

persons with co-occurring disorders were called “Double Trouble” and their format varied according to the 

needs of the group, with some being completely peer led by those in recovery and others co-led by a 

professional. This workshop reviews some of the history of such groups and discusses ways to facilitate the 

creation and maintenance of them. 


• Describe possible structures and functioning of dual recovery 12-step groups; 

• Identify benefits and cautions related to dual recovery groups; 

• Discuss resources and processes that can be of use in starting and maintaining dual recovery 12-step 

groups. 

NOTES:

M27: Dialectical Behavior Therapy (DBT): Moving from Conflict to Collaboration 

Veronica O. Bowlan, LSW 


Description: 

Both staff and consumers often feel that they are on an out-of-control roller coaster when confronting difficult 

behaviors such as rage and self-injury. DBT offers skills and strategies to learn how to recognize and manage 

issues related to trauma and PTSD in a more effective way. This workshop includes a demonstration of core 

skills such as mindfulness, radical acceptance and validation, and discusses co-occurring substance use issues. 


1. Cite DSM-IV-TR criteria for Borderline Personality Disorder; 

2. Describe major components of the DBT treatment model; 

3. Identify DBT skills that are effective for coping with emotional dysregulation. 

NOTES:


Goal of DBT 

“Is to work in collaboration with the 

person to remove barriers and identify 

ways to create a life worth living.” 

LEMONS TO LEMONADE 

If life gives you lemons 

DBT helps you find a way to make lemonade 

DBT validates that nobody chooses to have a life 

of lemons 


DSM-IV-TR 

Diagnostic Criteria for 

301.83 Borderline Personality Disorder: 

FRANTIC EFFORTS TO AVOID REAL 

OR IMAGINED ABANDONMENT 

• A pervasive pattern of instability of 

interpersonal relationships, self-image, and 

affects, and marked impulsivity beginning by 

early adulthood and present in a variety of 

contexts, as indicated by five (or more) of the 

following: 

A PATTERN OF UNSTABLE AND 

INTENSE INTERPERSONAL 

RELATIONSHIPS 

IDENTITY DISTURBANCE OR 

PROBLEMS WITH SELF-IMAGE OR 

SENSE OF SELF 

1


IMPULSIVITY THAT IS 

POTENTIALLY SELF-DAMAGING 

RECURRENT SUICIDAL BEHAVIOR 

OR PARA-SUICIDAL BEHAVIOR 

AFFECTIVE INSTABILITY 

CHRONIC FEELING OF EMPTINESS 

INAPPROPRIATE INTENSE OR 

UNCONTROLABLE ANGER 

TRANSIENT, STRESS-RELATED 

PARANOID IDEATIONS OR SEVERE 

DISSOCIATIVE SYMPTOMS 

2


EXERCISE: 

In Groups: 

•Review criteria of BPD 

•Identify person who meets the criteria 

•Role-play examples from your work 

Taking the Mystery Out of BPD 

Nature 

and 

Nurture 

Emotional Vulnerability - Nature 

• Emotional Temperament (Difficult) 

– Highly sensitive to everything around them 

Invalidating Environment - Nurture 

•Child with a difficult temperament lives 

in environment that does not meet needs 

– Emotional experiences are not validated 

– Intense responses to most things 

– Slow return to emotional calm 

– Attention is not given until behavior is 

already out of control 

– Oversimplifies ease of problem solving 

NAME THAT: 

NATURE 

IS IT NATURE? IS IT 

NURTURE? 

NATURE 

NURTURE 

NURTURE 

– Highly sensitive to 

everything around them 

– Intense responses to 

most things 

– Slow return to emotional 

calm 

– Emotional experiences 

are not validated 

– Attention is not given 

until behavior is already 

out of control 

– Oversimplifies ease of 

problem solving 

3


Biosocial Theory of DBT 

Emotional Dysregulation 

(Sensitive Child) 

and 


(Insensitive Caretakers) 


and 


= 

Child with some emotional problems already 


NOW…………… ADD 

Major TRAUMA 

• Sexual Abuse 

• Physical Abuse 

• Emotional Abuse 

• Severe Neglect 

BPD and PTSD 

BPD 

1. AVOID ABANDONMENT 

2. INTENSE RELATIONSHIPS 

3. PROBLEMS WITH SELF- 

IMAGE 

4. IMPULSIVITY IN SELF- 

DAMAGING AREAS 

5. RECURRENT SUICIDAL 

PARASUICIDAL BEHAVIOR 

TRAUMA 


4. NUMBING OF 

RESPONSES 

7. FEELINGS OF EMPTINESS 

8. INTENSE ANGER 

9. DISSOCIATIVE 

SYMPTOMS 

PTSD 

1. EXPOSURE TO TRAUMA 

INVOLVING INTENSE 

FEAR 

2. RE-EXPERIENCING 

TRAUMA 

3. AVOID STIMULI 

ASSOCIATED WITH 

5. INCREASED AROUSAL 

6. SYMPTOMS LAST 

LONGER THAN 1 MONTH 

7. IMPAIRS IMPORTANT 

AREAS OF FUNCTIONING 

Now that we know ALL about BPD 

DBT Treatment Responses 

Acceptance 

Change 

How do we help “THEM”? 

Validation 

4


Acceptance 

This is a 

DIALECTIC 

Change 

What is a Dialectic? 

• Opposites which exist within every 

person at the same time 

• It is a constant struggle to a find 

synthesis/balance between the two 

opposites 

Dialectical Approach 

Dialectical Approach 

• To fully understand a person’s 

behavior it must be placed in its 

behavioral and environmental context 

• Reality is always changing and an aim of 

therapy must be to help clients become 

more comfortable with inconsistency and 

CHANGE 

Exercise: 

Key Dialectics in BPD 

In pairs discuss……. 

5


Three Dialectical Dimensions of 

BPD Behavioral Patterns 


Self-Invalidation 

Unrelenting 

Crisis 

Biological (Nature) 

Social (Nurture) 

Emotional 

Vulnerability 

Apparent 

Competence 

Self- 

Invalidation 

Active 

Passivity 

Inhibited 

Grieving 

– Emotional Vulnerability 

• Sensitive to many things, intensely felt, difficult to 

return to baseline 

• No emotional skin 

– Self – Invalidation 

• Individual with BPD recreates their invalidating 

environment 

• Learns own emotions are not valid; looks to others 

for clarification of emotional experiences 

• Self-punishes 

Active Passivity 

Apparent Competence 

• Active Passivity 

– Approach problems passively, actively expecting 

others to solve problems for them 

– History of failure in problem solving and 

simultaneous self-control 

• Apparent Competence 

– Able to cope at some times 

– Unable to cope at other times in similar 

circumstances 

Unrelenting Crisis 

Inhibited Grieving 

• Unrelenting Crisis 

• Repetitive stressful events due to individual’s high 

reactivity 

• Never return to emotional calm due to temperament 

and chronic invalidating environment 

• Inhibited Grieving 

• Avoid and inhibit experience/expression of painful 

emotions 

• Repetitive, significant trauma without experiencing full 

resolution of any single event (no “normal” grieving) 

Exercise: 

WHICH DIMENSION? 

In groups: decide which dialectical 

dimension is represented in each 

scenario 

Why Validation? 

•Synonyms: 

•To confirm, to authenticate, to corroborate, to 

substantiate, to verify (not agreement) 

•Validate the feeling, not the behavior 

•Validation shows caring, understanding and 

a willingness to “live” in someone else’s 

world 

6


Forms of Validation 

• What you say 

– Communication and comments from therapist 

that their behavior is understandable and valid 

Levels of Validation 

1. Staying awake: non-judgmental listening 

and observing 

• What you do 

– Respond to the person as if what they are 

saying is valid, reasonable, understandable 

and IMPORTANT 


2. Accurate Reflection 


3. Listener stating the unverbalized 

emotions, thoughts, behaviors 



• 4. Validating in terms of past 

learning or biological dysfunction 

5. Validating in terms of present 

context or normative functioning 

7



6. Radical Genuineness 

Basic Assumptions 

about Patients 

Patients are doing the best they can 



Patients want to improve 



Patients must learn new behaviors in all 

relevant contexts 



Patients cannot fail in DBT 



Patients may not have caused all of their 

own problems, but they have to solve 

them anyway 

8




Patients need to do better, try harder, and/or 

be more motivated to change 



The lives of suicidal, BPD individuals are 

unbearable as they are currently being lived 

Basic Assumptions About Therapy 

• The most caring thing a therapist 

can do is help the person change in 

ways that bring them closer to their 

own ultimate goals 


• Clarity, Precision and Compassion 

are of the utmost importance in the 

conduct of DBT 


• The therapeutic relationship is a real 

relationship between equals 

Basic Assumptions About 

Therapy 

• Principles of behavior are universal, 

affecting therapists no less than 

patients 

9



Therapy 

• BDT therapists can fail 


Therapy 

• DBT can fail even when therapists do 

not 


Therapy 

• Therapists treating Borderline 

Personality Disorder patients need 

support 

10

Using Dialectical Behavior Therapy to Move from Conflict to Collaboration - F47 

Drexel University College of Medicine/Behavioral Healthcare Education 

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Washington, DC: American Psychiatric Press, pp 1-14.

TUESDAY 

May 16 th , 2006

Tuesday Morning Plenary Session 

“Changing the World: 

Implementation of Comprehensive Continuous Integrated 

Systems of Care for Individuals with 

Mental and Substance Use Disorders” 

Kenneth Minkoff, MD

Article by Kenneth Minkoff, MD and Christie A. Cline, MD 

http://www.kenminkoff.com/article2.html 

Page 1 of 23 

4/26/2006 

CHANGING THE WORLD: THE DESIGN AND IMPLEMENTATION OF COMPREHENSIVE 

CONTINUOUS INTEGRATED SYSTEMS OF CARE FOR INDIVDIUALS WITH CO-OCCURRING 

DISORDERS 

Kenneth Minkoff, MD a,b and Christie A. Cline, MD c 

a Clinical Assistant Professor of Psychiatry, Harvard Medial School and b Senior Systems Consultant, 

Zialogic, Albuquerque, New Mexico 

c President, Zialogic, Albuquerque, New Mexico 

a Corresponding author for 

proof and reprints: 

Kenneth Minkoff, MD 

c Co-author address: 

Christie A. Cline, MD, MBA 

Zialogic 

100 Powdermill Road, 12805 Calle del Oso Pl. NE 

Box 319 Albuquerque, NM 87111 

Acton, MA 01720 (505) 379-6145 

(781) 932-8792 x511 (415) 455-8016 (FAX) 

(415) 455-8016 (FAX) 

KMinkov@aol.com (email) 

cac@swcp.com(email) 

Article published in Psychiatric Clinics of North America, 27(4):727-43 © 2004 

Posted with permission from Elsevier. 

Background 

Individuals with co-occurring psychiatric and substance disorders are increasingly recognized as a



Page 2 of 23 

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population that is highly prevalent in both addiction and mental health service systems, associated with poor 

outcomes and higher costs in multiple domains. In addition, they have long been recognized to be “system 

misfits” in systems of care that have been designed to treat one disorder only or only one disorder at a time. 

Thus, instead of being prioritized for attention, these individuals with challenging problems are made more 

challenging because the systems of care in which they present have significant regulatory, licensing, and 

reimbursement barriers to the implementation of successful treatment. 

In spite of these system barriers, there has been increasing accumulation of evidence supporting a range 

of “best practice” treatment programs and interventions in this population, summarized recently in the 

Substance Abuse and Mental Health Services Administration’s (SAMHSA) Report to Congress on Cooccurring 

Disorders [1] and in the Center for Substance Abuse Treatment’s (CSAT) soon to be released 

Treatment Improvement Protocol on Co-occurring Disorders. [2] There is less information available on the 

implementation of these “best practices,” particularly within scarce resourced public sector delivery systems. 

One avenue that is being investigated is the implementation of a specific evidence based practice for individuals 

with serious mental illness and severe co-occurring disorders, termed Dual Diagnosis Integrated Treatment 

(IDDT) [3], for which SAMHSA will soon be releasing a formal implementation toolkit (2004). As part of the 

national EBP implementation project, several states are studying the implementation of this targeted program 

using additional resources for program start up and continuation. At present, the literature describing outcomes 

of this project is very preliminary, but two things are clear: First, implementation of any evidence based practice 

(EBP) cannot be isolated from the system context in which that implementation takes place, so that EBP 

implementation and system change strategies must be linked. [4] Second, the high prevalence of co-occurring 

disorders in all service populations and service settings indicates that this high priority population will never be 

adequately served by implementation of a small number of “programs” in a scarce resourced system. [5] 

Consequently, properly matched services and interventions must be provided for individuals with co-occurring 

disorders wherever they present, not only in specialized “programs”. As a result, in recent years, there has been 

increasing recognition of the need for system level change strategies to improve services for individuals with 

co-occurring disorders (cod). [6] 

. The Report to Congress (SAMHSA, 2002) indicates that because “dual diagnosis is an expectation” 

associated with poor outcomes and high costs, SAMHSA is beginning to develop systemic strategies to address



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the needs of individuals with cod, and plans to create funding mechanisms to support state level or regional 

initiatives to build better service capacity for cod within the entire service system. The Report to Congress 

provides anecdotal information on a number of state projects already in progress, specifically referencing a 

Technical Assistance document commissioned by SAMHSA describing one such project (the New Mexico Cooccurring 

Disorders Service Enhancement Initiative (NM-CDSEI) [7], which utilized the CCISC model to 

organize a system wide implementation of integrated services. The Report to Congress also references the 

Comprehensive Continuous Integrated System of Care (CCISC) model utilized in the NM-CDSEI as a best 

practice model for system design for co-occurring disorders. 

The purpose of this paper is to describe the CCISC model, to outline a strategic implementation process 

termed the “12 Step Program of CCISC Implementation, and then to describe examples of current CCISC 

implementation projects in the United States and Canada, along with information on project evaluation and 

outcomes. 

CCISC 

The CCISC was first outlined by Minkoff [8], organized and elaborated as part of a national consensus 

best practice development project [9] and first utilized in a formal consensus process in Massachusetts in 1998- 

1999. [10] The CCISC model is built on 8 evidence based principles of service delivery for co-occurring 

disorders that provide a framework for developing clinical practice guidelines for treatment matching [11] and 

can also be utilized to design a welcoming, accessible, integrated, continuous, and comprehensive system of 

care, initially within the context of existing resources. The rationale for system design is that dual diagnosis is 

an expectation in all settings, associated with poor outcomes and high costs in multiple domains, so that 

attention to cod must be a priority in all system activities and in the utilization of all system resources. 

Consequently, the system must require all programs to be designed as “dual diagnosis programs” by meeting 

minimal standards of “dual diagnosis capability” (DDC) [12], initially within existing program resources, (The 

system may also plan for some program components to be specifically designed as Dual Diagnosis Enhanced 

(DDE), but with the understanding that each program has a different “job”, providing organized matched 

services to its existing cohort of dually diagnosed clients, utilizing the treatment matching principles to



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determine the appropriate best practice interventions in that setting. 

The Four Basic Characteristics of the Comprehensive, Continuous, Integrated System of Care Model 

The Comprehensive, Continuous, Integrated System of Care (CCISC) model for organizing services for 

individuals with co-occurring psychiatric and substance disorders (ICOPSD) is designed to improve treatment 

capacity for these individuals in systems of any size and complexity, ranging from entire states, to regions or 

counties, networks of agencies, individual complex agencies, or even programs within agencies. The model has 

the following four basic characteristics: 

1. System Level Change: The CCISC model is designed for implementation throughout an entire 

system of care, not just for implementation of individual program or training initiatives. All 

programs are designed to become dual diagnosis capable (or enhanced) programs, generally within 

the context of existing resources, with a specific assignment to provide services to a particular cohort 

of individuals with co-occurring disorders. Implementation of the model integrates the use of 

strategically planned system change technology (e.g, Continuous Quality Improvement) with clinical 

practice technology at the system level, program level, clinical practice level, and clinician 

competency level to create comprehensive system change. 

2. Efficient Use of Existing Resources: The CCISC model is designed for implementation within the 

context of current service resources, however scarce, and emphasizes strategies to improve services 

to ICOPSD within the context of each funding stream, program contract, or service code, rather than 

requiring blending or braiding of funding streams or duplication of services. It provides a template 

for planning how to obtain and utilize additional resources should they become available, but does 

not require additional resources, other than resources for planning, technical assistance, and 

training. The most basic implementation strategy involves exploring regulatory guidelines for any 

funding stream (e.g. Medicaid) in any program or service (e.g., mental health care in a mental health 

clinic) and providing a specific set of guidelines and instructions for how to provide and document 

appropriately matched integrated treatment within the context of the already funded service. 

3. Incorporation of Best Practices: The CCISC model is recognized by SAMHSA as a best practice for 

systems implementation for treatment of ICOPSD. An important aspect of CCISC implementation



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is the incorporation of evidence based and clinical consensus based best practices for the treatment of all 

types of ICOPSD throughout the service system. This is based on the recognition that co-occurring 

disorders are not a single entity with a single “best practice” intervention, but rather that individuals 

with cod have a wide range of disorders and needs in combination, and that best practice treatment 

involves integrating the provision of best practice treatment for each disorder at the level of the 

client. This encourages the system to develop as extensive a range of best practices for mental 

health and substance disorders as it can, and organize them so that any best practice for either type of 

disorder is provided in a dual diagnosis capable fashion. 

4. Integrated Treatment Philosophy: The CCISC model is based on implementation of principles of 

successful treatment intervention that are derived from available research and incorporated into an 

integrated treatment philosophy that utilizes a common language that makes sense from the 

perspective of both mental health and substance disorder providers. This model can be used to 

develop a protocol for individualized treatment matching that in turn permits matching of particular 

cohorts of individuals to the comprehensive array of dual diagnosis capable services within the 

system. 

The Eight Principles of Treatment for the CCISC 

The eight research-derived and consensus-derived principles that guide the implementation of the CCISC 

are as follows: 

1. Dual diagnosis is an expectation, not an exception: Epidemiologic data defining the high 

prevalence of co-morbidity [13, 14], along with clinical outcome data associating ICOPSD with poor 

outcomes and high costs in multiple systems, imply that the whole system, at every level, must be 

designed to use all of its resources in accordance with this expectation. This implies the need for an 

integrated system planning process, in which each funding stream, each program, all clinical 

practices, and all clinician competencies are designed proactively to address the individuals with cooccurring 

disorders who present in each component of the system already.



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4/26/2006 

2. All ICOPSD are not the same; the national consensus four quadrant model for categorizing cooccurring 

disorders [15] can be used as a guide for service planning on the system level. In this 

model, ICOPSD can be divided according to high and low severity for each disorder, into high-high 

(Quadrant IV), low MH – high CD (Quadrant III), high MH – low CD (Quadrant II), and low-low 

(Quadrant I). High MH individuals usually have SPMI and require continuing integrated care in the 

MH system. High CD individuals are appropriate for receiving episodes of addiction treatment in 

the CD system, with varying degrees of integration of mental health capability. 

3. Empathic, hopeful, integrated treatment relationships are one of the most important contributors to 

treatment success in any setting; provision of continuous integrated treatment relationships is an 

evidence based best practice for individuals with the most severe combinations of psychiatric and 

substance difficulties. [16, 17] The system needs to prioritize a) the development of clear guidelines 

for how clinicians in any service setting can provide integrated treatment in the context of an 

appropriate scope of practice, and b) access to continuous integrated treatment of appropriate 

intensity and capability for individuals with the most complex difficulties. 

4. Case management and care must be balanced with empathic detachment, expectation, contracting, 

consequences, and contingent learning for each client, and in each service setting. Each individual 

client may require a different balance (based on level of functioning, available supports, external 

contingencies, etc.); and in a comprehensive service system different programs are designed to 

provide this balance in different ways. For example, dual diagnosis housing for individuals with 

SPMI may incorporate programming that is dry, damp, and wet. [18] On an individual client level, 

individuals who require high degrees of support or supervision can utilize contingency based 

learning strategies involving a variety of community-based reinforcers to make incremental progress 

within the context of continuing treatment. [19] 

5. When psychiatric and substance disorders coexist, both disorders should be considered primary, 

and integrated dual (or multiple) primary diagnosis-specific treatment is recommended. The system 

needs to develop a variety of administrative, financial, and clinical structures to reinforce this 

clinical principle, and to develop specific practice guidelines emphasizing how to integrate 

diagnosis-specific best practice treatments for multiple disorders for clinically appropriate clients



Page 7 of 23 

4/26/2006 

within each service setting. This incorporates psychopharmacology guidelines that define the 

expectation of continuing necessary non-addictive medication for the treatment of known serious 

mental illness for individuals who are continuing to use substances. [20] This incorporates the 

utilization of specific “disease management” skills training in either disorder to individuals in 

treatment for the other disorder [21, 22, 23], including adaptation of skills training in substance 

abuse reduction or elimination skills to individuals who have psychiatric disabilities. [24] 

6. Both mental illness and addiction can be treated within the philosophical framework of a “disease 

and recovery model” [25] with parallel phases of recovery (acute stabilization, motivational 

enhancement, active treatment, relapse prevention, and rehabilitation/recovery), in which 

interventions are not only diagnosis-specific, but also specific to phase of recovery and stage of 

change. Literature in both the addiction field and the mental health field has emphasized the concept 

of stages of change [26] or stages of treatment [27], and demonstrated the value of stage-wise 

treatment. [28] 

7. There is no single correct intervention for ICOPSD; for each individual interventions must be 

individualized according to quadrant, diagnoses, level of functioning, external constraints or 

supports, phase of recovery/stage of change, and (in a managed care system) multidimensional 

assessment of level of care requirements. This principle forms the basis for developing clinical 

practice guidelines for assessment and treatment matching. It also forms the basis for designing the 

template of the CCISC, in which each program is a dual diagnosis program, but all programs are not 

the same. Each program in the system is assigned a “job”: to work with a particular cohort of 

ICOPSD, providing continuity or episode interventions, at a particular level of care. Consequently, 

all programs become mobilized to develop cohort specific dual diagnosis services, thereby 

mobilizing treatment resources throughout the entire system. 

8. Clinical outcomes for ICOPSD must also be individualized, based on similar parameters for 

individualizing treatment interventions. Abstinence and full mental illness recovery are usually long 

term goals, but short term clinical outcomes must be individualized, and may include reduction in 

symptoms or use of substances, increases in level of functioning, increases in disease management 

skills, movement through stages of change, reduction in “harm” (internal or external), reduction in



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service utilization, or movement to a lower level of care. Systems need to develop clinical practice 

parameters for treatment planning and outcome tracking that legitimize this variety of outcome 

measures to reinforce incremental treatment progress and promote the experience of treatment 

success. 

IMPLEMENTATION 

The implementation of a complex multi layered system model requires an organized approach, 

incorporating principles of strategic planning and continuous quality improvement in an incremental 

process that involves interaction between all layers of the system (system, agency or program, clinical 

practice and policy, clinician competency and training) and all components of the system, regardless of 

the size or complexity of the system. Implementation can occur in systems of any size (entire state, 

regions, counties, complex agencies, individual programs), and in any population or funding stream 

(adults, elders, children; Medicaid, private payers, state block grant funds; urban/rural; culturally diverse 

populations). In order organize the complexity of this process the authors have developed the “Twelve 

Step Program of Implementation” (first implemented in Michigan in 2002), and have created a CCISC 

Toolkit to provide a framework for evaluating and monitoring progress at the system level, the program 

level, and the clinician level. [29] 

Twelve Steps for CCISC Implementation 

1. Integrated system planning process: Implementation of the CCISC requires a system wide integrated 

strategic planning process that can address the need to create change at every level of the system, 

ranging from system philosophy, regulations, and funding, to program standards and design, to 

clinical practice and treatment interventions, to clinician competencies and training. The integrated 

system planning process must be empowered within the structure of the system, include all key 

funders, providers, and consumer/family stakeholders, have the authority to oversee continuing 

implementation of the other elements of the CCISC, utilize a structured process of system change



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(e.g., continuous quality improvement), and define measurable system outcomes for the CCISC in 

accordance with the elements listed herein. It is necessary to include consumer and family driven 

outcomes that measure satisfaction with the ability of the system to be welcoming, accessible and 

culturally competent, as well as integrated, continuous, and comprehensive, from the perspective of 

ICOPSD and their families. The COFIT-100 (Zialogic, Albuquerque, NM) [30] has been 

developed by the authors to facilitate this outcome measurement process at the system level. 

2. Formal consensus on CCISC model: The system must develop a clear mechanism for articulating 

the CCISC model, including the principles of treatment and the goals of implementation, developing 

a formal process for obtaining consensus from all stakeholders, identifying barriers to 

implementation and an implementation plan, and disseminating this consensus to all providers and 

consumers within the system. 

3. Formal consensus on funding the CCISC model: CCISC implementation involves a formal 

commitment that each funder will promote integrated treatment within the full range of services 

provided through its own funding stream, whether by contract or by billable service code, in 

accordance with the principles described in the model, and in accordance with the specific tools and 

standards described below. Blending or braiding funding streams to create innovative programs or 

interventions may also occur as a consequence of integrated systems planning, but this alone does 

not constitute fidelity to the model. 

4. Identification of priority populations, and locus of responsibility for each: Using the national 

consensus four quadrant model, the system must develop a written plan for identifying priority 

populations within each quadrant, and locus of responsibility within the service system for 

welcoming access, assessment, stabilization, and integrated continuing care. Commonly, individuals 

in quadrant I are seen in outpatient and primary care settings, individuals in quadrant II and some in 

quadrant IV are followed within the mental health service system, individuals in quadrant III are 

engaged in both systems but served primarily in the substance system. Each system will usually 

have priority populations (commonly in quadrant IV) with no system or provider clearly responsible 

for engagement and/or treatment; the integrated system planning process needs to create a plan for 

how to address the needs of these populations, even though that plan may not be able to be



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immediately implemented. 

5. Development and implementation of program standards: A crucial element of the CCISC model is 

the expectation that all programs in the service system must meet basic standards for Dual Diagnosis 

Capability, whether in the mental health system (DDC-MH) or the addiction system (DDC-CD). In 

addition, within each system of care, for each program category or level of care, there need to 

written standards for Dual Diagnosis Enhanced programs (DDE). There needs to be consensus that 

these standards will be developed, and that, over time, they will be built into funding and licensing 

expectations (see items 2 and 3 above), as well as a plan for stage-wise implementation. Program 

competency assessment tools (e.g., COMPASS Zialogic, Albuquerque, NM) [31] can be helpful 

in both development and implementation of DDC standards. 

6. Structures for intersystem and inter-program care coordination: CCISC implementation involves 

creating routine structures and mechanisms for addiction programs and providers and mental health 

programs and providers, as well as representatives from other systems that may participate in this 

initiative (e.g., corrections) to participate in shared clinical planning for complex cases whose needs 

cross traditional system boundaries. Ideally, these meetings should have both administrative and 

clinical leadership, and should be designed not just to solve particular clinical problems, but also to 

foster a larger sense of shared clinical responsibility throughout the service system. A corollary of 

this process may include the development of specific policies and procedures formally defining the 

mechanisms by which mental health and addiction providers support one another and participate in 

collaborative treatment planning. 

7. Development and implementation of practice guidelines: CCISC implementation requires system 

wide transformation of clinical practice in accordance with the principles of the model. This can be 

realized through dissemination and incremental developmental implementation via CQI processes of 

clinical consensus best practice service planning guidelines that address assessment, treatment 

intervention, rehabilitation, program matching, psychopharmacology, and outcome. Obtaining input 

from, and building consensus with clinicians prior to final dissemination is highly recommended. 

Existing documents [32, 33, 34] are available to facilitate this process. Practice guideline 

implementation must be supported by regulatory changes (both to promote adherence to the



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guidelines and to eliminate regulatory barriers) and by clinical auditing and self-monitoring procedures 

to monitor compliance. Specific guidelines to facilitate access and identification and to promote 

integrated continuous treatment are a particular priority for implementation, (See items 8 and 9). 

8. Facilitation of identification, welcoming, and accessibility: This requires several specific steps: 1. 

modification of MIS capability to facilitate and incentivize accurate identification, reporting, and 

tracking of ICOPSD. 2. development of “no wrong door” policies and procedures that mandate a 

welcoming approach to ICOPSD in all system programs, eliminate arbitrary barriers to initial 

evaluation and engagement, and specify mechanisms for helping each client (regardless of 

presentation and motivation) to get connected to a suitable program as quickly as possible. 3. 

Establishing policies and procedures for universal screening for co-occurring disorders at initial 

contact throughout the system. 

9. Implementation of continuous integrated treatment: Integrated treatment relationships are a vital 

component of the CCISC. Implementation requires developing the expectation that primary 

clinicians in every treatment setting are responsible for developing and implementing an integrated 

treatment plan in which the client is assisted to follow diagnosis specific and stage specific 

recommendations for each disorder simultaneously. This expectation must be supported by clear 

definition of the expected “scope of practice” for singly licensed clinicians regarding co-occurring 

disorder [35, 36], and incorporated into standards of practice for reimbursable clinical interventions 

– in both mental health and substance settings – for individuals who have co-occurring disorders. 

10. Development of basic dual diagnosis capable competencies for all clinicians: Creating the 

expectation of universal competency, including attitudes and values, as well as knowledge and skill, 

is a significant characteristic of the CCISC model. Available competency lists for co-occurring 

disorders can be used as a reference for beginning a process of consensus building regarding the 

competencies. Mechanisms must be developed to establish the competencies in existing human 

resource policies and job descriptions, to incorporate them into personnel evaluation, credentialing, 

and licensure, and to measure or monitor clinician attainment of competency. Competency 

assessment tools (e.g., CODECAT Zialogic, Albuquerque, NM) [37] can be utilized to facilitate 

this process.



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11. Implementation of a system wide training plan: In the CCISC model, training must be ongoing, and 

tied to expectable competencies in the context of actual job performance. This requires an organized 

training plan to bring training and supervision to clinicians on site. The most common components 

of such training plans involve curriculum development and dissemination, mechanism for training 

and deploying trainers, career ladders for advanced certification, and opportunities for experiential 

learning. Train the trainer curricula have been developed [38] that have been adapted for use in a 

variety of state and regional systems, and which emphasize that the trainers are actually positioned 

individually and collectively as “system change agents” to link system managers with front line 

clinicians in order to appropriately advocate for policy to support good clinical practice, and to 

transmit that policy in turn to direct care staff. 

12. Development of a plan for a comprehensive program array: The CCISC model requires 

development of a strategic plan in which each existing program begins to define and implement a 

specific role or area of competency with regard to provision of Dual Diagnosis Capable or Dual 

Diagnosis Enhanced service for people with co-occurring disorders, primarily within the context of 

available resources. This plan should also identify system gaps that require longer range planning 

and/or additional resources to address, and identify strategies for filling those gaps. Four important 

areas that must be addressed in each CCISC are: 

a. Evidence based best practice: There needs to be a specific plan for identification of any 

evidence based best practice for any mental illness (e.g. Individualized Placement and 

Support for vocational rehabilitation) or substance disorder (e.g. buprenorphine 

maintenance), or an evidence based best practice program model for a particular co-occurring 

disorder population (e.g. Integrated Dual Disorder Treatment for SPMI adults in continuing 

mental health care) that may be needed but not yet be present in the system, and planning for 

the most efficient methods to promote implementation in such a way that facilitates access to 

co-occurring clients that might be appropriately matched to that intervention.. 

b. Peer dual recovery supports: The system can identify at least one dual recovery self-help 

program (e.g., Dual Recovery Anonymous [39], Double Trouble in Recovery [40]) and 

establish a plan to facilitate the creation of these groups throughout the system. The system



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can also facilitate the development of other peer supports, such as peer outreach and peer 

counseling. 

c. Residential supports and services: The system should begin to plan for a comprehensive 

range of programs that addresses a variety of residential needs, building initially upon the 

availability of existing resources through redesigning those services to be more explicitly 

focused on ICOPSD. This range of programs should include: 

1. DDC/DDE addiction residential treatment (e.g., modified therapeutic community 

programs) [41]. 

2. Abstinence-mandated (dry) supported housing for individuals with psychiatric 

disabilities. 

3. Abstinence-encouraged (damp) supported housing for individuals with psychiatric 

disabilities 

4. Consumer – choice (wet) supported housing for individuals with psychiatric 

disabilities at risk of homelessness. [42] 

d. Continuum of levels of care: All categories of service for ICOPSD should be available in a 

range of levels of care, including outpatient services of various levels of intensity; intensive 

outpatient or day treatment, residential treatment, and hospitalization. This can often be 

operationalized in managed care payment arrangements [43] and may involve more 

sophisticated level of care assessment capacity. [44, 45] 

CCISC implementation is an ongoing quality improvement process that encourages the 

development of a plan that includes attention to each of these areas in a comprehensive service 

array. 

Project Descriptions and Outcomes 

CCISC implementation efforts date back to 1998 [46], and have become progressively more



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sophisticated as more experience with the technology has accumulated, and more structure for 

implementation (e.g. toolkits) has been developed. Currently, there are state and or regional CCISC 

projects that have been initiatives in collaboration and consultation with one or both of the authors in the 

following systems: Arizona, Alaska, Alabama, California, District of Columbia, Florida, Hawaii, 

Illinois, Idaho, Louisiana, Maine, Maryland, Michigan, Montana, Minnesota, New Mexico, Oregon, 

Pennsylvania, South Carolina, Texas, Vermont, Virginia, Washington, Manitoba, and British Columbia. 

The following discussion will describe activities and outcomes in a selection of projects. 

New Mexico: The Co-occurring Disorder Services Enhancement Initiative [47] began under the 

leadership of one of the authors in her role as state behavioral health medical director in response to 

recognition of a higher death rate among individuals with co-occurring disorders as well as dramatic 

under--recognition of this population in both clinical processes and state data collection. A systematic 

CQI approach was organized to implement welcoming, screening, and improved data collection into 

contractual requirements for state Regional Care Coordination entities, that were expected to in turn 

contract for improved performance from providers. Quality performance was positively incentivized in 

contract language. Multilayered implementation included state commitment to removal of 

administrative barriers to data collection and promotion of utilization of block grant dollars to support 

integrated care, as well as identification of a train the trainer group that facilitated training and system 

improvement on the program level in each region. In edition, the state behavioral health authority has 

gotten legislative direction to work with the licensure agencies to implement a recommendation 

(developed by clinicians) for a defined integrated scope of practice for single licensed clinicians of any 

type. Over the past three years, this trainer group has expanded to include a wider array of programs. 

Data capture efforts have tripled, and the death rate for co-occurring disordered individuals has gone 

down significantly. The state has incorporate a first layer of Dual Diagnosis Capable requirements in 

behavioral health program standards, once it was clear that the vast majority of programs could already 

demonstrate adherence to those standards. 

Vermont: The Vermont DDMHS adult services division received Community Action Grant 

funding in 2000 to implement consensus on utilizing Integrated Dual Disorder Treatment (IDDT) as a 

best practice in its existing case rate funded intensive case management teams. After one year of



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consensus building and training, there was consensus that IDDT was a good thing, but very little 

organized implementation and resistance to change without new funding. In the second year, CCISC 

was added to develop a systemic approach to engaging agencies in implementation of core practices of 

integrated treatment (consistent with IDDT) in the context of existing resources. This process included 

development of a charter document that committed each agency to a change process, the development of 

small financial incentives for each agency to initiate activity in relation to project participation, and the 

development of a trainer cadre. As in all the other projects, the authors provided a customized 

curriculum, continued consultation and strategic planning with the leadership team, training of the cadre 

in both clinical and system change issues (here, quarterly), and program technical assistance visits to 

every agency during the first year. During the course of the first year of the project, all the agencies 

began to demonstrate new clinical processes for welcoming, identifying, assessing and providing 

integrated treatment. More than half the agencies moved the initiative from only adults with SPMI to 

encompass additional programming (often the whole agency), such as children’s services, substance 

abuse services, and developmental disability services. The CCISC model was expanded for application 

to a statewide human services integration project involving mental health, public health, substance 

abuse, corrections, child welfare, Medicaid, and juvenile justice, which is currently in the process of 

developing its own charter and work plans for effecting system change. The project is utilizing outcome 

measures for adult service agencies that combine the CCISC tools with IDDT fidelity tools, and expects 

to be able to explore the relationship between system change strategies and best practice 

implementation. 

Manitoba: The first CCISC project in Manitoba began as a regional collaborative between the 

Winnipeg Regional Health Authority, the Addictions Foundation of Manitoba, and Manitoba Health. 

Entitled CODI (Co-occurring Disorders Initiative), the project was implemented under the direction of 

an intersystem leadership team that was the first element of any kind of structure for integrated system 

planning. The leadership team drafted a charter document, aligned with regional strategic planning 

priorities, and was able to obtain broad consensus and sign off from both mental health and addiction 

treatment programs, including inpatient and outpatient, adult and children’s services. The team arranged 

for a jointly funded Project Coordinator, who was able to handle project logistics, such as coordinating



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training materials, access to web based resources, and a project newsletter. The system organized a 

group of “trainers”, working with the authors to receive training and consultation, and to utilize the 

toolkit in their own agencies to move in the direction of dual diagnosis capability. In addition, the 

authors provided program technical assistance visits to adapt the broad vision of the project to the 

concrete needs of each program developing its own action plan. The trainer cadre included individuals 

of multiple disciplines, including psychiatrists, and was able to organize itself to provide training in 

small groups to each other’s programs. Over time this group began to function as a team of change 

agents, and, in addition to work within their own programs, formed a regular meeting for the purpose of 

interagency case conferencing. By the end of the first year, the leadership team began to construct 

mechanisms for creating universal expectations of data collection across all providers. The project was 

experienced as having a dramatic impact on improving service system functioining at all levels. As a 

result, Manitoba Health has initiated an expansion of the project to all health authorities in the province, 

each of which is now in the process of designing its own initiative. The existing trainer group is a 

resource to assist other provincial systems in this process. 

San Diego: The San Diego County Health and Human Services Agency, composed of three 

divisions (Adult and Older Adult MH, Children’s MH, and Alcohol/Drug Services) which have 

historically operated fairly independently. Over the past several years, co-occurring disorders have been 

recognized as a systemic priority, particularly in the adult population, and an extensive interdivisional 

strategic planning process resulted in a comprehensive report in 2000 recommending systemic 

implementation of co-occurring disorder services. The strategic plan recognized that the co-occurring 

population was highly prevalent, but dramatically under-recognized; chart reviews indicated that only 

about 20—25% of clients who had co-occurring disorders by chart review had their dual diagnoses 

reported into the system data base. San Diego began a project to use the CCISC process to implement 

recommendations of its strategic plan. This involved the construction of a small interdivisional 

leadership team (3 members) under the auspice of a county leadership team from each division; an 

interagency committee in which executive directors of participating agencies were engaged, voluntary 

(at first) participation of agencies providing services in all three divisions. As in the above projects, a 

charter was developed that involved participating programs in using the tools for self assessment,



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developing an action plan, receiving technical assistance, and participating in the trainer cadre (about 40 

individuals). Because the divisions initially were in different stages of readiness to begin 

implementation, the initiative was designed to allow each division to participate at its own pace. Over 

time (the initiative has just begun its second year), the project has “attracted” more participation from 

the other divisions, with the following accomplishments: 

a. Incorporation of CCISC language and charter expectations into one regional contract for 

adult services, and into certain RFPs for children’s services. Incorporation of welcoming 

language planned for ADS contracts. 

b. Incorporation of co-occurring principles into the revision of the system mental health 

assessment form. 

c. Development of a ground breaking policy for welcoming individuals with co-occurring 

disorders into mental health services (adults and children), defining the population for data 

collection (including identifying substance abusing family members of child clients), and 

providing instructions for assessment, billing, and documentation. (This policy was 

presented in February, 2004 at a statewide meeting of county behavioral health leadership, 

and has generated widespread interest in other counties, at the state level in California, and at 

the SAMHSA level (Charles Curie was presenting at the conference). 

d. Incorporation of CCISC language into the Children’s MH Services business plan, and into 

the functioning of its CMHS System of Care grant, including the “wraparound training 

academy”. 

e. Development of a committee to update the 2001 consensus psychopharmacology practice 

guidelines 

f. Creation of a gradually more organized process of interdivisional quality improvement and 

planning 

g. Development of the cadre as an “independently functioning” team of change agents, who 

began to meet on their own, and to participate in policy change committees and activities. 

h. Availability of the trainer group to facilitate implementation of new system policies. 

i. Beginning of cooperative discussions of possible design of an integrated behavioral health



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department. 

Conclusion and Discussion 

This article has described the CCISC model, and the process of implementation of systemic 

implementation of co-occurring disorder services enhancements within the context of existing resources. Four 

projects were described as illustrations of current implementation activities. Clearly, there is great need for 

improved services for these individuals, and increasing recognition of the need for systemic change models that 

are both effective and efficient. The CCISC model has been recognized by SAMHSA as a consensus best 

practice for system design, and initial efforts at implementation appear to be promising. The existing toolkit 

may permit a more formal process of data driven evaluation of system, program, clinician, and client outcomes, 

in order to better measure the effectiveness of this approach. Some projects have begun such formal evaluation 

processes, but clearly more work is needed, not only with individual projects, but also to develop opportunities 

for multi-system evaluation, as more and more projects come on line. 

SYNOPSIS 

Individuals with co-occurring psychiatric and substance disorders are increasingly recognized as a 

population with high prevalence, poor outcomes, and high costs who are not well served in current service 

delivery systems. As increasing research has delineated evidence based programs and interventions that 

demonstrate success with this population, it has become abundantly clear that specialized programs are 

insufficient to meet the need. This article describes a recognized best practice model for systems design, the 

Comprehensive, Continuous, Integrated System of Care (CCISC), that organizes all aspects of the system to 

meet minimal standards of dual diagnosis capability (DDC) within the context of its existing resources and 

mission. The basic characteristics of the model are delineated, along with eight evidence based treatment 

principles that fit an integrated treatment philosophy and provide a framework for treatment matching 

throughout the system. The article then outlines a “Twelve Step Program of Implementation” for CCISC 

developed by the authors, and describes some examples of existing projects and outcomes. Evaluation of 

project outcomes is in process, but more research is needed to quantify methodologies for system design and 

implementation for individuals with co-occurring disorders. 

ACKNOWLEDGEMENTS 

The authors gratefully acknowledge the assistance of Leslie Hveem in the production of this article.



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INTEGRATED SCOPE OF PRACTICE For SINGLY TRAINED CLINICIANS 

working with PERSONS WITH CO-OCCURRING DISORDERS 

1. Convey a welcoming, empathic attitude, supporting a philosophy of dual recovery 

2. Screen for co-morbidity, including trauma history 

3. Assess for acute mental health/detoxification risk, and know how to get the person to 

safety 

4. Obtain assessment of the co-morbid condition, either one that has already been done, 

or, if needed, a new one. 

5. Be aware of – and understand - the diagnosis and treatment plan for each problem (at 

least as well as the person understands them) 

6. Support treatment adherence, including medication compliance, 12 step attendance, 

etc. 

7. Identify stage of change for each problem 

8. Provide 1-1 & group interventions for education & motivational enhancement, to help 

clients move through stages of change. 

9. Provide specific skills training to reduce substance use and/or manage mental health 

symptoms or mental illness (e.g., help people to take meds exactly as prescribed) 

10. Help person manage feelings and mental health symptoms without using substances 

11. Help person advocate with other providers regarding mental health treatment needs 

12. Help person advocate with other providers regarding substance abuse/dependence 

treatment needs 

13. Collaborate with other providers so that person receives an integrated message. 

14. Educate person about the appropriateness of taking psychiatric medications and 

participating in mental health treatment while attending 12 step recovery programs 

and participating in other addiction treatment support systems. 

15. Modify (simplify) skills training for any problem to accommodate a person’s cognitive 

or emotional learning impairment or disability, regardless of cause. 

16. Promote dual recovery meeting attendance, when appropriate for the person and 

such meetings are available.

T31: Implementing Evidence-Based Practices for Co-Occurring Disorders 


1.5 hours Focus: Systems Integration & Clinical Integrated Interventions 

Description: 

This workshop provides an overview of evidence- and consensus-based practices for CODs, and supplies 

definitions for both. The various methods by which a practice is established as “evidence-based” are reviewed. 

The session describes the specific evidence- and consensus-based practice models available to practitioners 

and programs in the field of co-occurring disorders. The final segment of the session focuses on technology 

transfer, i.e., the principles and practices needed to infuse evidence and consensus based practices into field 

settings. 


• Define the ways that evidence- and consensus-based practices are established; 

• Name major evidence- and consensus-based practices for co-occurring disorders; 

• Describe some principles and practices for technology transfer: means of infusing evidence- and 

consensus-based practices into field settings. 

NOTES:


Implementing Evidence–Based 

Practices 

for Treatment of Persons 

with Co-Occurring Disorders 

Stanley Sacks, Ph.D., Expert Leader 

SAMHSA’s Co-Occurring Center for Excellence 

(COCE) 



Background 

The importance of employing evidence-based practices is now 

widely accepted in the medical, substance, and mental health 

fields. 

The intention of determining evidence-based practices is to 

assist the clinician or program in improving treatment 

appropriateness, process and outcome for the individual. 

In substance abuse treatment, emphasis on evidence-based 

practices has influenced service delivery in areas ranging from 

initial engagement, as exemplified by an emphasis on training 

in motivation enhancement strategies, to community re-entry, 

as illustrated by a focus on cognitive behavioral strategies for 

relapse prevention. 



In the area of COD treatment, EBP is defined by COCE primarily as 

the use of current and best research evidence in making clinical and 

programmatic decisions about services to client[s). The research 

considerations involved in determining what constitutes an 

evidence-based practice include not only the robustness of the study 

findings but also the type of design employed and the 

methodological rigor of the procedures. 

A broader definition of EBP also includes taking into account 

clinician expertise and patient values, as indicated by the 

Institute of Medicine (2000) and more recently by the American 

Psychological Association (2005). 


What is a Consensus-Based Practice? 

Consensus-based practice (CBP) in the field of cooccurring 

substance use and mental disorder 

treatment is defined as agreements regarding 

treatment practice that are achieved through the 

general concurrence of treatment practitioners, 

researchers, clients and other experts in the field. 

Concurrence may be actively sought, such as through the development 

of a Treatment Improvement Protocol wherein clinicians and clinical 

researchers join forces to agree on appropriate practice[s], or through 

the use of constituent service organizations, such as the American 

Society for Addiction Medicine, to develop standards for service 

providers. 


Consensus- and Evidence-Based Practices for COD 




Essential 

Programming 



with COD (with evidence 

based in substance abuse 

treatment) 

Models 



Mentally Ill 


Perspective 


and Referral 

Motivational 

Enhancement 

Assertive 

Community 

Treatment 

Collaborative 



Viewpoint 



Contingency 

Management 

Techniques 

Modified 

Therapeutic 

Community 


Prescribing 






to Treatment 










Cognitive and 

Functional 

Impairments 

Use Support 

Systems to Maintain 

and Extend 

Treatment 

Effectiveness 


Classes 

Double Trouble 

Groups (Onsite) 

Dual Recovery 

Mutual 

Self-Help Groups 

(Offsite) 


Management 



Client 

Participation in 

Mutual Self-Help 

Groups 


Treatment 

Integrated Dual 

Disorder Treatment 

(Substance Use and 


Adapted from Substance Abuse Treatment for Persons With Co- 

Occurring Disorders TIP, 2005b 

1


Six Guiding Principles 

Consensus-Based 





treatment. 

5. Plan for the client’s cognitive and functional 

impairments. 




Essential Programming for Persons with COD 








intensive case management (ICM)* 

Evidence-Base Practices 

(from Substance Abuse Fields) 

*Can be seen either as an element of a program or as a full program model. 


Techniques for Working With 


Provide motivational enhancement to increase 

motivation for treatment. 

Design contingency management techniques to 

address specific target behaviors. 

Use cognitive–behavioral therapeutic techniques to 

address maladaptive thinking & behavior. 

Employ relapse prevention techniques to reduce 

psychiatric and substance use symptoms. 

Apply repetition and skills-building to address deficits 

in functioning. 

Facilitate client participation in mutual self-help group. 

Evidence–Based 

Models for 



2


Nine Essential Features of ACT 

Controlled Act Research 

1. Services provided in the community, most frequently in 

the client’s living environment. 

2. Assertive engagement with active outreach. 

20 

17 

ACT better than Standard 

ACT not better than Standard 

3. High intensity of services. 

15 

4. Small caseloads. 

5. Continuous 24-hour responsibility. 

6. Team approach (the full team takes responsibility for all 

clients on the caseload). 

Number of Studies 

10 

5 

6 

8 

7 7 

5 

7. Multidisciplinary team, reflecting integration of services. 

8. Close work with support systems. 

9. Continuity of staffing. 

0 

Time in 

Hospital 

3 

Housing 

Stability 

Quality of 

Life 

Client 

Satisfaction 

1 


Sacks, S. & Osher, F. 2003. [original reference to follow] 

Percent inRemission 

Fidelity Improves Outcomes 


Assessment Figure Points 1. Percent Baseline of 6 Participants mo. 12 mo. in Stable 18 mo. Remission 24 mo. 30 for mo. High-Fidelity 36 mo. ACT 

Hi-Fidelity Programs (E; 0n=61) 19.67vs. Low-Fidelity 26.23 29.51 ACT Programs 37.7 42.62 (G; n=26). 55.74 

Low-Fidelity 0 3.85 3.85 7.69 7.69 15.38 15.38 

60 

50 

40 

30 

to structure 

more flexible activities 

shorter meetings & 

activities 

more staff guidance 

Modified TC 

Key Modifications 

to process 

fewer sanctions 

engagement 

emphasis 

to elements 

accent on orientation & 

instruction 

individualized task 

assignments 

20 

10 

0 

Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo. 

McHugo, et al., 1999 

more staff 

responsibility as role 

models 

individually paced 

progress in program 

flexible criteria for 

moving to next stage 


live-out re-entry 

(aftercare) essential 

engagement emphasis 

throughout 

activities proceed at a 

slower pace 

counseling to assist use 

of community 

Summary 

Outcomes baseline vs 2-year follow-up 

The Modified TC is 

more flexible 

less intense 

more individualized 

3.5 

3 

2.5 

2 

1.5 

Modified TC 2 

TAU 

The quintessential elements remain 

peer self-help 

community-as-method 


1 

0.5 

0 

Drug 

Use 

De Leon, G., Sacks, S., et al. 2000. 

Alcohol 

# of 

Drugs 

Employment 

Drug 

Use 

Alcohol 

# of 

Drugs 

Employment 

baseline 

2-year 

follow-up 

3


Modified TC Program in 

Criminal Justice Settings 

MICA Offender 12 Month Outcomes 

Psycho-educational 

Classes 

Cognitive-behavioral 

Elements 

50 

40 

30 

20 

33% 

reincarceration 

rates 

Therapeutic 

Interventions 


10 

0 

MH 

16% 

TC only 

TC + 

aftercare 

5% 

Total n= 139 n=64 n=32 n=43 

Sacks, S., Sacks, J., et al. 2004 

CSAT 2005b. 

Why Integrate Services? 

Strong literature base supports the need for the integration of services 

provided to COD clients (CSAT, 2005). 

Need is generally based on: 

High rates of COD in community samples (National Comorbidity 

Study (NCS); National Epidemiologic Study on Alcohol and Related 

Conditions (NESARC); and the National Survey of Drug Use and 

Health (NSDUH), and in treatment samples (Sacks et al. 1997). 

Negative impact of each untreated disorder on recovery from the 

other (Drake et al 1998, Office of Surgeon General, 1999). 

Most treatment settings unprepared to effectively manage both 

substance use and mental disorders (SAMHSA, 2002). 

CSAT 2005b. 

Why Integrate Services? (Continued) 

Available research for the severely mentally ill 

(e.g., Drake et al., 2001) in combination with 

documents based on consensus-based 

practices (CSAT, 2005), support the principle 

that, provided that proper attention is paid to 

severity and type of disorder, services 

integration can play an important role in 

providing appropriate and effective treatment to 

persons with COD (SAMHSA, 2002). 

Why Integrate Services? (Continued) 

Most research evidence has focused on 

need for, and effects of, services integration 

for severe substance use and mental 

disorders (e.g. Drake et al., 2001). 

Integrated Treatment: Definition 

Integrated treatment refers broadly to any 

mechanism by which treatment interventions 

for COD are combined within the context of a 

primary treatment or service setting. 

CSAT 2005b. 

Less work has been done investigating 

services integration for those with severe 

addiction problems and less severe cooccurring 

mental disorders, (e.g., Quadrant III). 



coordinating substance abuse and mental 

health interventions to treat the whole person 

more effectively. 

4


Ways of Achieving Integrated Treatment 

Differing mechanisms can be used to achieve integration. For example: 

One clinician delivers a variety of needed services. 

Two or more clinicians work together to provide needed services 

A clinician may consult with other specialties and then integrate that consultation into 

the care provided. 

A clinician may coordinate a variety of efforts in an individualized treatment plan that 

integrates the needed services. For example, if someone with housing needs was not 

accepted at certain facilities, the clinician might work with a State-level communityhousing 

program to find the transitional or supported housing the client needs. 

One program can provide integrated care. 

Multiple agencies can join together to create a program that will serve a specific 

population. For example, a mental health center, a local housing authority, a 

foundation, a county government funding agency, a drug and alcohol treatment 

program, and a neighborhood association could join together to establish a treatment 

center to serve women and children with 


Issues in Evidence-Based Practices 

Context 

When the circumstances surrounding the 

application of the practice change to the 

extent that the practice must be modified, 

the original evidence or consensus base 

may well prove to be insufficient. 



Issues in Evidence-Based Practices 

Transferability 

Even once established across a range of 

client groups and settings, the 

transferability of treatment techniques 

and models is not assured. 

Do Clinically-Driven “Best Practices” Have a Role? 

The reality is that the number of evidence-based practices available 

to the clinician is insufficient to the task of treatment. 

Clients with co-occurring disorders present a variety of disorders, 

and appropriate treatment covers a wide spectrum of services — 

screening, assessment, engagement, intensive treatment, re-entry 

— with only a modest number of research-driven (i.e., evidencebased) 

practices available to clarify and guide the selection 

process. 

Under these conditions, the clinician must turn to accepted, 

sensible, and seemingly effective practice. 

Evidence Based practices where available, Consensus- Based 

practices where necessary. 



Technology Transfer Approach 

Backer, T. 1991 

Technology 

Transfer 

The transmission of information 

to achieve application. 

Principles 

Relevant 

Timely 

Clear 

Credible 

Multifaceted 

Continuous 

Bi-directional 

Practices 

Readiness for change 

Interpersonal Strategies 

Organizational support 

Use of: 

• Translators 

• Early adopters 

• Champions 


Follow-up and support 

Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders TIP, 2005b & ATTC. 2000. The Change Book. 

5


Implementation Drivers 

CONSULTATION 

& COACHING 

PRESERVICE 

TRAINING 

STAFF 

EVALUATION 

INTEGRATED & 

COMPENSATORY 

RECRUITMENT 

AND SELECTION 

DECISION SUPPORT 

DATA SYSTEMS 

FACILITATIVE 

ADMINISTRATIVE 

SUPPORTS 

SYSTEMS 

INTERVENTIONS 

Fixsen, et al. 2005 

Staff 

Time & 

Place 

Program 

Climate 

Resources 

Staff 

Motivation 

Program Change Model 

Reception 

& Utility 

Stages of Transfer 

1-Exposure 

(Training) 

• Lecture 

• Self Study 

• Workshop 

• Consultant 

• Satisfaction 

• Ease of use 

• Values fit 

2-Adoption 

(Leadership decision) 

3-Implementation 

(Exploratory use) 

4-Practice 

(Routine use) 

Institutional 

Supports 

Program 

Improvement 

(Services/Process/ 

Management) 

• Monitoring 

• Feedback 

• Rewards 

Simpson, 2002 

Program 

Climate 

Resources 

Staff 

Motivation 

Organizational Functioning 

Climate: 

• Mission 

• Cohesion 

• Autonomy 

• Communication 

• Stress 

• Change 

Resources: 

• Offices 

• Staffing 

• Training 

• Equipment 

• E-Communications 

Job Attitudes: 

• Burnout 

• Satisfaction 

• Director Leadership 

Staff: 

• Growth 

• Efficacy 

• Influence 

• Adaptability 

Motivation: 

• Program Needs 

• Training Needs 

• Pressures 

Workplace Practices: 

• Peer Collaboration 

• Deprivatized Practice 

• Collective Responsibility 

• Focus on Outcomes 

• Reflective Dialogue 

• Counselor Socialization 

Simpson, 2002 

Co-Occurring Center for Excellence (COCE) Change Model 

Inputs 

(Advances in 

the field) 

Resources 

Available 

SAMHSA 

Initiatives 

NIH 

Research 

Change 

Agents 

CO- 

OCCURRING 

DISORDERS 

CENTER 

National Steering 

Council 

Project 

Management Team 

Project Staff 

Subcontractors 

Consultants 

Technology 

Transfer 

Approach 

Principles: 

• Relevance 

• Credibility 

• Clarity 

• Feasibility 


factors 

Practices: 

• Matching goals to 

readiness 


Strategies 

• Organizational 

support 

• Use of: 

–Translators 

– Early adopters 

–Champions 


• Follow-up and 

support 

Targets of 

Change 

Norms and 

Culture of 

Practice 

Legislative 

Regulatory 

Context 

COSIG and 

non-COSIG States 

Sub-State Entities 

(Cities, Counties, 

Tribes, and 

Tribal Organizations) 

Providers 

(community-based, 

educational 

establishments, 

homelessness 

system, criminal 

justice, other 

social and 

public health) 

Clinical 

Practice 

Outcomes 

Short Term 

Long Term 

Willingness to 

Science and practice 

challenge 

viewed as coequal 

traditional 

partners in advancing 

assumptions 

patient outcomes 

Incentives for 

change 

Removal of 

barriers 

Support of and 

resources for 

innovation 

Interagency 

communication, 

cooperation 

Cross 

competence 

Readiness for 


change and 

development 

Support of clinical 

innovation 

Readiness 

for/adoption of 

innovation 

Institutionalization of 

evidence-based 

practices through 

reimbursement, 

licensing, etc. 


practices as 

strategic goals 

Capacity 

development 

No wrong door 

Integrated 

systems 

System 

sustainability 


practices as 


norm 


practices as 

standard of care 

Building Blocks for Constructing a 

Co-Occurring Treatment System 

Clinical Capacity 

Evaluation and Monitoring 

Evidence and Consensus- Based 

Practices 

Workforce Development and 

Training 

Screening, Assessment, & 


Definitions, Terminology, 





Licensure 

Financing Mechanisms 



Service & System Change 

Co-Occurring Center of Excellence (COCE) 

Type 

Higher Intensity 

Technical 

Assistance 

Main Outcome 

Service & 

System Change 

Areas Of Emphasis 

Services & Services 


Systems 

Evaluation and 


Evidence 

Monitoring 

and 


Consensus- Based 

Workforce 

Licensure 

Practices 

Development and Financing Mechanisms 

Screening, 

Training 

Assessment, & 


Definitions, 


Terminology, 



Approach 

comprehensive 

collaborative 

proactive 

longitudinal 


6


Conclusion 

References 

Much has been accomplished in the field of COD in the last 10 

years, and the knowledge acquired is ready for broader 

dissemination and application. 

The importance of the transfer and application of knowledge 

and technology has likewise become better understood. 

New government initiatives (for example, COSIG, COCE, and 

MHT) are underway that improve services by promoting 

innovative technology transfer strategies using material that 

reflect the recent advances in the field. 

Source: Center for Substance Abuse Treatment. 2005b 

Addiction Technology Transfer Center (ATTC). 2000. The Change Book: A Blueprint for Technology 

Transfer. University of Missouri-Kansas City. CSAT: SAMHSA. 

Alexander, M.J., Sussman, S., & Teleki, A. (2004) Trauma-Informed Screening and Assessment for 

Women with Co occurring Mental Health and Substance Abuse Problems in Correctional 

Settings. Center for the Study of Issues in Public Mental Health Nathan Kline Institute for 

Psychiatric Research Orangeburg, NY 10960. 

Backer, T. 1991. Drug Abuse Technology Transfer, Rockville, MD: NIDA. 

Backer, T., David, S.L. & Saucy, G. (eds.) 1995. Reviewing the behavioral science knowledge base on 

technology transfer. NIDA Research Monograph 155. Rockville, MD: National Institute on Drug Abuse. 

Carroll, J.F.X, & McGinley, J.J (2004) Guidelines for Using the Mental Health Screening Form III. 

Presentation to the Screening & Assessment COCE/COSIG Workgroup. 

De Leon, G., Sacks, S., Staines, G., & McKendrick, K. 2000. Modified therapeutic community for homeless 

MICAs: Treatment Outcomes. American Journal of Drug and Alcohol Abuse, 26(3), 461-480. 

Dennis, M.L., White, M.K. & Titus, J.C (2001) Common measures that have been used for both 

clinical and research purposes with Adolescent Substance Abusers. Chestnut Health Systems, 

Bloomington, IL Drake, R.E., Mueser, K.T. Brunette, M.F. & McHugo, G.J. (2004). A review of 

treatments for people with severe mental illnesses and co-occurring substance use disorders. 

Psychiatric Rehabilitation 27(4), 360-374. 


Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. 2005. Implementation 

Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la 

Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI 

Publication #231). 

Grant, B.F., Stinson, F.S., Dawson, D.A., Chou, S.P., Dufour, M.C., Comptom, W., Pickering, R.P. & 

Kaplan, K. (2004) Prevalence and co-occurrence of substance use disorders and independent 

mood and anxiety disorders. Archives of General Psychiatry, 61, 807–816. 

Institute of Medicine 2000. Crossing the quality chasm: A new health system for the 21st century. 

Washington, DC: National Academy Press. 

Jeffery, D.P., Ley, A., McLaren, S. & Siegfried, N. 2000. Psychosocial treatment programmes for 

people with both severe mental illness and substance misuse. The Cochrane Database of 

Systematic Reviews 2000, Issue 2. Art. No.: CD001088. DOI: 10.1002/14651858.CD001088. 

NASMHPD and NASADAD (1999). National dialogue on co-occurring mental health and substance use 

disorders. Washington, DC. 


Lamb, S., Greenlick, M.R. & McCarty, D. (eds.) 1998. Bridging the gap between practice and 

research. Washington, DC: National Academy Press. 

McLellan, A.T., Lewis, D.C., O’Brien, C.P., Kleber, H.D. 2000. Drug Dependence, a chronic medical 

illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American 

Medical Association, 284(13), 1689-1695.McHugo, G.J., Drake, R.E., Teague, G.B. & Xie, H. 1999. 

Fidelity to assertive community treatment and client outcomes in the New Hampshire dual 

disorders study. Psychiatric Services, 50(6), 818-824. 

Minkoff, K. 2001. Service Planning Guidelines: Co-occurring psychiatric and substance disorders. 

Fayetteville, IL: University of Chicago, Center for Psychiatric Rehabilitation, Behavioral Health 

Recovery Management. Online [retrieved 11-10-04] at 

http://www.bhrm.org/guidelines/ddguidelines.htm 

Mueser, K.T., Torrey, W.C., Lynde, D., Singer, P., & Drake, R.E. 2003. Implementing evidence-based 

practices for people with severe mental illness. Behavior Modification, 27(3), 387-411. 

Office of the Surgeon General. 1999. Report on Mental Health. Publication #017-024-01653-5, 

Superintendent of Documents, Washington, DC. 

Rogers, E.M. 1995a. Diffusion of innovations. 4th Edition. New York, NY: Free Press. 

Rogers, E.M. 1995b. Lessons for guidelines from the diffusion of innovations. Joint Commission 

Journal on Quality Improvement, 21(7): 324-328. 




Sackett, D.L., Rosenberg, M.C., Muir Gray, J.A., et al. 1996. Evidence-based medicine: What it 

is and what it isn’t. British Medical Journal, 312, 71-72. 

Sacks, S. 2000. Co-occurring mental & substance abuse disorders—Promising approaches & 

research issues. Journal of Substance Use & Misuse 35(12-14), 2061-2093. 

Sacks, S., Sacks. J.Y., De Leon, G., Bernhardt, A.I. & Staines. G.L. 1997. Modified therapeutic 

community for mentally Ill chemical abusers: Background; influences: Program description: 

Preliminary findings. Substance Use and Misuse, 32(9), 1217-1259.Sacks, S. & Osher, F. 

2003. Evidence- and Consensus-Based Practices for Clinical Capacity Building. Presented 

at the COSIG New Grantee Meeting, Washington, DC. 

Sacks, S., Sacks, J.Y., McKendrick, K., Banks, S., & Stommel, J. 2004. Modified TC for MICA 

Offenders: Crime Outcomes. Behavioral Sciences & The Law, 22, 477-501. 

Sacks, S. Melnick, G. & Coen, C. (2006) Co-Occurring Disorders Screening Instrument for 

Criminal Justice Populations (CJ-CODSI). GAINS Annual Conference, Boston, MA. 

Substance Abuse and Mental Health Services Administration. 2002.Report to Congress on the 

Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental 

Disorders. Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Substance Abuse & Mental Health Administration. (2004). Results from the 2003 National 

Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied 

Studies. 

Simpson, D.D. 2002. A conceptual framework for transferring research to practice. Journal of 

Substance Abuse Treatment, 22, 171-182. 







tel 212.845.4429 fax 212.845.4650 


7

T32: Berks County Adolescent Pilot Project: Lessons for Integration 

Joan Buniski Groves, MA, Cheryl Knepper, MA, ATR-BC, LCP, CCDP, Sarah Lengel, MA, CAC, 

LPC, CCDP, & Robin Teitelbaum, MBA 

1.5 hours Focus: Systems Integration, Clinical Integrated 

Interventions & Children & Adolescents 

Description: 

This workshop provides a clinical overview of the Department of Health and the Department of Public 

Welfare’s COD pilot project in Berks County focused on the development and implementation of 

comprehensive, integrated services for adolescents. A brief historical review of the project highlights steps 

necessary for program development and replication. Also discussed are practical strategies for providing 

treatment to adolescents with CODs; the inclusion of an integrated case management protocol to fortify the 

adolescent and family service plan; and the incorporation of the CASSP principles into the program design and 

the integrated service delivery system for adolescents. 


• Recognize strategies for systems integration at both the county and provider level; 

• Identify benefits and challenges of providing integrated MISA services for adolescents; 

• Discuss practical and applicable clinical skills for applying a single, concurrent treatment approach to 

providing services to MISA adolescents and their families; 

• Access technical assistance for MISA service development. 

NOTES:


Project Administration 

Berks County 

MISA Services 

Mental Illness & Substance Abuse 

WORKING TOWARD A SINGLE SOLUTION TO MULTIPLE 

DISORDERS 

Berks County MH/MR 

Program 

(County Agency) 

Council On Chemical Abuse - 

Drug and Alcohol SCA 

(Private Non-Profit Agency) 

Joint Projects- Collaboration of staff and funding 

Adult Dual Outpatient Treatment 

Student Assistance Programs 

CASSP 

HealthChoices 

Dual Adult Transitional Living 

Outpatient Satellite Project 

Parent Partner 

MISA 

Berks County MISA Project 

Collaborative Effort between the Berks 

County Mental Health/Mental Retardation 

Program and the Council On Chemical 

Abuse 

Only Child/Adolescent Program Proposal 

funded by the State 

Comprehensive care including integrated 

treatment and case management services 

Berks County MISA Project Key 

Components 

Berks County MISA Program Coordinator 

MISA Training 

MISA Workgroup 

Implementation of Targeted MISA Services 

Development of MISA Continuum of Care 

MISA Program Coordinator 

Serve as liaison between county administration, 

state and service providers 

Monitor Current MISA service providers and 

pursue expansion of the MISA Continuum of 

Care within the County 

Develop and organize trainings for advanced 

MISA competencies and integrate core 

curriculum as a college course offering 

Facilitate the MISA Work Group 

Coordinate the collection and submission of 

MISA project evaluation data 

MISA Work Group 

Family, consumer and community involvement. 

Encourage Providers to become involved in system 

integration. 

Forum for discussion on issues related to the 

treatment of co-occurring disorders and services in 

the community. 

Workgroup operates as a subcommittee of the 

CASSP Advisory Committee. 

1



Treatment 

Assessment 

Intensive Outpatient 

Outpatient 


Challenges 

Although MISA is an integrated project, 

funding streams remain distinct between 

mental health and drug/alcohol. This affects 

provider billing practices, data collection, and 

analysis of outcomes. 

MISA continuum is limited due to dual 

licensing requirement for providers. 

Few Board certified Child/Adolescent 

Psychiatrists available to provide direct 

services. 

Resource Coordination 

Administrative 

Intensive 

Challenges 

Medical Assistance requires ASAM for 

drug/alcohol treatment authorization and 

placement despite mental health 

diagnosis/classification. 

Formulating procedures to insure 

simultaneous assessment of psychiatric 

and addictive disorders. 


Providing Integrated services for adolescents within the 

framework of Mental Health and Drug and Alcohol 

Confidentiality Regulations. 

– Successful implementation of the targeted MISA Services 

– Expansion of MISA continuum 

– Integrated Assessment Protocols at CIU and BSU 

– Integrated SAP assessments 

– Integrated assessments at Youth Center as part of County 

Integrated Children’s Services Plan (ICSP) 

Development and implementation of appropriate, 

comprehensive continuing care plans, despite limited 

MISA provider network. 


Partnership with the Berks County Medicaid 

managed care entity for enhanced rates and 

inclusion of MISA screen in CCBHO contracts. 

Solidified the relationship between the Single 

County Authority, The Council On Chemical 

Abuse, and the Berks County Mental 

Health/Mental Retardation Program. 

Increased public and provider awareness of 

co-occurring disorders and integrated 

treatment models. 

2


Service Access & Management, Inc. 

Integrated Case Management 

For Adolescents with Co-occurring Mental 

Illness & Substance Abuse Disorders 

Conference on Co-occurring Disorders 

May 16, 2006 

• Manages the day-to-day operation of the MH/MR system 

• Provides intake, case management, crisis and emergency 

services . 

• Contracts with treatment providers on behalf of the 

County. 

• Is a provider of Behavioral Health Service under Health 

Choices. 

Referrals to SAM, Inc. 

• A child/adolescent is displaying social/emotional disturbances, 

and/or behavior difficulties that disrupt his/her ability to interact 

with people or his/her environment. 

• Possible markers 

• Psychiatric/Drug & Alcohol history 

• Medical history 

• Educational progress 

• Environmental stressors 

• Comparison to peers 

• Parent report 

SAM, Inc. Intake 

• Screen for safety 

• Determine eligibility for county funded services 

• Provide information about the MH/MR system and 

other human services in Berks County. 

• Refer for assessment, treatment, supports & 

services. 


• MISA Case Management 

• Children/Adolescents with co-occurring disorders 

of mental illness & substance abuse 

• Three Levels of Case Management 

• Intensive Case Management (ICM) 

• Resource Coordination (RC) 

• Administrative Case Management 

• Assessment of Need 

• Development of Service Plan 


• Referrals for appropriate level of service 

• Community supports 

• Formal treatment 

• Participate in treatment team meetings 

• Participate in family education meetings 

• Monitors ongoing services/treatment 

• Monitors progress towards goals 

• Participate in discharge meeting 

1



• CORE training 

• Collect data pertinent to MISA project 

• Admission to case management 

• Service links 

• Follow-up activities/contacts while in case management 

• Discharge from case management 

• Transition activities 

• Follow-up 

• 90 days after admission to MISA Case Management 


• Data – March 2006 

• 18in MISA ICM 

• 18 in MISA RC 

• 5in MISA Administrative Case Management 


Service Access & Management, Inc. 

• Data – March 2006 (continued) 

• Levels of treatment 

• MISA IOP 

• MISA Outpatient 

• Mental Health In-Home Family Based 

• BHRS 

• Outpatient 

• MH Residential Treatment (RTF) 

• Drug & Alcohol Residential Facility 

19 North Sixth Street 

Suite 300 

Reading, PA 19601 

610-236-0530 

Robin Teitelbaum 

Director for Children’s Services 

2

T33: Forensic Principles to Facilitate Diversion 

Sam K. Gully, III, MS 


Description: 

This workshop reviews basic knowledge in the overlapping areas of mental health and the law. It explores 

methods for increasing the use of Diversion through the use of mental health and drug courts for consumers 

coming in contact with the criminal justice system. It also discusses what needs to be done to stop 

“transinstitutionalization.” 


• Review such concepts as “competency to stand trial;” 

• Recognize the differences between “not guilty by reason of insanity” and “guilty but mentally ill;” 

• Explain legal versus psychological principles in the determination of guilt or innocence; 

• Summarize the findings and recommendations of the Criminal Justice/Mental Health Consensus Task 

Force. 

NOTES:


What is a forensic issue? 

Forensic Prerequisites to 

Facilitate Diversion 

Sam K. Gully, III 

• Forensic is generally associated with matters 

that involve an overlap of law, science, and 

health (physical/mental). 

• The term is also used to describe judicial 

processes and court proceedings. 

• It is also used to describe debate and public 

discourse. 

• For our purposes, it refers to mental health and 

contact with the criminal justice system. 

Forensically Related Positions 

Cont’d 

• Forensic psychiatrist 

or psychologist 

• Corrections 

Psychologist 

• Criminologists 

• Police Chiefs 

• Consumers 

• Legislators 

• Probation Officers 

• Parole Officers 

• Judges 

• County Executives 

• State Corrections 

Executives 

• Jail Administrators 


Advocates 

• Judicial Officers 


Administrators 

• Researchers 

• Crime victims 


Providers 

• Prosecutors 

• Defense Attorneys 

• Sheriffs 

• Police Officers 


Professionals 

• Case Managers 

• Substance Abuse 

Professionals 

• Correctional Mental 

Health Officials 

Fact Sheets 

(MH/CJ, 2002; GAINS Center, 2003) 

• Today, there are over 2 million people 

incarcerated in U.S. prisons or jails, the 

equivalent of one in every 142 U.S. 

residents—and another 5 million people 

on probation or parole. 

• Approximately 10 million people are 

booked in U.S. jails over the course of a 

year. 

Cont’d 

• About 5% of the U.S. population has a serious 

mental illness (SMI)—about 16% of the prison 

system has SMI. 

• Men involved in the public mental health system 

are four times as likely to be incarcerated as 

men in the general population—for women the 

ratio is six to one. 

• Three-quarters of inmates have a co-occurring 

substance –related disorder. 

1


Cont’d 

• Inmates imprisoned with SMI are 2.5 times 

as likely to be homeless. 

• Nearly half the inmates with a mental 

illness were incarcerated for committing a 

nonviolent crime. 

• In PA, an inmate with SMI is three times 

as likely to serve their maximum sentence 

than other inmates. 

Juvenile Justice Facts 

(GAINS CTR., 2003) 

• At least 20% of youth in contact with the 

juvenile justice system experience SMI. 

• Of youth in contact with the juvenile justice 

system who experience a mental disorder, 

between 50 and 75% have a co-occurring 

substance –related disorder. 

Facts on Minority Incarceration 

(Han, Y.L.,2000) 

• In 1950---65% of prisoners were white. 

• In 1990---OVER 65% of prisoners were nonwhite. 

• African -American males are 7X more likely than 

whites to be incarcerated. 

• The incarceration rate for Hispanics has tripled 

since 1980. 

• Query: Are systems culturally competent? 

Adolescent Females (Prescott, L., 1998) 

• The number of arrests for adolescent females 

has increased for most offenses, in comparison 

for males. 

• Females have higher levels of abuse/trauma 

• Have higher rates of MH problems 

• May be pregnant or already have their own 

children and face serious parenting and other 

interpersonal relationships challenges 

Common Forensic Terms 

• 3 Types of Incarceration: 

– Jails—operated by the county; sentence less 

than 2 year 

– Prisons—operated by the state; sentence 

more than 2 years 

– Penitentiary—operated by the federal 

government; all inmates convicted of federal 

crimes regardless of length of sentence 

•Systems: 

• Criminal Justice 

• Juvenile Justice 


• Substance Abuse/Dependence 

• Co-occurring Disorders 

• Local, State, and Federal Issues 

• Inherent Cultural/Racial/Poverty Factors 

2


•Critical Issues: 

• Screening 

• Diagnosis 

• Assessment 

• Point of Entry 

• Reintegration 

• Treatment/Rehabilitation 

• Recovery 

Screening: 

• Detect current MH and SUD disorders 

• Identify people with a history of violent 

offenses/behavior or severe medical 

problems 

• Identify people who have severe cognitive 

deficits 

• Identify people without co-occurring d/o’s 

Diagnosis (Dx): 

• Identify the presence of specific DSM-IV 

Mental Health (MH) and Substance Use 

Disorders (SUD) 

• Develop plans for psychosocial 

assessment 

Assessment: 

• Assessment provides a comprehensive 

examination of bio-psycho-social needs 

and problems including the severity of MH 

and SUD D/O’s, conditions associated 

with the occurrence of these D/O’s, other 

problems, individual motivation, & areas 

for appropriate interventions, & is 

conducted through interview & specialized 

instruments 

The Issue of Competence 

• Civil issues where competence is 

important: 

– Making a will; entering into contracts; 

decisions about one’s person or property; 

marrying, etc. 

• Criminal issues include: 

– Waiver of rights, standing trial, pleading guilty, 

being sentenced, waiver of appeal, and being 

executed. 

Cont’d 

• Children’s issues: 

– Areas of delinquency; child custody; 

termination of parental rights; testifying in 

court as either victim or witness. 

• Competence is a core principle of criminal 

jurisprudence. 

• Competence is a legal, not a psychiatric 

standard. 

3


Competence: A Historical Perspective 

• Medieval Common Law: if the defendant 

does not enter a plea they could be forced 

to do so, sometimes by dramatic methods. 

• Barbarism later replaced by use of a jury; 

– If the jury found the accused incapable of 

standing trial then prison was the place to 

learn (This issue finally addressed in Jackson 

vs. Indiana, 1992). 

Cont’d 

• Codified standards for use of a jury began 

in the late 1700’s. 

• Eventually the standard for competency 

placed heavy emphasis on the person’s 

cognitive capacity: 

– Possess sufficient reason to understand 

charges 

– Ability to participate in the trial in one’s own 

defense. 

Standards for Assessment 

• Clinician must distinguish between 

“competence” and other clinical /legal 

issues such as: 

– Presence of psychosis 

– Suitability for civil involuntary commitment 

– Responsibility for criminal acts 

• A standardized protocol with a rating scale 

is recommended (validity and reliability). 

McGarry Guidelines 

• 1. Ability to appraise the legal defenses 

available 

• 2. Level of unmanageable behavior. 

• 3. Quality of relating to attorney 

• 4. Ability to plan legal strategy* 

• 5. Ability to appraise the roles of various 

participants in the courtroom proceedings* 

• 6. Understanding of court procedure* 

• 7. Appreciation of the charges 

• 8. Appreciation of the range and nature of 

possible penalties 

• 9. Ability to appraise the likely outcomes* 

• 10. Capacity to disclose pertinent facts to 

attorney 

• 11. Capacity to challenge prosecution witnesses 

realistically 

• 12. Capacity to testify relevantly 

• 13. Manifestation of self-serving vs. selfdefeating 

motivation 

Role of the Mental Health Professional 

in Determining Competence 

• Competence is determined by a judge but 

clinicians now almost always assist. 

• Contemporary concerns revolve around 

constitutional concerns and maintaining 

faith in the criminal justice system. 

• Competence evaluation is required if there 

is “a bona fide doubt’ re: competence to 

stand trial. 

4


Current Standards 

• 1. Each state determines standards 

governing criminal trials (see 

McNaghten). 

• 2. Dujsky vs. U.S. applies in federal 

cases: 

– Whether defendant has sufficient present 

ability to consult lawyer with reasonable 

degree of rational understanding, and 

whether defendant has a rational as well 

as a factual understanding of the 

proceedings against the defendant. 

Cont’d 

• 3. Current standards understood in the 

context of the following principles: 

– Understand the nature of the charges. 

– Understand the nature and purpose of the 

court proceedings. 

– Have a rational as well as a factual 

understanding of the proceedings. 

Should the clinician offer an opinion on 

a person’s competency to stand trial? 

• 1) Two opinions on how the clinician should 

present information re: competence: 

– A. Should not offer an opinion and provide only raw 

data; note that competence is not a clinical decision; 

and assert no expertise in legal areas. 

– B. As an arm of the court they should offer an opinion 

to be useful to the court; legitimate role of clinician; 

and recognizing bias in assessment & evaluation 

minimizes its effect. 

2.) When pressed to give an 

opinion: 

• Cave in and give an opinion 

• Can protest that clinicians are not experts 

in legal matters 

• Note: clinician is not acting in traditional 

helping relationship and providing 

information to a third party may or may not 

be in the best interests of the person they 

are evaluating. 

3.) Why you might abstain: 

• Distortion of the clinician/patient relationship 

• Court may use clinicians skills to the person’s 

detriment 

• The person could be seduced into confiding 

• The clinician is employed by a third party and 

not employed to provide treatment to the 

individual 

• Clinicians to not want to be viewed as an agent 

of social control. 

4.) Why you might opine: 

• Forensic evaluation can protect the 

fairness function of the courts. 

– Clinician discomfort is not a reason to desist. 

• Clinicians should help courts as an 

obligation to society. 

– The clinician must grapple with the reality of 

ethical dilemmas. 

5


Escaping the Dilemma 

• Be sure that the defendant: 

• Knows in advance the purpose of your 

interview and that the information from 

your assessment will likely be revealed in 

court (Note: Their attorney should also 

know the same). 

Mental Health, Law Enforcement, the 

Courts, and the Community 

(Consensus Report, 2002) 

• Contact with the Law 

– Request for police service 

– On-scene assessment 

– On-scene response 

– Incident documentation 

– Police response evaluation 

Pretrial Issues, Adjudication, and 

Sentencing 

– Appointment of Counsel 

– Consultation with Victim 

– Prosecutorial Review of Charges 

– Modification of Pretrial Diversion Conditions 

– Pretrial Release/Detention Hearing 

– Modification of Pretrial Release Conditions 

– Intake at County/Municipal Detention Facility 

– Adjudication 

– Sentencing 

Cont’d 

– Modification of Conditions of 

Probation/Supervised Release 

Incarceration and Reentry 

– Receiving and Intake of Sentenced Inmates 

– Development of Treatment Plans, Assignment 

to Programs, and Classification/ Housing 

Decisions 

– Subsequent Referral for Screening and 

Mental Health Evaluation 

– Release Decision 

– Development of Transition Plan 

Cont’d 

– Modification of Conditions of Supervised 

Release 

– Maintaining Contact Between Individual and 

Mental Health System 

6


Improving Collaboration 

• Obtaining and Sharing Resources 

• Sharing Resources 

• Institutionalizing the Partnership 

Training Practitioners and Policy 

Makers and Educating the Community 

– Determining Training Goals and Objectives 

– Training for Court Personnel 

– Training for Corrections Personnel 

– Training for Mental Health Professionals 

– Educating the Community and Building 

Community Awareness 

– Identifying Trainers 

– Evaluating Trainers 

Antisocial Personality Disorder 

• Many people working in mental health and 

criminal justice know little about APD or 

have obsolete and inaccurate ideas about 

it. 

• Some see the diagnosis as a useless 

myth. 

• Others are confused and easily misled 

when making or implementing treatment 

protocols. 

Core Features of APD 

(Hare, 1993) 

• Inadequate conscience or superego 

– Absence of moral judgment 

– Absence of guilt 

• Developmental Disruption 

– Emotional Immaturity/Egocentricity/ 

Impulsivity 

– Physical and intellectual functioning intact, but 

emotional development seriously impaired. 

(cont’d) 

• Lives in the present, the here and 

now—no evidence of long-term 

planning 

• Life is a hit or miss affair, a series of 

impulsive acts 

• Loss of insight related to their own 

egocentricity and impulsivity 

• Substance abuse/dependence is 

rampant 

(cont’d) 

• High incidence of parental separation, 

divorce, early death or desertion 

• Very high incidence of childhood abuse 

• Greater degree of alcoholism and 

criminality in the immediate family (e.g. 1/5 

sociopaths; 1/3 alcoholics). 

7


Sex Offenders 

(Flora, 2001) 

• Defining a sex offense 

–A criminal action involving inappropriate 

sexual behavior that occurs when one party 

does not give, or is incapable of giving, 

informed consent (O’Conell et al, 1990). 

• Who may commit a sex offense? 

– Sex offenders may be preadolescent, 

adolescent, or adults. 

cont’d 

• The majority of offenders are male, 

although more more female offenders are 

being reported. 

• A sexual offender is an individual who 

commits a sexual crime that violates 

cultural morals or laws, although these 

laws may vary by locality and community 

standards (Coleman et al, 1996). 

cont’d 

• Sex offenders (SXO’s) are found among 

all races, cultures, age groups, and 

religious faiths. 

• SXO’s exist within all income groups. 

• SXO’s exist within all levels of educational 

achievement. 

• SXO’s may be known to their victims or 

may be strangers. 

SXO’s and Social Policy 

• Several decades ago SXO’s were considered 

good candidates for treatment services that 

would provide a cure and protect the 

community. 

• Most states enacted sex offender 

commitment laws in some form, known as: 

– “Sexual psychopath laws; Sexually 

dangerous persons acts; or Mentally 

dangerous sex offenders acts”. 

• The desire to commit SXO’s has 

resurfaced. 

cont’d 

• Several states have adopted 

indeterminate commitment statutes 

• Some new laws are slanted toward 

commitment of a SXO only after 

incarceration in prison 

• Dangerous SXO’s now being involuntarily 

committed to a state psychiatric facility 

after their sentence has expired. 

cont’d 

• Parole boards are more reluctant to 

discharge a SXO if they have the option to 

continue incarceration 

• Offenders who refuse treatment may serve 

longer sentences or not be released at all. 

• Courts are now giving longer sentences 

• Professionals in general are now more 

alert to the signs of sexual abuse. 

8


Violent Crime Control and Law 

Enforcement Act, 1996 (Megan’s Law) 

• Amended to require the release of information to 

protect the public from violent SXO’s. 

• Mandates community notification of the release 

of SXO’s from prison. 

• Half of the states require registration with law 

enforcement agencies 

• Some states maintain a Web page on the 

Internet listing names, addresses, and a recent 

photograph of certain types of SXO’s 

Who should provide services? 

• Many offenders have been referred to the 

“Corrections” system for care in the past 

• Correctional facilities are concerned about 

their role in working with this population on 

a clinical basis. 

• Psychiatric facilities are concerned about 

placing SXO’s among persons with mental 

illness. 

Elements of an Effective Mental 

Health System 

– Evidence-Based Practices 

– Integration of Services 

– Co-occurring Disorders 

– Housing 

– Consumer and Family Member Involvement 

– Cultural Competency 

– Workforce 

– Accountability 

– Advocacy 

Measuring and Evaluating 

Outcomes 

• Identifying Outcome Measures 

• Collecting Data 

• Disseminating Findings 

The APIC Model 

• Assess: 

– Assess the inmate’s clinical and social needs, 

and public safety risks 

•Plan: 

– Plan for the treatment and services required to 

address the inmate’s needs 

• Identify: 

– Identify required community & correctional 

programs responsible for post-release 

services 

Cont’d 

• Coordinate 

– Coordinate the transition plan to ensure 

implementation and avoid gaps in care with 

community-based services. 

9

T34: Implementing Integrated Dual Disorders Treatment on Assertive Community Treatment 

Teams in Allegheny County 

Sara Leiber, LCSW & Kim Patterson, MSW 


Description: 

Allegheny County Office of Behavioral Health, Allegheny Health Choices, Inc., Community Care, providers and 

other stakeholders collaborated to promote effective community treatment strategies for high-risk consumers. 

This workshop demonstrates how dual diagnoses treatment has been implemented on the ACT teams in 

collaboration with the above stakeholders. The presentation describes the present model of stage-wise 

treatment, harm reduction and motivational interviewing; and reviews the lessons learned in moving toward 

the evidence-based model for co-occurring disorders. 


• Discuss managed care collaboration with the county, providers and other stakeholders; 

• Describe evidence-based models of treatment for co-occurring disorders; 

• Identify key components of treatment for consumers with co-occurring disorders on an ACT team; 

• Examine how to apply evidence-based treatment for consumers with co-occurring disorders. 

NOTES:


Topic Description 

Allegheny County: Implementing 

Dual Disorders Treatment on 


Teams 

Community Care 

Allegheny HealthChoices, Inc. 

Mercy Behavioral Health 

This presentation will describe how, with 

collaboration among key stakeholders, the 

evidenced-based practice of Integrated 

Dual Disorders Treatment is being 

implemented on Assertive Community 

Treatment Teams (ACTT) in Allegheny 

County. 

Stakeholders 

• Allegheny County Office of Behavioral 

Health 

• Community Care 

• Allegheny HealthChoices, Inc. 

• Providers 

• Consumers 

• Family 

• Advocates 

Stakeholder Communication and Feedback Loop 

Level I: Leadership Team 

Stakeholder Feedback 

Financial Strategy 

Data Design, Reporting, Analysis 

Outcomes Development and Analysis 

Level II: CTT Network Workgroup 

Stakeholder Feedback 

Financial Accountability 

Data Design, Collection, and Reporting 

Outcomes Accountability 

Level III: Team Workgroups 

Stakeholder Input 

Financial Accountability 

Data Reporting and Use 

Data Review 

Ad Hoc Consumer Advisory Committee 

Input and Feedback 

MULTI-LEVEL PARTNERING 

ALLEGHENY COUNTY 

ACT Teams 

ACT Teams 

4 Teams 

Transition Age 

3 Adult 

3 providers 

As of 12/05, 356 consumers (between 

81 and 97 per team) 

47% female, 53% male 

43% African American, 55% White 

36% living independently 

16% living with family 

4% supportive housing 

9% Community Residential Rehab 

14% Personal Care 

8% Jail 

3% Shelter/homeless 

10% all other 

1


ACT Teams 

ACT Teams 

65% unemployed 

9% actively seeking 

13% paid competitive 

6% supported, transitional 

5% volunteer 

47% 

The Most Common Diagnoses for CTT Consumers 

2% 

20% 

Adjustment D/O 

17% 

4% 

Bipolar D/O 

Conduct D/O 

Depressive D/O and Maj. 

Depr. 

Schizophrenia 

Allegheny HealthChoices, Inc., 2004 

ACT Teams 

Road to Implementation 

Approximately 70% of all CTT consumers have a co-occurring disorder. 

100% 

80% 

60% 

40% 

20% 

0% 

Four Team Average: Percentage of CTT Consumers by Diagnostic 

Type (HealthChoices only) 

2002 Q 1 2002 Q 2 2003 Q 1 2003 Q 2 

MISA 

MH 

Original Plan 

Designated D and A 

specialist on team. 

Direct provision of all 

D and A individual and 

group TX 

(ACT=TX Home). 

Mid-Analysis 

Change title to MISA 

specialist. 

Difficulty in engaging 

consumers in D and A 

TX. Poor group 

attendance, 1/1 

provided on the fly and 

inconsistently. 

Goals 

Fully integrated MISA 

specialist. 

Adopt stage-wise 

assessment and 

treatment approaches; 

adopt Motivational 

Interviewing as a 

primary approach. 

Allegheny HealthChoices, Inc., 2004 



Original Plan 

Divert from rehabs and 

other outpatient and 

residential (reduce 

cost ). 

Mid-Analysis 

Reduction in 

utilization: key 

components of 

ACT(assertive 

outreach, high 

tolerance, 24/7 crisis, 

contingency funds, 

assisting with 

housing,own respite) 

and informal use of 

harm reduction TX 

strategies, in some 

cases by default. 

Goals 

ACTT provides all dual 

disorders treatment 

and rehab, all teams 

formally adopt and 

provide Integrated 

Dual Disorders 

Treatment as an EBP. 

Original Plan 

D and A specialist 

works with the 

treatment team and 

trains team staff in 

D and A TX. 

Harm reduction as 

prevailing TX strategy. 

D and A treatment ongoing 

and integrated. 

Mid-Analysis 

D and A specialist 

provides all D and A 

treatment; other staff 

‘pass off’ D/A issues to 

specialist. 

Informal harm 

reduction strategies by 

individual staff. 

D/A TX goals 

separate and distinct 

from life goals; D/A 

addressed during 

crisis. 

Goals 

All team members 

provide TX and rehab 

to consumers with 

dual disorders. 

Methodical and 

strategic harm 

reduction strategies 

reinforced by team. 

All teams provide 

integrated treatment 

planning. 

2


Implementing 

the Evidenced-Based Practice 

of Integrated Dual Disorders 

Treatment (IDDT) 

on ACTT 

Assertive Community Treatment Teams 

and Integrated Dual Disorders 

Treatment: 

A Natural Fit 

EBP of ACTT: Critical Ingredients 


HUMAN RESOURCES: STRUCTURE & 

COMPOSITION 

• SMALL CASELOAD 

• TEAM APPROACH 

• PROGRAM MEETING 

• PRACTICING TEAM LEADER 

• CONTINUITY OF STAFFING 

• STAFF CAPACITY 

• PSYCHIATRIST ON STAFF 

• NURSE ON STAFF 

• SUBSTANCE ABUSE SPECIALIST ON STAFF 

• VOCATIONAL SPECIALIST ON STAFF 

• PROGRAM SIZE 

Dartmouth Assertive Community Treatment Scale (DACTS) 

ORGANIZATIONAL BOUNDARIES 

• EXPLICIT ADMISSION CRITERIA 

• INTAKE RATE 

• FULL RESPONSIBILITY FOR TREATMENT 

SERVICES 

• RESPONSIBILITY FOR CRISIS SERVICES 

• RESPONSIBILITY FOR HOSPITAL ADMISSIONS 

• RESPONSIBILITY FOR HOSPITAL DISCHARGE 

PLANNING 

• TIME-UNLIMITED SERVICES (GRADUATION RATE) 



EBP of IDDT: Critical Ingredients 

NATURE OF SERVICES 

• COMMUNITY-BASED SERVICES 

• NO DROPOUT POLICY 

• ASSERTIVE ENGAGEMENT MECHANISMS 

• INTENSITY OF SERVICE 

• FREQUENCY OF CONTACT 

• WORK WITH INFORMAL SUPPORT SYSTEM 

• INDIVIDUALIZED SUBSTANCE ABUSE TX 

• DUAL DISORDER TREATMENT GROUPS 

• DUAL DISORDERS (DD) MODEL 

• ROLE OF CONSUMERS ON TX TEAM 


• Multidisciplinary Team 

• Integrated Substance Abuse Specialist 

• Stage-Wise Interventions 

• Access for IDDT Clients to Comprehensive DD 

Services 

• Time-Unlimited Services 

• Outreach 

• Motivational Interventions 

SAMHSA Integrated Dual Disorders Treatment Fidelity Scale 

3


EBP of IDDT: Critical Ingredients 

• Substance Abuse Counseling 

• Group DD Treatment 

• Family Psycho-education on DD 

• Participation in Alcohol & Drug Self-Help Groups 

• Pharmacological Treatment 

• Interventions to Promote Health 

• Secondary Interventions for Substance Abuse 

Treatment Non-Responders 

Corresponding 

Fundamentals 

• Multidisciplinary team 

• MISA specialist 

• Harm-reduction orientation 

• Capacity to provide comprehensive 

services 

• Time-unlimited services 

• Outreach capacity 

• Access to a variety of resources 

SAMHSA Integrated Dual Disorders Treatment Fidelity Scale 

Corresponding Fundamentals 

Corresponding Fundamentals 

• Motivation orientation and approach 

• Provide individual and group 

• Community integration (use of self-help) 

• Psychiatrist on team 

• Family inclusion 

• Wellness and health orientation 

• Capacity to treat non-responders 

• Engagement as a critical approach 

• Comprehensive assessments 

• Relapse Prevention 

Bridging the Gap: Target Areas 

• Integrated Treatment Planning 

• Stage-Wise Treatment 

• Motivational Interviewing 

• Harm Reduction Housing 


Planning 

• A consumer’s prevailing life goals pave the 

path of the plan. 

• For someone with a co-occurring disorder, both 

mental health and substance abuse must 

always be addressed in the plan. 

• Focusing on the building of both skills and 

supports for the consumer’s life 

goals=Integrated Treatment Planning 

4



• Stage-wise treatment: 

Vignette # 1 

Allows for differing patterns of use, 

decreasing or increasing. 

Provides treatments/strategies for stagespecific 

behaviors. 

Demonstrates, behaviorally, how individuals 

relate to treatment providers at different 

stages of recovery. 

Results in continual help to individuals, no 

eject-no reject. 

SAMHSA Integrated Dual Disorders Treatment Toolkit 


The Substance Abuse Treatment Scale 

(McHugo, Drake, Burton, Ackerson) 

Pre-engagement. The person does not have contact with a case 

manager, mental health counselor or substance abuse counselor, 

and meets criteria for substance abuse or dependence. 

Engagement. The client has had only irregular contact with an 

assigned case manager or counselor, and meets criteria for 

substance abuse or dependence. 

Early Persuasion. The client has regular contacts with a case 

manager or counselor, continues to use the same amount of 

substances or has reduced substance use for less than 2 weeks, 

and meets criteria for substance abuse or dependence. 

Late Persuasion. The client has regular contacts with a case 

manager or counselor, shows evidence of reduction in use for the 

past 2-4 weeks (fewer substances, smaller quantities, or both), but 

still meets criteria for substance abuse or dependence. 


Early Active Treatment. The client is engaged in treatment and has 

reduced substance use for more than the past month, but still 

meets criteria for substance abuse or dependence during this 

period of reduction. 

Late Active Treatment. The person is engaged in treatment and has 

not met criteria for substance abuse or dependence for the past 1-5 

months. 

Relapse Prevention. The client is engaged in treatment and has not 

met criteria for substance abuse or dependence for the past 6-12 

months. 

In Remission or Recovery. The client has not met criteria for 

substance abuse or dependence for more than the past year. 


Treatment Matching Paradigm: Sub-Type of Dual Disorder by 

Phases of Treatment 

(Kenneth Minkoff,MD) 

I. Low Severity MI + Low Severity SA 

II. SPMI +Substance Abuse 

III. Low Severity Psychiatric Disorder + High Severity SA Disorder 

(addiction) 

IVA. High Severity Psych (SPMI) + High Severity Substance 

(addiction) 

IVB. High Severity Psych Disturbance (non-SPMI ) + 

High Severity Substance (addiction) 


Example: Sub-type II: SPMI +Substance Abuse 

 

 

 

 

 

 

 

Continuity Interventions 

Continuing case management with an ind clinician, case 

management team, or CTT team, depending on intensity of 

need. 

Ongoing responsibility of mental health agency/system. 

Unconditional support commensurate with disability. 

Continued medication, regardless of continuing substance 

use. 

Development of ongoing treatment plan, balancing care and 

support with structured expectation and contingencies, while 

maintaining continuity. 

Stage-specific interventions as indicated 

5



Sub-type II: SPMI +Substance Abuse 

 

 

 

 

Acute Interventions 

For severe MI decompensation, DDC IP unit. 

For substance use stabilization, no detox needed. 

For substance related symptomatic exacerbation of MI, 

without severe decompensation, DDC psychiatric crisis 

stabilization bed. 



Pre-Engagement, Engagement, Early Persuasion, Late 

Persuasion Interventions 

 

 

 

 

Individual MI, assuming role of DD recovery companion. 

Encourage participation in pre-motivational and persuasion 

groups. 

Involve families and other collaterals to support the 

motivational process and to promote interventions. 

Promote harm reduction and behavioral plans to promote 

contingency based learning, use payeeships,other 

contingencies. 



Pre-Engagement, Engagement, Early Persuasion, Late 

Persuasion Interventions 

 

 

 

 

Utilize negative consequences and adverse outcomes in a 

supportive context to promote learning and encourage 

change. 

Use best psychotropic medication available. Certain 

medication changes can be contingent upon reduced 

substance use. 

Harm reduction-housing (wet housing and damp housing) 

supports. 

Supported Employment (Individualized Placement & 

Support) for vocational rehabilitation. 



 

 

 

 

 

Action-Early Active TX and Late Active Interventions 

Continuing meds for MI, along w/appropriate TX supports: 

ind and grp, day TX/psych rehab, housing support, CM, etc. 

Emphasize building strengths/skills (including substance 

reduction skills) to promote recovery from MI. 

Cognitive-behavioral skills training (appropriate for level of 

psych disability) to promote substance reduction & 

elimination, in ind and grp settings integrated into MH TX. 

Skills training may be integrated into day treatment or psych 

rehab or CTT program. 



 

 

 

Action-Early Active TX and Late Active 

Interventions 

Abstinence is recommended goal, but appropriate 

outcome can be non-harmful use (e.g., alcohol 



• Motivational interviewing/counseling: 

An approach to counseling that helps to enhance motivation. 

Vignette # 2 

Techniques can be used to help consumers to become motivated 

for mental health TX, or to make other changes in their lives. 

Is a consumer-centered counseling approach that aims to help 

individuals who aren't yet ready to change. 

Consumers can be seen NOT as "resistant" or "in denial" of their 

substance abuse or of their need for mental health TX but as 

needing help to increase their readiness to change behavior by 

linking change to their life goals. 

Results in remission of substance abuse for the majority of 

consumers who receive the TX. 


Principles of Motivational 

Interviewing 

Principles of Motivational 

Interviewing 

• Motivational interviewing uses five principles, which are always kept in 

mind during interactions with the consumer: 

Express empathy: actively listening without offering judgment, 

criticism, or advice. 

Develop discrepancy: identify and amplify discrepancy between 

behavior and goals through clarifying life goals and understanding 

the pros and cons to using that interferes with achieving goals. 

Avoid argumentation: the principle is to avoid arguments in general, 

with the assumption that arguments simply strengthen people's 

beliefs, rather than helping them change their beliefs. 

Roll with resistance: 

It is important to let the consumer express his/her differing 

opinions and to "roll with it" instead of trying to fight it. 

Support self-efficacy: 

Self-efficacy is the belief that one can succeed at change. The 

final principle in motivational interviewing is to support the client's 

self-efficacy. This is particularly critical for people who are 

demoralized, depressed, or hopeless. 



Harm Reduction Housing 

Vignette # 3 

• No eject, no reject 

• Housing for housing sake 

• Stage-wise treatment and supports 

• Safe, affordable 

• Stage specific (wet and damp, 

substance free) 

7


Taking Action… 

Vignette # 4 

• Monthly expert clinical consultation 

• Monthly educational and training with team 

leaders 

• Outcomes benchmarking 

• Revisions in data collection methods 

• Training MISA specialists in IDDT 

• Increase team competencies in other EBP 

such as supported employment and ACT 

Contacts 

• Sara Leiber, Community Care 

Leibers@ccbh.com 

• Kim Patterson, Allegheny HealthChoices, Inc. 

Kpatterson@ahci.org 

• Christine Gregor, Mercy Behavioral Health 

Cgregor@mercybh.org 

8

T35: CCISC Implementation in Pennsylvania: Blair County 

Christie A. Cline, MD, MBA, Kenneth Minkoff, MD & Theresa Rudy, BSW 


Description: 

Doctors Cline and Minkoff discuss strategies for implementing the CCISC model described in the plenary 

presentation, as well as lessons learned from implementation projects all over the United States and Canada. 

Ms. Rudy presents specific lessons learned from the Blair County Pilot Project implementation, followed by 

interactive discussion of the application of CCISC in Pennsylvania to date. 


• Describe the components of the CCISC model; 

• Identify strategies for implementing a CCISC model in the local area; 

• Review lessons learned from prior implementation attempts, including a Pennsylvania county; 

• Use the information in integrating services for persons with CODs. 

NOTES:


CHANGING THE WORLD: 

COMPREHENSIVE, CONTINUOUS, 

INTEGRATED SYSTEMS OF CARE 

FOR INDIVIDUALS AND FAMILIES WITH CO- 

OCCURRING PSYCHIATRIC AND SUBSTANCE 

USE DISORDERS 

Presented by: 

Christie A. Cline, M.D., M.B.A., P.C. 

Kenneth Minkoff, MD 

“Co-occurring Psychiatric & Substance Disorders in 

Managed Care Systems: Standards of Care, Practice 

Guidelines, Workforce Competencies & Training 

Curricula” 

CENTER FOR MENTAL HEALTH SERVICES 

MANAGED CARE INITIATIVE 

CONSENSUS PANEL REPORT 

Info@ZiaLogic.org 

www.ZiaLogic.org 

ZiaLogic©2002, 2003 

Kminkov@aol.com 

www.kenminkoff.com 

1998 

FIVE SECTIONS OF 

PANEL REPORT 

• I. CONSUMER/FAMILY STANDARDS 

• II. SYSTEM STANDARDS/PROGRAM 

COMPETENCIES 

• III. PRACTICE GUIDELINES 

• IV. WORKFORCE COMPETENCIES 

• V. TRAINING CURRICULA 

CONSUMER/FAMILY SYSTEM 

STANDARDS 

• WELCOMING 

• ACCESSIBLE 

• INTEGRATED 

• CONTINUOUS 

• COMPREHENSIVE 

Individuals with Co-occurring Disorders 

PRINCIPLES OF SUCCESSFUL 

TREATMENT: 

Dual diagnosis is an expectation, 

not an exception. 

This expectation must be incorporated in 

a welcoming manner into all clinical 

contact, to promote access to care and 

accurate identification of the population. 

1


The Four Quadrant Model is a viable 

mechanism for categorizing individuals 

with co-occurring disorders for purpose of 

service planning and system responsibility. 

SUB-GROUPS OF PEOPLE WITH 

COEXISTING DISORDERS 

Patients with “Dual Diagnosis” - combined psychiatric and substance abuse 

problems - who are eligible for services fall into four major quadrants 

PSYCH. HIGH 

SUBSTANCE HIGH 

Serious & Persistent Mental 

Illness with Substance 

Dependence 

QUADRANT IV 

PSYCH. HIGH 

SUBSTANCE LOW 

Serious & Persistent Mental 

Illness with Substance Abuse 

QUADRANT II 

PSYCH. LOW 

SUBSTANCE HIGH 

Psychiatrically Complicated 

Substance Dependence 

QUADRANT III 

PSYCH. LOW 

SUBSTANCE LOW 

Mild Psychopathology with 


QUADRANT I 

Treatment success derives from the 

implementation of an empathic, hopeful, 

continuous treatment relationship, which 

provides integrated treatment and coordination 

of care through the course of multiple 

treatment episodes. 

Within the context of the empathic, hopeful, 

continuous, integrated relationship, 

case management/care 

(based on level of impairment) and 

empathic detachment/confrontation 

(based on strengths and contingencies) 

are appropriately balanced 

at each point in time. 

When substance disorder and psychiatric 

disorder co-exist, each disorder should be 

considered primary, and integrated dual 

primary treatment is recommended, 

where each disorder receives appropriately 

intensive diagnosis-specific treatment. 

Both substance dependence and serious 

mental illness are examples of primary, 

chronic, biologic mental illnesses, which 

can be understood using a disease and 

recovery model, with parallel phases of 

recovery. 

2


PARALLELS 

PROCESS OF RECOVERY 

• PHASE 1: Stabilization 

- Stabilization of active substance use or acute psychiatric 

symptoms 

• PHASE 2: Engagement/ 

Motivational Enhancement 

- Engagement in treatment 

- Contemplation, Preparation, Persuasion 

• PHASE 3: Prolonged Stabilization 

- Active treatment, Maintenance, Relapse Prevention 

• PHASE 4: Recovery & Rehabilitation 

- Continued sobriety and stability 

- One year - ongoing 

There is no one type of dual diagnosis 

program or intervention. For each 

person, the correct treatment intervention 

must be individualized according to 

subtype of dual disorder and diagnosis, 

phase of recovery/treatment, level of 

functioning and/or disability associated with 

each disorder. 

In a managed care system, individualized 

treatment matching also requires 

multidimensional level of care assessment 

involving acuity, dangerousness, 

motivation, capacity for treatment 

adherence, and availability of continuing 

empathic treatment relationships and other 

recovery supports. 

Treatment Matching 

and 


CCISC CHARACTERISTICS 

• 1. SYSTEM LEVEL CHANGE 

• 2. USE OF EXISTING RESOURCES 

• 3. BEST PRACTICES UTILIZATION 

• 4. INTEGRATED TREATMENT 

PHILOSOPHY 

CHANGING THE WORLD 

• A. SYSTEMS 

• B. PROGRAM 

• C. CLINICAL PRACTICE 

• D. CLINICIAN 

3


12 STEPS OF IMPLEMENTATION 

• 1. INTEGRATED SYSTEM PLANNING 

• 2. CONSENSUS ON CCISC MODEL 

• 3. CONSENSUS ON FUNDING PLAN 

• 4. IDENTIFICATION OF PRIORITY 

POPULATIONS WITH 4 BOX MODEL 

• 5. DDC/DDE PROGRAM STANDARDS 

• 6. INTERSYSTEM CARE 

COORDINATION 


• 7. PRACTICE GUIDELINES 

• 8. IDENTIFICATION, WELCOMING, 

ACCESSIBILITY: NO WRONG DOOR 

• 9. SCOPE OF PRACTICE FOR 

INTEGRATED TREATMENT 

• 10. DDC CLINICIAN COMPETENCIES 

• 11. SYSTEM WIDE TRAINING PLAN 


• 12. PLAN FOR COMPREHENSIVE 

PROGRAM ARRAY 

– A. EVIDENCE-BASED BEST PRACTICE 

– B. PEER DUAL RECOVERY SUPPORT 

– C. RESIDENTIAL ARRAY: WET, DAMP, 

DRY, MODIFIED TC 

– D. CONTINUUM OF LEVELS OF CARE IN 

MANAGED CARE SYSTEM: ASAM-2R, 

LOCUS 2.0 

DUAL DIAGNOSIS CAPABLE 

ROUTINELY ACCEPTS DUAL DIAGNOSIS PATIENT 

WELCOMING ATTITUDES TO COMORBIDITY 

CD PROGRAM: MH CONDITION STABLE AND 

PATIENT CAN PARTICIPATE IN TREATMENT 

MH PROGRAM: COORDINATES PHASE-SPECIFIC 

INTERVENTIONS FOR ANY SUBSTANCE DX. 

POLICIES AND PROCEDURES ROUTINELY LOOK AT 

COMORBIDITY IN ASSESSMENT, RX PLAN, DX 

PLAN, PROGRAMMING 

CARE COORDINATION RE MEDS (CD) 

Dual Diagnosis Capable: 

DDC-CD 

• Routinely accepts dual patients, provided: 

• Low MH symptom acuity and/or disability, that 

do not seriously interfere with CD Rx 

• Policies and procedures present re: dual 

assessment, rx and d/c planning, meds 

• Groups address comorbidity openly 

• Staff cross-trained in basic competencies 

• Routine access to MH/MD consultation/coord. 

• Standard addiction program staffing level/cost 

Dual Diagnosis Capable: 

DDC-MH 

• Welcomes active substance users 

• Policies and procedures address dual assessment, 

rx & d/c planning 

• Assessment includes integrated mh/sa hx, 

substance diagnosis, phase-specific needs 

• Rx plan: 2 primary problems/goals 

• D/c plan identifies substance specific skills 

• Staff competencies: assessment, motiv.enh., rx 

planning, continuity of engagement 

• Continuous integrated case mgt/ phase-specific 

groups provided: standard staffing levels 

4


DUAL DIAGNOSIS ENHANCED 

(DDE) 

MEETS DDC CRITERIA PLUS: 

CD: MODIFICATION TO ACCOMMODATE MH 

ACUITY OR DISABILITY 

MH SPECIFIC PROGRAMMING, STAFF, AND 

COMPTENCIES, INCLUDING MD 

FLEXIBLE EXPECTATIONS; CONTINUITY 

MH; ADDICTION TREATMENT IN PSYCH MANAGED 

SETTINGS (DUAL DX INPT UNIT) OR 

INTENSIVE CASE MGT/OUTREACH TO MOST 

SERIOUSLY MI AND ADDICTED PEOPLE 

Dual Diagnosis Enhanced: 

DDE-CD 

• Meets criteria for DDC-CD, plus: 

• Accepts moderate MH symptomatology or disability, 

that would affect usual rx. 

• Higher staff/patient ratio; higher cost 

• Braided/blended funding needed 

• More flexible expectations re:group work 

• Programming addresses mh as well as dual 

• Staff more cross-trained/ senior mh supervision 

• More consistent on site psychiatry/psych RN 

• More continuity if patient slips 

Dual Diagnosis Enhanced 

DDE-MH 

• Meets all criteria for DDC-MH, plus: 

• Supervisors and staff: advanced competencies 

• Standard staffing; specialized programming: 

a. Intensive addiction programming in 

psychiatrically managed setting (dual inpt unit; dry 

dual dx housing, supported sober house) 

b. Range of phase-specific rx options in ongoing 

care setting: dual dx day treatment; damp dual dx 

housing 

c. Intensive case mgt outreach/motiv. enh.: CTT, 

wet housing, payeeship management 

CCISC INITIATIVES 

State/Province 

– Alaska – CCISC implementation, 


– Arizona – CCISC implementation, 


– Arkansas – COSIG, CCISC 

consultation 

– California – CCISC consultation 

– Colorado – CCISC consult, tool license 

– District of Columbia – CCISC 

implementation, COSIG 

– Florida – CCISC consultation, state 

provider association tool license 

– Hawaii – CCISC implementation, 


– Idaho – CCISC consultation 2001 

– Louisiana – CCISC implementation, 


– Maine – CCISC implementation, 


– Manitoba – CCISC implementation 

– Maryland – CCISC consultation, tool 

license 

– Massachusetts – CCISC consensus 

1999 

Michigan – CCISC implementation multiple local 

projects, tool license 

Minnesota – CCISC consultation, statewide 

provider network tool license 

Montana – CCISC implementation 

New Mexico – CCISC implementation (BHSD), 


New York – CCISC consultation 

Oklahoma – CCISC implementation, COSIG 

Pennsylvania – CCISC implementation, COSIG 

South Carolina – CCISC consultation, tool 

license 

South Dakota – CCISC implementation 

Texas – CCISC consultation (state hospitals), 


Vermont – CCISC implementation, COSIG 

Virginia – CCISC implementation, COSIG 

Wisconsin – CCISC consult, tool license 

CCISC INITIATIVES 

Local/Network (non-state) 

SYSTEM FEATURES 

– Alabama – Birmingham 

– British Columbia – Vancouver Island 

Health Authority, and multiple locations 

with tool licenses 

– California – San Diego, San Francisco, 

Placer, Kern, San Mateo Counties, 

Mental Health Systems, Inc (network) 

– Colorado – Larimer County 

– Florida – Tampa, Miami, Ft. 

Lauderdale, West Palm Beach, 

Pensacola Districts 

– Illinois – Peoria (Fayette Companies) 

– Indiana – Regional provider network 

– Maryland – Montgomery, Worcester, 

Kent Counties 

– Manitoba – Winnipeg RHA 

– Michigan – Kent, Oakland, Venture 

Behavioral Health, CareLink network, 

Washtenaw, and multiple other 

networks and counties. 

– Minnesota – Crookston 

– Missouri – Mark Twain Area 

Counseling Ctr 

– New York – Oneida County 

– Nova Scotia – Cape Breton RHA 

– Ohio – Akron 

– Ontario - Hamilton 

– Oregon – Mid Valley Behavioral Care 

Network 

– Pennsylvania – Blair County 

– Virginia – Lynchburg (CVCSB) 

– Washington – Spokane RSN 

– Wisconsin – Green Bay, Milwaukee 

consultation 

• All systems are complex with unique structures and 

cultures 

• All systems work within the context of limited 

resources and with complex funding issues 

• Data is often inconsistent with epidemiologic 

findings 

• Each has significant strengths and weaknesses at all 

levels (system, program, clinical practice, and 

clinician) 

• Under utilization of leverage (carrots and sticks) 

• Everyone falls into the training trap at some point 

• Each is becoming more sophisticated about 

outcomes measurement (system and clinical) and 

continuous quality improvement approaches 

5


PUBLIC BEHAVIORAL 

HEALTH CARE 

• Multiple State Agencies and Governing 

Bodies 

• Multiple Funding Streams 

• Multiple Systems of Care 

• Severely Limited Resources 

• Poverty 

• Rural and Urban 

• Cultural Diversity 

IDENTIFICATION OF NEED 

– Morbidity and Mortality 

– Gross Under Identification 

– Inefficient Use of Resources 

– Unmet Needs 

STRATEGIC ALIGNMENT 

– CCISC – Principle-driven Systems 

Improvement Approach 

– CCISC – Supports Implementation of 

Evidence-based Approaches and Improves 

Routine Practices 

– CCISC – Can be Implemented with Existing 

Resources Using Traditional Funding 

Streams 

IMPLEMENTATION 

• Top-down/Bottom-up Development 

• Aligning the Parts of the System 

• Inclusion, not Exclusion (programs and 

populations) 

• Strategic Use of Leverage (Incentives, Contracts, 

Standards, Licensure, etc….) 

• Outcomes and CQI (CO-FIT 100) 

• Model Programs 

• Evaluation of Core Competencies (COMPASS 

and CODECAT) 

• “Action Planning” 

• Train-the-Trainers 

• “Backfilling” 

STARTING PLACES 

• Identification of the Population in Need 

• Administrative Barriers – Access: Welcoming, No 

Wrong Door 

• Administrative Barriers – Data Capture: MIS system; 

feedback 

• Administrative Barriers – Fiscal: Billing and auditing 

practice 

• Universal Integrated Screening 

• Assessment Process (ILSA) 

• Treatment Matching 

• Treatment Planning 

• Engagement, Stage of Change and Contingency 

Management 

• Evaluation of Trauma 

• Interagency Coordination 

PRINCIPLES OF SUCCESSFUL 

TREATEMENT… 

• Co-morbidity is an expectation, not an exception. 

• Treatment success derives from the implementation of 

an empathic, hopeful, continuous treatment 

relationship, which provides integrated treatment and 

coordination of care through the course of multiple 

treatment episodes. 

• Within the context of the empathic, hopeful, 

continuous, integrated relationship, case 

management/care and empathic detachment/ 

confrontation are appropriately balanced at each point 

in time. 

6


…PRINCIPLES OF SUCCESSFUL 

TREATEMENT… 

…PRINCIPLES OF SUCCESSFUL 

TREATEMENT 

• When substance disorder and psychiatric disorder coexist, 

each disorder should be considered primary, and 

integrated dual primary treatment is recommended, 

where each disorder receives appropriately intensive 

diagnosis-specific treatment. 

• Both major mental illness and substance dependence 

are examples of primary mental illnesses which can be 

understood using a disease and recovery model, with 

parallel phases of recovery, each requiring phasespecific 

treatment. 

• There is no one type of dual diagnosis program or 

intervention. For each person, the correct treatment 

intervention must be individualized according to 

diagnosis, phase of recovery/treatment, level of 

functioning and/or disability associated with each 

disorder, and level of acuity, dangerousness, 

motivation, capacity for treatment adherence, and 

availability of continuing empathic treatment 

relationships and other recovery supports. 

LINKING PRINCIPLES, 

IMPLEMENTATION AND OUTCOMES 

•Examples: 

– Principle: Co-morbidity is an Expectation, not 

an Exception 

– CQI Initiative: Removal of Administrative 

Barriers to Data Collection 

– Measure of Success: Improved Population 

Identification and Data Collection 

LINKING PRINCIPLES, 

IMPLEMENTATION AND OUTCOMES 

• Examples: 

– Principle: Individualized Treatment Matching 

according to diagnosis, phase of recovery/treatment, 

level of functioning/disability, level of acuity, 

dangerousness, motivation, capacity for treatment 

adherence, availability of continuing empathic 

treatment relationships and recovery supports 

– CQI Initiative: Integrated Longitudinal Strength-based 

Assessments (ILSA) 

– Measure of Success: Improved Identification of Need 

and Improved Treatment Matching 

ROLES OF THE TRAINER 

TRAIN THE TRAINER 

PROGRAM 

• Develops Systems and Clinicians 

• Identifies Barriers to Implementation 

• Informs Policy and Procedure 

• Bridges Systems and Clinicians 

• Extends Training and TA Capacity 

7


COMPONENTS OF THE 

PROGRAM 

• Master Trainers 

• Master Trainer Sessions 

• Master Trainer Curriculum 

• Trainings and Technical Assistance 

• Development and Feedback Loops 

8

Volume 1, Issue 5 

BLAIR COUNTY’S 

CO-OCCURRING DISORDERS (MISA) PROJECT 

INFORMATION BULLETIN 

TRAINERS GROUP 

The Blair County Co-occurring Disorder Project desired to have a cadre of 

clinical persons in each provider organization who would teach the CCISC 

principles and generally act as a change agent for their organization and 

for the county. With the assistance of Dr. Ken Minkoff and Dr. Chris Cline, 

the project initiated a Train-the-Trainers project. 

The Trainers were identified and formally appointed by each programs 

CEO or Executive Director through the distribution of a formal 

appointment letter. It is important that this appointment letter be signed 

by the highest person of authority possible. Supervisors, clinical and 

support staff all need to understand the importance of this system change 

initiative. A sample/draft appointment letter is included as Attachment A. 

At the same time, the Consensus Document (See Volume 1 Issue 1) was 

circulated, either attached to the appointment letter or shared during 

subsequent trainings. 

The following tasks were identified as the functions of the trainers within 

their own organizations: 

1. Assist in understanding of the Consensus Document. 

2. Teach the eight Best Practice Principles found in Consensus 

Document. 

3. Work over a period of time to help all persons in the organization 

actualize the principles. 

4. Be placed between persons who make policy & those who 

implement policy so that problems can be solved both up and down 

the system chain. 

5. Facilitate learning either directly by the trainer or find other sources 

to respond to the training need. 

6. Provide consultation to the program and to the project. 

7. Facilitate completion of the COMPASS 1 within their organization and 

the development of action plans to address issues identified. 

8. Be a change agent in their organization. 

9. Manage the completion of the CODECAT 2 and the development of 

plans to address training needs. 

1 A program audit tool to evaluate dual diagnosis capability. 

2 A competency assessment and a self- teaching tool for clinicians. 

As of June 2005


The Trainers meet regularly to work together as a group to complete 

the following functions: 

1. Organize a communication process using a list serve or any other 

form of communication (ZiaLogic is included in that communication 

process). 

2. Help each other teach. 

3. Bring back barriers to the Performance Improvement Committee for 

priority and attention. 

4. Help the project stay on task. 

5. Instruct the system on moving toward an integrated system of 

treatment and recovery. 

6. Develop an institutional memory to assure people learn and that 

long-term change occurs. 

7. Be autonomous from other organizations or groups. 

8. Provide a reality check for the Project. 

9. Be informed of system priorities to keep work plan on track. 

The following is a list of the basic training sessions that each program is 

offering to inform their staff about the Co-occurring Disorder Project: 

A. Brief explanation of the Co-occurring Disorder (MISA) 

Initiative 

B. Provide an understanding of the CCISC model 

Use CCISC handout (Volume 1 Issue 4) 

C. Review the Consensus Document and letter of appointment 

D. Discussion of the Best Practice Principles 

(Found in the Consensus Document) 

E. Discussion of the COMPASS 

General review of tool 

Schedule time to begin completing 

F. Case study discussions using the Best Practice Principles 

Ongoing through clinical supervisory sessions 

As of June 2005


Draft Trainer appointment memo 

On agency letterhead 

Attachment A 

To: 

From: 

Re: 

All ____”agency name”_____ Staff 

“CEO or Executive Director” 

Appointment of Agency Co-occurring Disorder Trainer/s 

Over the past few years, the “Agency” has been working with the Blair 

County Behavioral Health Program to improve services system wide to 

individuals with co-occurring psychiatric and substance use disorders. 

As part of that system change initiative, Blair County adopted the 

Comprehensive Continuous Integrated System of Care (CCISC) model, 

which is described in the Consensus document included with this memo. 

I have selected “Name of Trainer/s” to represent our agency as “a 

trainer/trainers” in this initiative to not only help our staff learn the 

attitudes, values, knowledge, and skills required to treat individuals with 

co-occurring disorders, but also to function as a systems change agent. 

“Name of Trainer/s” will function as “a system change agent/system 

change agents” to help our organization, and the system as a whole, be 

reorganized to provide more welcoming, accessible, integrated, 

continuous, and comprehensive services to individuals with co-occurring 

disorders. Our experience shows that these are persons who tend to 

have the poorest outcomes at the highest cost, and are usually perceived 

as “system misfits” rather than system priorities. 

Over the next few months “name of trainer/s” will coordinate training on 

the Consensus document and the CCISC model and will be working with 

all of you on how to implement the CCISC model, making the system 

changes necessary to more effectively support your efforts to offer best 

practice integrated interventions to your clients. 

Please do not hesitate to call me if you have any questions or concerns. 

Thank you for your support of this very important effort. 

“Signed” 

“CEO – Executive Director” 

As of June 2005



CO-OCCURRING DISORDERS (MISA) PROJECT 

INFORMATION BULLETIN 

CONSENSUS DOCUMENT 

The Blair County COD Project has worked on their Consensus Document 

over the past few months. The document presents the project vision and 

mission and then describes Blair’s commitment to providing welcoming, 

accessible, integrated, continuous, and comprehensive services to 

individuals with co-occurring disorders by adopting the CCISC 

(Comprehensive, Continuous, Integrated System of Care) model for 

designing system change at the local and state level, developed by 

Kenneth Minkoff, MD. 

The CCISC model’s 8 best practice principles and the 5 core 

implementation characteristics are described succinctly in the document. 

The document then includes a detailed Implementation Action Plan for 

both the Blair County MH/MR/D&A Program and the Blair County 

Providers. The action plan describes specifically what both parties agree 

to do that will move the county toward integrated treatment and system 

change. 

The Consensus Document was develop over many months of discuss with 

all stakeholders and has now been formally endorsed by the Behavioral 

Health (BH) Advisory Committee of the Blair County BH & MR Advisory 

Board, the Blair County Behavioral Health Providers Organization, the 

MH/MR/D&A Administrator and Drug and Alcohol Administrator, directors 

of numerous individual mental health and substance use disorder 

providers and representatives of other community service organizations. 

The Consensus Document includes Scopes of Practice for Mental Health 

and Substance Use Practitioners working in singly licensed organizations. 

Information on that can be found in Volume 1, Issue 2 of these Information 

Bulletins. 

The final version of Consensus Document is attached to this Issue of the 

Information Bulletin and counties are encouraged to use this document as 

a model in their own work to implement system change. 

As of December 2004



CO-OCCURRING MENTAL HEALTH AND SUBSTANCE USE DISORDERS 

INITIATIVE [MISA] 

As of December 2004


Vision/Mission 

CO-OCCURRING MENTAL HEALTH AND SUBSTANCE USE 

DISORDERS INITIATIVE 

[MISA] 


July 2004 

July 2004 

In early 2000, the Blair County Mental Health and Drug and Alcohol Programs began working 

together to address the barriers to services and supports experienced by persons with co-occurring 

mental health and substance use disorders 1 . The two programs recognized individuals with cooccurring 

mental health and substance use disorders as a population with unacceptable outcomes 

and higher costs in multiple clinical domains. 

Persons with co-occurring disorders are often poorly served in both mental health and substance 

use disorder settings, resulting in over-utilization of resources in criminal justice, primary health 

care, child protection, and women’s and homeless shelter systems. Individuals with co-occurring 

disorders are sufficiently prevalent in all mental health and substance use disorders service 

settings that they should be considered an expectation, rather than an exception. 

In the process of developing a system of recovery for persons with co-occurring disorders, the 

following vision and mission for a treatment and support services system that would welcome 

individuals with co-occurring disorders were developed and adopted by Blair County: 

Project Vision 

Blair County persons with mental health disorders and 

substance use disorders have the opportunity to exercise 

choice and control in their lives, supported by a system of 

recovery that integrates mental health and drug and alcohol 

services into a behavioral health system of care. 

Project Mission 

Blair County MH/MR/D&A program office, Blair County 

behavioral health providers network, and the Blair County 

consumers/clients and families will implement a plan to 

integrate mental health and drug and alcohol services into a 

behavioral health system of care for “persons with cooccurring 

disorders.” 

1 Substance use disorders are defined as substance abuse and/or substance addiction. 

As of December 2004


Background 

In February 2003, the realities of operating what some have called “a third system” became 

obvious. The development and funding of dually licensed programs has resulted in an admission 

criteria that limited the availability of the services and supports for persons with co-occurring 

disorders [MISA] resulted in many individuals who are in need of these services being placed on 

a waiting list or denied services due to lack of meeting the admission criteria. Providers and other 

departments within dually licensed organizations felt that if they identified a person needing 

services for co-occurring disorders [MISA] that the new protocol required them to refer those 

persons to the funded, dually licensed programs. 

Through this pilot, Blair County has learned that the entire treatment system must have the ability 

and the capability to accept and treat persons with co-occurring disorders and that all facilities 

licensed to provide treatment for mental health disorders, all facilities licensed to provide 

treatment for substance use disorders, and dually licensed facilities must become welcoming to 

persons with mental health and substance use disorders. 

Therefore, in order to provide welcoming, accessible, integrated, continuous, and comprehensive 

services to individuals with co-occurring disorders, the MISA Policy Council and the Blair 

County Mental Health and Drug and Alcohol Program have adopted the Comprehensive, 

Continuous, Integrated System of Care (CCISC) model and will adapt it for designing systems 

change at the local level and for modeling and supporting change at the state-wide level. 

This Consensus Document contains a description of the principles and characteristics of CCISC 

as well as an implementation action plan for the participating organizations. 

Endorsement of this Consensus Document by the principal partner organizations or by other 

stakeholder organizations within the mental health and substance use disorders systems will: 

1. Signify their support and participation as a partner in this initiative, and 

2. Commit their organizations to adopting the CCISC model and to participating in a change 

process consistent with the principles and philosophies set out here. 

Best Practice Principles 

This model is based on the following eight best clinical consensus practice principles (adapted 

from Minkoff, 1998, 2000), which espouse an integrated clinical service philosophy. These 

principles make sense from the perspective of both the mental health and the substance use 

disorders service systems. 

1. Co-occurring disorders are an expectation, not an exception. This expectation must be a 

consideration in every aspect of system planning, program design, clinical procedure, and 

clinician competency, and incorporated in a welcoming manner into every clinical 

contact. 

2. The core of success in any setting is the availability of empathic, hopeful clinical 

relationships that provide integrated and coordinated service during each episode of care 

across multiple episodes. 

As of December 2004


3. The population of individuals with co-occurring disorders can be organized into four 

subgroups for service planning purposes, based on high and low severity of each type of 

disorder. 

4. Within the context of any clinical or helping relationship, supportive case management 

needs to be balanced with empathetic detachment at each point in time, based on each 

individual’s specific needs, goals and strengths. 

5. When mental health and substance use disorders co-exist, a comprehensive, continuous, 

integrated approach, which supports the provision of concurrent responses to both as 

primary disorders, is recommended. 

6. Mental health and substance use disorders both tend to be persistent, biopsychosocial 

problems that can be addressed using a CCISC model. Each disorder has parallel phases 

of recovery and stages of change. Helping services for individuals with co-occurring 

disorders need to be matched across all levels of care. 

7. There is no one correct program or intervention. Service responses or interventions must 

be individualized for clients/patients according to: assessment/diagnosis, disability, 

strengths/supports, problems/contingencies, phase of recovery, stage of change, and 

assessment of level of care requirements. Programs must also be sensitive to age, culture 

and gender specific needs of its clients/patients. In a CCISC environment, all programs 

are co-occurring disorder programs that meet at least minimum criteria of “capability”, 

but each program has a different “job” that is matched to a specific cohort of 

patients/clients. 

8. Similarly, outcomes for patients/clients need to be individualized. Outcome variables 

need to include not only abstinence, but also reduction in harm, movement through stages 

of change, changes in type, frequency, and magnitude of substance use or psychiatric 

symptoms, and improvements in specific problem management skills and program 

adherence. 

Implementation Characteristics 

Using these principles, implementation of the CCISC will be based on the following five core 

characteristics: 

1. The CCISC requires participation from all state and local components of the mental 

health and substance use disorders service systems, with the expectation that singly 

licensed mental health disorder treatment programs, singly licensed substance use 

disorder programs, and clinicians will meet, at minimum, co-occurring disorder 

capability standards 2 (and in some instances co-occurring disorder enhanced capacity 3 

standards). It was also be the expectation that those programs and clinicians will plan 

services to respond to the needs of appropriately matched consumers and persons in 

recovery. 

2. Implementation of the CCISC requires a commitment from all state and local 

administrative and service system components to cooperate and collaborate with the 

COSIG 4 pilot counties in the elimination and prevention of barriers. This commitment 

2 Capacity for providing services to individuals with co-occurring disorders within the usual service mix of the 

program through modification of program infrastructure within the context of the existing program design 

3 More extensive modification to provide services to individuals with more severe conditions (e.g., modified addictions 

program), or to provide services that are more specialized or integrated (e.g., intensive addiction rehabilitation within 

a psychiatric inpatient program) 

4 Co-occurring State Incentive Grant 

As of December 2004


includes barriers identified in data gathering, licensing processes, clinical record keeping 

regulations or in any other process that interferes with the implementation of an 

integrated treatment system for persons with co-occurring disorders. 

3. The CCISC will be implemented initially with no new funding, within the context of 

existing operational resources, and will maximize the capacity to provide integrated 

services proactively. 

4. The CCISC incorporates utilization of the full range of evidence-based best practices and 

clinical consensus best practices for individuals with mental health and substance use 

disorders, and promotes integration of appropriately matched best practices for 

individuals with co-occurring disorders. 

5. Using the eight principles listed above, the CCISC incorporates an integrated services 

philosophy, develops common clinical language, and develops specific strategies to 

implement clinical programs, procedures, and practices in accordance with the principles 

throughout the service system. 

Implementation Action Plan 

During the implementation of the Co-occurring State Incentive Grant [COSIG], all participating 

parties will agree to the following action steps: 

Blair County MH/MR/D&A Program agrees to: 

 

 

 

 

 

 

 

Sign the Consensus Document and disseminate the document as an example of a model of 

system change to all Blair County staff, providers, and other organizations and individuals 

identified. 

Assure that staff and advisory board members are familiar with the CCISC model by 

providing training on the consensus document and the model while supporting 

implementation of the model in Blair County. 

Utilize the model as a CQI initiative for system design that will be applied to accomplish the 

COSIG grant requirements. 

Support the development of an organized communication framework that will provide 

constructive feedback to Blair County and to the State on the experience of providers 

regarding financial, regulatory, and credentialing/licensing barriers. The framework should 

describe barriers that interfere with the capacity of the system to appropriately address the 

needs of persons with co-occurring disorders wherever they present in the service system; 

i.e., referral settings, facilities licensed to provide treatment for mental health disorders, 

facilities licensed to provide treatment for substance use disorders, or dually licensed 

facilities. This communication framework will be developed as part of the CCISC model to 

meet the objectives of the COSIG grant activities. 

Participate in partnership with the provider system in the development of systemic cooccurring 

disorder capability standards for programs and clinicians. 

Within the capacity of the county, adopt policies and procedures to support welcoming access 

and to remove barriers whenever possible in both emergent and routine situations for persons 

with co-occurring disorders. 

Adopt requirements for all providers to more accurately identify and report co-occurring 

disorder prevalence through moving them toward an improved quality management process 

that includes universal, integrated screening and data capture. 

As of December 2004


 

 

 

 

 

 

 

 

Complete the CCISC Outcome Fidelity and Implementation Tool [CO-FIT 100 TM ] to assess 

the systems ability to provide services and supports to individuals with co-occurring 

disorders, analyze the results, and develop a short and long term strategic plan based on the 

results. 

Prepare and approve a draft of the Blair County Mental Health and Drug and Alcohol Scopes 

of Practice for providing services to persons with co-occurring disorders for approval by both 

OMHSAS and BDAP. 

Work collaboratively with providers to assist them to participate in a self-survey using the 

Comorbidity Program Audit and Self-Survey for Behavioral Health Services 

[COMPASS TM ] to evaluate the status of co-occurring disorder capability. 

Work collaboratively with the providers to define the frequency with which the providers will 

use the COMPASS TM to evaluate their progress toward co-occurring disorder capability in 

the context of its own action plan. 

Coordinate with providers to identify appropriate clinical and administrative staff to 

participate as trainers in the statewide and local system-wide train-the-trainer initiative, and 

assume responsibility for implementation of a developmentally appropriate local training plan 

which will result in co-occurring disorder competency for all clinical staff over the lifetime of 

the project. 

Assist providers in coordinating the completion of the COMPASS TM and development and 

monitoring of the provider-specific action plan. 

Develop a mechanism by which any participating providers will receive appropriate training 

and technical assistance to achieve the objective of co-occurring disorder capability and of 

improving care for individuals they are currently serving with co-occurring disorders, 

whether those programs are licensed to provide treatment for mental health disorders, 

licensed to provide treatment for substance use disorders or are dually licensed. 

Develop a mechanism by which the County Performance Improvement Committee [PIC], 

under the guidance of the MISA Project Coordinator, becomes a vehicle where all data and 

information generated by project participants is collected, organized, and disseminated in 

order to help the project generally and the providers individually to achieve their goals. Each 

provider will be encouraged to identify regulatory, reimbursement, credentialing, and 

licensing barriers that interfere with its capacity to provide co-occurring disorder capable 

services to its clients and to collect and organize that information for the purpose of assisting 

the state with achieving the goals of the COSIG grant. 

Blair County Providers agree to: 

Sign the Consensus Document and disseminate the document as a model for system change 

to their staff and leadership. 

Assure that staff and advisory board members are familiar with the CCISC model by 

providing training on the consensus document and the model while supporting 

implementation of the model in Blair County. 

Utilize the model as a CQI initiative for system design that will be applied to accomplish the 

COSIG grant requirements. 

Participate in partnership with the County in completing the CO-FIT 100 TM to assess the 

systems ability to provide services and supports to individuals with co-occurring disorders 

[whether in a mental health licensed facility, a drug and alcohol licensed facility, or a dually 

licensed facility], analyze the results and develop a short and long term strategic plan based 

on the results. 

Participate in partnership with the County in the development of systemic co-occurring 

disorder capability standards for programs and clinicians. 

As of December 2004


 

Participate with the support of the County in a self-survey using the Comorbidity Program 

Audit and Self-Survey for Behavioral Health Services [COMPASS TM ] at intervals agreed 

to by the provider and the County to evaluate the status of co-occurring disorder capability. 

 

 

 

 

 

 

 

Following completion of the self-survey, develop a provider-specific action plan outlining 

measurable changes at program level, the clinical practice level, and the clinician competency 

level to move toward co-occurring disorder capability. Monitor the progress of the action 

plan at time frames agreed upon by the providers and the county. Participate in system-wide 

training and technical assistance with regard to implementation of the action plan. 

Participate in system-wide efforts to create a quality improvement process that will move the 

system in the direction of improving the identification and reporting of individuals with cooccurring 

disorders through incorporating agency specific improvements in universal 

screening and data capture. 

Participate in system-wide efforts to improve welcoming access and reduce barriers for 

individuals with co-occurring disorders by: 

a) Adopting agency specific welcoming policies, materials, and expected staff 

competencies, 

b) Identifying specific plans to expand access to treatment and improve capability to 

provide integrated continuous services, and 

c) Identifying and removing barriers to welcoming access whenever possible. 

Assign appropriate clinical leadership to participate in the MISA Team meetings or any other 

interagency coordination meetings that are developed and organized. 

In partnership with the County participate in system-wide efforts to identify required 

attitudes, values, knowledge, and skills for all clinicians regarding co-occurring disorders, 

and adopt the goal of co-occurring disorder competency for all clinicians as part of the 

agency’s long-range plan. 

Participate in clinician competency self survey using the Co-occurring Disorders Education 

Competency Assessment Tool [CODECAT TM ] at intervals agreed to by the providers and 

the County, and use the findings to develop an agency specific training plan. 

Identify and support staff within each provider as trainers who would be responsible for 

training others in becoming capable to provide services to persons with co-occurring 

disorders [MISA] and for continuing to encourage and sustain system change. 

As of December 2004


The forgoing Consensus Document is endorsed by the following partner organizations of the 

Blair County MISA Project. . 

_________________________________ 

Administrator 

Blair County Mental Health/Mental 

Retardation /Drug and Alcohol Program 

____________________________ 

Date 

_________________________________ 

Drug and Alcohol Administrator 

Blair County Single County Authority 

________________________ 

Date 

_________________________________ 

Blair County Behavioral Health 

Provider Organization 

________________________ 

Date 

As of December 2004


The forgoing Consensus Document is endorsed by the following stakeholder agencies 

participating in Phase I of the Co-occurring Mental Health and Substance Use Disorder Initiative. 

Agency/Program Representative Signature Date 

As of December 2004


Language for Interpretive Guidelines on the Appropriate Scope of Practice for 

(Licensed or Unlicensed) Mental Health Professionals 

Operating within a Singly Licensed Mental Health Program 

Attachment I 

As it is the expectation and the finding that individuals seeking and receiving services in 

the public behavioral health care systems have a high likelihood of having co-occurring 

mental health and substance use 5 disorders, it is prudent that all licensed or unlicensed 

mental health professionals operating within a licensed mental heath program have a 

clear understanding of the appropriate scope of practice when providing care to 

behavioral health consumers/persons in recovery. Licensed or unlicensed persons 

covered under this scope of practice include Bachelor and Master Level Counselors, 

Licensed Social Workers, and Psychologists. 

This scope of practice is not intended to be all-inclusive, but rather to include specific 

practices that augment the current scopes of practice. 

Licensed or unlicensed mental health professionals operating within a singly licensed 

mental health program should routinely: 

1) Demonstrate a welcoming, empathic, and hopeful philosophy of dual recovery 

2) Screen for identification of co-occurring disorders 

3) Arrange for immediate intervention when a co-occurring disorder is identified as 

emergent 6 

4) Obtain a release to acquire existing assessment information or complete an 

assessment for a co-occurring disorder when a co-occurring disorder is identified 

as urgent 7 or routine 8 

5) Refer when appropriate to a substance use disorder treatment provider 

6) Be aware of and consistently document accurate substance use disorder diagnosis 

(abuse vs dependence) and treatment recommendations 

7) Support compliance with medications for substance use disorder treatment and 

treatment adherence that enhances recovery 

8) Identify abstinence as a goal, but not a requirement for continued mental health 

treatment 

9) Identify and document stage of change in both areas of dual recovery 

10) For clients who are not motivated to change, engage the client in individual, 

group and/ or system (e.g. family, court) strategies for motivational enhancement 

11) For clients who are trying to change, review their activities to reduce use and 

provide suggestions for how to do better using techniques of skills training for 

psychological disabilities 

12) Help clients identify the painful feelings, relapse triggers and psychiatric 

symptoms and how to manage these with abusing alcohol or other drugs 

5 Substance Use Disorder is defined as substance abuse and/or substance addiction. 

6 Emergencies should be seen face-to-face within one hour. 

7 Urgent treatment should occur within 24 hours (HealthChoices requirement). 

8 Routine treatment should occur within 7 days (HealthChoices requirement). 

As of December 2004


13) Provide educational information and materials regarding the nature of substance 

use and its effects on individuals and families 

14) For individuals in relapse prevention/recovery phase, support participation in 

continuous recovery programs and substance treatment 

15) Help clients advocate/educate with substance use disorder providers regarding 

substance use disorder treatment needs and mental illness medication/symptoms/ 

disabilities 

16) Communicate and collaborate with substance use disorder providers 

17) Promote access to dual recovery meetings 

18) Educate clients regarding how to attend and participate in mental health disorder 

group treatment while continuing to be aware of their substance use disorder 

19) Educate client with a substance use disorder regarding importance of adherence to 

prescribed non-addictive medications and avoidance of addictive medications 

20) Educate client and family regarding effects of substance use on exacerbating or 

masking psychiatric symptoms and on reducing effectiveness of psychotropic 

medications 

Specifically NOT within the Scope of Practice for a Licensed or Unlicensed Mental Health 

Professional Operating with a Singly Licensed Mental Health Program: 

• Advertise as a counselor for substance use 

• Perform comprehensive substance use assessments 

• Establish or rescind a substance use diagnosis 

• Prescribe or make specific medication recommendations 

Documentation: 

It is appropriate for mental health counselors operating within a singly licensed mental health 

program to document drug and alcohol (or medical) diagnoses in the following instances: 

a. The person has an established diagnosis documented in records or reports from other 

providers. 

b. The person reports that he or she has a diagnosis (and it appears to be a fairly reliable 

report, particularly if associated with a treatment/medication regime). 

In the event that the person has no established diagnosis, then mental health counselors should be 

able to document based on screening, the person appears to meet criteria for a particular condition, and then 

arrange for appropriate assessment: 

E.g., R/O Alcohol (based on screening data); D&A Assessment will be scheduled. 

As of December 2004


Language for Interpretive Guidelines on the Appropriate Scope of Practice 

for Drug and Alcohol Abuse Counselors 

Operating within a Singly Licensed Drug and Alcohol Program 

Attachment II 

As it is the expectation and the finding that individuals seeking and receiving services in 

the public behavioral health care systems have a high likelihood of having co-occurring 

mental health and substance use disorders 9 , it is prudent that all drug and alcohol 

counselors operating within a licensed drug and alcohol program have a clear 

understanding of the appropriate scope of practice when providing care to behavioral 

health consumers. Licensed or unlicensed persons covered under this scope of practice 

include Bachelor and Master Level Counselors, Licensed Social Workers, and 

Psychologists. 

This scope of practice is not intended to be all-inclusive, but rather to include specific 

practices that augment the current scopes of practice. 

Drug and alcohol counselors operating within a singly licensed drug and alcohol program 

should routinely: 

1) Demonstrate a welcoming, empathic, and hopeful philosophy of dual recovery 

2) Screen for identification of possible co-occurring disorders 

3) Assess acute mental health risk (suicidality) and arrange for immediate 

intervention when a co-occurring disorder is identified as emergent 10 

4) Obtain a release to acquire existing assessment information or complete an 

assessment for a co-occurring disorder when a co-occurring disorder is 

identified as urgent 11 or routine 12 

5) Refer when appropriate to a facility or practitioner licensed to provide treatment 

for mental health disorders 

6) Be aware of and consistently document an accurate mental health diagnosis and 

treatment recommendations for any mental health disorder 

7) Support medication compliance and treatment adherence that enhances recovery 

8) Identify and document stage of change fro each problem identified 

9) For clients who are not motivated to change, engage the client in individual, 

group and/ or system (e.g. family, court) strategies for motivational 

enhancement 

10) For clients who are trying to change, review their activities to follow mental 

health treatment and relapse prevention recommendations and provide 

suggestions for how to do better, in order to be more successful in 

maintaining sobriety 

11) Help clients identify painful feelings, relapse triggers and psychiatric symptoms 

and how to manage these without abusing alcohol and other drugs 

9 Substance Use Disorder is defined as substance abuse and/or substance addiction. 

10 Emergencies should be seen face-to-face within one hour. 

11 Urgent treatment should occur within 24 hours (HealthChoices requirement). 

12 Routine treatment should occur within 10 days (HealthChoices requirement). 

As of December 2004


12) Provide educational information and materials on mental illness and recovery 

13) Help clients advocate with or educate providers who offer treatment for mental 

health disorders regarding his/her substance use disorder and treatment 

14) Communicate and collaborate with providers who offer treatment for mental 

health disorders to provide a unified message about treatment 

15) Promote access to dual recovery meetings 

16) Educate clients regarding how to attend and participate in recovery meetings (e.g. 

12-Step, Double Trouble in Recovery), paying particular attention to the 

specific needs of clients with mental health disorders in substance use 

disorder settings who may be receiving information/advice that is in conflict 

with appropriate disorder-specific treatment recommendations 

17) Be aware of how mental health disorders interfere with learning substance use 

disorder recovery skills and how to modify substance use disorder 

interventions to simplify skills acquisition 

Specifically NOT within the Scope of Practice for drug and alcohol counselors operating within a 

singly licensed drug and alcohol program: 

• Advertise as a mental health counselor 

• Perform comprehensive mental health assessments 

• Establish or rescind a mental health diagnosis 

• Prescribe or make specific medication recommendations 

Documentation: 

It is appropriate for drug and alcohol counselors operating within a singly licensed drug and 

alcohol program to document mental health (or medical) diagnoses in the following instances: 

c. The person in recovery has an established diagnosis documented in records or reports 

from other providers. 

d. The person in recovery reports that he or she has a diagnosis (and it appears to be a fairly 

reliable report, particularly if associated with a treatment/medication regime). 

In the event that the person has no established diagnosis, then drug and alcohol counselors should 

be able to document whether based on screening, the person appears to meet criteria for a particular 

condition, and then arrange for appropriate assessment: 

E.g., R/O Major Depression (based on screening data); MH Assessment will be scheduled. 

As of December 2004

T36: The Co-Occurring Distinction: Myths and Misdirections 

Jim Cowser, LCSW, CADC, CCDP-D 


Description: 

The current narratives and myths surrounding addictive disorders and their separation from other mental 

health disorders have a significant impact on both clinicians and those using their services. Conscious 

examination of these myths by practitioners can increase the effectiveness of clinical practice. The field of Co- 

Occurring Disorders treatment resulted because of the need to escape from past misdirections. Practitioners in 

the evolving field of CODs need consistent reflection about what myths this new field’s distinction may create 

and need to test their practice by evidence and outcomes rather than dogma and acculturation. 


• Identify the different strengths and barriers created by specialization; 

• Describe which myths are most powerful in co-occurring disorder treatment; 

• Analyze how myths have shaped their practice abilities with clients; 

• Use this information with persons using their services to examine and discuss the effects that myths 

about co-occurring disorders have on the therapeutic relationship. 

NOTES:

The field distinction of 


(Dual Diagnosis) 

CD/ SUD 

Psych 

MICA 

Myths and Misdirections 

Jim Cowser 

MISA 

Learning Objectives 

•Evaluate the importance of the Co-occurring 

distinction. 

•Identify how a specialization focus may 

impact practice . 

•Reveal the dominant myths we wrestle with in 

practice and their benefits and barriers . 

•Identify implications for continued self 

reflection and field evaluation. 

What is the Co-Occurring 

Distinction? 

An evolving narrative resulting from 

reflections on practice. By nature, it 

is a slippery separation. 

Supports specific treatment 

approaches to address the 

pervasive co-morbidity of 

substance use disorders and 

psychiatric illnesses. 

Co-Occurring Field Separation. 

Specific discussions and research 

began in the early 1980s e.g. Sciacca 

and the NYC integrated model efforts. 

Fueled by allegations that there has 

been a lack of programs for the Dually 

Diagnosed client. 

The Value of the Co-occurring 

Distinction 

•The diagnostic clusters are not as 

responsive to the separate psych/CD 

models. 

•Identifies the specific complications 

of co-morbidity . 

•Supports the need for individualized 

care. 

The distinction as “Eraser” 

•Deconstruction (theory). 

•Reconstruction (practice). 

•Dissolves the separation, but not the 

value in the traditions. 

1

Integration or Occupation? 

•QUESTION: Can we leave the distinction 

without dissolving back into our previous 

debates? 

•We need Pedagogy in order not to return 

to the old Cannon. 

“My propositions are 

elucidatory . . . senseless, 

when he has climbed out 

through them, on them, over 

them. (He must so to speak 

throw away the ladder, after 

he has climbed up on it.)” 

Ludwig Wittgenstein, Tractatus: 6.54 (1-6) 

The Co-occurring “Occupation” of 

the Field 

Could raise its own “Watch-Dogmas.” 

Specializations and Fences 

“For example, many peoples claim 

certain sites or territories because 

they are “sacred” for them or of 

special historical significance. 

In practice, this means that they have 

linked their myths of origin with 

them.” 

Aleksandar Boškovič 

Department of Social Anthropology, 

University of the Witwatersrand 

Ritual and Power – Lecture on myth § 1 

Our Mythical framework and 

Its Impact on Practitioners 

Do my assumptions lead back to my 

specialization’s origins? 

Are they used to protect my field’s 

perceived value? 

Myths for the practitioner 

CD Practitioner 

Addictionologist 

Mental Health Practitioner 

Psychiatrist 


Practitioner 

Counselor 

Therapist 

Psychologist 

M.D. 

2

Substance Use Disorder Treatment Myths 

Examples: 

•Abstinence focus/ medication debates. 

•Research Myths (“They-say” epistemology). 

• Hitting a “Bottom” (consequences). 

• Minnesota Model. 

•Addictive Personality. 

•Denial/ Co-Dependency. 

• Development is arrested at onset of use. 

Mental Health Treatment Myths 

Examples: 

• Professional distance. 

• “50-minute hour.” 

• Symptom Management. 

• Psychopharmacology. 

• Rigorous academic tradition. 

•Easily manipulated by CD clients. 

Co-Occurring Disorder Treatment Myths 

Examples: 

• Is irresponsible and either too cautious or 

too permissive with clients. 

• Must be versed in traditions of CD and Psych. 

• Has a privileged position on Individualized 

treatment and is “best of both worlds.” 

• Over-arching system changes must occur in 

order to provide sufficient care. 

Practitioner Myths 

• What examples are familiar? 

• What is their lure? 

• How do these myths effect 

practice? 

Practitioner Myths 

• Do clients believe these myths? 

•Do clients bring their own myths? 

•How do these myths impact my 

practice? 

Barriers to Progress 

We have created difficulty by attempts to 

treat our defined clients in an “otherwise” 

defined system. 

Focus on system change has not led to 

individual clinician belief changes as rapidly 

as hoped. 

Within dual diagnosis programs, separate 

model myths permeate treatment 

approaches on individual levels. 

3

Coming to a Balance 

“Rather shall we reflect that 

the roads to recovery are many; 

That any story or theory of 

recovery from one who has trod 

the highway [of practice] is 

bound to contain much truth.” 

(B. Wilson, Grapevine 1944) 

4

T37: Acquired Brain Injury: Characteristics, Programming Considerations, Screening, and 

Diagnostics 

Scott Peters, MS, OTR/L 


Description: 

Acquired brain injury (ABI) poses a complex array of challenges for the treatment practitioner working in COD 

programs. Symptoms of ABI may include physical changes (movement disorders, pain, and sensory deficits), 

cognitive impairment, emotional/behavioral instability, deficits in self awareness, etc. Survivors of ABI struggle 

when presented with traditional program interventions. This presentation provides COD practitioners with 

specific information about this challenging population and recommends possible screening tools to help 

identify the ABI survivor who may also have co-occurring mental and substance use disorders. 


• Summarize the mechanics of ABI and the residual symptoms; 

• Describe the relationship between substance abuse and brain injury; 

• Discuss possible treatment approaches/settings; 

• Recommend possible screening tools and diagnostics to help identify the ABI survivor. 

NOTES:


Acquired Brain Injury: 

Characteristics, Programming 

Considerations, Screening and 

Diagnostics 

What is Acquired Brain Injury 

(ABI)? 

13 th Pennsylvania Conference on Co – Occurring 

Disorders 

May 16, 2006 

Scott R. Peters 

Three Types of Brain Injury 

Occur 

• Closed brain injury 

• Open brain injury 

• Acquired brain injury 

Closed Brain Injury 

• Resulting from falls, motor vehicle crashes, etc. 

• Focal damage and diffuse damage to axons 

• Effects tend to be broad (diffuse) 

• No penetration to the skull 

Types of Closed Brain Injury 

Hematoma 

Concussion 

1


Open Brain Injury 

• Results from bullet wounds, etc. 

• Largely focal damage 

• Penetration of the skull 

• Effects can be just as serious 

• Aneurysm 

Acquired Brain Injury 

What Happens Immediately 

After ABI? 

• Cardiac arrest 

• Tumor 

• Encephalitis 

• Anoxia / Hypoxia 

• Toxic Poisoning 

ABI: A Biological Event Within 

the Brain 

• Tissue Damage 

• Bleeding 

• Swelling 

• Space Occupying Deficit 

2


ABI: Changes in Functioning 

• Loss of consciousness/coma 

• Post-traumatic amnesia (PTA) 

• Other changes due to the ABI 

Injured Brain 

• Does not mend fully 

• Leads to problems in functioning 

• Impact on the individual is variable 

Recovery 

• A multi-stage process 

• Continues for years 

• Differs for each person 

How to Measure “Severity” 

What Do We Mean by 

Severity of Injury? 

Amount of brain tissue damage 

• Duration of loss of consciousness 

• Initial score on Glasgow Coma Scale (GSC) 

– GCS defines the severity of traumatic brain injury within 48 hours of 

injury and goes from 1 (severe) to 15 (mild). 

• Length of post-traumatic amnesia 

• Rancho Los Amigos Scale (RLA) 

– RLA indicates severity of deficits in cognitive functioning ranging from 

Level I (no response) to Level VIII (purposeful, appropriate) 

3


Mild Injury 

0-20 minute loss of consciousness GCS = 13-15 

PTA < 24 hours 

Moderate Injury 

20 minutes to 6 hours LOC GCS = 9-12 

What is the Long-term Impact 

of a Moderate or Severe TBI 

in the Person’s Functioning? 

Severe Injury 

> 6 hours LOC GCS = 3-8 

Impact Depends On: 

• Severity of initial injury 

• Rate/completeness of physiological recovery 

Areas of Function Affected 

• Cognition 

• Functions affected 

• Areas of function not affected by TBI 

• Meaning of dysfunction to the individual 

• Resources available to aid recovery 

Cognitive Functions 

Areas of Function Affected 

• Attention 

• Concentration 

• Memory 

• Speed of Processing 

• Confusion 

• Perseveration 

• Impulsiveness 

• Language Processing 

• “Executive functions” 

• Cognitive 

• Sensory/Perceptual 

4


Sensory / Perceptual Functions 

Areas of Function Affected: 

• Vision 

• Hearing 

• Smell 

• Vestibular 

• Taste 

• Touch 

• Balance 

• Cognitive 

• Sensory/perceptual 

•Seizures 

Seizures 


• Studies suggest that seizures occur in about 5 to 

10% of ABI survivors (non - injured < 1%) 

• May occur initially following the injury and after 

about 9 month to one year post injury 

• May be life threatening if uncontrolled 

• Usually treated with anticonvulsant medications 

• Alcohol lowers seizure threshold 

• Cognitive 


•Seizures 

• Other physical changes 

Other Physical Changes: 

• Physical paralysis/spasticity 

• Chronic pain 

• Control of bowel and bladder 

• Sleep disorders 

• Loss of stamina 

• Appetite changes 

• Regulation of body temperature 

• Menstrual difficulties 


• Cognitive 


•Seizures 

• Other physical changes 

• Social-emotional 

5


Social-emotional 

• Dependent behaviors 

• Emotional lability 

• Lack of motivation 

• Irritability 


• Depression 

• Disinhibition 

• Denial / lack of awareness 

Awareness Deficits 

(Sohlberg, et al, 1998) 

• Awareness has been identified as a major determinant of 

successful rehabilitation after acquired brain injury. 

• Patients who seem unaware of the nature, degree or 

impact of their impairments may be resistant or 

ambivalent about treatment and are perceived as more 

difficult to work with than those who are eager to engage 

in rehabilitation. 

• There is only a limited amount of information regarding 

the effectiveness of awareness intervention strategies. 

Awareness in Healthy Individuals 

(Flashman and McAllister, 2002) 

• Inaccurate self – representation occurs in 

healthy individuals that is not always conscious 

or deliberate 

• Represent a normal pattern of functioning and 

linked to well – being and self – esteem. 

• Most likely to occur when: 

– Lack of concrete information 

– The motivation to self deceive is high 

Prevalence of Awareness Deficits 

in TBI Populations 

• Up to 45% of individuals with moderate to 

severe TBI demonstrate awareness 

deficits (Fishman and McAllister, 2002) 

• In a study of 66 post acute TBI patients, 

Sherer, et al, found that, depending on the 

method of measurement, 76% to 97% of 

showed some degree of impaired self 

awareness. 



• Several studies have found that patients 

with TBI overestimate their abilities 

(Anderson and Tranel, 1989) 

• Prigatino et al found that TBI patients were 

more likely than controls to rate 

themselves as more competent than the 

informant. 



• TBI patients consistently show greater impaired self 

awareness for cognitive and behavioral deficits than for 

physical impairments (Sherer, et al, 2003) 

• TBI patients with more acute self awareness are more 

likely to complain of symptoms of depression (Sherer, et 

al, 2003) 

• There is a direct relationship between lack of awareness 

and poor outcome with respect to lower vocational 

achievement, independent living status and greater 

behavioral difficulties (Flashman and McAllister, 2002) 

6


Self Awareness 

• The ability of TBI survivors to modify their 

perceptions and acknowledge their deficits after 

being given objective feedback. 

• Acceptance 

• Coping 

Definition of Terms: 


• Agnosia (Flashman and McAllister, 2002) 

– Denotes an impairment in recognition that 

cannot be explained on the basis of primary 

motor or sensory impairment ; failure to 

recognize the significance of objects 

• e.g. Visual agnosia 

• Successful Outcome in Rehabilitation 



• Anosagnosia (Flashman and McAllister, 2002) 

– A lack of knowledge about a deficit. Usually 

used to describe an apparent loss of 

recognition or awareness of following an 

abrupt brain insult. Currently used to describe 

the frank denial of a neurological deficit. It is 

often used to refer to the inability to truly 

recognize one’s strengths and deficits 

following a TBI. 



• Denial of Illness (Flashman and McAllister, 2002) 

– Implies a psychological or psychodynamic 

level of explanation. Patients with denial are 

felt to be motivated to block distressing 

symptoms from awareness by using a 

defense mechanism. 



• Anosodiaphoria (Flashman and McAllister, 2002) 

– The absence of concern or indifference to an 

acknowledged deficit or illness 

Permanence of Change? 

• Physical recovery 

• Reeducation of the individual 

• Environmental modifications 

• Acceptance of changes and willingness to 

adapt 

7


Mild TBI 

What Happens With Mild 

(or Minor) TBI? 

• Lesser levels of brain damage 

• Brief or no loss of consciousness 

• Often referred to as “concussion” 

Mild Injury is Important to 

Discuss 

• Long-term impact for 15% 

• Don’t see that TBI is cause of deficits 

• Repeated injury leads to problem emergence- 

”second impact syndrome” 

• 300,000 sports and recreational injuries 

• CT, MRI and EEG are usually normal 

Effects of Mild TBI: Outcomes 

• Problems disappear on their own in about 

85% of cases 

• Compensatory skills acquired 

• Education prevents emotional upset 

(“shattered sense of self”) 

Effects of Mild TBI: Outcomes 

• Problems are not attributed to TBI 

• Compensatory skills are not learned 

• Best approach is early education and 

information 

How Common is TBI and Who 

is the Typical Person with 

TBI? 

• Best rehab assessment is a neuropsychology 

evaluation 

8


Who is the Typical Person With 

TBI? 

• 4:1 ratio, males to females 

• 15 to 25 years of age 

• 1.5 million brain injuries per year in 

US 

Adolescents and Young 

Adults: Highest Rate 

Aged: second highest 

• Alcohol is the leading risk factor 

TBI Causes 

• Transportation Related 

44% 

• Falls 26% 

• Other or unknown 13% 

• Non Firearm Assaults 9% 

• Firearms 8% 

The Problem 

There is a known relationship 

between substance abuse and the 

occurrence of a brain injury 

Every 21 seconds, one person in the U.S. sustains a traumatic 

brain injury 

(Brain Injury Association) 

The Problem 

Defining The Problem 

• Alcohol plays the greatest role in risk 

for ABI (more than age, occupation, etc.) 

• Alcohol complicates the ABI and 

its recovery 

• In acute settings, the extent of the problem may 

not be known and the physical withdrawal 

symptoms will have subsided 

• 14% of admissions have a positive drug screens 

upon admission 

• 50-70% of moderate to severe brain 

injuries involve ETOH at the time of injury 

• 30-50% of moderate to severe TBI 

survivors return to ETOH use 

• 60% of mild TBI survivors have BAL 

at injury 

• 90% of mild TBI survivors return to 

alcohol use 

9


Incidence and Prevalence 

• 44% to 66% of persons with ABI as 

compared to 24% of US population 

classified as heavy drinker (Corrigan ‘95) 

• Nearly 58% of people with ABI had a prior 

history of alcohol abuse or dependence (Kreutzer 

‘90) 

• 33% of ABI outpatients used illicit drugs 

prior to their ABI (Kreutzer ‘91) 

Incidence and Prevalence 

• As many as 50% of individuals will return to 

using drugs and alcohol post injury (Sparadeo et 

al. ‘90) 

• About 40% of all patients in post acute rehab 

facilities have moderate to severe problems with 

substance abuse. Alcohol is the substance 

abused in almost 90% of the cases (National Head 

Injury Task Force on Substance Abuse ‘88) 

Incidence of Substance Abuse 

History Before ABI (Ohio Valley Center) 

• Literature suggests that having prior history of substance 

abuse is more common than being intoxicated at the 

time of the injury 

Incidence of ABI Victims Who Are 

Intoxicated at the Time of Injury: 

(Ohio Valley Center) 

• At least 20% of adolescents and adults who are 

hospitalized 

• At least 30% are intoxicated at the time of their 

injury 

• Possibly due to diminished motor control, 

blurred vision, poor decision making or greater 

vulnerability of being victimized when intoxicated 

Incidence of ABI Among Persons 

Receiving Substance Abuse Treatment 


• A collection of studies over the past 20 years suggest it 

may be as high as 50% 

How Do I Determine if 

Someone Has a Brain Injury? 

Screening 

Formal Testing 

Neurodiagnostics 

10


• Trauma 

• Behavior 

• Impact 

Brain Injury Screening 


Information for this section is obtained from: 

The Ohio Valley Center for Brain Injury Prevention and Rehabilitation 

www.ohiovalley.org/abuse 

Brain Injury Screening: 

Trauma 

• Ask … Have you ever: 

– Been injured following a blow to your head? 

– Been hospitalized or treated in an emergency 

room following an injury? 

– Had any major surgeries? Broken bones? 

Illnesses? Strokes? Heart Attacks? 

– Been unconscious following an accident or 

injury? If so, how long? 

– Been injured in a fight? 

– Been injured by a spouse or family member? 


Behavior 

• Ask … Since the trauma: 

– Do you get stuck on one thought and find you 

cannot switch to something else, even when 

you try? 

– Is it harder to start new things? 

– Do you say things impulsively? 

– Do you say things you wish you had not said 

or “put your foot in your mouth?” 

Brain Injury Screening: Behavior 

• Ask … since the trauma: 

– Do you notice changes with any of the following 

abilities or conditions following your injury? 

• Irritability 

• Problem Solving 

• Impulsivity 

• Time Management 

• Memory Loss 

• Attention / Concentration 

• Sensitivity to bright lights or noise 

• Judgment 

• Confusion 

• Walking or balance 

• Speech 

Brain Injury Screening: Impact 

• Ask … Since you were injured, have you: 

– Had problems keeping a job or lost a job? 

– Noticed changes in your relationships with 

your family (wife, husband, parents or 

friends)? 

– Had your friends or family members point out 

changes to you? 

– Been treated by a psychiatrist or a 

psychologist? 

Brain Injury Screening: Impact 

• Ask … Since you were injured, have you: 

– Ever taken medication for seizures? 

– Been on probation or parole or awaiting 

charges? 

– Noticed headaches, dizziness, vision 

problems, or fatigue? 

11



The Alaska Screening Tool for Dual Diagnosis and TBI 

• Ask … 

– Have you ever had a blow to the head that was 

severe enough to make you lose consciousness? If 

yes, how long? 

– Have you ever had a blow to the head that was 

severe enough to cause a concussion? If yes, how 

long did the concussion last? 

– Did you ever receive treatment for a head injury? 


The Alaska Screening Tool for Dual Diagnosis and TBI 

• Ask … 

– If you had a blow to the head that caused 

unconsciousness or concussion, was there a 

permanent change in any of the following? 

• Physical Abilities 

• Ability to care for yourself 

• Speech 

• Hearing, vision or other senses 

• Memory 

• Ability to concentrate 

• Mood 

• Temper 

• Relationships with others 

• Ability to work or do school work 

*Did you receive treatment for any of the things that changed 

after the head injury? 

Neuropsychological Evaluation: 

Cognistat 

The Northern California Neurobehavioral Group, Inc 

PO Box 460, Fairfax, CA PO Box 460, Fairfax, CA 94978 

• Comprehensive assessment of cognitive and behavioral 

functions using a set of standardized tests and 

procedures 

• Mental functions tested: 

– Intelligence 

– Problem Solving and conceptualization 

– Planning and Organization 

– Attention, Memory and learning 

– Language 

– Academic Skills 

– Perceptual and motor abilities 

– Emotions, behavior and personality 

• Standardized neurobehavioral screening test 

• Administered to identify basic cognitive strengths 

and weakness 

• Takes less than 45 minutes to administer 

• Areas explored include: 

» Level of consciousness 

» Orientation 

» Attention 

» Language 

» Constructional ability 

» Memory 

» Reasoning 

Neurodiagnostic Testing 

• Brainstem Evoked Responses 

• Cerebral Angiography 

• Computerized Axial Tomography 

• Magnetic Resonance Angiography (MRA) 

• Magnetic Resonance Imaging (MRI) 

• Positron Emission Tomography (PET) 

• Electroencephalogram (EEG) 

How Do I Work with a Brain 

Injured Survivor? 

12


Brain Injury Sequelae 

• Physical Changes 

• Cognitive Changes 

• Emotional / Behavioral Changes 

• Personality Changes 

• Language Changes 

• Sensory Processing Changes 

• Awareness Deficits 

Treatment Frames of 

Reference 

• Behavioral Issues 

– Behavioral Analytic Model 

• Pain Issues 

– Integrated Pain Programming 

• Vestibular Issues 

• Substance Abuse Issues 

– Motivational Interviewing (Stages of Change) 

• Community Safety Issues 

• Medical Issues 

Treatment: Lifestyle Modification 

• Development of a structured activity pattern 

– Structured sobriety plan (Substance Abuse Counseling) 

– Residential skills and responsibilities (OT) 

• Budget 

• Meal management 

– Leisure skills development (TR) 

– Return to work (vocational services) 

– Healthy activities 

• Exercise (PT) 

Sobriety Plan Includes: 

• Medical intervention 

• Residential responsibilities 

• Work 

• Play 

• Relapse prevention skills 

• Counseling/Support 

• Fellowship/Friends 

Suggestions for Substance Abuse 

Treatment Providers (Ohio Valley Center) 

• Must determine a person’s unique 

communication and learning styles … 

– Evaluate how a person reads and writes 

– Evaluate how well a person is able to comprehend 

both written and spoken language 

– If a person is not able to speak, inquire as to alternate 

methods of expression 

– Evaluate a person’s attention span (busy versus quiet 

environment) 

– Evaluate a person’s capacity for new learning 



• Assist the individual to compensate for unique 

learning style 

– Modify written material (concise) 

– Paraphrase concepts, use concrete examples 

– Allow the person to take notes 

– Encourage the use of a planner 

– Write down homework assignments 

– Review main points after group sessions 

– Provide assistance with homework 

– Enlist others to reinforce goals 

– Do not assume generalization of newly learned info 

– Repeat, rehearse, repeat, review, rehearse 

13




• Provide direct feedback regarding 

inappropriate behaviors 

– Let a person know a behavior is 

inappropriate; do not assume they know this 

and is choosing to do so anyway 

– Provide straightforward feedback about when 

and where behaviors are appropriate 

– Redirect tangential and excessive speech, 

including a predetermined method of signals 

to use in groups 



• Be cautious when making inferences about 

motivation based on observed behaviors 

– Do not presume non-compliance arises from lack of 

motivation or resistance, check it out 

– Be aware that unawareness of deficits can be due to 

specific damage to the brain and may not be due to 

denial 

– Confrontation shuts down thinking and elicits 

resistance 

– Do not discharge for noncompliance; follow up and 

find out why someone has not shown up or not 

followed through 

TBI Explanation of the 12 Steps 

by Bill Peterman 

• Original Step 1 

• TBI Explanation Step 1 

TBI Explanation of the 12 Steps 

by Bill Peterman 

• Original Step 10 

• TBI Explanation Step 10 

We admitted we were 

powerless over 

alcohol; that our lives 

had become 

unmanageable 

Admit that if you drink or 

use drugs your life will be 

out of control. Admit that 

the use of substances 

after having a TBI will 

make your life 

unmanageable. 

Continued to take 

personal inventory and 

when we were were 

wrong, promptly 

admitted it. 

Continue to check yourself 

and your behaviors daily. 

Correct negative 

behaviors and improve 

them. If you hurt another 

person, apologize and 

make corrections. 

Questions? 

14

T41: Offering Positive Incentives to Change Behavior: Promoting Awareness of Motivational 

Incentives (PAMI) 

Amy Shanahan, MS, CAC, CASAC 


Description: 

This interactive workshop introduces the NIDA-SAMHSA Blending Initiative and its work to develop a 

dissemination packet of products and activities to increase awareness of Motivational Incentives as a sciencebased 

therapeutic strategy to increase the frequency of a desired behavior. The campaign incorporates 

examples and lessons learned from the MIEDAR CTN protocol, particularly implementation of the Fishbowl 

Technology. Products and activities are designed to educate, inform and generate interest in adoption of 

Motivational Incentives which have proven efficacy in promoting positive behavior change. 


• Identify Motivational Incentives and their underlying principles; 

• Examine the history of this intervention; 

• Review current research findings; 

• Engage in practical applications using the Fishbowl Technology; 

• Discuss challenges and strategies for implementing low-cost incentives as a support to psychosocial 

therapy in addiction treatment. 

NOTES:


Offering Positive Incentives 

To 

Change Behavior 

Beyond 2006: Promoting Recovery-Oriented 

Programs and Practices for Persons with Cooccurring 

Mental and Substance Use Disorders 

May15, 2006 

Presented by Amy Shanahan 

Course Content 

Why Motivational Incentives 

Definitions 

History & Research 

Founding Principles 

Low Cost Incentives 

Clinical Applications 

Why 

Motivational Incentives? 

o Research has consistently shown + client 

motivation 

o Recognition provides valuable mechanism for 

acknowledging success 

o Tool to help clients achieve goals 

o Opportunity to celebrate positively 

o Increases retention 

o Reduces drug use 

Terminology, Jargon, Glossary,… 

Motivational 

Incentives 

v 

s 

Contingency Management 

Motivational 

Incentives 

vs 


1


Operant 

Conditioning 

vs 

Classical Conditioning 

Reinforcement 

vs 

Punishment 

Reinforcement 

vs 

Reward 

Definitions 





History 

• Motivational incentives 

have their roots in 

Operant Conditioning - 

the work of B. F. 

Skinner 

• Behaviors that are 

rewarded are more 

likely to re-occur 

• Behaviors that are 

punished are less likely 

to re-occur 

History 

1960’s 

Operant 

Conditioning 

principles 

applied in 

Addiction 

studies 

1970’s 

Johns 

Hopkins 

studies 

principles 

with 

Alcohol & 

Methadone 

Patients 

1980’s 

University 

of Vermont 

studies 

principles 

with 

Cocaine & 

Crack 

Patients 

1990’s 

Magnitude & 

Duration of 

the Incentive 

Program is 

researched 

2000’s 

Lower-cost 

Incentives 

are 

researched 

"The major problems of the world today can be solved only if we improve our 

understanding of human behavior" About Behaviorism (1974) 

2


MIEDAR 

NIDA Research 

Motivational Incentives 

for Enhanced Drug 

Abuse Recovery 

RESEARCH RESULTS 

Hand-Off 

Meeting 

A Blending Team - researchers, providers, and 

Addiction Technology Transfer members is 

formed to address critical needs in the 

treatment field 

Blending 

Team 

Develops products 

for use in the field 

PAMI 

Promoting Awareness 

Of 

Motivational Incentives 

Motivational Incentives for 

Enhanced Drug Abuse Recovery 

(MIEDAR) 

• Eligible Patients – Stimulant abusers 

• Random Assignment – Usual care vs. 

Usual care enhanced with incentives 

• Primary drug targets – stimulants & 

alcohol 

– Secondary – Opiates and marijuana 

• Sample Collection twice weekly 



(MIEDAR) 

• Abstinence Bowl 

• Each drug free week # of draws from 

the bowl increased 

• Bonus draws were given when 

screened negative for secondary drug 

• 42% items were small ($1-$5); 8% 

Large ($20) 

Course Content 

Definitions 





CORE PRINCIPLES 

3


Identify the Target Behavior 

Offer Choice of Reinforcement 

Magnitude of 

Reinforcement 

Quality of the 

Reinforcement 

Frequency of 

Reinforcement 

Timing of Reinforcement 

4


Lower-Cost Incentives 

Duration of the 

Intervention 

• Cost-effective strategies that demonstrate 

equal efficacy. 

• Fishbowl Drawing Method - select a slip of 

paper from a fish bowl. 

• Each slip offers a prize or a statement such 

as “good job.” 



• Half of the slips offer a “good job” 

reward. 

• The other half are winners of prizes 

as follows: 

–½ - small prize ($1) 

–1/16 – medium prize ($20) 

–1/250 – jumbo prize ($100) 

• Clients select an increasing number of 

draws. 

–A client may get one draw for the first 

drug-free urine sample, three draws 

for the second drug-free urine, and so 

on. 

Challenges 

• Cost of incentives 

• On-site testing 

• Gambling concerns 

• Managing prize cabinet 

• Counselor resistance 

The following may contribute to a 

greater or lesser response to 

incentive programs: 

• The level of past and present drug use; 

• The patient’s history of success or failure at 

stopping the use of drugs 

• The presence or absence of Antisocial 

Personality Disorder 

• The nature and vitality of their social networks; 

• Their own personal historical responsiveness to 

reinforcements and punishments as motivators 

for behavior change. 

Maxine Stitzer et al. (1984) 

5


What do Clients Say? 

What do Treatment Staff 

Say? 

• “I felt that I was going down the drain 

with drug use, that I was going to die 

soon. This got me connected, got 

me involved in groups and back into 

things. Now I’m clean and sober” 

(Kellogg, Burns, et. al. 2005) 

• “We came to see that we need to 

reward people where rewards are 

few and far between. We use 

rewards as a clinical tool – not as 

bribery – but for recognition. The 

really profound rewards will come 

later.” 

(Kellogg Burns et al 2005) 

What Do Administrators 

Say? 

• “The staff have heard clients say that 

they had come to realize that there are 

rewards just in being with each other in 

group. There are so many traumatized 

and sexually abused patients who are 

only told negative things. So, when they 

heard something good – that helps to 

build their self-esteem and ego.” 

What Do You Say? 

• What are your thoughts about 


• What are your concerns? 

• What are some things you would 

need to do to consider implementing 


(Kellogg, Burns, et. al. 2005) 

6

Treatment of Cocaine 

Dependence 

Treatment of Cocaine Use 

In Methadone Patients 

Retained Through 

6 month Study 

>8 Weeks of Cocaine 

Abstinence 

Retained Through Study 

>8 Weeks of Cocaine 

Abstinence 

100 

75 

% 50 

25 

0 

Incentive 

Standard 

100 

75 

% 50 

25 

0 

Incentive 

Standard 

Higgins et al., 1994 

100 

75 

% 50 

25 

0 

Incentives 

Standard 

% 

100 

75 

50 

25 

0 

Incentives 

Standard 

Silverman et al., 1996 

Retention 

Percent Positive for 

Any Illicit Drug 

% Retained 

100 

80 

60 

40 

20 

0 

2 4 6 8 

Standard 

Incentives 

50 

40 

30 

% 

20 

10 

0 

Intake Week 4 Week 8 

Standard 

Incentives 

Weeks 

Petry et al., 2000 

Petry et al., 2000 





100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Intake 4 8 12 

Percent Positive Urines Over Time 

Treatment as usual 

Treatment as usual 

plus incentives 

Percentage Retained 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Improved Retention in Counseling Treatment 

2 4 6 8 10 12 

Control 

Incentive 

Study Week 

1





Percentage of negative samples 

70 

60 

50 

40 

30 

20 

10 

0 

Incentives Improve Outcomes in 

Methamphetamine Users 

1 2 3 4 5 6 7 8 9 10 11 12 

Week 

Treatment as Usual 


plus Incentives 

Percentage of stimulant negative samples 

70 

60 

50 

40 

30 

20 

10 

0 

Incentives Reduce Stimulant use in 

Methadone Maintenance Treatment 

1 5 9 13 17 21 

Study Visit 



plus Incentives 

2

T42: Cultural Considerations in Working with Latino Youth with CODs and Their Families 

Marie Linares, MCAT, ADTR, LPC 

1.5 hours Focus: Children & Adolescents & Cultural Competency 

Description: 

Latino youth and their families engage more readily in services designed to reduce risks and assess and treat 

existing co-occurring disorders when those services include culturally appropriate components. This workshop 

examines those components and includes considerations when the adolescent is also already involved in the 

criminal justice system. 


• Identify cultural considerations particular to Latino youth and their family members; 

• Discuss how to adapt engagement, assessment and intervention strategies to reflect the needs and 

preferences of the Latino culture; 

• Use the information presented within one’s own practice setting. 

NOTES:

T43: Prison to Community: Reducing Recidivism Through Peer Support and Continuity of Care 

Tara Swartzendruber-Landis, BA, Patricia Luizaga, BA, Karim Bey, John Rogers, BA 


Description: 

By conservative estimates, about twenty percent of incarcerated people throughout the United States have a 

serious, persistent mental illness. Recidivism rates are alarmingly high. The Prison to Community Project, a 

program of the Mental Health Association of Southeastern Pennsylvania, is a new community reentry initiative 

designed to support mental health consumers with a co-occurring addiction who are incarcerated at the county 

prison in Philadelphia, PA. This workshop discusses: program design; implementation and goals; application of 

both a peer support and continuity of care model; and data collection design and implementation. 


• Critique and adapt community reentry programs for their own communities; 

• Describe and implement peer support models; 

• Discuss the development, design, collection and interpretation of outcome measures. 

NOTES:

T44: Promoting Recovery in Adults with Co-occurring Substance Abuse and Severe and 

Persistent Mental Illness 

Jacki Kennedy, MA, & Deb Draper, MA 


Description: 

Pikes Peak Mental Health, located in Colorado Springs, has implemented a treatment program for adults with 

SPMI co-occurring with substance abuse disorders. This program successfully combines Recovery Principles 

with best-practices for substance abuse treatment, and incorporates a community continuum of care. Critical 

program elements and outcome data are presented. 


• Apply Recovery Principles to the treatment of adults with SPMI co-occurring with substance abuse 

disorders; 

• Describe a community continuum of care for adults with serious mental disorders co-occurring with 

substance abuse disorders; 

• Design appropriate outcomes for a treatment program for similar populations. 

NOTES:


WELCOME 

PROMOTING RECOVERY IN ADULTS 

WITH CO-OCCURING SUBSTANCE USE 

AND SERIOUS MENTAL DISORDER 

May 16, 2006 

Jacki Kennedy, LPC, CACIII 

Deb Draper, LPC 

Pikes Peak Mental Health Adult Network 

© Copyright Pikes Peak Mental 

Health Center System, Inc. 2006 

PIKES PEAK MENTAL HEALTH 

• Community Mental Health Center 

• Licensed as a Mental Health and 

Substance Abuse Provider 

• El Paso, Teller and Park Counties 

including Colorado Springs, CO 

• 7,339 total clients served in FY04-05 

• 1,600 open to the Adult Network currently 



Payor Mix 

Our Staff 

9.3% 

13.2% 

Revenue Profile - PPMHC 

4.1% 4.8% Self-Pay & 3rd Party 

Medicaid 

DMH 

Contracted Services 

Donated Medications 

• 97 staff and 7 MA/PhD Interns 

• 20 Operations staff (PAP, 

Secretaries, Med Records) 

• 5 Managers 

• 59 Clinical Staff 

• 13 Medical Prescribers (8 FTE) 

68.5% 





Credentials and Training of Staff 

Multi-disciplinary Teams 

• Peer Specialists 

• Client Advocates 

• Service Coordinators (Non-degreed to MA) 

• Clinicians (MA and PhD) 

• Nurses 

• Prescribers (Prescribing Nurses and MD) 

Population Served 

• Adults over 18 

• Severe and Persistent Mental Illness 

• Co-occurring Mental Health and 

Substance Abuse is over 40% 

• Some DD/MH Co-occurring as well 

• Homeless 





1


Previous Model 

Service Silos 

Our Recovery Philosophy 

Recovery is an ongoing personal process 

of developing and achieving healthful goals 

despite the current presence of psychiatric 

disability and substance abuse. 

SPMI 

Adult 

Outpatient 

Geriatric Forensics Substance 

Abuse 

The mental health center’s role in recovery 

is to provide services to help individuals to 

develop satisfying, hopeful and fulfilling 

lives in the community of their choice. 





Ohio Department of 

Mental Health Model 

• Evidence Based Model for Recovery of Mental 

_ Health issues 

• Not Specifically Designed to Treat Co-occurring 

_ MH/SA Issues 

• Demands a large array of service be available 

• Emphasizes client choice and participation in 

_ treatment 

• Requires specific levels of care be defined 

Levels of Care 



© Copyright Pikes Peak Mental Health Center 

System, Inc. 2006 

© Copyright Pikes Peak Mental Health 

Center System, Inc. 2006 

Typical CORE 

Client 

Typical Discovery 

Client 

• Cannot identify personal needs 

• Uninformed of resource opportunities 

• May be angry, anxious, distrustful, unmotivated 

• May not accept diagnosis 

• Symptoms of Mental Health and Substance Abuse tend to be 

_ active /untreated 

• May be reluctant to seek treatment for either or both issues 

• Stigma may interfere with motivation 

• May lack experience developing trusting relationship 





• Aware of illness(es) 

• Beginning to Gain Control of Symptoms at Least Intermittently 

• Depends heavily upon professional care 

• Aware of services and choices available 

• May not feel empowered or desire to make appropriate choices 

• Begins to set Basic Recovery Goals 

• Often lacks self confidence, unable to be self sustaining 

• May not have interaction or decision-making skills needed for 

work environment 

• May be afraid of losing benefits 

• Feels powerless and victimized 

• Begins to see relationship between decisions and quality of life 

• Goals still shaped by external needs rather than consumer 

preference 





2


Typical Passages 

Client 

• Takes responsibility for life goals, personal growth 

and fulfilling needs 

• Makes choices independently 

• Capable of taking risks 

• Reasonably self confident, positive values of 

personal worth 

• Chooses level of involvement based on needs / 

interests 

• Works toward achieving recovery goals for Mental 

Health and Substance Use 

• Capable of sustaining personal care and existence 

• May be vulnerable to relapse in either arena or both 

• Aware of consequence of decisions 

• Aware of personal responsibility 

• Understands the need for assistance 

Typical Summit 

Client 

• Views service providers & personal support 

system as partners/peers 

• Willing and ready to give back to community 

• Serves as role model for other consumers 

• May move out of public system for employment 

and private benefits 

• Understands roles in work environment and seeks 

to contribute 

• Aware of how he/she affects other lives 

• Asks for help when needed 

• Obtains & uses needed information and resources 

with minimal support 

• Completed all major recovery goals 

• Effectively manages Substance and Mental Health 

Issues 









Medical Team Interface 

What we wanted… 

• Integration of care across teams 

• Better cross-coverage of medical job duties 

• Increased nursing, CM and operations support 

• Centralized medication samples 

• Expansion of medication assistance program 

(PAP) 

• Efficiency within the team, connections 

outside 

Medical Team Interface 

How we got it… 

• Medical staff chose to practice in their 

specialty including substance abuse 

• Prescribers, nurses and medical 

casemanagers assigned to clinical teams 

• Staffing, networking and fun on clinical 

teams included medical team staff 

• Medical team able to focus on mission 





Client Movement 

Through the Model 

Admission and Discharge 

Criteria for each Level of Recovery 

CORE: Admission Criteria 

• Expectation for improvement 

• GAF score < 45 

• Resistant to medication 

• Denial of illness/addiction 

• Recent inpatient 

• Homelessness 

• Difficulty keeping appointments 

• Needs case management-type services 

• Requires support to attend to basic ADLs 

• Resistant to traditional mental health and/or 

substance abuse services 

• Unable to identify personal needs 





3


CORE: Transfer/Discharge Criteria 

1. Expresses willingness to continue recovery process 

2. Ability to use public transportation 

3. Can tolerate structured setting for at least 30 minutes 

4. 80% medication compliance 

• < 1 recent inpatient stay 

• GAF score > 45 

• Understands medications 

• Stable housing 

• Met at least one goal 

• Involved in some outside activities 

• Understands next steps toward recovery 

• Applied for benefits 

Discovery: Admission Criteria 

• Can tolerate group > 15 min. 

• Likely to improve or stabilize 

• Willing to engage in Recovery 

• SA and/or MH symptoms don’t impede 

participation Admissions Criteria: 

• GAF of 40-60 

• Understands MH and SA minimally 

• Willing to participate 

• Can set goals and design a WRAP 

• Minimal support systems 





Discovery: Transfer/Discharge Criteria 

• Achieved major goals and desires psychotherapy 

• Is discharged to more intensive services or 

external provider 

• Has not been hospitalized in the last six months 

• Takes responsibility for own recovery and has the 

skills to manage symptoms 

Passages: Admission Criteria 

• Has needs requiring psychotherapy 

• Participates in care 

• Has some external support systems 

• GAF > 55 

• Minimal case management 

• Minimal crisis potential 

• Self sufficient 

• Symptoms/Addiction largely controlled 

• Attends services 

• Effective recovery process 





Passages: Transfer/Discharge Criteria 

• Has an external prescriber 

• Sustained social occupational functioning 

• MH/SA Symptoms managed 

• GAF > 61 

• Has met primary goals 

• No longer needs regular services 

• Participates in no more than one group weekly 

• Needs no more than one contact per month 

• Needs only occasional services as a booster to 

recovery program 

Summit: Admission Criteria 

Must meet at least the first 5 criteria: 

• Met goals and is stable 

• No recent detox / hospitalizations 

• Attends sessions consistently 

• GAF > 61 

• Need monthly one to one contact 

• Attends group or Clubhouse 

• Occasional need for brief episodic care (4-8 sessions) 

• Has an outside therapist/other providers but needs 

medications that cannot be provided by PCP 





4


Summit: Graduation Criteria 

• Outside provider for medications 

• No longer needs medications 

• No hospitalizations > year 

• Utilizes support systems in the community 

• Prescriber has agreed to the discharge 

• Is transferred to more intensive services or 

to external provider 

Lighthouse 

Acute Treatment 

Unit 

Detox& 

Inpatient MH/SA Care 

and Crisis Services 

Benefits 

Team 

Housing / Benefits / 

Payeeships 

Drop in Center 

Haven 

House 

Adult Network 

CORE 

Discovery 

Passages 

Summit 

Program 

Interdependencies 

Outreach Services 

Community Resources 

Churches 

Red Cross 

Community Health 

Soup Kitchen 

Dental Clinic 

Wahsatch 

Transitional Housing 

House 

Outreach Admissions 

Clubhouse 

Aspen 

Diversified 

Industries 

Vocational 

Work Ordered Day 

Services 

Community-Based 

Prevocational 



Services 



Continuum Available 

Lighthouse Programs 

• Medical Detox 

• Acute Treatment Unit 

– Mental Health Only 

– Co-Occurring Disorders 

• Transitional Residential Treatment 

• Intensive Outpatient Treatment 

• Harbor House 



Metric 

Pre and Post Recovery 

Implementation Outcomes 

Increase Client Clubhouse Involvement 

Serve More People / Less Money (LOS > 

500) 

Increase in Clinical Productivity 

Reduce No Show Rates (Passages) 

Reduce ALS with Same Outcomes 

Reduce Cost of Service with Same 

Outcomes (per person per month) 

2002 

15 

74% 

44% 

33% 

1936 days 

$385 



2003 

78 

61% 

2004 

156 

62% 

58% 74% 

10% 7% 

1840 days 1827 days 

$237 $122 

Continuing Recovery Model 

Outcomes 

• Lehman Quality of Life 

• Basis 24 

• Level of Functioning 

• Length of Stay in any given level of the 

model 

• Movement Between Levels 

Subjective Domain 

General Life Satisfaction 

Satisfaction with Living Situation** 

Satisfaction with Daily Activities 

Satisfaction with Family Contact 

Satisfaction with Social Relations 

Satisfaction with Finances 

Satisfaction with Safety 

Satisfaction with Health 

Lehman Quality of Life 

Average QOL 

Score on 

First Test 

4.57 

4.42 

4.68 

4.33 

4.87 

3.49 

4.85 

4.44 

Average QOL 

Score on 

Most Recent 

Test 

4.76 

4.97 

4.77 

4.64 

5.00 

3.78 

4.67 

4.50 

PPMH Change Compared 

with Change for Similar 

Clients Reported by 

Lehman [1] 

.19 (PPMH) 

vs .12 

.55 (PPMH) 

vs .17 

.09 (PPMH) 

vs .13 

.31 (PPMH) 

vs .22 

.13 (PPMH) 

vs. .04 

.29 (PPMH) 

vs. .14 

-.18 (PPMH) 

vs. .07 

Comparison data not 

available 

[1] Lehman’s comparison of change from baseline to two month follow-up for clients with SPMI 

**Difference between first and second test significant, p=.02 





5


Type of Score 

Depression/ 

Functioning 

Relationships 

Self-Harm 

Emotional Labiality 

Psychosis 


Overall Score 

PPMH 

Intake 

Group 

(n=333) 

2.21 

1.80 

0.58 

2.41 

1.10 

0.70 

1.84 

Basis 24 

National 

Intake 

Group 

(n=850) 

1.82 

1.40 

0.50 

1.86 

0.61 

0.71 

1.49 

PPMH 

Midtreatment 

Group 

(n=151) 

1.81 

1.75 

0.54 

1.84 

1.09 

0.52 

1.55 



National 

Follow-up 

Group 

(n=850) 

1.41 

1.18 

0.32 

1.54 

0.44 

0.47 

1.16 

(Score based on a scale of 0-4, with a higher score indicating more adverse symptoms) 

PPMH 

Change 

Score 

0.40 

0.05 

0.04 

0.57 

0.01 

0.18 

0.33 

National 

Change 

Score 

0.41 

0.22 

0.18 

0.32 

0.17 

0.24 

0.32 

Challenges 

• Movement from level to level 

• Reluctance of clients to change clinicians 

• Reluctance of clinicians to do CM 

• Ensure specialty care is provided 

• Developing evidence-based protocols 

• Communicating the model to clients and 

the community 

• Constant funding changes 



QUESTIONS 



6

T45: Workforce Issues and Co-occurring Disorders 

Donna N. McNelis, PhD, CPRP 

1.5 hours Focus: Systems Integration and Recovery Supports 

Description: 

This session describes several of the dilemmas that co-occurring programs and personnel encounter when 

addressing multi-system treatment and administrative issues. Concurrence on an integrated approach is 

presented from a national and state policy level. Additionally, examples of integrated approaches for program 

management and staff education and training are detailed. Technology and evidenced-supported practices 

that specific staff should utilize are addressed. 


• Name several broad workforce dilemmas that co-occurring programs and practitioners encounter; 

• Identify national and PA policy initiatives that are addressing the dual system issues; 

• Cite practices that enhance treatment outcomes for persons with co-occurring disorders; 

• Judiciously use technology to enhance continuing education and training. 

NOTES:


What Works: Workforce Issues 

Workforce Issues and 


Donna N McNelis 

Drexel University College of Medicine 

Behavioral Healthcare Education 

Philadelphia, PA 

• COD Workforce Dilemmas 

• Concurrence on COD Approach: 

– National and PA’s Development 

•Policy 

• Program 

• Staff 

• Embracing Technologies at All Levels 

COD Workforce Dilemmas 

• COD is a misnomer, actually many 

disorders co-exist 

• Demands for differential diagnosis and 

ability to work with many COD 

• Above skills are taught in graduate level 

programs ( MD, MSW, MSN, PhD,) but 

most do not provide specialized training 

with COD 


• The undergraduate and graduate 

educational programs have not fully 

embraced COD 

• There are no uniform standards in 

curricula or field supervision 

• Great variation in community college 

certificate programs 

• There is more potential for innovation and 

fewer resources to permit the innovation 


• Greater variation at the program/ 

provider/practitioner level 

• Provider system remains non-integrated at 

the local, regional and state level 

• Programs do not have a whole-person 

focus* 

• Peer specialists are few 


• Burnout and frustration is high at the 

direct-care level 

• Strong need to increase number of 

graduates each year to keep pace with 

growth in the field 

1


Current Dimensions 

• Crisis stage 

– New York Whitepaper on Addictions 

Workforce 2002 

• Increase in professionalism in the field including 

increase of addiction specialties across disciplines, 

but fewer people are choosing the field and there 

is a rise in the numbers of people leaving 

• Field is in transition from experientially trained 

workforce to one that emphasizes graduate 

training 

Current Dimensions: NAADAC 

Survey 

• CSAT 2003 Survey of workforce 

– 70% female, 78%white, 42y/o mean 

– 40% master’s degree 

– Drawn to field by personal factors 

– 50% see opportunity for career advancement 

Staff Recruitment and Turnover: 

NEATTC 2005 

• 13.7% staff terminated, laid off, resigned 

annually 

• Programs spend little time and money on 

recruitment 

• Directors report trouble filling positions 

–Low salaries 

– Insufficient funding for open positions 

– Insufficient number of applicants 

Staff Recruitment and Turnover: 

NEATTC 2005 

• Applicants did not meet requirements due 

to lack of education, experience or 

appropriate certification 

• Competition from other fields 

• Perception of addiction professionals 

Building Bridges: Co-occurring MI and Addictions 

Consumers and Service Providers, Policymakers and 

Researchers in Dialogue (2004) 

• Form and maintain healthy, consumer-driven partnerships in policymaking, 

research, and service delivery. 

• Embed a whole-person focus in research and service delivery. 

• Transform workforce development, emphasizing peer-based approaches. 

• Expand programs to reduce stigma and discrimination against underserved 

populations. 

• Create incentives for coalition building. 

• Engage actively in public awareness and education. 

• Support appropriate policy for systems change. 

• Support collaborative research. 

• Redesign the reimbursement system. 

• http://www.mentalhealth.samhsa.gov/publications/allpubs/SMA04%2D3892/ 



• Initiate a 10 year SAMHSA workforce 

development plan 

• Design & support recruitment campaign 

for peer specialists 

• Place strong emphasis on curriculum 

development on COD in academic 

programs 

• Develop licensure requirements for BH & 

SA treatment in collaboration with 

university graduate programs 

2


Transforming Workforce 

Development 

• Establish credentials for professionals who 

work with COD 

• Increase block grant flexibility to add 

workforce development plans 

• Assure that workforce development 

programs apply to rural areas. 

Solutions to Workforce 

Dilemmas 

National, PA and Practitioner 

National Strategic Plan on Behavioral 

Health Workforce Development 

• Clarify a mission and vision that can guide 

future workforce development efforts 

• Identify a set of strategic goals that can 

focus these efforts 

• Detail a range of specific interventions that 

are highly likely to improve recruitment, 

retention, education, training and other 

aspects of workforce development 

SAMHSA CMHS Vision for 

Workforce Kathryn Power 

• Ethnically and racially diverse 

– eg PRIME Grant (2002-2005) 

– Minority fellowship program 

• Competent workforce trained in EBP and 

intervention 

• Totally committed to recovery 

• Joint project with CMHS, CSAP, CSAT 

• Training for families 

Consensus- and Evidence-Based 

Practices for COD 



Perspective 


Viewpoint 


to Treatment 





Impairments 


Maintain and Extend Treatment 

Effectiveness 


Essential 

Programming 


and Referral 




Management 

Prescribing 




Psychoeducational Classes 


(Onsite) 



with COD (with 

evidence based in 


treatment) 

Motivational 

Enhancement 

Contingency 

Management Techniques 







Mutual Self-Help Groups 


Models 

Assertive 

Community 

Treatment 

Modified 

Therapeutic 

Community 



Mentally Ill 

Collaborative 








Treatment (Substance Use and 


Six Guiding Principles Tip 42 





treatment. 

5. Plan for the person’s cognitive and functional 

impairments. 




Self-Help Groups (Offsite) 

Adapted from Substance Abuse Treatment for Persons With Co-Occurring 

Disorders TIP42 

3


Policy Background (COSIG Executive 

Report) 

Pennsylvania’s Workforce 

Development 2005 

Policy 

Program 

Personnel 

• 1997-99 Mental Illness & Substance Abuse 

Consortium (joint participation by OMHSAS and 

DOH) 

• 5 county pilot projects with 2 year evaluation 

• Co-occurring State Incentive Grant (COSIG) 

– Develop permanent statewide infrastructure to 

support co-occurring service delivery 

– Co-occurring State Advisory Committee (CODAC) 

• 5 sub-committees (Screening & Assessment; Provider 

Approval; Workforce Development; Data Integration; 

Reimbursement) 

Drafted Joint Bulletin 

• COD Capable Programs will be licensed 

this year 

• Licensing staff are be trained in the 

components of a COD Capable Program 

• COD program staff must demonstrate the 

COD competencies 

COD Capable Facility 

‣A licensed facility that: 

Addresses co-occurring psychiatric and 

substance use disorders in its policies and 

procedures; 

Provides integrated assessment, coordinates 

treatment planning and programming 

addressing both sets of disorders; 

Develops interagency coordination for cooccurring 

services and ensures COD 

discharge planning; 

Addresses interaction between disorders re: 

readiness to change, relapse & recovery. 

COD Enhanced Facility 

‣A dually-licensed facility that: 

Has programmatic capacity to provide 

integrated substance use and psychiatric 

treatment to persons presenting with 

symptomatic and/or functional impairments as 

a result of their co-occurring disorders; and 

Address CODs using an integrated 

philosophy and treatment model in a single 

setting. 

Program Features 

A. COD Mission and Philosophy 

B. COD Screening 

C. COD Assessment Process 

D. COD Program Content 

E. Integrated Treatment Planning 

F. Medication 

G. Crisis Intervention Procedures 

H. Communication, Collaboration & Consultation 

I. Staff Competencies 

J. Transition/Discharge/Aftercare 

4


A. COD Mission & Philosophy 

1. Mission statement & program philosophy which 

incorporates an understanding of the “Principles of 

Successful Treatment” approved by the governing body 

of the facility. 

2. Description of treatment modalities that include 

consensus & evidence-based practices for ageappropriate 

co-occurring treatment. 

3. Quality improvement plan that monitors compliance with 

program philosophies, treatment modalities, and 

consumer satisfaction with services. 

4. Co-occurring program performance measures linked to 

the quality improvement activities. 


The program shall: 

1. Develop written procedures for screening for cooccurring 

issues. 

2. Identify staff qualified to provide screening. 

3. Document staff training on screening procedures. 

4. Utilize screening instruments that identify both 

psychiatric and substance use disorders 

All of these must apply to an adolescent population when 

that is the population served by the facility. 



1. Develop written procedures for a strength-based 

assessment process for co-occurring disorders. 

2. Identify staff qualified to complete the assessment 

process for individuals with CODs. (staff qualifications 

& training documented) 

3. Document staff training on the co-occurring disorder 

assessment process. (dates, times, outline of training, 

attendance sheets) 

COD Assessment Process (continued) 

4. Utilize assessment instruments that address both 

psychiatric and substance use disorders. (written 

rationale for the use of all assessment instruments - 

including youth-appropriate ones when the target 

population) 

5. Develop protocols for referrals to enhanced cooccurring 

services. (if not available in the community, 

consultation with local experts should be contracted 

and documented) 


In addition to current licensed activities, the program shall 

identify and describe specific co-occurring disorder 

services that, at a minimum, include: 

1. Stage of Change Interventions, 

2. Motivational Enhancement Interventions, 

3. Contingency Management, 

4. Individual and Group Interventions, 

COD Program Content (con’t.) 

5. Skill-Building Interventions, 

6. Mental Health and/or Addiction 

Education, 

7. Medication Education, 

8. COD Education for Individuals & 

Families 

9. COD Relapse Prevention, and 

10. Access to Self-Help Recovery 

Resources. 

5



Integrated Treatment Planning (continued) 

1. The individual’s participation in the development of 

his/her integrated treatment plan. 

2. Input from the multidisciplinary treatment team, 

collaborating agencies & practitioners. 

3. Goals and measurable objectives that reflect the 

presence of both disorders and how treatment 

interventions may vary to meet the needs of the 

individual. 

4. Individualized goals that are stage-specific based upon 

the assessment of co-occurring needs. (Evidence of use 

of Stage of Change assessment and goals that are 

clearly THIS person’s – not a “cookie cutter” plan) 

5. Identification and incorporation of the individual’s 

strengths in accomplishing the identified goals. 

6. Reviews and revisions based upon additional clinical 

information obtained through the ongoing assessment 

and evaluation process. 

7. Recovery supports for both disorders. 

F. Medication 


1. Develop medication policies and procedures that 

address the prescribing, dispensing, and 

administration of medication, as well as the reporting 

of medication errors and adverse drug reactions for all 

medications prescribed by the facility’s attending 

physician. 

2. Provide written justification for all medications 

prescribed by the facility correlating them to specific 

symptoms, as well as identifying potential side-effects. 

Medication (continued) 

3. Document a medication record including drug, dose, 

frequency, and prescribing physician. 

4. Develop a system to monitor medication adherence, 

including self-report. 

5. Develop policies and procedures addressing access to 

medication, if not available within the facility. 

6. Develop policies and procedures outlining the 

coordination of care between all programs providing 

treatment services and medications to the individual. 

G. Crisis Intervention 

Procedures 

The program shall develop policies and procedures to 

address the following: 

1. Psychiatric emergencies 

2. Withdrawal emergencies 

3. Medication emergencies 

4. Intoxication 

H. Communication, Collaboration 

& Consultation 

1. Written agreements to maintain linkages with 

practitioners and organizations necessary to support 

co-occurring service needs. 

2. Policies and procedures for integrating input from 

ollaborating agencies into the treatment process. 

3. Procedures for obtaining written consent from the 

individual receiving services for all communication and 

collaboration with other agencies. 

4. Procedures for identifying situations requiring 

consultation. 

6



1. Documentation of credentialed staff, including the 

CCDP. 

2. Number of staff who have completed the approved cooccurring 

core training curriculum. 

3. Program training plan addressing co-occurring issues. 

4. Documentation of credentialed supervisors, including 

the CCDP. 

5. Documentation of ongoing supervision to address cooccurring 

services. 


1. Aftercare needs planning commencing upon admission 

to the program. 

2. Referral for psychiatric access and medication 

management. 

3. Identification of and referral to a community support 

network including recovery self-help groups and other 

individualized support/ services for recovery 

4. Instructions for accessing crisis services. 

5. Linkage with case management services for 

community resources, if appropriate and available. 

Personnel: Credentialing Staff 

• Co-occurring Disorders Certification 

– CCDP and CCDP Diplomate 

• Education 

• Supervision 

• Experience 

• Code of ethical conduct 

• Recertification 

Continuing Education 

• Workforce development sub-committee 

charged 3 PA Training Institutes to 

develop extensive curriculum in 1998 

• Has been offered throughout the 

Commonwealth every year since 1999 

• Participants receive a certificate of 

completion of all required courses 

PA COD Approved Curriculum 

• Co-occurring Disorders: Integrated Concepts and 

Approaches 

• Co-occurring Disorders: Ethics and Boundaries for 

Effective Practice 

• Co-occurring Disorders: Treatment Planning and 

Documentation Issues 

• Treatment and Supports for Co-occurring Disorders 

• Co-occurring Disorders : Recovery, Rehabilitation 

and Self-Help: What, When and How 


• Co-occurring Disorders: Crisis Prevention, 

Intervention and Postvention 

• Co-occurring Disorders : Groups and Group Skills 

• Co-occurring Disorders: Working Respectfully with 

Family Members and Significant Others 

• Co-occurring Disorders and Psychopharmacology: 

An Overview 

• Co-occurring Disorders: Practice Principles for 

Continuous Quality Improvement and Collaboration 

7



• Co-occurring Disorders and Specific Communication 

Skills: A Review of Principles and Practices 

• Co-occurring Disorders and Special Populations 

• Children and Adolescents with Co-occurring 

Disorders: Principles of Engagement 

• DSM Major Mental Disorders in Adults 

• DSM Substance Use Disorders in Adults 

Undergraduate Education 

Drexel (BACS Program) 

BACS 414 (3 credits) Co-Occurring Disorders 

• This course introduces an integrated treatment approach for working 

with individuals who have co-occurring psychiatric and substance 

use disorders. The characteristics and unique needs of each 

disorder will be addressed. Issues to be reviewed will include 

psychopharmacology, recovery strategies, 12-step and other selfhelp 

recovery approaches, harm reduction, rehabilitation and 

relapse prevention approaches, and utilizing community supports. 

Alvernia 

ADA 414 (3 credits) Differential Diagnosis 

Individuals suffering from substance use disorders frequently manifest 

symptoms of other forms of psychopathology. Some major categories of 

mental illness likely to coexist with substance use disorders are explored in 

depth. 

Embracing Technologies at All 

Levels 

• Undergraduate and graduate education 

• Continuous education 

• Judicious internet and listserv information 

– Dualdx@treatment.org 

– www.ireta.org/attc 

– coce.samhsa.gov 

• Conferences such as this 


Levels 

• Peer based approaches 

– Certification process in place 

• Partnering with families 

• Systems change technology 

– Change agents at all levels 

– CQI approaches 

• Evidence based practices 

– Application in the provider system 

– SAMHSA’s Toolkit on COD 


Levels 

• Therapeutic technologies 

– MET, Contingency-based Treatment 

– Dialectical Behavior Therapy 

– Psychiatric Rehabilitation and Recovery 

• Clinical supervision 

• Application of cultural competence 


Levels 

• Unification of clinicians and researchers at 

the practice level 

• Encouragement of boundary spanners 

• Knowledge of neuropsychiatry and 

psychopharmacology and methods to 

teach such to individuals 

8


Closing Statement Anthony, 2004 

…”I was thinking about the fact that I 

couldn’t remember all the principles my 

colleagues and I have suggested over the 

years… Is there not just one simple 

principle that transcends all others?... 

….the principle of personhood.. 

Closing Statement Anthony, 2004 

…persons with disorders want to selfdetermine 

their own goals, be involved in 

their own lives, believe in their own 

capacity to grow and have hope… 

…if the principle of personhood can 

transcend all of our research, training and 

services, good things will follow. 

Donna N McNelis, PhD, CPRP 


Associate Professor, Psychiatry 

Director, Behavioral Healthcare Education 

Donna.Mcnelis@Drexelmed.edu 

9

T46: Creation of Local Housing Options Teams (LHOT's) in Your Community 

John Ames, Housing Specialist, PA OMHSAS 


Description: 

The Pennsylvania Office of Mental Health and Substance Abuse Services offers intensive technical assistance to 

counties in order to expand housing opportunities for people with mental illness and co-occurring disorders. 

This assistance covers three areas: 1) developing and implementing housing needs assessments; 2) 

developing strategies for addressing the needs identified; and 3) developing and implementing specific 

housing initiatives. The result has been the creation of more than twenty-five Local Housing Option Teams, 

which are coordinated efforts on the local level that bring together housing and human service professionals, 

people with disabilities, and family members to jointly address housing issues in their communities. 


• Describe how LHOTs help counties develop housing and services for persons with CODs; 

• Identify some successful funding strategies for development of affordable housing options in the 

community; 

• Discuss how to start or effectively participate in an LHOT in their own Counties. 

NOTES:


What is an LHOT? 

LOCAL HOUSING OPTIONS TEAMS 

(LHOTS) 

Local Housing Options Team 

Collaboration/Consortium/Coordination 

Key stakeholders coming together on the county or multi-county level 

What is the purpose of an LHOT? 

Individual LHOT missions, goals and priorities vary 

Purposes include: 

To identify housing needs 

To expand housing options 

To create housing opportunities 

for people with disabilities. 

Who are the members of an LHOT? 

Key stakeholders in participating county or counties: 

Disability 

Housing 

Human Service 

Members vary but most common are: 

County MH/MR departments 

Service providers 

Housing authorities 

Housing providers 

Disability organizations 

County housing/community/economic/business development 

County office of human services 

County children and youth services 

People with disabilities 

LHOT Activities? 

Networking among local agencies 

Educating other members and sharing information 

Troubleshooting/problem solving (case studies) 

Conducting needs assessments 

Developing housing strategies 

Creating partnerships to address problems 

Planning and financing specific housing programs 

or projects 

Defining characteristic of an LHOT? 

Each LHOT is unique. 

Who sets the agenda and priorities? 

Members of the LHOT determine its action agenda 

and priorities 

Start with a high priority local need 

How many LHOTs are there in PA? 

14 Active LHOTs 

5Forming LHOTs 

Notable Accomplishments? 

Housing Needs Assessments 

Focus Groups 

522 New Housing Opportunities 

Shelter Plus Care Programs 

Supportive Housing Programs 

Local Housing Authority Set-Asides and Preferences 

HUD Section 8 Mainstream Program 

HUD Section 811 Program 

Educational Forums (Fair Housing, Home Mods., Section 8) 

Funding for LHOT Staff/Coordination 

Landlord Outreach Programs 

Pilot Project 

Housing Cooperative 

Is technical assistance available to form, 

facilitate, or advise an LHOT? 

YES. 

TA Available from two sources: 

1. OMHSAS 

(Office of Mental Health and Substance Abuse Services) 

County office of mental health must: 

Submit written request 

Be an active participant in the LHOT 

Prioritize housing for people with mental illness, 

especially through the recovery model 

For more information contact: 

John Ames / OMHSAS at 717-705-9510 

Summary Chart in Packets 

1


LOCAL HOUSING OPTIONS TEAMS 

(LHOTS) 

2. SDHP (The Self-Determination Housing Project of PA) 

Provides training, facilitation, and technical assistance 

to eligible groups interested in developing an LHOT 

LHOT must prioritize housing solutions that 

maximize individual choice and control 

TA available through the Regional Housing 

Coordinator Program 

Contact Gail Hoffmann, Project Director at 

215-884-2091 

Or the RHC in your area 

(Brochures at the resource table) 

2

T47: Fetal Alcohol Spectrum Disorders: Theory, Parent Challenges and a Functional Model of 

Diagnosis and Treatment of Co-Occurring Disorders (continued as T57) 

Paula J. Lockhart, MD, Ana Maciel, MD, LCPC & Diane L. Seager, Parent Advocate 


Description: This workshop explores Fetal Alcohol Spectrum Disorders (FASD), one of the most common 

causes of preventable cognitive disability. The history, epidemiology, basic science, clinical aspects and real 

life history of a family coping with this very poorly understood developmental disability is presented. The 

presenters describe a model of diagnosis and treatment that functionally analyzes a person’s strengths and 

areas of impairment by connecting disciplines that traditionally work separately, integrating mental health with 

other disciplines to devise comprehensive and optimal treatment plans for persons with this co-occurring 

disorder. 


• Describe the physical, behavioral and cognitive features of fetal alcohol spectrum disorders; 

• Identify persons in your programs that may have FASD; 

• Develop a diagnostic and treatment program that supports families with a child or children with FASD. 

NOTES:


Overview 

Improving the Long Term Outcome of 

Individuals with 

Fetal Alcohol Spectrum Disorders 

Paula J. Lockhart, MD 

The Kennedy Krieger Institute 

• Over 94% of individuals with FASD have mental health 

problems (Stressguth et al, 1996) 

• More than likely you probably know someone with 

FASD already 

• It does make a difference to know that someone is 

alcohol exposed because it puts behaviors in 

perspective that may have been attributed to another 

causes 

• It is estimated that 9.1 in 1000 live births have FASD 

Introductory Comments 

• Leading cause of 

preventable behavioral, 

cognitive, and social 

disability 

• Often escapes recognition 

by mental health 

professionals 

• May be one of the most 

under treated of the 

developmental disabilities 

in psychiatry and other 

mental health disciplines 

Importance of Diagnosing Fetal 

Alcohol Exposure in our Patients 

• They may qualify for special 

services if they are diagnosed 

• Is associated with behavioral, 

emotional, and cognitive 

disability that is often mistaken 

for other psychiatric diagnosis 

• Alcohol exposure complicates 

psychiatric recovery 

Importance of Diagnosing Prenatal Alcohol Exposure 

early in Our Patients Presenting for mental health 

Diagnosis and Treatment 

•Can pose on-going therapeutic challenges 

• Often require life-long mental health treatment and psychosocial support 

•An informed mental health professional can dramatically change life 

trajectory 

•The earlier the diagnosis is made the better to decrease behavior and 

emotional fall-out from the cognitive disability impacting on the environment 

Examples of Problems in General 

Cognition in Patients with FASD 

• “But I wanted to see a rainbow”( 15 y/o girl poured sand down 

the bathroom basin which had a clear pipe) 

• “I did it because I wanted to!” (4 year y/o after killing the family 

dog) 

• “I did it because you wouldn’t let me go with my friends” 

(smashed a picture window with a brick, he knew a baby was 

sleeping underneath) 

• “I don’t know why I did it” (stole the “for rent” signs multiple 

times at their apartment bldg and then took them all back 

dressed as someone else for the reward. Mother had to move 

family) 

• “But you told me not to let the dog out of the front door.” (after 

letting the dog out the back of the house while his parents 

were not home) 

• “But you never gave me a birthday party” (parent gave 

birthday parties every year that her son could not remember 

and became aggressive with her every time he brought up the 

issue) 

1


But Don’t All Doctors Learn about 

FASD in Medical School? 

30 years of molecular biological, clinical and 

psychosocial research on Fetal Alcohol 

Spectrum Disorders is not in the current 

medical school curriculum 

What is the Evidence that We Need to Do 

a Better Job in Diagnosing and 

Treatment? 

• These individuals are treated by psychiatrists as 

youngsters but are ending in the prison system 

• Comprise a large percentage of the foster care, 

residential treatment population and are hospitalized in 

high numbers 

• Are in inappropriate school placements because they are 

not identified as being disabled or they “look good” 

• Parents are frustrated and “burnt out” by their children’s 

behavior never knowing that they need to conceptualize 

their children’s behavior differently as a cognitive 

disability 

• When we evaluate a child and do not factor in cognitive 

disability the diagnosis may not be accurate and the 

treatment plan will not be comprehensive enough to 

manage the complexity of the disability 

Costs of FAS 

• FAS costs US $5.4 billion in 2003 

• An FAS birth carries lifetime health costs of 

$860,000 although can be as high as $4.2 million 

• Including quality of life, FAS prevention may be 

“cost effective” at up to $850,000 per child 

• 1 in 100 births in US will have effects from 

exposure to alcohol 

NOFAS 

Caretakers 

• Experience high degree of burn-out” 

• Experience anxiety over developmental delays 

• Often have to come to terms with lack of independence 

• Experience problems finding skilled professionals who understand 

the reasons for the behavioral issues 

• Have to chronically fight the system for appropriate resources 

• Are at risk for abusing their child because of unrealistic 

expectations and not having any effective means to manage the 

demands of parenting a child with complex cognitive disability 

Caretakers (continued) 

• Be ready to support the caretaker as much as necessary to 

decrease emotional reactivity 

• Require much time to absorb the reality of the situation of 

having a special needs child (may take years) 

• Needs understanding from helping professionals (therapist 

may need support from colleagues to avoid “burn-out”) 

• Blame and or provoking guilt should be avoided in all 

interactions (most parents just don’t know that their behavior 

towards the child is unjustified) 

• They have to be taught to understand and be more accepting 

• Be ready to believe the fantastic stories they report 

• These stories are generally true 

• Need to evaluate the neurotic issues and stress behavior of 

caretakers 

Russian prosecutors to investigate adoption procedure of boy who 

died in US 

AP Worldstream; August 5, 2005; MARIA DANILOVA, Associated 

Press Writer; 343 Words 

... about the fate of Russian-born children adopted ... prompted a senior 

Russian lawmaker to call on halting adoptions by U.S. citizens ... 

Merryman was the 13th Russian-born child to die ... allowed foreign 

adoptions in the early 1990s ... said. Some 260,000 Russian orphans 

are ... 

2


Comments from Physicians 

• “I have only seen a few cases of FAS in my whole career” 

• “Most individuals with FAS are mentally retarded” 

• If you don’t have the characteristics of FAS then you are out of the 

woods 

• “FAS is present in only certain populations” 

• “Taking a glass of wine from time to time during pregnancy is not going 

to hurt” 

Alcohol is a potent neurotoxic substance 

when exposed to a developing brain 

• “It doesn’t matter if the history of alcohol exposure is known or not 

because we wouldn’t do anything different anyway” 

• “If you have a hammer everything you see is a nail” 

• We really don’t need anything else for physicians to have to learn. 

The Multidimensionally Complex Patient 

Psychosocial 

Stress from: 

• Impaired social skills 

• Stressful parent interactions 

• Expectations based on IQ different 

Than would be expected 

• Over stimulated easily by normal daily 

situations 

Cognitive 

•Theory of Mind issues 

• Working Memory Problems 

• Attention Problems 

• Judgment and insight 

• Adaptive Functioning 

•Organization problems 

•Initiation of activities 

•Working under stress or chaotic 

Emotional 

Symptoms 

•Anxiety Disorders 


•Adjustment Symptoms 

Behavioral 

• Hyperactivity 

• Impulsivity 

• Distractibility 

• Oppositionality 


• Vindictive behaviors 

• Social inappropriateness 

FAS Study 

Mental Health Problems 

94% 

Inappropriate Sexual Behavior 

45% 

Disrupted School Experience 

43% 

Trouble with the Law 

42% 

Psychiatric Hospitalization in the 6-11 Age Group 8% 



0 10 20 30 40 50 60 70 80 90 100 

Percentage out of 415 Individuals with FAS /FAE 

Streissguth, 1996 

Nomenclature 

1 in 100 individuals have 

FASD 

Fetal Alcohol Spectrum Disorders (FASD) 

Diagnoses 

1. FAS-Fetal Alcohol Syndrome 

2. pFAS-Partial Fetal Alcohol Syndrome 

3. ARBD-Alcohol Related Birth Defects 

4. ARND- Alcohol Related Neurodevelopmental 

Disorder 

3


Alcohol Diffuses to the Fetus during 

Gestation and in Breast Milk during 

Breastfeeding 

Placenta 

Umbilical 

arteries and 

veins 

Umbilical 

cord 

Heart 

The facial features of FAS in mouse fetus that was 

exposed to single binge of alcohol during 1 st 

trimester. 

Dysmorphic Features Seen in Individuals 

with Prenatal Alcohol Exposure 

child with FAS 

Narrow forehead 

mouse fetus 

Short palpebral fissures 

Small nose 

Small midface 

Thin upper lip with 

flattened philtrum 

alcohol-exposed 

normal 

Early Identification of Fetal Alcohol 

Syndrome leads to improved 

outcome 

Examples of dysmorphic features 

in older Individuals with FASD 

(FAS) 

• Small palprebral fissures 

• Smooth philtrum 

• This upper lip 

4


Deleterious effects appear multifactorial 

Fetuses are differentially susceptible to the 

effects of alcohol exposure 

Type of Teratogenesis Based on Day 

of Exposure 

Gestational Day 7 in the 

mouse lead to facial 

anomalies, brain anomalies, 

ocular defects 

Gestational Day 8 in the 

mouse lead to cardiac 

anomalies, skeletal 

anomalies 

Alcohol is More Neurotoxic than Cocaine, 

Heroin, PCP or Marijuana 

Gestational Day 9 and 10 in 

the mouse lead to urogenital 

abnormalities (hydronephrosis, 

hydroureter) 

Late 3rd and 4th week 

post fertilization in the 

human is the 

corresponding time that is 

very vulnerable to 

producing facial, brain 

and organ anomalies 

Cognitive, Behavioral, Emotional and other 

Problems Can Each Appear Across a Continuum 

of Severity 

Cognition 

Behavior 

Social 

Skills 

Speech and 

Language 

Emotion 

Mild 

Mild 

Mild 

Mild 

Mild 

Poor insight and judgment, poor planning, 

impairment in short term memory and processing 

speed 

Aggression, temper outbursts, impulsivity, 

restlessness, vindictiveness 

Poor boundaries, difficulty reading facial 

expressions or body language 

pragmatic speech, receptive and 

expressive language 

anxiety and mood lability 

Severe 

Severe 

Severe 

Severe 

Severe 

Motor Skills 

Mild 

Fine, gross motor skills impairment 

Severe 

5


Executive Functioning in FAS/ADHD Compared to ADHD 

The BRIEF 

inhibit 

Shift 

Emotional Control 

Initiate 

Working Memory 

Plan/Organize 

Organ materials 

Monitor 

Bri 

MI 

GEC 

0 20 40 60 80 

control-36 

ADHD-20 

ARND-16 

FAS-10 

Research demonstrates that 

there is no safe amount of 

alcohol to consume during 

pregnancy 

Lockhart, Mahone, Mostofsky (unpublished data) 

CNS Effects 

•Depends upon developmental period the exposure occurs 

•Depends upon the sensitivity of the region to alcohol’s toxic 

effects 

•Cell types throughout the CNS and within the same structure 

are differentially sensitive to the toxic effects during certain 

times in gestation 

Brain Behavior Principles 

• The extent of damage is in a “dose-response” relationship 

although this is modulated by genetic variability (Binge 

drinking is worse) 

• There appears to be a synergistic effect of certain added 

compounds like cocaine on the developing CNS 

• Parts of the brain are affected differentially by alcohol 

• Certain regions of the brain are damaged and other regions are 

spared 

• Certain cell types are damaged whereas certain cell types are 

spared 

• Most neurotransmitters systems appear to be affected 

• The absence of dysmorphology does not indicate that the 

individual is spared 

Other Mechanisms of Alcohol Induced 

Neurotoxicity 

• Acetaldehyde formation is teratogenic and is a primary byproduct 

of alcohol metabolism 

• Increased apoptosis can occur from increased free radical 

formation and reactive oxygen intermediates such as 

superoxide and hydrogen peroxide. 

• These molecules can damage proteins and lipids in cells 

leading to apoptosis 

• fetal tissues have less capacity to block the deleterious effects 

of free radical damage because of the lower level of radical 

scavengers such as superoxide dismutase, peroxidase and 

other protecting substances 

Alcohol Induced Cell Death 

• The MNDA antagonist and GABA mimetic properties of 

alcohol can lead to massive apoptotic neurodegeneration in 

the developing brain 

• Action on these receptors may be responsible for the lost of 

millions of neurons during the period of synaptogenesis or 

period of rapid brain growth 

• May be responsible for decrease in brain size 

Ikonomidou, 2000 

6


Suspected Mechanisms Implicated in 

CNS Damage 

• Cell death modes(necrosis and apoptosis) 

• Free radical damage 

• Interference with growth factor functions 

• Adverse effects on astrocyte formation 

• Abnormal development of neurotransmitter system 

• Altered glucose transport and uptake 

• Abnormal cell adhesion molecules 

• Altered regulation of gene expression 

Cerebrum 

Corpus Callosum 

Change in brain size 

Cerebellum 

100 

95 

90 

85 

80 

75 

Cerebrum 

p < 0.010 

PEA 

Cerebellum 

*** 

** 

FAS p < 0.001 

Mattson et al., 1994 

Cerebral Cortex 

Migration Problems 

• cerebral architecture is affected 

• changes in myelination. 

• neurons do not make their way to their 

proper location. 

• frontal lobes and parietal lobes can be 

heavily affected 

During embryonic development cells fail to 

migrate to their proper location 

Miller, 1986 

Blood vessel 

Neuron 

Cortical layer 

I 

II 

III 

IV 

V 

Neuronal Effects 

• neurogenesis 

• neuronal differentiation 

• neuronal migration 

• arborization 

• synaptogenesis 

VI 

Miller, 1986 

7


Radial glia 

In the developing nervous system, radial glia 

provide a scaffold for the outward migration of 

cortical cells. In the mature brain, the cerebellum 

and retina retain characteristic radial glial cells. 

In the cerebellum, these are Bergmann glia, 

which regulate synaptic plasticity. In the retina, 

the radial Müller cell is the principal glial cell, 

and participates in a bidirectional communication 

with neurons. 

GLIA 

Basal Ganglia 

• The caudate and putamen have been found 

to be affected alcohol exposed individuals 

• The caudate in particular has been found to 

be smaller in heavy prenatal alcohol exposure 


• shown to be absent or “thinned”. 

• phenomenon especially demonstrated in 

autopsied brains of alcohol exposed individuals 

I 

• in other cases it’s spatial relationship to other sections of the central 

nervous system is altered even when the size is unaffected. 

Clark et al 2000 

Riley, 2000 

Streissguth, 2000 

8


Corpus callosum 

abnormalities 

Corpus Callosum Abnormalities 

Mattson, et al., 1994; Mattson & Riley, 1995; Riley et al., 1995 

Lockhart, P, Mahone, M., Mostofsky, S unpublished data 

Cerebellum 

• exposure during the last trimester is 

damaging to the cerebellar vermis 

• This period of time is the early post-natal 

period in mice and has been replicated in a 

number of studies 

• particularly affected are the purkinje and 

granule cells 

Alcohol and the Cerebellum 

Purkinje 

Cell 

Layer 

Sowell, 1996 

Pictures courtesy of James West 

Susceptibility Factors 

• Pattern 

• Duration 

• Timing 

• Dose 

• Genetic factors 

• Parity 

• Age of the mother 

• Binge drinking 

• Smoking 

• Other drug use 

• Constitutional 

factors 

• Physical health 

• Poor nutrition 

• Trauma 

• Stress 

Animal models – Example of the 

comparability of effects 

• Growth retardation 

• Facial characteristics 

• Heart, skeletal 

defects 

• Microcephaly 

• Reductions in basal 

ganglia and cerebellar 

volumes 

• Callosal anomalies 

• Hyperactivity, 

attentional problems 

• Inhibitory deficits 

• Impaired learning 

• Perseveration errors 

• Feeding difficulties 

• Gait anomalies 

• Hearing anomalies 

Driscoll, et al., 1990; Samson, 1986 

9


Regions of the Brain Most Commonly 

Affected By Prenatal Alcohol Exposure 

Frontal Lobes 

Parietal Lobes 


Basal Ganglia 

Cerebellar Vermis 

EEG Findings 

• Down’s and FAS compared 

– EEG used to measure alpha waves 

– Lower alpha wave activity in both groups 

– Pattern was different however 

–Down’s 

•Slower 

• Posterior cerebral cortex 

–FAS 

• Weaker wave activity 

• Left hemisphere of the cerebral cortex 

O’Malley, 2000 

Central Nervous System Effects of 

Prenatal Alcohol Exposure 

Hope derives from new concepts of treatment: 

– Psychopharmacology (improving cognition, reduction of 

anxiety and mood problems) 

– Psychotherapy (family support, repetitive messages) 

– Environmental manipulation (structure, mentoring, etc.) 

– Parenting therapy 

– Speech and Language (social skills practice) 

– Occupational Therapy 

– Behavioral Therapy (reward systems) 

– Energy therapy (reduction of anxiety) 

Diagnosing the Patient with FASD 

• Get as much background information as 

possible before the appointment (OT, S and L, 

previous psychiatrics, educational records) 

• Presenting complaint (evaluate historians) 

– Let the caretakers ventilate for part of the session 

– Look for anger, frustration, “burn-out”, or giving up 

Diagnosing the Patient with FASD 

• Elements of the HPI 

– Check for usual Axis I major mental illness and Axis II 

disorders but also check for the following: 

– executive functioning problems (ability to organize, insight, ability to shift 

attention, “cause and effect” reasoning, short term memory) 

– adaptive living skills problems (ability to be alone, taking care of oneself) 

– Social Skills problems (boundaries, treating other children properly, 

touching, hitting, biting, etc.) 

– Motor Skills Problems (fine and or gross motors skills i.e. graphomotor 

skills problems) 

– Speech and Language problems (pragmatic speech, receptive and 

expressive language) 

– Environmental stress and expectations (chaos, abuse, neglect, etc.) 

– How long the child was in every placement 

– Parent expectations and attitude towards the child-quality of attachment 

Development History 

• Birth history( type of exposures, quantity, 

concentration, timing, frequency) 

• Stress and nutrition of the mother (prenatal care?) 

• Birth conditions (non-traumatic, traumatic or high 

risk, prematurity, meconium staining, Apgars) 

• NICU, “Billy” lights, feeding problems, height and 

weight parameters) 

• Quality of acquisition of developmental milestones 

• Easy or difficult baby (colic, quality of sleep, 

appetite, allergies, infections) 

10


Mental Status Exam 

• Presence or absence of dysmorphic features (palpebral 

fissues, mid facial flattening, lip and philtrum appearance, HC, 

palmer crease, hair whorl) 

• Tremors 

• Ability to engage/Eye contact 

• Quality of play 

• Motoric activity 

• Ability to maintain boundaries 

• Presence of hallucinations or delusions 

• Insight/ability to understand right and wrong 

• Working memory and short term memory 

• Concentration 

• Ability to read facial expressions and body language 

Sample Diagnostic Work Up 

• Dysmorphology evaluation 

• Possible genetic testing 

• Lead level 

• MRI 

• EEG 

• Neurological evaluation 

• Neuropsychology Evaluation 

• Speech and Language Evaluation 

• Occupational Therapy Evaluation 

• Behavioral Psychology Evaluation 

Diagnosis of FASD 

• Diagnosis of Exclusion 

• Can have major Axis I diagnosis/es but features of FASD 

may also appear like bipolar disorder, autism, conduct 

disorder, etc. 

• Important to look at the quality of the symptoms and how 

close they are to DSM IV criteria 

• Facial dysmorphic features are suggestive of FASD but also 

rule out presence of a genetic disorder 

• Growth retardation needs to be ruled out (chart growth-are 

there any reasons for non-alcohol associated growth 

problems) 

• Contribution of psychosocial problems to the symptoms 

• What are the protective factors 

Diagnosis of FASD 

• Individuals with FAS and ARND will of course appear 

different 

• But these individuals may be equally cognitively and 

behaviorally disabled 

• Because individuals with ARND are usually not 

identified early they have endured more 

environmental distress and may have more 

secondary symptoms 

Prevention is the Key to Complete 

Elimination of this Very Serious Public 

Health Problem 

Practice prevention in your own lives 

and that of family, friends and social 

contacts 

11


Thank you! 

12

Fetal alcohol spectrum disorders for mental health 

professionals - a brief review 

Paula J. Lockhart 

Fetal alcohol spectrum disorders, characterized by emotional, 

behavioral, cognitive and/or social disability, is an important 

condition to those providing mental health treatment worldwide. 

With no safe level of alcohol consumption found during 

pregnancy, symptoms at the severe end of the spectrum can be 

obvious, easily diagnosed and extremely debilitating; at the mild 

end of the spectrum the disabilities may be subtle, and often 

attributed to other causes. Common symptomatology in an 

individual with fetal alcohol spectrum disorders includes: 

attention problems, impulsivity, mood disorders, conduct and 

oppositional defiant disorder symptoms, drug and alcohol 

problems, impaired executive functioning, memory 

disturbances, learning disabilities, poor social skills and 

reduced ability to function independently as an adult. Because 

of the lack of widespread knowledge of this disorder by mental 

health providers, especially in the absence of mental retardation 

or dysmorphic features, individuals with fetal alcohol spectrum 

disorders are often not identified as having an organically based 

mental health, and/or cognitive disorder; thus reduces their 

ability to qualify for special support services found to improve 

long-term outcome. Despite the great need for neuropsychiatric 

treatment research that could lead to improved fetal alcohol 

spectrum disorders targeted multilevel mental health, and social 

support services, there is much the mental health professional 

can provide at this time to improve the lives of these individuals. 

Accordingly, the mental health community needs to be 

prepared, as the disorder becomes more widely recognized by 

affected patients and their families; they will be requesting 

formal diagnoses and sensitive, creative options to prenatal 

alcohol related problems in all areas of neuropsychiatric 

treatment. Curr Opin Psychiatry 14:463±469. # 2001 Lippincott Williams & 

Wilkins. 

The Kennedy Krieger Institute, Baltimore, Maryland, USA 

Correspondence to Paula J. Lockhart, MD, The Kennedy Krieger Institute, Baltimore, 

MD, USA 

E-mail: lockhart@kennedykrieger.org 

Current Opinion in Psychiatry 2001, 14:463±469 

Abbreviations 

ADHD attention deficit hyperactivity disorder 

ARND alcohol-related neurodevelopmental disorder 

CNS central nervous system 

FAS fetal alcohol syndrome 

FASD fetal alcohol spectrum disorders 

# 2001 Lippincott Williams & Wilkins 

0951-7367 

Introduction 

Fetal alcohol spectrum disorders (FASD) are leading 

causes of preventable emotional, behavioral, cognitive, 

and social dysfunction currently encountered by psychiatrists 

and other mental health professionals 

[1 . ,2,3,4 .. ]. Despite the high pro®le these disorders 

hold in society, this spectrum of conditions often escapes 

recognition by mental health professionals, and may 

represent one of the most under treated of the life long 

developmental disabilities in psychiatry and the other 

mental health disciplines [4 .. ]. 

Experts in the ®eld emphasize that there is a great need 

for an in-depth understanding of these conditions by 

mental health practitioners because of the high prevalence 

of these disorders [4 .. ]. Despite the volumes of 

information known on the neurobiology and neuropsychology 

of FASD, there remains a paucity of 

neuropsychiatric treatment research available to help 

the practitioner [4 .. ]. 

Parents and guardians who have children with FASD 

struggle in managing the severe behavior, emotional and 

cognitive problems of these individuals. They especially 

struggle with the poor adaptive living skills, developmentally 

impaired social skills, and dependency that 

are so characteristic of this population [3]. In addition, 

the criteria that are required to be eligible for disability 

assistance is much narrower than the disability itself. 

This leads to the problem of many individuals not 

qualifying for the ®nancial assistance they require to 

support a lifetime of psychosocial dysfunction [3,4 .. ]. 

This article will highlight the current concepts of 

prenatal alcohol related disability from a neuropsychiatric 

perspective. The current body of literature is vast with 

new and exciting developments, however only speci®c 

issues will be covered in this article because of space 

considerations. General approaches to treatment will also 

be offered, with the understanding that we know far 

more about the etiology and description of these 

disorders, but comparatively little about the amelioration 

of many of these life-long symptoms. 

Historical perspectives 

Lemoine et al. of Nates, France, was one of the early 

investigators who originally observed changes in 127 

offspring of mothers with alcoholism that became known 

as the signs and symptoms of fetal alcohol syndrome 

463

464 

Mental retardation 

(FAS), the most serious case of FASD [5]. Several years 

later, Jones and Smith [6] and Jones et al. [7] of the 

United States brought this disorder to the attention of 

the professional community by publishing their ®ndings 

in the Lancet and naming this disorder `Fetal Alcohol 

Syndrome'. They observed that infants with dysmorphic 

features and growth retardation were being born to 

mothers who abused alcohol during pregnancy. Naming 

this disorder brought to the attention of the community 

the fact that alcohol use and abuse during pregnancy is a 

serious public health hazard, and should be avoided in 

those who are pregnant, or expecting to become 

pregnant. The identi®cation of this disorder also brought 

to the forefront the very serious problem of alcohol 

abuse and addiction in women and men of childbearing 

age, making it a `family disease'. 

Definitions and diagnostic issues 

Diagnosis, and what diagnostic labels actually refer to 

functionally in individuals affected, is an intensely 

studied area in the ®eld of alcohol-related teratogenesis. 

The term fetal alcohol effects (FAE) was widely used in 

research and became a useful clinical term to describe 

any alcohol-related disorder that is not speci®cally FAS. 

The term is being used less often in favor of other less 

ambiguous terms. In an effort at avoiding confusion and 

providing organization and coherency to research ®ndings 

regarding diagnostic issues, Congress mandated the 

Institute of Medicine (IOM) of the National Academy of 

Sciences in 1996, to study FAS and related disorders [8]. 

The IOM arrived at ®ve categories of alcohol-related 

disability, which are summarized as follows: 

(i) 

(ii) 

FAS, with con®rmed maternal alcohol exposure: 

evidence of a characteristic pattern of facial 

anomalies, such as small palpebral ®ssures, thin 

upper lip, ¯attened ®ltrum and midface; evidence 

of growth retardation; and neurodevelopmental 

disability such as microcephaly, structural brain 

anomalies, or neurological hard signs; 

FAS, without con®rmed maternal alcohol exposure: 

the use of the same criteria as (i) without con®rmed 

maternal alcohol exposure; 

(iii) partial FAS, with con®rmed maternal alcohol 

exposure: some components of the characteristic 

facial anomalies, evidence of growth retardation, 

central nervous system (CNS) neurodevelopmental 

abnormalities, a complex pattern of behavior or 

cognitive abnormality that is inconsistent with 

developmental level and cannot be explained by 

familial background or environment; 

(iv) Alcohol-related birth defects (ARBD): the presence 

of congenital anomalies, malformations or dysplasias 

arising as a consequence of prenatal alcohol exposure; 

(v) Alcohol-related neurodevelopmental disorder 

(ARND): evidence of CNS neurodevelopmental 

abnormalities such as decreased cranial size, structural 

brain anomalies, presence of neurological hard 

or soft signs, or a complex pattern of behavioral or 

cognitive abnormalities inconsistent with developmental 

level, which cannot be explained by familial 

background or environment [9]. 

These de®ned categories continue to be used to 

speci®cally communicate the impairment of the prenatally 

alcohol exposed individual. However, it is generally 

accepted that there is a continuum of disability from lethal 

and not consistent with life, to severe, moderate, and mild 

effects that can still leave the individual quite disabled. 

FASD, a new term introduced by O'Malley and 

colleagues, refers to all of the prenatal alcohol-related 

disorders: including FAS, ARND, alcohol-related birth 

defects (ARBD) and FAE. This term implies that the 

disabilities related to prenatal alcohol exposure can occur 

across a continuum and overlap across behavioral, 

emotional, cognitive, social and physical domains of the 

same individual. Astley and Clarren [10,11 . ] have 

created a diagnostic system based on the degree to 

which the facial dysmorphic features, growth retardation, 

and CNS involvement exists as a consequence of 

prenatal alcohol exposure. 

Despite the necessity of being con®ned by labels, 

improved diagnostic accuracy, consistency and clarity is 

provided by an active research community that continues 

to move forward in ®ne-tuning our understanding 

of this spectrum of disorders. 

Prevalence 

Determining the prevalence of FASD worldwide is 

dif®cult, as a result of differences in maternal alcohol 

consumption from region to region, the variability of the 

criteria that are being used for its de®nition, and 

dif®culties determining a diagnosis of FASD at birth. 

However, on the basis of studies by Sampson and 

colleagues [12] it is estimated that there are approximately 

one to three infants born with FAS per 1000 live 

deliveries. The rate of occurrence of both FAS and 

ARND in the Seattle study is estimated to be 9.1 per 

1000 cases, or approximately one child in 100 live births 

with FASD [12]. In other areas of the world, owing to 

harsh economic circumstances, the incidence of FAS can 

be staggeringly high. For example, evaluation of all ®rst 

grade children in a Western Cape community in South 

Africa resulted in 48 out of 1000 children meeting criteria 

for FAS [12]. 

Susceptibility factors to alcohol-induced 

neurotoxicity 

The cause of alcohol's deleterious effects on the CNS 

appears to be multifactorial, with fetuses differentially

Fetal alcohol spectrum disorders for mental health professionals Lockhart 465 

susceptible to the same pattern, duration, timing, and 

dose of alcohol. Because heavy maternal alcohol 

consumption leads to full FAS features in 25±45% of 

exposed pregnancies, other factors seem to in¯uence the 

outcome of the fetus [2,3]. Constitutional genetic factors, 

smoking, other drug use, physical illness and infection, 

poor nutrition, trauma, stress, parity, age of the mother, 

and having given birth to a child previously with FAS, 

are all factors related to the severity of alcohol-related 

neurotoxicity in the fetus [2,3]. 

Alcohol has been shown in numerous human and animal 

studies to have potent direct and indirect effects on the 

developing brain, with there appearing to be no safe 

level of prenatal alcohol exposure [2,3]. Genetic 

variability and the degree of the other in¯uences 

described above in both the fetus and the mother, 

seem to modulate its deleterious effects in certain 

individuals in whom the blood alcohol concentration has 

been high throughout gestation. Several studies demonstrate 

that `binge' drinking (intermittent drinking 

leading to high blood levels) is associated with more 

severe CNS effects than the continuous consumption of 

alcohol throughout pregnancy [13 . ]. The production of 

high blood alcohol concentrations intermittently 

throughout pregnancy appears to cause the most 

extreme cases of prenatal alcohol-related disability in 

those susceptible [13 . ]. 

Central nervous system effects 

Alcohol's neurotoxic effects [14,15 . ] have been shown to 

cause a disturbance of the normal architecture of the 

brain along a continuum in a `dose±response' relationship. 

Autopsy ®ndings demonstrate the range of severe 

CNS malformations that can be caused by this neurotoxin. 

The vulnerability of the CNS to alcohol is related 

to: the developmental period during which the exposure 

occurs, the dose, and the sensitivity of the brain region to 

alcohol's toxic effects. For example is has been shown 

that alcohol can trigger massive neurodegeneration 

through apoptosis (programmed cell death) during one 

of the most vulnerable periods of gestation ± synaptogenesis 

(extending from 6 months of gestation to several 

years after birth). By blockade of N-methyl, D-aspartate 

(NMDA) glutamate receptors and excessive activation of 

gamma-butyric acid (GABA), prenatal alcohol exposure 

can cause the death of millions of neurons in the rat 

forebrain. This can result in reduced brain mass, and in 

the case of the human infant, the possibility of later 

neuropsychiatric problems among other dif®culties [16]. 

It is demonstrated in numerous studies that cell types 

throughout the CNS, and cell types within the same 

structure appear to be differentially sensitive to alcohol's 

neurotoxic effects during different times in gestation 

[17,18 . ]. 

Alcohol's effects can also cause less dendritic branching 

in the frontal and parietal lobes, causing fewer connections 

with neighboring neurons. Studies conducted over 

the past two decades [17,19±21] demonstrate alcoholinduced 

defects in neuronal migration, reduced number 

of neurons in the mature cortex with the same origin, 

delay in cortical neurons being generated, and alteration 

in the distribution of neurons on a speci®c day. Studies 

further suggest that alcohol has an effect on the 

`desynchronization' of radial glia (precursor cells) into 

astroglia. The results of this desynchronization lead to 

late generated neurons unable to complete their migration 

to the super®cial cortex; resulting in neurons being 

stranded in the deep cortex in certain cases. The impact 

of desynchronization may then lead to cortical neurons 

having dif®culty establishing normal circuitry, and 

therefore dif®culties establishing normal CNS architecture 

[19±21]. Adding to these ®ndings, Archibald et al. 

[22 . ] found that white matter volumes, especially in the 

parietal lobe, are more affected than gray matter 

volumes, emphasizing the deleterious effect alcohol 

may have on normal myelination in the CNS. The 

cortex therefore is particularly sensitive to alcohol, 

leading to a thinner cortex, reduced overall mass, fewer 

neurons and a reduced number of glia. Other structures 

of the brain that appear particularly sensitive to the 

direct and indirect effects of alcohol include the corpus 

callosum [23 . ], basal ganglia (particularly the caudate) 

[24] and cerebellar vermis (lobules I±V)] [25]. 

In selected studies, dopamine and norepinephrine 

[26 .. ], serotonin [27], glutamate [28 . ], gamma-aminobutyric 

acid [29 . ] and other neurotransmitter systems have 

all been found to be affected as a consequence of early 

prenatal alcohol exposure. These neurotransmitter abnormalities 

and structural brain changes are of prime 

importance in the etiology of speci®c neuropsychiatric 

conditions, mental retardation, and other cognitive 

disorders. 

Positron emission tomography (PET) studies have 

demonstrated that even in brains without obvious gross 

pathological changes, disturbances in the metabolism of 

certain structures are evident (e.g. caudate nucleus) 

[29 . ]. This indicates that even when the brain is 

displaying no visible changes in its gross architecture, 

the damage can be microscopic. These changes that are 

not readily obvious can also lead to disturbances in 

cognition and behavior. Behavior problems in particular 

appear to be the most sensitive indicator of the presence 

of prenatal alcohol-related disability [29 . ]. 

As the next section indicates, when these structural and 

neurotransmitter abnormalities are combined, they may 

form the neurobiological substrate of such problems as: 

altered response inhibition, memory disturbances, and

466 


attention problems, ultimately effecting the executive 

functioning of these individuals. 

Neuropsychological considerations 

Current research ®ndings describing the neuropsychological 

impact of prenatal alcohol exposure, continue to 

con®rm that a spectrum of cognitive de®cits present in 

individuals with FASD. As the studies are re®ned over 

time, it is becoming more obvious that distinctions such 

as the presence or absence of dysmorphic features, or 

higher or lower IQ in individuals with FAS, do not 

necessarily change the fact that underlying cognitive 

disturbances appear to be related to the FASD disorders 

phenotype. The studies described are examples of this 

overall ®nding. 

Neuropsychological research demonstrates that individuals 

with prenatal alcohol exposure have a wide range 

of neuropsychological impairment in tests measuring 

language, verbal learning, memory, academic skills, 

®ne-motor speed, and visual-motor integration [30]. 

Additionally, research ®ndings are suggesting that these 

disabilities exist in both FAS and in individuals with 

heavy prenatal alcohol exposure without the features 

necessary for a diagnosis of FAS. It appears from these 

studies that these neuropsychological de®cits present a 

consistent pattern in individuals affected. Mattson and 

Riley [30] evaluated whether socioeconomic factors or 

cognitive ability may be responsible for the behavioral 

problems observed in children with heavy prenatal 

alcohol exposure. They employed a non-exposed 

control group matched with the prenatal alcohol 

exposed group for age, sex, verbal IQ, socioeconomic 

status and ethnicity. The group of children with 

prenatal alcohol exposure was composed of both 

individuals with FAS and heavy prenatal alcohol 

exposure without meeting the FAS criteria. They 

concluded that there was a clinically signi®cant 

elevation of scores in the social, aggression, attention 

and delinquent domains of the Child Behavior Checklist 

(CBC) in the FAS and the prenatally alcohol 

exposed group when compared with the non-exposed 

control group. The study demonstrates that socioeconomic 

factors and verbal IQ were not responsible 

for clinically signi®cant behavior scores in children with 

heavy prenatal alcohol exposure. The behavior rating 

scores of the two alcohol-exposed groups were more 

similar to one another than they were to the control 

group [30]. 

Coles et al. [31 .. ] compared two groups of adolescents 

(an alcohol exposed group with an unexposed control 

group of adolescents with attention de®cit hyperactivity 

disorder (ADHD)) on tests of visual sustained attention 

and auditory processing. She and her team found that 

the group with prenatal alcohol exposure had intact 

scores in auditory processing, but impaired scores in 

visual processing. This provides additional evidence that 

the attention problems of individuals with prenatal 

alcohol exposure may be different than in those with 

ADHD without alcohol exposure. 

Kerns et al. [32] demonstrated that adults with FAS 

who had borderline to below average IQ, exhibited 

similar neuropsychological impairment when compared 

to adults who have FAS with average to above average 

IQ. Similarly executive functioning (EF) is shown to 

be impaired in individuals with prenatal alcohol 

exposure with and without mental retardation, and is 

important because of the profound effects impaired EF 

has on daily living skills and self-perception. Mattson 

et al. [33] demonstrated this ®nding in a study 

evaluating executive function, using several assessment 

instruments covering four areas felt to re¯ect normal 

executive function. In their study, executive function 

was impaired in individuals with and without FAS or 

mental retardation on all domains of executive function, 

including planning ability, cognitive ¯exibility, 

selective inhibition, concept formation, and reasoning. 

The team correlated the neuroanatomical ®ndings of 

volume reduction of speci®c structures within the 

fronto-subcortical system as the possible neuroanatomical 

substrate grossly underlying this dysfunction 

[33]. 

Memory in children with FASD may also be impaired as 

a conseqeunce of prenatal alcohol exposure [34]. A study 

by LaForce et al. [34] demonstrated that explicit memory 

(conscious awareness, social adaptation) is impaired and 

implicit memory (accessed through performance) is 

preserved in FASD. The authors also suggest that 

incremental skill learning may be impaired in this 

population. This skill is important in the ability to 

acquire a skill after `extensive' practice. 

Neuropsychiatric complications of prenatal 

alcohol exposure 

It is generally accepted that individuals with prenatal 

alcohol exposure suffer from neuropsychiatric disorders 

that are multifactorial in origin [35,36]. In addition to the 

direct and indirect effect of alcohol exposure on the 

CNS, environment, genetic predisposition to psychiatric 

illness, history of trauma, multiple foster placements, use 

of other drugs by the mother during gestation, smoking, 

stress, and physical illness all contribute to a high 

percentage of alcohol exposed individuals having serious 

life-long neuropsychiatric disability [37]. 

The presence of psychopathology in alcohol-exposed 

individuals has been a prevailing theme since FAS was 

®rst identi®ed 30 years ago. Although individuals with 

FAS and related disorders are heterogeneous with


respect to their psychiatric presentation, attention 

disorders, depression, suicide threats/attempts, panic 

attacks and hallucinations, were the most common 

mental health problems in a group of 415 individuals 

in the `secondary disabilities' study of Streissguth et al. 

[38]. In that study, exposed individuals also had more 

problems with conduct disorder, sexual problems and 

substance use disorders than the general population. 

Attention disorders, a common and pervasive problem 

for alcohol-exposed individuals, continues to be poorly 

understood. In an important study by Coles et al. [39], a 

group of children with attention de®cit hyperactivity 

disorder (ADHD) was compared to children with 

prenatal alcohol exposure on various measures of 

attention, as de®ned by Mirsky et al. [40] (e.g. focus, 

shift, encode and sustain). Her team found that the two 

groups were different on these four attention measures. 

Children with prenatal alcohol exposure had more 

dif®culties with encoding and shifting attention, 

whereas the children diagnosed with ADHD had more 

dif®culties with focus and sustaining attention. Streissguth 

et al. [4 .. ] found that 60% of subjects aged 6±21 

years with both FAS and fetal alcohol exposure reported 

attention de®cit problems. Attention problems appear to 

be a common disability in this population, but studies 

are still underway to understand its underlying neurobiology 

and relationship with the clinical diagnosis of 

ADHD. 

Oesterheld et al. [41] found a prevalence rate of ADHD 

symptoms in 54.5% of 22 subjects with FAS at their 

Birth Defects Clinic (followed from 1984 to 1997), 

utilizing the Connors parent rating scales and the 

Connors teaching rating scales. Oesterheld et al. [42] 

also carried out a pilot study on the effectiveness of 

methylphenidate in four native American children with 

FAS living in a residential center. She found that 

methylphenidate was effective in all four children on 

scores of hyperactivity but not on daydreaming attention 

scores. 

A self-report questionnaire for maternal and child 

depression was administered by O'Connor and Kasari 

[43 .. ], to study the relationship between prenatal alcohol 

exposure and depressive symptoms. They found that 

prenatal alcohol exposure, maternal depression, and the 

child's gender seemed to be highly correlated with 

childhood depressive symptoms. The authors suspect 

from their ®ndings however that mood disorder symptoms 

elicited in this study may be more the organic 

effect of alcohol related neurotoxicity than environmental 

or genetic factors; although they clearly must be 

considered as possible factors [44]. They concluded that 

prenatal alcohol exposure is a risk factor for early onset 

depression. 

There is a huge body of data accumulating about the 

neurobiological underpinnings of DSM IV disorders 

especially ADHD. Treatments for these disorders 

continue to be based on research performed on 

individuals without the markedly disturbed CNS that 

is characteristic of many of those with prenatal alcohol 

exposure. As a result, attempts at psychopharmacological 

and psychotherapeutic approaches to behavior and 

emotional disorders using generic treatments for these 

individuals continue to be even more complicated and 

challenging than in the treatment of non-alcohol 

exposed populations. 

Treatment implications 

For mental health providers, one of the most challenging 

issues is the ability to identify a patient (especially an 

older patient) who may have psychiatric and cognitive 

disability as a consequence of prenatal alcohol exposure. 

In the identi®cation, there is an acknowledgement that 

the patient has an organically based disability, and is not 

necessarily exhibiting dif®cult behaviour out of wilful 

disobedience or other motivation. These individuals 

have, in addition to the major psychiatric symptoms 

present, executive functioning abnormalities and social 

skills disability that may not improve greatly with an 

amelioration of mood, ADHD, psychotic or anxiety 

symptoms. The neuropsychiatric symptoms when superimposed 

on cognitive disability can produce even more 

severe psychosocial disability not treatable with medication 

alone. And as described previously, because of the 

delirious effects of alcohol on the developing brain, 

these individuals may not respond fully to standard 

pharmacological protocols. These standard treatments 

however can be helpful and often reduce the sometimes 

extreme nature of behavioral and emotional dif®culties. 

Alcohol exposed individuals with even average or higher 

intelligence often are described by their parents and 

teachers as having social and moral de®cits, as well as 

problems in adaptive living skills. These organically 

based de®cits appear to lead them into everyday 

problems of understanding cause and effect, exercising 

good judgment, avoiding victimization, being appropriately 

guarded with strangers, and not acting on impulses. 

These individuals are also susceptible to committing 

`innocent crimes', in which they can be arrested or 

incarcerated for offences they did not understand they 

were committing. These are problems that continue to be 

dif®cult to solve even with appropriate psychiatric care, 

emphasizing the importance of multilevel treatment [44]. 

Important areas to cover in the affected alcohol exposed 

patient include psychopharmacological treatment, behavior 

therapy, proper educational placement, speech and 

language services, occupational therapy, direct advocacy 

(with a personal 1 on 1 aide), parent education and 

support, social services, and vocational services.

468 


For the psychiatrist who is managing medications, and is 

part of a team of other mental health professionals, when 

accepting a patient with FASD, they will very often ®nd 

themselves caring for an individual with chronic and 

persistent mental illness. The symptomatology and the 

response to medication may wax and wane over time as 

the individual grows and matures, passing physiologically 

into different phases of their life. In addition to 

concrete symptom relief, being able to support the 

patient and family through crisis is one of the most 

important and meaningful tools that psychiatrists and 

other mental health providers have at their disposal. 

Even if the treatment is not as effective as hoped, 

helping the family to avoid `burn-out', maintain hope 

and enthusiasm for the individual's welfare, and entering 

into a partnership with them to lead this individual to 

their best outcome, are all skills that are important to 

desperate parents [44]. 

When approaching psychopharmacological treatment, 

the psychiatrist needs to be cognizant of common 

physical problems that can complicate one's ability to 

treat these individuals safely (cardiac problems, possibly 

lowered seizure threshold, optic nerve hypoplasia, 

auditory and vestibular problems) as well as atypical 

responses to commonly used medications. Approaching 

carefully as in the treatment of other organic brain 

syndromes is in order; especially in severely affected 

individuals. 

Conclusion 

Mental health treatment research is understood to be 

one of the most urgent areas in need of further 

development. Better psychopharmacological approaches, 

focused individual and group psychotherapy across a 

number of domains (behavioral, social and cognitive) 

need to be developed speci®cally for these individuals. 

Disability criteria need to be broadened in each region, 

to accommodate the recent neurodevelopmental data 

demonstrating severe disability across a spectrum of 

effects. Those with the full FAS criteria are just a small 

proportion of those experiencing severe limitations in 

functioning as a consequence of prenatal alcohol 

exposure. The rather large number of individuals with 

some alcohol-related disability, with and without dysmorphic 

features, or mental retardation leaves the mental 

health community worldwide with the great responsibility 

of identifying and providing life-enhancing support, 

understanding and treatment to this very needy 

population. 

Acknowledgements 

The author wishes to thank Cynthia Keysor, PhD and Elaine Tierney, 

MD for their assistance in preparing this manuscript. 

References and recommended reading 

Papers of particular interest, published within the annual period of review, have 

been highlighted as: 

. of special interest 

.. of outstanding interest 

1 Committee on Substance Abuse and Committee on Children with Disabilities. 

. Fetal alcohol syndrome and alcohol-related neurodevelopmental disorders. 

Pediatrics 2000; 106: no 2. 

This is a quick overview of prenatal alcohol exposure related disabilities. 

2 Hagaman RJ. Fetal alcohol syndrome in neurodevelopmental disorders ± 

diagnosis and treatment. Oxford University Press, New York; 1999. pp. 1± 

59. 

3 Streissguth AP. Fetal alcohol syndrome: A guide for families and communities. 

Brooks Publishing, Baltimore, Maryland; 1997. 

4 Streissguth AP, O'Malley K. Neuropsychiatric implications and long-term 

.. consequences of fetal alcohol spectrum disorders. Semin Clin Neuropsychiatry 

2000; 5:177±190. 

This very timely article explains that there is an urgent need for treatment research 

into the neuropsychiatric sequelae of FASD. The authors review the `secondary 

disabilities', that can arise from the disorder especially if not adequately identified 

early by the medical and mental health community. 

5 Lemoine P, Harouseau H, Borteryu JT, Menuet JC. Les enfants des parents 

alcooliques: anomalies observeÂ es apropos de 127 cas. Ouest Medical 1968; 

21:476±482. 

6 Jones KL, Smith DW. Recognition of the fetal alcohol syndrome in early 

infancy. Lancet 1973; 2:999±1001. 

7 Jones KL, Smith D, Ulleland CN, Streissguth AP. Pattern of malformation in 

offspring of chronic alcoholic mothers. Lancet 1973; 1:1267±1271. 

8 Olson HC. Helping individuals with fetal alcohol syndrome and related 

conditions: a clinician's overview. Presented at the National FAS Conference. 

Atlanta, Georgia, 27±28 April 2001. 

9 Stratton, K. Howe, C. Battaglia, F. (editors) Fetal alcohol syndrome: 

Diagnosis, epidemiology, prevention and treatment. Institute of Medicine 

National Academy Press, Wash. DC; 1996; 4±5. 

10 Astley SJ, Clarren SK. A case definition and photographic screening tool for 

the facial phenotype of fetal alcohol syndrome. J Pediatr 1996; 129:33±41. 

11 Astley SJ, Clarren SK. Measuring the facial phenotype of individuals with 

. prenatal alcohol exposure: correlations with brain dysfunction. Alcohol and 

Alcoholism 2001; 36:147±159. 

This article describes a 4-Digit Diagnostic Code that quantifies and correlates the 

expression of the facial features of FAS and other alcohol related symptoms with 

structural brain abnormalities in alcohol exposed individuals. 

12 Sampson PD, Streissguth AP, Bookstein FL, Barr HM. Environmental health 

perspectives. On categorizations in analyses of alcohol teratogenesis. 

Environ Health Perspect 2000; 108 (Suppl. 3):421±428. 

13 Su B, Debelak KA, Tessmer LL, et al. Genetic influences in craniofacial 

. outcome in an avian model of prenatal alcohol exposure. Alcoholism, Clin Exp 

Res 2001; 25:60±69. 

This article demonstrates that influences on craniofacial development are 

multifactorial and that genetic influences may underlie the differences in facial 

dysmorphia in alcohol exposed chicks when dose and timing of exposure were 

held constant. 

14 Chaudhuri Joydeep D. Alcohol and the developing fetus ± A Review. Med Sci 

2000; 6:1031±1041. 

15 Menegola E, Broccia ML, Di Renzo F, Giavini E. Acetaldehyde in vitro exposure 

. and apoptosis: a possible mechanism of teratogenesis. Alcohol 2001; 23:35± 

39. 

Acetaldehyde is shown in this study to be as teratogenic as ethanol. 

16 Ikonomidou C, Bittigau P, Ishimaru J, et al. Ethanol±induced apoptotic neurodegeneration 

and fetal alcohol syndrome. Science 2000; 287:1056±1060. 

17 Bonthius DJ, Woodhouse J, Bonthius NE, et al. Reduced seizure threshold 

and hippocampal cell loss in rats exposed to alcohol during the brain growth 

spurt. Alcohol Clin Exp Res 2001; 25:70±82. 

18 Ponnappa BC, Rubin E. Modeling alcohol's effects on organs in animal models. 

. Alcohol Research Health 2000; 24:93±104. 

This review very clearly describes a number of possible neurobiological 

mechanisms underlying alcohol's toxic effects on a number of organ systems 

including the central nervous system. 

19 Miller MW. Effects of alcohol on the generation and migration of cerebral 

cortical neurons. Science 1986; 233:1308±1311.


20 Miller MW. Effect of prenatal exposure to ethanol on the development of 

cerebral cortex: I. Neuronal generation. Alcoholism, Clin Exp Res 1988; 

12:440±449. 

21 Miller MW. Cortical neurons is altered by gestational exposure to ethanol. 

Alcoholism, Clin Exp Res 1993; 17:304±314. 

22 Archibald SL, Gamst A, Riley EP, et al. Brain dysmorphology in individuals with 

. severe prenatal alcohol exposure. Developmental medicine and child neurology. 

Dev Med Child Neurol 2001; 43:148±154. 

As in an earlier study significant microcephaly and reduced basal ganglia was 

found disproportionate to the size of the brain. As a result of new findings with this 

higher resolution imaging protocol they were able to demonstrate white matter 

volumes affected more severely than gray matter volumes, and the parietal lobe 

affected more than the temporal and occipital lobes. 

23 Swayze V, Johnson VP, Hanson JW, et al. Magnetic imaging of brain anomalies 

. in fetal alcohol syndrome. Pediatrics 1997; 99:232±240. 

This paper describes the use of structural magnetic resonance imaging to evaluate 

brain abnormalities and compare these scans with a healthy group of control 

subjects. In addition, they demonstrated in this study that there is a relationship 

between midline CNS structures and the severity of dysmorphic facial features. 

24 Mattson SN, Riley EP, Sowell ER, et al. A decrease in the size of the basal 

ganglia in children with fetal alcohol syndrome. Alcoholism, Clin Exp Res 

1996; 20:1088±1093. 

25 Sowell ER, Jernigan TL, Mattson SN, et al. Abnormal development of the 

cerebellar vermis in children prenatally exposed to alcohol: size reduction in 

lobules I±V. Alcohol Clin Exp Res 1996; 20:31±34. 

26 Xu C, Shen R. Amphetamine normalizes the electrical activity of dopamine 

.. neurons in the ventral tegmental area following prenatal ethanol exposure. The 

Journal of Pharmacology and Experimental Therapeutics 2001; 297:746±752. 

In this article the hypofunctioning dopamine neurotransmitter system is described 

as a possible result of prenatal alcohol exposure with its possible significance in 

the etiology of hyperactivity and attention problems in individuals with prenatal 

alcohol exposure. 

27 Eriksen JL, Gillespie RA, Druse MJ. Effects of in utero ethanol exposure and 

maternal treatment with a 5-HT1a agonist on S100B-containing glial cells. 

Developmental Brain Research 2000; 121:133±143. 

28 Thomas JD, Fleming SL, Riley EP. MK-801 can exacerbate or attenuate 

. behavioral alterations associated with neonatal alcohol exposure in the rat, 

depending on the timing of administration. Alcohol Clin Exp Res 2001; 25:764± 

773. 

This team uses the non-competitive NMDA receptor antagonist S100B to study 

ethanol's action at the NMDA receptor and describes how acute exposure and 

withdrawal. 

29 Clark CM, Li D, Conry J, et al. Structural and functional brain integrity of fetal 

. alcohol syndrome in non-retarded cases. Pediatrics 2000; 105:1096±1099. 

This article demonstrates that in a non-mentally retarded population of individuals 

with FAS, 18 of 19 individuals had normal sMRIs. The implication is that gross 

structural brain anomalies may be more common in individuals with FAS and 

mental retardation, with the population in this study representing more of the mildly 

effected group. They go on to state that in certain individuals the alcohol induced 

damage may be on more of a microscopic level and may lead to symptoms 

consistent with FASD. 

30 Mattson SN, Riley EP. Parent ratings of behavior in children with heavy 

prenatal alcohol exposure and IQ-matched controls. Alcoholism, Clin Exp 

Res 2000; 24:226±231. 

31 Coles CD, Platzman KA, Lynch ME, Friedes D. Auditory and visual sustained 

.. attention in adolescents exposed to alcohol. Poster Presentation-National FAS 

Conference, April 27-28, Atlanta, Georgia, 2001. 

This poster presentation provides more evidence that attention problems arising 

from prenatal alcohol exposure may have different characteristics than attention 

problems in the clinical disorder attention deficit hyperactivity disorder. This study 

demonstrates that visual processing is more impaired in individuals with prenatal 

alcohol exposure than auditory processing which is more impaired in ADHD. 

32 Kerns K, Don A, Mateer CA, Streissguth AP. Cognitive deficits in 

nonretarded adults with fetal alcohol syndrome. J Learning Disabil 1997; 

30:685±693. 

33 Mattson SN, Goodman AM, Caine C, et al. Executive functioning in children 

with heavy prenatal alcohol exposure. Alcoholism, Clin Exp Res 1999; 

23:1808±1815. 

34 LaForce R, Hayward S, Cox LV. Impaired skill learning in children with heavy 

prenatal alcohol exposure. J Int Neuropsychol Soc 2001; 7:112±114. 

35 Steinhausen HC, Gobel D, Nestler V. Psychopathology in the offspring of 

alcoholic parents. J Am Acad Child Psychiatry 1984; 23:465±471. 

36 Steinhausen H-C, Willms J, Spohr H-L. Correlates of the psychopathology 

and intelligence in children with fetal alcohol syndrome. J Child Psychol 

Psychiatry 1994; 35:323±331. 

37 Famy C, Streissguth AP, Unis AS. Mental illness in adults with fetal alcohol 

syndrome and fetal alcohol effects. Am J Psychiatry 1998; 155:552±554. 

38 Streissguth AP, Barr HM, Kogan J, Bookstein FL. Understanding the 

occurrence of secondary disabilities in clients with fetal alcohol syndrome and 

fetal alcohol effects. Final Report to the Centers for Disease Control and 

Prevention (CDC). University of Washington, Fetal Alcohol and Drug Unit. 

Tech. Rept. No 96-06, Seattle. 1996. 

39 Coles CD, Platzman KA, Raskind-Hood CL, et al. A comparison of children 

affected by prenatal alcohol exposure and attention deficit hyperactivity 

disorder. Alcoholism, Clin Exp Res 1997; 20:150±161. 

40 Mirsky AF, Anthony BJ, Duncan CC, et al. Analysis of the elements of 

attention: a neuropsychological approach. Neuropsychol Rev 1991; 2:75±88. 

41 Oesterheld JR, Kofoed L, Keppen L, et al. Prevalence of attention deficit 

hyperactivity disorder in children with fetal alcohol syndrome. Poster 

Presentation; Conference on Fetal Alcohol Syndrome, Breckenridge, Colorado,1998. 

42 Oesterheld JR, Kofoed L, Tervo R, et al. Effectiveness of methylphenidate in 

native American children with fetal alcohol syndrome and attention deficit 

hyperactivity disorder: a controlled pilot study. J Child Adolesc Psychopharmacol 

1998; 8:39±48. 

43 O'Connor MJ, Kasari C. Prenatal alcohol exposure and depressive features in 

.. children. Alcoholism: Clin Exp Res 2000; 24:1084±1092. 

This article discusses factors that could be etiologic to the development of 

depression in the exposed child such as environmental or genetic factors, but 

announce the possibility that depressive symptoms could be organically derived 

from structural brain abnormalities arising from prenatal alcohol exposure. 

44 Olson HC, Morse BA, Huffine C. Development and psychopathology: fetal 

alcohol syndrome and related conditions. Semin Clin Neuropsychiatry 1998; 

3:262±284.

MY 9-YEAR-OLD SON’S HISTORY OF DIAGNOSES 

ANXIETY DISORDER NOT OTHERWISE SPECIFIED 

SENSORY INTEGRATION DISORDER 

OPPOSITIONAL DEFIANT DISORDER 

PERVASIVE DEVELOPMENT DISORDER NOS 

MOOD DISORDER NOS 

OBSESSIVE COMPULSIVE DISORDER 

EARLY ONSET BIPOLAR DISORDER 

INTERMITTENT EXPLOSIVE DISORDER 

REACTIVE ATTACHMENT DISORDER 

FETAL ALCOHOL EFFECTS

MY 9-YR-OLD SON’S HISTORY OF MEDICATION TRIALS 

ZOLOFT 

RISPERDAL 

DEPAKOTE SPRINKLES 

CELEXA 

TEGRETOL 

PAXIL 

SEROQUEL 

CLONIDINE 

HALDOL 

TRILEPTAL 

TENEX 

REMERON 

LEXIPRO

MY 9-YR-OLD SON’S MENTAL HEALTH TREATMENT HISTORY 

DIAGNOSTIC EVALUATIONS: 

2 PEDIATRIC NEUROLOGISTS 

4 PSYCHIATRISTS 

2 OCCUPATION THERAPY EVALUATIONS 

1 SPEECH EVALUATION 

2 EEG’S 

2 NEUROPSYCHOLOGICAL EVALUATIONS 

MODALITIES OF TREATMENT: 

4 INPATIENT HOSPITALIZATIONS 

2 DAY TREATMENT PROGRAMS 

2 THERAPEUTIC SUMMER TREATMENT PROGRAMS 

1 CCR HOST HOME (THERAPEUTIC FOSTER HOME) 

OT THERAPY FOR 6 MONTHS 

WRAP-AROUND SERVICES IN HOME TWO DIFFERENT YEARS 

FAMILY BASED SERVICES IN HOME TWO DIFFERENT AGENCIES 

OUTPATIENT PSYCHIATRIC VISITS FOR THE LAST 5-1/2 YRS 

TWO OUTPATIENT THERAPLAY (FOR RAD) WITH DIFFERENT THERAPISTS 

THREE OUTPATIENT PSYCHOLOGISTS 

MARRIAGE THERAPY 

DIDACTIC THERAPY 

INDIVIDUAL THERAPY FOR MY HUSBAND AND MYSELF

Don’t Ask My Child to Fly 

Bruce Ritchie 1997 

Don’t ask my child to fly, 

for he has not wings. 

Don’t ask my child to see the glint on the eagle’s beak, 

For his vision has been diminished. 

Don’t ask my child to remain calm amid the din, 

For his ability to screen out the noises has been taken away. 

Don’t ask my child to be careful with “strangers”, 

For he is affectionate with everyone and prey for the unscrupulous. 

Don’t ask my child to “settle down”, 

For the clock which works for you and I, does not exist for him 

Don’t ask my child to not play with the toys of others, 

For he has no concept of property. 

Don’t ask my child to remember you tomorrow, 

Although you met today. 

Don’t ask my child to heal your wounds, 

For his hands cannot hold a scalpel or sutures. 

Don’t ask my child to meet the challenges set by society, 

For you have denied him the tools. 

Don’t ask my child to forgive society for standing idly by, 

While he was being tortured in his mother’s womb, 

For he WILL, 

But He should not.

T51: Adult Persons with Co-Occurring Mental Health and Substance Abuse Disorders 

Residing and Receiving Treatment in Mercer County 

Cindy Robison, BS, CCDP, Lisa Marshall, BS, CCDP, Stacy Colbert, MA, CAC-D, CCDP-D, 

Lora Shrock, MA, Clyde “Kip” Hoffman, LSCW, Mary Pollock, LPC, MAC 


Description: 

This workshop highlights Mercer County’s MISA Pilot Program, including the levels of care provided by its 

contracted provider network. The focus is on the development of integrated treatment services and the 

barriers faced in implementing a third system of care for those with co-occurring disorders. The Mercer 

County Behavioral Health Commission (MCBHC) describes the admission process, data collection measures, 

and case management services within this program. The providers outline their clinical services, including the 

benefits of providing integrated treatment vs. traditional services, increased training relative to dual diagnosis 

needs, and their successes and challenges in this process. 


• Describe the goals of this pilot program and clinical services available within it; 

• Examine the training needed by staff when delivering integrated services; 

• Identify pros and cons of integrated MISA treatment vs. traditional mental health and drug and alcohol 

treatment services. 

NOTES:


Mercer County Pilot 

Project Proposal 

For Services and Systems 

Integration for Persons with Cooccurring 

Mental Health and 

Substance Abuse Disorders (MISA) 

Introduction 

Mercer County is located in Northwest 

Pennsylvania along the Ohio border and the 

corridors of Interstate Routes 79 and 80. 

The County covers 672 square miles and is 

considered a mixed urban/rural county with 

a population of 122,254. The densest 

urban area is Shenango Valley, which 

consists of a cluster of small cities and 

boroughs. Nearly 40% of the County’s 

population lives in the Shenango Valley 

which is within 20 miles of the greater 

Youngstown-Warren, Ohio area. 

Effective July 1, 1998, Mercer County 

integrated the administration, coordination 

and delivery of all publicly funded Drug and 

Alcohol, Mental Health and Mental 

Retardation services within the authority of 

the private, nonprofit Mercer County 

Behavioral Health Commission, Inc. 

(MCBHC). 

Statistics 

MCBHC Provides: 

Mercer County Behavioral Health 

Commission, Inc. is the Single County 

Authority in Mercer County. Mercer County 

began the Pilot in January 2002, and by 

December 2005 had 385 consumers (81%) 

enrolled in our program with a total of 477 

consumers completing the SIIP. Not all 

were able to come into the Pilot because of 

incarceration, relocation, unable to contact, 

etc. 

1. Intake 

- to determine if MISA eligible 

2. Assessment 

- to determine appropriate level of care 

3. Program Coordinator 

- Position to oversee pilot project/make sure we’re 

meeting state requirements 

4. Case Management 

- 2 positions 

5. Utilization Review 

- Focuses on data collection and length of stay 

authorization for inpatient levels of care 

6. Administrative Oversight 

1


Providers 

MCBHC contracts out for the MISA 

treatment with 

• Sharon Region Health System 

• PHP, IOP and OP 

• Community Counseling Center 


• UPMC/Horizon (For approximately 1 year) 


(MCBHC also has 3 contracts with inpatient 

facilities) 

Mercer County 

Behavioral Health Commission, Inc. 

MISA Pilot Project Admission Criteria 

Consumer is at least 18 years old 

Any level and/or combination (i.e. quadrant) of dual 

disorders are present which interfere with the 

consumer’s ability to function 

Acknowledgement by the consumer that the disorders 

area related to one another 

The consumer is not currently active in either the MH 

or D&A systems (ensuring a random sample) 

Voluntary consent to participate in both MISA 

Treatment and MISA Case Management Services 

Must be a resident of Mercer County 

What has worked for Mercer 

County MISA Pilot Program 

1. One area to complete intakes/ assessments 

2. Case Management Services are mandatory (over past few months, 

MCBHC has not been as stringent in this area) 

3. Case Management Summary/Lisa Marshall Comments 

4. Engagement Meetings 

• Entry meeting to begin services 

• Required attendance: 

• Consumer 

• Therapist 

• Program Coordinator 

• Case Manager 

• MISA Assessor 

• Others that are welcome to attend: 

• Significant Other 

• Probation & Parole 

• Family, etc. 

What has worked (continued) 

5. Actively coordinating MISA services with the criminal justice 

system since it was identified after year one that a large 

percentage of MISA consumers were forensic consumers 

6. Re-engagement Meetings 

• Meetings held for consumers who aren’t compliant to reassess 

circumstances, resolve barriers, etc. 

7. Consumers appear to benefit from all services in one central 

location 

8. The MCBHC pilot has established a third system of care that 

provides all levels of care within that system. 

What has not worked for the Mercer 

County MISA Pilot Program 

1. Transportation 

• It is offered but not for all consumers (i.e. 

outpatient level of care) 

2. Support Group 

• After several attempts were made to start a 

dual support group, it has not succeeded. 

3. Follow-up 

• It has been very difficult to contact 

consumers in the period of 6 months to 12 

months after being discharged. 

2


Introduction 

Sharon Regional Health System 

Behavioral Health Services 

MISA Program 

Levels of Treatment (PHP, IOP and OP) 

Staffing 

Types of Groups/Group Schedule 

Length of Stay 

Transportation 

Growing Pains 

• Dr. shortage 

• Staff changes 

• Different Philosophies 

• Need for rules and regulations to be revised 

Referall Source - January 2002 to March 2006 

70% 

61% 

60% 

MISA Statistics 

50% 

40% 

30% 

20% 

18 % 

10% 

4% 

4% 4% 4% 5% 

0% 

Courts BHC Internal (BHS) CYS Welfare Self Other 

Mental Health Symptons - January 2002 to March 2006 

Substance Abuse Diagnosis - January 2002 to March 2006 

50% 

60% 

45% 

40% 

43% 

50% 

49% 

35% 

40% 

30% 

25% 

30% 

26% 

20% 

15% 

17% 

17% 

20% 

14 % 

10% 

5% 

4% 

3% 

7% 

1% 

6% 

2% 

10% 

5% 

7% 

0% 

Bipolar Depression Major 

Depression 

PTSD ADHD Schrizophrenia Impulse Cont rol Anxiet y Ot her 

0% 

Polysubstance Alcohol Marijuana Cocaine Opiates 

3


Type Discharge - January 2002 to March 2006 

What has worked for the 

MISA Pilot Program? 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

71% 

24% 

2% 3% 

to Maximum External Factors 

Successful Unsuccessful Prior 

Benefit 

1% 

Transfer 

1. Having a psychiatrist readily 

accessible who is knowledgeable in 

the areas of both substance abuse 

and mental health. 

2. Dealing with the substance abuse 

and mental health issues at the 

same treatment program. 

3. Staff training for MISA 

4. Case Management 

What Has Worked (continued) 

What has not worked for the 

MISA Pilot Program 

5. Theme Groups to educate the MISA 

clients 

6. Providing transportation-removing an 

obstacle to treatment. 

7. MISA clients had no concerns regarding 

how to pay for treatment which removed 

an obstacle to entering treatment. 

8. Random drug screens with levels. 

9. Re-engagement meetings. 

1. Forensic Clients 

• Majority of MISA clients were from 

the legal system. This resulted in a 

more D&A slant. 

2. Medication component related to 

Dual Diagnosis 

Future Plans 

Co-Occurring Tract within D&A 

program 

Other staff will be sent to MISA 

trainings 

At least one staff member will obtain 

CCDP 

Goal is to be licensed as Co- 

Occurring Competent 

Community Counseling Center 

MISA Services 

4


Community Counseling 

Center MISA Services 

1. 06/03 1 st client flow from BHC 

2. 3 staff attended 12 week training 

3. Outpatient Services – Capacity 7 clients 

a. Therapy up to 5 hours/week 

b. Medication management 

4. Group therapy integrating psychoeducation with 

therapy. Full 12 week curriculum with handouts, 

videos and written assignments. 

Benefits 

1. 1 chart, 1 set of paperwork for the client instead of 1 

mental health and 1 D&A. 

2. Engagement meeting provided a clear set of 

expectations and responsibilities of all parties. 

3. ICM access provided support outside the office 

setting and a realistic view of the home environment. 

4. Ability for full collaboration between providers 

allowed for consistent and coordinated services. 

5. Psychiatric availability was improved. 

6. Clients understanding the interaction of illnesses 

allows for better relapse prevention. 

SUCCESSES/WHAT WORKED 

OBSTACLES 

1. Easy and timely access to services 

2. Collaboration with ICM, Doctor, P.O., BHC 

3. Psychoeducation 

4. Quarterly meetings with BHC for 

collaboration and program directions 

5. 12 week training in MISA 

6. Ability to see clients more than 7 

times/month 

1. Limited to 1 level of care, therefore clients had to 

change providers if needed higher level of care. 

2. High forensic population with less motivation to 

recover. 

3. Transportation (lack of). 

4. Inability to add internal clients to the program. 

5. Lack of housing options for this particular population, 

especially if they were having difficulty remaining 

chemically free. 

6. Low population of clients due to limited level of care. 

7. Shortage of psychiatric services within the county. 

FUTURE PLANS 

1. CCC will continue to provide 

services to this population under the 

existing systems of care. 

2. CCC will pursue licensure as a cooccurring 

disorder facility. 

3. Expand and improve integration of 

services internally between drug and 

alcohol and mental illness. 

5

T52: Multisystemic Therapy: Applications in PA 

Howard S. Rosen, PhD, Alesia D. Brooks, MA & Gary Soltys, MA 


Description: 

Three licensed MST providers in PA describe the evidence-based model, Multisystemic Therapy, discuss the 

characteristics of the youth/families served, and present long-term outcomes of this intensive in-home and 

community-based treatment. Particular emphasis is on youth with co-occurring mental health and substance 

use disorders. 


• Define the MST model and distinguish MST from other home and community-based models; 

• Describe the mental health and substance use disorders among youth served in MST; 

• Evaluate the continuum of care in their county or agency for youth with serious behavioral and 

emotional problems; 

• Summarize the outcome evaluation of MST. 

NOTES:

1 

Multisystemic Therapy 

MST 

Model 

Hempfield Behavioral Health 


215 Wiconisco Street 


717.221.8004 (voice) 717.221.8006(fax) 

Howard S. Rosen, PhD 

– Focus on “empowering” 

caregivers to solve current 

& future problems 

– Community-based, familydriven 

treatment for 

antisocial/delinquent 

behavior 

– 25 years of solid research 

– Ecology of the youth 

• Family 

• Peers 

• School 

• Neighborhood 

Causal Model of antisocial behavior 

MST Approach 

• Family 

• Low monitoring 

• Low affection 

• High conflict 

• Peer 

• Law-breaking 

• School 

• Low involvement 

• Poor academic achievement 

• Community 

• High mobility 

• Individual 

• Poor verbal and social sills 

1. Address multiple 

risk factors present 

2. Comprehensive 

services 

3. Family-focused and 

collaborative 

4. Well trained & 

supervised staff 

5. Intervene in the 

natural setting 

MST 

Implementation Model 

1. Single Therapist 

with 4-6 families 

2. 4 months (60 hours) 

services 

3. 24/7 team availability 

4. Home, school, & 

community 

5. MST Staff deliver all 

treatment 

6. Lead role in clinical 

decision-making 

SUSTAINABLE RESULTS: Adolescents 

Re-arrests 

Out-of-home placements 

Substance use 

Psychiatric 

symptoms

2 

HBH 30-month 

outcomes 

• 106 youth complete 

MST Treatment 

• 77 (73%) no placement 

post MST 

• 29 (27%) placed 

• Among 29 Placed youth 

• 12 (41%) during MST 

• 17 (59%) post MST 

• Only 16% overall failed 

treatment after 

completing MST 

Youth Characteristics 

• Gender 

• Male 57% 

• Female 43% 

• Race 

• Caucasian 47% 

• AA 39% 

• Latino 6% 

• Bi-racial 8% 

• Age 

• 10-13 19% 

• 14-16 58% 

• 17+ 23% 

DSM-4 4 Diagnosis 

• No Diagnosis 25% 

• Depressed 20% 

• ODD 19% 

• CD 12% 

• D&A 17% 

• ADHD 4% 

• Disruptive 2% 

• IED 1% 

Family Characteristics 

• Family Status 

• Unmarried 35% 

• Married 33% 

• Divorced 33% 

• Living Arrangements 

• Mom only 55% 

• Dad only 8% 

• Both 37% 

Referral Problems 

Previous Treatments 

Curfew Violations 41 

Physical Assault 57 

D&A Use 59 

Theft 40 

Truancy 48 

Terroristic Threats 20 

Vandalism 15 

Runaway 15 

Weapon Possession 9 

D&A sales 6 

• None 29% 

• Therapy 42% 

• Family Tx 16% 

• Boot Camp 6% 

• Residential 7%

3 

NCFAS RESULTS: Adolescents & Parents 

Supervision 88% 

Washington State Institute For Public Policy 2001 

Benefits Minus Costs of Delinquency Prevention Programs 

Disclipline 97% 

Youth Beh. 91% 

School Perf. 97% 


Treatment Foster Care 

Functional Family Therapy 

Scared Straight Programs 

$31,661 

$21,836 

$14,149 

-$6,572 

Family Rel. 97% 

Peer Rel. 97% 

Endorsed As Model Program 

REPLICATION PROGRAMS 

MST operates in 9 countries in addition to 

more than 30 states in the U.S. 

Office of Juvenile 

Justice & Delinquency 

Prevention


Lehigh County, Pennsylvania 

Jill Hoch, Program Director 

John Stein, Area Director 

Lehigh County 

• CSI’s partnership with Lehigh County Juvenile Probation began in 

the spring of 2001. However, the commitment to bring 

Multisystemic Treatment to Lehigh County began several years 

before. The Deputy Chief of the Lehigh County Juvenile Probation 

Office attended a presentation of all the Blueprint models, he then 

attended a presentation by Susan Pribyson from CSI on MST. 

• CSI and JPO began a partnership and identified funding through a 

county grant. 

• In January of 2002 a Lehigh MST team was formed to services JPO 

referrals. 

Juvenile Probation- Lehigh County 

Julie DePhillips, LCSW 

Supervisor 

MST Team 

• Jovanka Mena 

• MaryBeth McNicholas – SPORE Referrals 

• Leah Beil 

– 10 JPO 

– 5 SPORE 

Clients Discharged: 36 

Completed Treatment: 94.44% 

Youth Still at home: 97.22% 

Youth in school/education: 97.22% 

Youth with no new arrest: 88.89% 

» Reporting period 1/1/05-6/30/05 

CSI Partners with OCYS 

• CSI’s partnership with Lehigh County Office of Children Youth and 

Family Services began in 2003. 

• Due to the existing partnership with LCJPO, The child welfare 

department expressed an interest in beginning a MST team due to 

the cost savings that MST would provide in comparison with the 

many foster care agencies they were currently utilizing. 

Office of Children and Youth 

Services – Lehigh County 

Julie DePhillips, LCSW 

Supervisor 

MST Team 

• Wallenstein Viduarre 

• Ashlee Geiger 

– 10 slots 

Clients Discharged: 16 

Completed Treatment 87.5% 

Youth Still at home: 93.75% 

Youth in school/education: 68.75% 

Youth with no new arrest: 81.25% 

» Reporting period 1/1/05-12/31/05 

1

Adelphoi Village 


Gary J. Soltys, M.A 

Director of MST 

Pennsylvania Infrastructure 

Adelphoi Village—USA 

(over 30 years of services to youth) 

Adelphoi USA – is a nonprofit corporation serving communities 

of need through exemplary and affordable human service 

programs for children, youth and families. Adelphoi 

Village is leveraging its experience as an MST provider to 

promote more cohesive state dissemination of MST. 

1. Adelphoi Village- JCAHO services to kids & families: RTF 

programs, group homes, foster care, day treatment and 


2. Adelphoi, Inc.-technical and administrative 

3. Ridgeview Academy-education services 

4. Homes Build Hope-affordable housing 

History of MST Services in Pennsylvania 

< 1998 # of kids served-0 

1999- 2000 # of kids served-35 

2000- 2001 # of kids served-100 

2001- 2002 # of kids served-180 

2002- 2003 # of kids served-300 

2003- 2004 # of kids served-400 

2004- 2005 # of kids served-500 

2005- 2006 # of kids served-675 

MST Services by Counties in 

Pennsylvania 

67 counties in Pennsylvania 

MST services in 20 counties-April 

2006 

Expansion plans for MST to 5 

additional counties in 2006 

2005 MST Services in Pennsylvania 

20 counties 

Adelphoi USA MST 

14 Teams 

Adelphoi USA Teams =14 counties 

Adelphoi USA Network Providers = 4 

Community Solutions Inc. = 2 

Hempfield Associates = 2 

Two additional MST providers in 

2006 

Adams-JP0 

Armstrong-JPO & 

CYS 

Beaver- JPO & CYS 

Blair-JPO & CY 

Cambria-JPO & CYS 

Cumberland-JPO & 

CYS 

Fayette- 

JPO,CYS,MH 

Greene – JPO, CYS 

Indiana – JPO & CYS 

Mercer-JPO & CYS 

Washington-JPO & 

CYS 

Warren – JPO & CYS 

Westmoreland-JPO 

York-JPO 

1

Adelphoi Network Providers 

4 counties + 

2 Other MST Providers 

Mars Home 

Venango- JPO & CYS 

Butler- JPO 

Cray Youth & Family 

Lawrence – JPO & CYS 

Hempfield Associates – Dauphine Co. 

Juvenile Probation and Children & Youth 

Community Solutions, Inc. – Lehigh Co. 

Juvenile Probation 

Child Guidance Center 

Delaware – JPO & CYS 

2005 

ADMISSION DATA REVIEW 

FOR 

ADELPHOI VILLAGE’S 

Blair MST Program 

Blair County Juvenile Probation 

And 

Blair County Children and Youth Services 

Total number of clients serviced 48 

Total by Agency 

1/1/2005 – 12/31/2005 

Juvenile Probation 20 

Children and Youth 28 

Total discharges both agencies: 

TOTAL 

DISCHARGE 

S 

GOALS MET/ 

PARTIAL MET 

GOALS 

NOT MET 

31 27 4 

% % % 

100% 87% 13% 

DISCHARGES PER AGENCY 

TOTAL 

DISCHARGES 

JPO 

GOALS MET/ 

PARTIAL MET 

GOALS 

NOT MET 

12 11 1 

% % % 

100% 92% 8% 

*** Three cases not counted due to exclusionary criteria. 

2

DISCHARGES PER AGENCY 

TOTAL 

DISCHARGES 

CYS 

GOALS MET/ 

PARTIAL MET 

GOALS 

NOT MET 

19 16 3 

% % % 

100% 84% 16% 

Average Length of Stay per Discharges 

(JPO) 

TOTAL 

DISCHARGES 

GOALS MET/ 

PARTIAL MET 

GOALS 

NOT MET 

12 11 1 

# of Days # of Days # of Days 

1627 1591 36 

Average # of Days Average # of Days Average # of Days 

136 145 36 

*** Three families not counted due to exclusionary criteria. 

Average Length of Stay per Discharges 

(CYS) 

TOTAL 

DISCHARGES 

GOALS MET/ 

PARTIAL MET 

GOALS 

NOT MET 

19 16 3 

# of Days # of Days # 0f Days 

2867 2380 487 

Average # of days Average # of days Average # of days 

151 149 162 

DISPOSITION UPON RELEASE 


# of youth 

Children and 

Youth #of youth 

Home 11 17 

Hilltop Home 0 1 

Cove Forge 1 0 

Youth Forestry Camp 1 0 

Current Active MST 

Clients (as of 

12/31/05) 

5 6 

Placement Referrals for MST 

Referred From: 


# of youth 

Children and 

Youth #of youth 

Greystone 2 0 

Foster Care 0 1 

Mon Run 1 0 

Cove Forge 1 0 

Holy Family 0 1 

Home 16 26 

Current Active 

Cases 

5 6 

Total Clients with Mental Health 

Diagnosis/Diagnostics 

Number of Clients Mental Health Diagnosis Percentage/Average 

Total 27 100% 

JPO 14 52% 

CYS 13 48% 

Mental Health Diagnosis 

Juvenile Probation # of 

youth 

Children and Youth #of 

youth 

ADHD/ADD/ODD/Cond 

11 8 

uct Disorder 

Depression 5 4 

PTSD 1 0 

Bipolar Disorder 1 1 

Adjustment Disorder 0 0 

Anxiety 1 0 

3

Total Clients Referred with 

Substance Abuse/Diagnosis 

Total Clients with Truancy 

Behaviors 

Number of Clients Substance Abuse Percentage/Average 

Total 24 100% 

JPO 10 42% 

CYS 14 58% 

Number of 

Clients 

Truancy 

Percentage 

Total 24 100% 

Referred With: 


# of youth 

Children and Youth 

#of youth 

JPO 9 37% 


4 12 

Problems 

Axis Diagnosis 6 2 

Total 10 14 

CYS 15 63% 

Age by Placing Agency 


Children and Youth 

Age 

No. of 

Youth 

% Age No. of 

Youth 

11 0 0% 11 0 0% 

12 1 5% 12 2 7% 

13 4 20% 13 3 11% 

14 4 20% 14 7 25% 

15 3 15% 15 8 28.6% 

16 3 15% 16 6 21.4% 

17 5 25% 17 2 7% 

Total 20 100 Total 28 100 

Average 

Age 

14.9 Average 

Age 

14.7 

% 

Total by Race by Agency 

Juvenile Probation Children and Youth 

Race # Youth % Race # Youth % 

White 14 70% White 24 86% 

Black 3 15% Black 3 11% 

Other 3 15% Other 1 3% 

Total 20 100% Total 28 100% 

Thank you.. 

And now for questions and 

comments. 

4

T53: Using Change Theory to Assess Readiness for Change in Persons with Co-Occurring 

Disorders 

Carol Auerbach, MA 


Description: 

This workshop describes the use of change theory to assess a person’s readiness for change regarding any 

and all diagnoses and issues he/she may present at assessment and beyond. The ways that readiness 

assessment informs program structure and selection for persons with co-occurring disorders is discussed. 

Tools and resources for program and practitioner use are presented. 


• List the stages of change and the characteristics of persons within each stage; 

• Describe simple assessment procedures for correctly identifying someone’s current stage for any 

diagnosis or area of concern; 

• Identify tools and resources for creating program/practitioner responses that meet people where they 

are in terms of their stage of change readiness.


Workshop Objectives 

TR53 Using Change Theory to Assess 

Readiness for Change in Persons 


2:45PM – 4:15PM, May 16, 2006 

Carol J. Auerbach, MA 



By the end of this workshop, participants will be 

able to: 

– List the stages of change and the 

characteristics of persons within each stage 

– Describe simple assessment procedures for 

correctly identifying someone’s current stage 

for any diagnosis or area of concern 

– Identify tools and resources for creating 

program/practitioner responses that meet 

people where they are in terms of their stage 

of change readiness. 

The Transtheoretical Stages of 

Change Model (Prochaska and 

DiClemente, 1984) 

Research (1972): Smokers and people 

in a behavioral weight loss program 

“What makes for successful selfchange?” 

Conclusions: 

Behavioral change is gradual 

Involves a series of invariant, 

developmental, observable stages 

and behaviors 

The Transtheoretical Stages of 

Change Model (Cont’d.) (Prochaska and 


Is influenced strongly by: 

Readiness 

Sense of self-efficacy 

Results: 

Development of a model of change 

that includes making the decision to 

change and maintaining the change 

once it was made 


(Prochaska & DiClemente, 1991, Miller & Rollnick, 1991) 

I. Precontemplation: 

Person has no intention 

to change because they 

are: 

1.Unaware 

2.Uninterested 

3.Unwilling 



II. Contemplation: 

Person is aware that a problem exists and is 

ambivalent about whether to do anything 

about it 

– Giving up on an enjoyed behavior causes 

a feeling of loss 

– People want to weigh the barriers to 

change against the benefits of change 

– Making a final decision is difficult; people 

therefore refuse to make a commitment 

either way 

1




III.Preparation or Determination: 

The person has made a decision to 

change in the next month and is preparing 

for it. 

• The person may be experimenting with 

small changes 



IV. Action: 

The person is actively changing 

their environment, behavior, and/or 

experiences in order to overcome 

pain or pursue a goal and has 

maintained their changes for three 

to six months. 



V. Maintenance: 

The person is working to prevent 

relapse and consolidate what they 

have gained from taking and 

maintaining action for over 6 

months. 



VI. Relapse: The person 

has: 

• minor slips or 

• major relapses 

Change Process as a Wheel 


Tools and Instruments to 

Identify Stage of Change 

• University of Rhode Island 

Change Assessment Scale 

(URICA) (DiClemente & Hughes, 

1990) 

• Readiness to Change Ruler 

(Prochaska et al., 1992) 

• Stage of Change Algorithm (Rossi 

et al. 1993; Prochaska & 


2


Tools and Instruments to 

Identify Stage of Change (Cont’d.) 

• Stages of Change Readiness and 

Treatment Eagerness Scale 

(SOCRATES) (Miller & Tonnigan, 1996) 

• Readiness to Change Questionnaire 

(RCQ-TV) (Heather et al., 1996) 

• Others 

– http://casaa.unm.edu/inst.html 

– http://www.health.org/govpubs/BKD342/3 

5o.aspx 

Implications of the Stages of 

Change Model (Miller & Rollnick, 1991) 

• Helping a person move along the 

stages of change is the focus of 

treatment 

• The counselor needs to match 

intervention strategies to the 

person’s current stage of change to 

be most effective 

Edwards, L., Jones,H. & Belton, A. ( 1999), 

Interventions for Individuals in 


•Engage 

• Raise doubt about current behavior 

•Methods: 

– Explore person’s attitude towards 

their behavior 

– Provide data and information in a 

low key manner 

– Stress options/choice in 

behavior. 

Interventions for Individuals in 

Precontemplation (Cont’d.) 

• Depending on the behavior of the 

individual: 

– Arguing: Listen empathetically and reflect; 

remind person of choice 

– Expressing hopelessness: Listen for evidence 

of past success and praise; state your own 

hopefulness 

– Minimizing: give data on individual’s situation 

compared to the norm 

Therapist’s Tasks in 

Contemplation 

(Prochaska et al, 1994) 

• Explore the risks and benefits of not 

changing 

• Explore the risks and benefits of 

changing 

• Increase the person’s perception of the 

pros of changing 

• Strengthen the person’s sense of selfefficacy 

3


Therapist’s Tasks in Preparation 

(Miller & Rollnick, 1991) 

• Affirm their decision 

• Identify their options for 

change 

• Develop detailed plans 

Therapist’s Tasks in Preparation 

(Cont’d.) (Miller & Rollnick, 1991) 

• Reduce barriers to change: 

• Connect to support systems and 

community resources) 

• Address concerns re: friends, social 

status, leisure time 

• Rehearse 

Therapist’s Tasks in Action 


• Help the person take steps toward 

change (problem-solve) 

• Support; do with; demonstrate; practice 

• Process emotions 

– Reassure 

• Increase awareness of benefits of 

changing 

Therapist’s Task in Relapse 

(from Miller & Rollnick, 1991, Dolan, 2004) 

Lapses 

• Help the individual see lapse as normal 

part of the change process 

• Redirect to the change process 

• Encourage the person to have hope 

• See lapse as a" Learning experience” 

• Make modifications to plan if needed 

Therapist’s Task in Relapse 

(Cont’d) (from Miller & Rollnick, 1991) 

Major relapses (additional tasks) 

– Determine current stage of change 

– Re-examine motivation 

–Reassure 

– Rebuild sense of self-efficacy 

4


Therapist’s Task in Maintenance 

(from Miller & Rollnick, 1991) 

• Help the person to identify 

strategies to: 

– Get continual support 

– Prevent relapse 

• Address new threats of 

relapse and desires to return 

to old patterns 

Current Status of TTM 

(Brug et al., 2005) 

• Utility debated 

•Concerns: 

– Too simplistic 

– “Targeted interventions” rather than 

“tailored to individual” 

– Shows poor long-term outcomes 

– Stage instability 

Current Status of TTM (Cont’d.) 

(Brug et al., 2005) 

– Need for objective assessment 

– Need knowledge of important modifiable 

stage determinants 

– Progression thru stages is insufficient for 

behavior change 

• For ongoing information on the status of the 

research go to: 

http://bmj.bmjjournals.com/cgi/eletters/332/ 

7539/458#128200 

Short Bibliography 

• Amador, X. (2000). I AM NOT SICK I DON’T NEED HELP! Helping the 

seriously mentally ill accept treatment: A practical guide for families and 

therapists . New York: Vida Press. 

• Bellack, A.S. & DiClemente, C.C. (1999). Treating substance abuse 

among patients with schizophrenia. Psychiatric Services, 50 (1), 75-80. 

• Brug, J., Connor, M., Harre,N., Kremers, S., McClellar, S and Whitelaw, 

S. The Transtheoretical Model and Stages of Change: a critique. (2005). 

Health Education Research, 20, 244-258. 

• DiClemente, C.C. & Hughes, S.O.(1990). Stages of change profiles in 

outpatient alcoholism treatment. 

Substance Abuse.2, 217-35 

• Dolan, M. The Revised Stage of Change Model. Unpublished PowerPoint 

presentation April 22, 2004. 

• Edwards, L., Jones,H., Belton, A. ( 1999), The Canadian Experience 

in the Development of a Continuing Education Program for Diabetes 

Educators Based on the Transtheoretical Model of Behavior Change 

Diabetes Spectrum, 12, 157 

• Heather, N.; Luce, A.; Peck, D.; and Dunbar, B. "Development of the 

Readiness to Change Questionnaire (Treatment Version)." Report to the 

Northern and Yorkshire R & D Directorate, 1996a. 

Short Bibliography (continued) 

• Miller, W.R. & Rollnick, S. (1991). Motivational interviewing: Preparing 

people to change addictive behavior. New York: Guilford Press. 

• Miller, W.R. SOCRATES. (1995). The Stages of Change Readiness and 

Treatment Eagerness Scale (Version 8). Albuquerque (NM): University of 

New Mexico 

• Miller, W.R. & Tonigan, J.S. (1996). Assessing drinkers’ motivations for 

change: The Stages of Change Readiness and Treatment Eagerness Scale 

(SOCRATES). Psychology of Addictive Behaviors, 10(2), 81-89. 

• Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of 

how people change: Applications to addictive behavior. American 

Psychologist, 47, 1102-1114. 

• Prochaska, J.O.& DiClemente, C.C. (1984). The transtheoretical approach: 

Crossing traditional boundaries of therapy. Homewood, IL: Dow Jones- 

Irwin. 

• Rollnick, S., Heather, N.,Gold, R. & Hall, W. (1992). Development of a short 

‘readiness to change’ questionnaire for use in brief, opportunistic 

interventions among excessive drinkers. British Journal of Addiction, 87, 

743-754. 

5

The following questionnaire is designed to identify how you personally feel about your drinking 

right now. Please think about your current situation and drinking habits, even if you have given up 

drinking completely. Read each question below carefully, and then decide whether you agree or 

disagree with the statements. Please tick the answer of your choice to each question. If you have 

any problems, please ask the questionnaire administrator. 

Your answers are completely private and confidential 

Key: SD = Strongly Disagree D = Disagree U = Unsure A = Agree SA = Strongly Agree 

SD D U A SA For office 

use only 

1. There is no need for me to _____ _____ _____ _____ _____ PC 

change my drinking habits. 

2. I enjoy my drinking, but _____ _____ _____ _____ _____ C 

sometimes I drink too 

much. 

3. I have reached the stage _____ _____ _____ _____ _____ PA 

where I should seriously 

think about giving up or 

drinking less alcohol. 

4. I am trying to stop drinking _____ _____ _____ _____ _____ A 

or drink less than I used to. 

5. I was drinking too much at _____ _____ _____ _____ _____ M 

one time, but now I've 

managed to cut down (or 

stop) my drinking. 

6. It's a waste of time thinking _____ _____ _____ _____ _____ PC 

about my drinking because 

I do not have a problem. 

7. Sometimes I think I should _____ _____ _____ _____ _____ C 

quit or cut down on my 

drinking. 

8. I have decided to do _____ _____ _____ _____ _____ PA 

something about my 

drinking. 

9. I know that my drinking _____ _____ _____ _____ _____ A 

has caused problems, and 

I'm now trying to correct 

this. 

10. I have changed my _____ _____ _____ _____ _____ M 

drinking habits (either cut 

down or quit), and I'm 

trying to keep it that way. 

11. There is nothing seriously _____ _____ _____ _____ _____ PC 

wrong with my drinking. 

12. My drinking is a problem _____ _____ _____ _____ _____ C 

sometimes. 

13. I'm preparing to change _____ _____ _____ _____ _____ PA 

my drinking habits (either 

cut down or give up 

completely). 

14. Anyone can talk about _____ _____ _____ _____ _____ A 

wanting to do something 

about their drinking, but I 

am actually doing 

something about it. 

15. It is important for me to _____ _____ _____ _____ _____ M

hold onto the changes I've 

made, now that I've cut 

down (or quit) drinking. 

16. I am a fairly normal 

drinker. 

17. I am weighing up the 

advantages and 

disadvantages of my 

present drinking habits. 

18. I have made a plan to stop 

or cut down drinking, and I 

intend to put this plan into 

practice. 

19. I am actually changing my 

drinking habits right now 

(either cutting down or 

quitting). 

20. I have already done 

something about my 

drinking (either cut down or 

stopped completely), and 

I'm trying to avoid slipping 

back. 

21. Giving up or drinking less 

alcohol would be pointless 

for me. 

22. I'm uncertain whether or 

not I drink too much. 

23. I have a drinking problem, 

and I really want to do 

something about it. 

24. I have started to carry out 

a plan to cut down or quit 

drinking. 

25. I am working hard to 

prevent having a relapse of 

my drinking problem. 

26. There is nothing I really 

need to change about my 

drinking. 

27. Sometimes I wonder if my 

drinking is out of control. 

28. If I don't change my 

drinking soon, my 

problems will just get 

worse. 

29. I am actively working on 

my drinking problem. 

30. I've succeeded in stopping 

or cutting down drinking. 

_____ _____ _____ _____ _____ PC 

_____ _____ _____ _____ _____ C 

_____ _____ _____ _____ _____ PA 

_____ _____ _____ _____ _____ A 

_____ _____ _____ _____ _____ M 

_____ _____ _____ _____ _____ PC 

_____ _____ _____ _____ _____ C 

_____ _____ _____ _____ _____ PA 

_____ _____ _____ _____ _____ A 

_____ _____ _____ _____ _____ M 

_____ _____ _____ _____ _____ PC 

_____ _____ _____ _____ _____ C 

_____ _____ _____ _____ _____ PA 

_____ _____ _____ _____ _____ A 

_____ _____ _____ _____ _____ M

THE STAGES OF CHANGE APPLIED TO COUNSELING FOR:____________________________________ 

DENIAL GET READY GET SET GO MAINTENANCE 

Essential 

cognition 

“I have no interest 

______________.” 

“I am ready to 

______________.” 

“I am a _____________ 

___________________.” 

“I want to 

________________ 

but I really like 

________________.” 

Ambivalence Not ambivalent; wants to 

____________________. 

Ambivalent 

Behavior Rejects new information Willing to receive new 

information 

Characteristic Denial, defiance, 

Fear of failure, fear of 

resistance rationalization, ignorance consequences 

Counseling 

approach 

Acceptance, patience; 

acknowledging; encourage 

client to listen to the 

experience of others; be 

satisfied with minimal 

progress conceptualize this 

client:_________________ 

in deep denial, not a 

troublemaker; introduce 

ambivalence: “Is there any 

way at all in which you 

would be better off if you 

_____________________ 

that might be something to 

think about. 

Acceptance, patience; 

review coping skills 

and addiction 

knowledge; identify the 

resistance; explore 

potential barriers to 

success; explore both 

sides of the 

ambivalence: “What do 

you like about 

_________________. 

How would you be 

better off if you 

________________? 

What will you miss 

most about 

________________? 

Which withdrawal 

symptoms gave you 

trouble in the past? 

Not ambivalent; wants to 

stop________________. 

Requesting advice and 

information 

Fear of failure, 

ignorance 

Directness, clarity, specific 

suggestions; identify an 

approach that the client will 

accept, identify sources of 

support, use approval, 

praise, encouragement, 

make follow-up 

appointment. “You have 

made a good decision. 

Let’s work together. How 

can I help you? What 

problems do you 

anticipate? 

“I don’t ____________ 

___________________ 

anymore.” 

Frequently want to 

_______________again. 

Accepts new information 

Frustration 

Identifying relapse issues 

as they arise: dealing with 

strategies to counter 

pressures to relapse, 

providing encouragement 

and support, treating 

depression if it occurs, 

encouraging use of 

___________________ 

and peer support. “How 

have you done since we 

last met? How did you 

deal with wanting to 

___________________? 

Tell me what’s worked for 

you?” 

Occasionally want to 

_________________. 

Gives information to others 

Self-righteousness 

Praise, reassurance; 

identifying relapse issues 

and patterns of behavior; 

group or individual 

psychotherapy dealing with 

core issues, providing 

support to others. “Let’s talk 

about the person you want 

to be. What are you doing to 

become more like that 

person? What issues have 

appeared in your recovery?” 

Goal 

Primary 

objective 

Education 

The client will move from 

_____________________. 

Introduce ambivalence 

Education 

The client will move 

from “get ready” to 

“get set”. 

Resolve ambivalence in 

favor of ____________. 

Education 


“get set” to “go”. 

Provide strategies for 

___________________. 

Education 


“go” to “maintenance”. 

Eliminate relapse triggers. 

Education 

The client will discover the 

truth about his or her life. 

Promote emotional and 

spiritual growth. 

(Caldwell, 1998)

T54: Medication Use with Co-Occurring Diagnoses 

Craig Strickland, PhD 


Description: 

This seminar takes a look at evidence-based practice as applied to prescribing, or not prescribing, psychotropic 

medications for the person with both a mental illness and substance use diagnosis. Major medication classes 

are discussed in terms of benefits and side effects and, whenever possible, recommendations of one 

medication type over another for the dually-diagnosed consumer. Introductory material relating to the 

neuroanatomy and physiology of the central nervous system is also presented and linked to why some 

medications should be prescribed and why others should be avoided in this population. 


• Identify the basic brain structures and primary neurotransmitters involved in chronic mental illness as 

well as in substance abuse; 

• Describe the rationale for prescribing (or not prescribing) a psychotropic medication for a consumer 

with a known substance use diagnosis; 

• List at least three non-benzodiazepine alternative pharmacotherapies for treating anxiety disorders. 

NOTES:


Medication Use with Co-Occurring 

Disorders (The Why and Why Not of 

Prescribing Medications) 

The Real Goal 

• “The challenge for clinicians lies in 

matching a patient’s clinical and 

biochemical profile with that of a 

drug’s pharmacological actions, in 

order to achieve optimum outcomes” 

Craig Strickland, Ph.D. 

Voruganti, Cortese and Oweumi, et. al. 

(2002) 

Mindset: 

Risk factors influencing both psychiatric 

and D&A disorders 

• Genetic Risk 

–Structural changes 

–Neurochemical changes 

• Environmental risk: socioeconomic 

and some of the more “external” factors 

• Pharmacological risk: this category 

truly refers to the why and the why 

not of prescribing medications 

Mindset: 

What are the goals of 

Psychopharmacology??? 

•Reduction of psychiatric and D&A 

symptoms in terms of: 

–Symptom Intensity 

–Symptom Frequency 

–Symptom Duration 

• Minimize Side-effects 

Mindset: 

“Side-effects”of medications 

can cause: 

• Physical side-effects (including 

tolerance and withdrawal) 

• Stimulating, sedating or euphorigenic 

effects 

•Abuse and/or addiction potential 

• D&A disorder relapse 

• Psychiatric disorder relapse 

TREATING 

SCHIZOPHRENIA 

1


• Nigrostriata 

Dopamine and 

Schizophrenia 

• Mesolimbic 

• Hypothala 

mic- 

Pituitary 

Schizophrenia & the 

Brain: Dopamine & The 

Limbic System 

Schizophrenia and the 

Brain: Dopamine 

Schizophrenia & Serotonin (5-HT) 

Serotonin 

Pathways 

2


Anti-psychotics and MISA 

• Atypical Anti-Psychotics: advantages 

over traditional anti-psychotic meds. 

– ↓ of positive & negative symptoms 

–Incidence of EPS/tardive dyskinesia: 

lower 

•MISA consumers are more at risk for 

EPS/tardive dyskinesia 

•With atypicals, less need for anti-cholinergic 

meds; used to control side-effects 

•Improvement in compliance 


–Do not block “reward system” compared 

to traditional neuroleptics 

–Atypicals may reduce drug seeking 

behavior (through 5-HT2a 

receptor?) 


• Other uses for Atypical Antipsychotics 

–Bipolar Affective Disorder 

–Anxiety disorders (PTSD?) 

–Augmentation therapy 

–Depression??? 


• Disadvantages of atypical antipsychotic 

meds. 

–Metabolic Syndrome which includes: 

•Increased insulin resistance/diabetes 

•Lipid level increase 

•Cardiovascular conditions 

•Hyperprolactinemia 

Anti-depressants and MISA 

Treating 

Depression 

• MAOIs: 

– effective in vegetative/major depression 

– dietary restrictions 

•TCAs 

– block re-uptake of 5-HT and NE 

–reduce craving? (Norpramin, Tofranil) 

– many are sedating (histamine effect) 

– cholinergic side-effects 

– cannot mix with CNS depressants nor 

psychostimulants; OD potential 

3


Anti-depressants and MISA 

•SSRIs 

– better side-effect profile; leads to 

better compliance 

– reduce impulsive/compulsive behaviors 

– reduce anxiety 

–safer when mixing with drugs/ETOH 

–not more effective than TCAs 

– does not mix with OTC cold remedies 

–may produce slight to moderate 

stimulation 

Anti-depressants & MISA 

•Novel anti-depressants 

–Serzone: 5-HT2a receptor blocker & 

blocks 5-HT reuptake 

–Wellbutrin: weak 5-HT/NE reuptake 

inhibitor; may act to inhibit DA reuptake 

–Remeron: enhances brain 5-HT and NE; 

has a strong anti-histamine action (similar 

to Desyrel) 

–Cymbalta (duloxetine; see next slide) 

Anti-depressants & MISA 

•Duloxetine (Cymbalta): the “new Effexor” 

–Does not induce hypertension (sometimes seen 

with drugs that increase NE) 

–No significant effects on body weight? 

–Can reduce anxiety levels 

–No differences in female sexual functioning (as 

compared to Paxil) 

–Comparable delay in orgasm in men as 

compared to Paxil 

–Reduction in pain severity 

The 

Hypothalamic- 

Pituitary Axis 

& Depression 

Anxiolytics and MISA 

Treating Anxiety 

•Benzodiazepines (BZDs) 

– are psychoactive, mood altering and 

reinforcing 

– should be used in certain situations 

•withdrawal/detox. from alcohol or other 

CNS depressants 

•Acute psychosis/paranoid symptoms 

•Extreme agitation 

4



BZD Characteristics 

– BZDs should not be used to treat 

anxiety unless all other options have 

at least been considered. If indicated 

then... 

•Closely monitor use 

•Limit time frame if possible 

•Regulation of dose/proper dosing 

•Use lower potency BZDs 

•Use BZDs with a long half-life 

Na m e Do se (m g/d ) R a pid ity? 

1/2 life 

(h rs ) 

Va lium 5-40 m g/d Ra pid 24 hrs 

Librium 10-100 m g/d Inte rm e dia te 10 hrs 

Tranx e ne 7.5-60m g/d Ra pid 60 hrs 

Ativa n 1-6m g/d Inte rm e dia te 15 hrs 

Klonopin 0.5-3m g/d Interm ediate 30 hrs 

Serax 15-90m g/d Slow /Inter 8 hrs 

Ha lcion 0.125-0.5m g/d Inte rm e dia te 2.5 hrs 

X a n a x 0 .5 -4 m g /d I nte rm e d ia te 1 2 h rs 


• Buspar 

–Lacks mood alteration, sedation and 

somatic side-effects compared to BZDs 

–May be less effective with persons who 

have experience taking BZDs 

–Takes several weeks to reach clinical 

response 


•Inderal (Beta-blocker) &Clonidine (alphaagonist) 

– Reduces adrenergic activity associated 

with somatic components of anxiety 

– Use during detox from CNS depressants 

(Inderal) or opiate withdrawal (Clonidine) 

– Reduces hypertension and other somatic 

symptoms of anxiety 

– Downside: tolerance occurs quickly 


• SSRIs (or novel anti-depressants) 

–FDA approved to treat many types of 

anxiety disorders 

–Research re: SSRIs and PTSD 

–Probably has an effect on anxiety 

because serotonin may be the final 

pathway in anxiety (GABA 5-HT) 

–Polypharmacy use with BZD and SSRIs 

or Buspar and SSRIs 

Treating Bipolar 

Affective Disorder 

5


Difficulty Treating Bipolar 

Affective Disorder 

• Misdiagnosis of Bipolar Affective Disorder 

– Manic phenotypes 

• Mania (Type I) 

• Hypomania (Type II) 

• Recurrent/brief hypomania (


Generic Name 

Gabapentin 

Lamotrigine 

Topiramate 

Oxcarbazepine 

Zonisamide 

Anticonvulsant Meds. 

Trade Name 

Neurontin 

Lamictal 

Topamax 

Trileptal 

Zonegran 

Use/Utility 

Adjunct for 

insomnia, anxiety, 

agitation, pain 

Maintenance for 

acute depression 

Adjunct for obesity 

Acute mania, 

maintenance? 

Adjunct for obesity 

Atypical Anti-psychotic 

medications in treating Bipolar 

Advantages over anti-convulsant treatment 

• Do not have significant side-effect burdens of 

other mood stabilizers 

• Polypharmacy: safer with meds. from different 

classes (e.g. atypical + anticonvulsant) 

• Can treat symptoms of psychosis as well other 

symptoms of mania (as seen in Bipolar, Type I) 

• Each atypical has unique pharmacological profile 

Atypical Anti-psychotic 

medication in treating Bipolar 

Disadvantages vs. anti-convulsants 

• Weight gain/obesity 

• Metabolic syndrome ( insulin resistance/ 

diabetes; lipid level increases; obesity; 

cardiovascular conditions) 

• Hyperprolactinemia 

• Elongated QTc interval 

Recommendations for 

Treating Bipolar 

• Avoid antidepressant monotherapy in Bipolar Type I 

• Initiate Depakote in Bipolar Type I & Lamictal (or 

Symbyax) in Bipolar Type II 

• Move rapidly to add-on therapy if needed 

– Atypical anti-psychotic 

– Second mood stabilizing anti-convulsant 

• Choosing Depakote or Lamictal over Lithium due to 

enhance efficacy and tolerability 

Bowden, C (2004) Early intervention to reduce depression in bipolar disorder. 

Program & Abstracts of the International Congress of Biological 

Psychiatry, Feb. 9-13: Sidney, Australia, Symposium 40 

Other uses being explored for 

Mood Stabilizers 

• In addition to Bipolar Affective Disorder, 

Schizophrenia/Schizoaffective disorder and 

seizure disorders, mood stabilizers are being 

investigated for 

– Decrease substance abuse 

– Use as alternative to BZDS in alcohol 

withdrawal 

– Aggressive behavior 

– Binge Drinking 

– Pain management 

– Anxiety disorders 

Lithium, Mood Stabilizers and 

MISA 

•Lithium/mood stabilizers are 

consistent with MISA best practice. 

However: 

– In bipolar & depression must look for 

• suicidal ideation 

• history of attempts, etc. especially during 

substance withdrawal 

– Liver problems not as much of a 

concern as kidney 

7


Drug/Medication Interactions 

• Alcohol and barbiturates increase 

hepatic enzymes; will reduce serum 

levels of many psychotropic classes 

• Both alcohol and older anti-psychotics 

interfere with thermoregulatory centers in 

the brain 

• Hypertensive crisis can occur from 

MAOIs/nutrition combination or from a 

combination of older anti-depressants 

and psychostimulants 

Drug/Medication Interactions (continued) 

• Alcohol and cocaine enhance respiratory 

depression effects of the opioids & 

phenothiazines (e.g. Thorazine) 

•Marijuana has anti-cholinergic effects; may 

lead to anti-cholinergic psychosis when 

combined with anti-cholinergic meds. 

•People with schizophrenia are at high risk 

of hallucinations from withdrawal from the 

CNS depressants 

Drug/Medication Interactions (continued) 

•Some anti-psychotics (Haldol, Clozaril) 

and anti-depressants lower the seizure 

threshold; increases risk of seizure from 

CNS depressant withdrawal 

• Alcohol intoxication and withdrawal 

disturbs electrolyte levels which can 

lead to lithium toxicity 

Summary 

•Psychopharmacology is, for the most 

part, as much art as it is science. But 

current best practice does generally 

indicate: 

– Atypical antipsychotics over traditional 

(typical) antipsychotics 

– SSRIs or novel anti-depressants over 

TCAs/MAOIs 

Summary (cont.) 

–Choices do exist when prescribing 

anxiolytics; however, benzodiazepines 

are sometimes needed 

–Prescribed medications are sometimes 

psychoactive; psychoactive medications 

are sometimes prescribed 

Summary (cont.) 

The individual is the key; 

standards are, at best, 

standard. 

THANK YOU 

8

T55: Creating Co-Occurring Centers of Excellence Across Maine: A Multi-Site Change 

Initiative 

Catherine S. Chichester, MSN, APRN, Shawn Delaney, MS, & Dorothy J. Farr, LSW, LADC, CCDP-D 


Description: 

The workshop describes the Co-Occurring Collaborative of Southern Maine and its partners’ experiences in 

implementing the CCISC change model with 8 agencies across Maine in a two-year foundation funded project. 

The structure and technical assistance model used in the multi-site project are discussed, as are the outcome 

evaluation methods and outcome data on access, effectiveness, quality and costs. 


• Develop a structure to apply the CCISC model to multi-agency change initiative; 

• Describe the feasibility of utilizing existing data sources for multi-site evaluation; 

• Critique tools developed to measure outcomes. 

• 

NOTES: 

:


Creating Co-Occurring 

Centers of Excellence 

Across Maine: 

A Multi-Site Change 

Initiative 

Presenters: 

Catherine S. Chichester, Co-Occurring 

Collaborative of Southern Maine 

Dorothy Farr, Consultant 

Shawn Delaney, Hornby Zeller Associates 

Foundation for Change 

• Co- Occurring Collaborative 

of Southern Maine 

• SAMHSA Community Action 

Grant 

• Maine Health Access 

Foundation (MeHAF) 

COD Project 

• COSIG Maine 

Two Year Multi-Site Co-Occurring 

Change Project 

Funding: 

• Maine Health Access Foundation, 

• Office of Substance Abuse through 

AdCare Educational Institute, and 

• In-kind contributions 

Structure of the Project 

Year One 

• 4 diverse pilot sites chosen as “Centers of 

Excellence” 

– Geography 

– Population Served 

– Services Provided 

– Historical Commitment 

Year 2 

• 4 additional sites chosen 

Site Requirements 

• COMPASS completed annually 

• Development of Action Plan 

• Semi-annual site visits with consultants 

• Chart audits and consumer surveys 

• Monthly cross-site meetings 

• Mentoring across sites 

Technical Assistance Model 

• Semi-annual site visits with Doctors Cline 

and Minkoff 

• Support and monitoring by Catherine 

Chichester & Dorothy Farr 

• Semi-annual site progress reports, 

consumer feedback and outcomes by 

Hornby Zeller Associates 

1


Centers of Excellence Activities 

• Built full agency commitment on multiple levels 

• Addressed multiple domains within their 

agencies 

– Mission statement 

– Policy & Procedures 

– Screening & Assessment 

– Human Resources 

– Staff Competencies 

– Regulatory 

• Defined measurable steps through action plans 

• Focused on Welcoming, Measuring Prevalence, 

and Enhancing Screening & Assessment 

(Stages of Change) 

Lessons Learned 

• Requires overt commitment from management & 

throughout the organization 

• Change work occurs best through continuous 

quality improvement process 

• Change occurs incrementally with feedback & 

data & procedure/structural change 

• Agencies do best with positive reinforcement, 

recognition of successes and on-going support 

• Training by itself doesn’t result in change 

Lessons Learned continued 

Outcomes 

• Cultural change is hard—takes time 

• Structural barriers are real & need to be 

addressed on multiple levels to develop, 

maintain & sustain change 

• Mentoring works—agencies can learn from each 

other and challenge each other within a safe 

environment 

• Agencies are in different stages of change 

• Change requires simultaneous work in multiple 

systems 

Access 

Cost 

Quality 

Outcome 

Effectiveness 

Measures of Access 

• Screen for both disorders 

• Assess for both disorder 

• Treat for both disorders 

• Consumers perceive change from past 

Percent 

Identification of a Co-Occurring 

Disorder 

120 

100 

80 

60 

40 

20 

0 

60 

62 

95 

Screening Assessment Integrated 

Assessment 

97 

62 

75 

Baseline Time Period 1 

2


Treatment of a Co-Occurring 

Disorder 

Consumer Perception 

80 

70 

65 

Both disorders treated at same time: 

• Before: 66% 

• Now: 88% 

Percent 

60 

50 

40 

40 

34 

38 

30 

Stage of Change Assessment 

Treatment for Both Disorders 


Measures of Quality 

• Consumer perception of: 

– Improved condition 

– Self-determination 

– Respect by workers 

– Cultural sensitivity 

Treatment of Co-occurring 

Disorder 

• Consumer survey 

– Improved: 47% 

– Same: 47% 

– Worse: 6% 

• Over 75% decide own treatment goals 

• 88% say staff help them get information to 

take charge of their lives 

Percent 

96 

94 

92 

90 

88 

86 

84 

82 

80 

State Surveys 

95 

93 

91 

88 

88 

85 

Informed of their Rights Staff Respect their Wishes Staff are Culturally Sensitive 

Regarding Sharing Information 

Outcome 

Effectiveness 

• GAF Scores 

• Relapses 


OSA Survey 

BDS Survey 

3


GAF Score Comparison 

Relapse 

Substance 

Abuse Only 

Group 

62 

66 

Substance Abuse Only Group 

0.4 

Co-Occuring Group 

3.8 

Co-occurring 

Group 

56 

56 

50 55 60 65 70 

GAF Scores 

Admission 

Discharge 

None 

99.6 

One 

95.2 

None One Two 

Employment 

Costs 

Percent 

40 

30 

20 

10 

30 

Full-time Employment 

34 

11 

12 

• Measured by use of services 

0 

Substance abuse only group 


Co-occurring group 

Service Use: higher among cooccurring 

group 

Medical care 

Service 

Drug and alcohol education 

Prescription medications 

HIV risk reduction/education 

Mental health services 

Smoking cessation 

Client urine testing 

Crisis intervention 

Legal assistance 

Financial counseling 

Transportation to treatment 

Child/counseling 

Substance Abuse Only 

Number 

(N=284) 

266 

47 

29 

37 

21 

30 

21 

7 

13 

14 

7 

8 

Percent 

94% 

16% 

10% 

13% 

7% 

11% 

7% 

3% 

5% 

5% 

4% 

3% 

Co-occurring Only 

Number 

(N=105) 

99 

34 

28 

18 

25 

14 

8 

14 

5 

2 

7 

6 

Percent 

94% 

32% 

27% 

17% 

24% 

13% 

8% 

13% 

5% 

2% 

7% 

6% 

Next Steps & Replication 

• COSIG next steps 

• Make infrastructure changes on the state 

level 

• Pilot Sites to expand mentoring & data 

collection 

• Quarterly regional cross-agency meetings 

• Consultation teams provides technical 

assistance to all agencies 

4

Co-occurring Substance Use and Mental Health Disorders 

Chart Review Tool 

Agency: 

_________________________________________________________ 

Reviewer: 

Date of Review: / / 

PLEASE COMPLETE FOR THE PERSON UNDER REVIEW. 

1. Date of First Contact with Agency: / / 

2. Date of Birth: / / 

3. Gender: |___| 

1 – Male 

2 – Female 

4. Program or Unit: ____________________________________________ 

5. Was person screened for: |___| 

1 – Substance use/abuse only 

2 – Mental health only 

3 – Both substance use and mental health 

4 – Neither 

6. Was person screened for physical health: |___| 

1 – Yes 

2 – No 

7. Is there evidence of past or current substance abuse issues: |___| 

1 – Yes 

2 – No 

8. Is there evidence of past or current mental health issues: |___| 

1 – Yes 

2 – No 

9. Is there an assessment for: |___| 




4 – Neither 

10. Is there evidence of integrated assessment: |___| 

1 – Yes 

2 – No 

3 – No assessment 

11. Is there evidence of assessment of stage of change: |___| 

1 – Yes 

2 – No 

3 – No assessment

12. What is the diagnosis: |___| 




4 – Neither 

13. Is there evidence that the diagnosis was substantiated: |___| 

1 – Yes 

2 – No 

14. Is there evidence of an integrated treatment plan: |___| 

1 – Yes 

2 – No 

3 – No treatment plan 

15. Is stage of change reflected in treatment plan: |___| 

1 – Yes 

2 – No 

3 – No treatment plan 

16. Is stage of change reflected in progress notes: |___| 

1 – Yes 

2 – No 

3 – No progress notes 

17. Is there evidence of communication with provider of physical health care if 

physical health care need identified: 

|___| 

1 – Yes 

2 – No 

3 – No health care need identified 

Comments: 

Thank you. 

Please mail completed forms to: 

Hornby Zeller Associates 

100 Commercial Street., Suite 300 

Portland, ME 04101

Consumer Satisfaction Survey for Co-occurring Disorders 

This agency is involved in an effort to improve the quality of services you receive by helping you to address both mental 

health and substance abuse issues at the same time. We are interested in learning more about your treatment experience 

with us so we can determine the degree to which it meets your needs at this time. Please take a few minutes to answer these 

questions, anonymously. 

Agency: _____________ 

Date: ______________________ 

1. Are you currently being treated for : 

 

 

 

An alcohol or other drug problem 

A mental health problem 

Both 

2. Have you received treatment in the past for: 

 

 

 

 

An alcohol or other drug problem 

A mental health problem 

Both 

Neither 

If you have received treatment did you receive it from 

 

 

Us 

Another service provider 

3. Were your alcohol, drug and mental health issues both treated at the same time in the 

past? 

 

 

 

Yes 

No 

Uncertain 

4. One this treatment occasion did we encourage you to talk about and work on any mental 

health, alcohol and drug issues you have at the same time? 

 

 

 

Yes 

No 

Uncertain 

5. If you have received treatment previously, please indicate how your current treatment 

experience has differed from your previous experience. 

 

 

Better (if better, was your previous experience ___here or ___elsewhere) 

Worse (if worse, was your previous experience ___here or ___elsewhere) 

Same (if same, was your previous experience ___here or ___elsewhere) 

Please feel free to explain (use back of sheet if necessary):

Fact Sheet 

A Project to Establish A More Welcoming System of Integrated Treatment* 

for People with Co-occurring Disorders (COD) in 

Mental Health and Substance Abuse Treatment Centers in Maine 

A two-year project of the Co-occurring Collaborative of Southern Maine funded by the Maine Health Access Foundation and the Office of Substance Abuse 

*Integrated treatment is a model in which one clinician or treatment team provides mental health and substance abuse 

services without prioritizing treatment for one disorder over the other. It promotes individualized interventions, 

inspiring a clinician to advance beyond traditional approaches to treat effectively both mental health and substance use 

issues at the same time. 

Project Summary 

This two-year project establishes the Institute for Quality Behavioral Health Care, a collaboration of 

mental health and substance use providers, administrators, payors, and advocates which will focus 

concurrently on two areas: 

1) Removing structural barriers to integrated treatment for co-occurring disorders (COD) including at the 

policy, funding, regulatory, contracting, training, and program levels. 

2) Developing or enhancing integrated programs for co-occurring disorders (COD) in ten treatment centers 

throughout Maine through technical assistance, support, and evaluation. 

This project expands on a federal community action grant awarded in 2002 by the Substance Abuse and 

Mental Health Service Administration (SAMHSA) to the Maine Department of Behavioral and 

Developmental Services. That grant was used to build consensus for the integration of substance abuse and 

mental health services among key stakeholders using a model called the Comprehensive Continuous 

Integrated Systems of Care (CCISC) Model. 

Funding 

The two-year-project is funded with approximately $200,000 by the Maine Health Access Foundation and 

$60,000 from the Office of Substance Abuse through training sub-contracts with AdCare Educational 

Institute of Maine and the CCSME, for a total of $260,000. The grants are matched by significant in-kind 

contributions from project partners. 

Problem statement 

Co-occurring disorders are common, they affect from 7 to 10 million adults in the US each year. Youth also 

may experience co-occurring disorders. According to the US Surgeon General report “Forty-one to 65 

percent of individuals with a lifetime substance abuse disorder also have a lifetime history of at least one 

mental disorder, and about 51 percent of those with one or more lifetime mental disorders also have a 

lifetime history of at least one substance abuse disorder.” 

When one co-occurring disorder goes untreated, both usually worsen. Complications arise which result in 

serious medical, psychological and social problems such as HIV, Hepatitis B and C, and cardiac and 

pulmonary disease, suicide, unemployment, homelessness, incarceration, and alienation from help and 

support of family and friends. Consequently, people with COD often require high cost services such as 

emergency room care, hospitalization, and a range of social services. 

People with co-occurring disorders need complex, comprehensive, integrated treatment which most do not 

receive. They historically have received parallel or sequential treatment from separate mental health and 

substance abuse services.

The need for integrated services 

Maine’s behavioral health service delivery system continues to struggle with the needs of those with cooccurring 

disorders. Service providers consistently identify the need for integrated substance use and mental 

health services in behavioral health. 

A 2001 survey of Maine professionals in substance abuse and mental health treatment centers found that 89 

percent identified substantial structural barriers to establishing integrated treatment for co-occurring disorders 

including separate administrative structures, funding disparities, differing treatment philosophies, differing 

clinician abilities, and differing eligibility criteria. 

The CCISC Model 

The project uses the Comprehensive Continuous Integrated Systems of Care (CCISC) Model, a systems change 

model developed by Kenneth Minkoff, MD, to establish integrated treatment within the Centers for Excellence. The 

model has four basic characteristics: system-level change, efficient use of existing resources, incorporation of best 

practices and integrated treatment philosophy. Integrated treatment is established by implementing change in 

treatment philosophy, policy, procedures and practices. 

The Centers of Excellence 

Four treatment centers established in year one represent diverse services and geographic distribution. Those 

agencies and their administrative offices include: 

• Aroostook Mental Heath Services, Inc. (d.b.a. AMHC), Caribou 

• Day One, Cape Elizabeth 

• Maine Medical Department of Psychiatry and Spring Harbor Hospital, Portland 

and Westbrook 

• Crisis and Counseling Centers, Augusta 

The initial four treatment centers will mentor and support four additional treatment centers in year two. Additional 

treatment centers in year two include: 

• Wellspring, Bangor 

• Community Health and Counseling Services, Bangor 

• MaineGeneral Health, Waterville 

• Spurwink, Portland 

System Change Strategies/Tools 

• Agency Commitment through MOU 

• Use of agency assessment tool: COMPASS 

• Development of Action Plans for change 

• Encouragement to utilize agency Continuous Quality Improvement processes 

• Biannual visits of national experts Doctors Minkoff and Cline with follow up reports 

• Additional consultant services from Dorothy Farr and NAMI ME 

• Monthly tele-video conferences among Centers of Excellence lead change agents 

• Chart audits 

• Mentoring across Centers 

• Evaluation/Outcomes through Hornby Zeller Associates, Inc. 

Contact 

Catherine Chichester, Co-Occurring Collaborative of Southern Maine, tel. 207-878-6170, 

cchichester@ccsme.org, www.ccsme.org 

Partners of the Institute for Quality Behavioral Health Care 

National Alliance for the Mentally Ill-Maine (NAMI Maine) ● AdCare Educational Institute of Maine 

Aroostook Mental Health Services, Inc (AMHC) ● Drug Rehabilitation Incorporated (also known as Day One) 

Anthem Blue Cross Blue Shield ● Maine Primary Care Association (MPCA) 

Maine DHHS, Bureau of Medical Services (BMS) ● Dept. of Health and Human Services (HHS) 

Office of Substance Abuse (OSA)

Planning and Implementing a Welcoming System 

for Maine Adolescents and Adults with Co-Occurring 

Mental Health and Substance Abuse Disorders 

Maine Statewide Memorandum of Understanding 

September 2002 

A. Purpose 

Adolescents and adults with co-occurring disorders are sufficiently prevalent in all behavioral 

health settings that they can be considered an expectation rather than an exception. The 

purpose of this memorandum of understanding is two-fold: (1) to describe the principles and 

core characteristics of a system of services that is welcoming for Maine adolescents and adults 

with co-occurring mental health and substance abuse disorders; and (2) to specify the action 

steps that stakeholders at the state and regional levels will take to plan for and implement 

such a system. It is understood that the action steps identified in this memorandum of 

understanding will be implemented within the existing level of resources. 

B. Definition of Terms 

For the purposes of this memorandum of understanding, the following terms have the following 

meanings: 

1. “BDS” or “the department” means the Maine Department of Behavioral and Developmental 

Services. 

2. “Co-occurring disorders” means that mental health and substance abuse disorders exist in 

an individual at the same time. 

3. “Dual diagnosis capable” means providers who are able to provide integrated mental health 

and substance abuse services to individuals with a low level of symptomatology. 

4. “Dual diagnosis enhanced” means providers who have more advanced skills and training in 

order to be able to provide integrated mental health and substance abuse services to 

individuals with a higher level of symptomatology. 

5. “Dual primary treatment” means treatment for co-occurring disorders of mental illness and 

substance abuse, provided with a high degree of integration without prioritizing treatment 

for one disorder over the other. 

6. “Integration” means that mental health and substance abuse service providers and systems 

work closely together so that individuals with co-occurring disorders receive needed 

services in a coordinated, welcoming manner. 

7. “Participating organizations” means organizations which have signed this memorandum of 

understanding. 

C. CCISC—Eight Principles 

In order to provide more welcoming and accessible services to Maine adolescents and adults 

with co-occurring disorders, the organizations signing this memorandum of understanding 

have reached a consensus to build on the Comprehensive, Continuous, Integrated System of 

Care (CCISC) model for designing systems changes in order to improve outcomes within the 

context of existing resources. This model is based on eight principles (Minkoff, 1998, 2000), 

which are: 

1. Dual diagnosis is an expectation, not an exception. This expectation has to be included in 

Page 1

every aspect of system planning, program design, clinical procedure, and clinician 

competency, and incorporated in a welcoming manner into every clinical contact. 

2. The core of treatment success in any setting is the availability of empathic, hopeful 

treatment relationships that provide integrated treatment and coordination of care during 

each episode of care, and, for the most complex individuals, provide continuity of care 

across multiple treatment episodes. 

3. Assignment of responsibility for provision of such relationships can be determined using a 

consensus model for system level planning, based on high and low severity of the 

psychiatric and substance disorder. 

4. Within the context of any treatment relationship, case management and care, based on the 

client’s impairment or disability, must be balanced with empathic detachment, 

confrontation, contracting, and opportunity for contingent learning, based on the client’s 

goals and strengths, and availability of appropriate contingencies. A comprehensive system 

of care will have a range of programs that provide this balance in different ways. 

5. When mental illnesses and substance disorders co-exist, each disorder should be 

considered primary, and integrated dual primary treatment is required. 

6. Mental illness and substance dependence are both examples of often persistent, biopsychosocial 

disorders that can be understood using disease, recovery, and trauma, and 

other promising practice models. Each disorder has parallel phases of recovery (acute 

stabilization, engagement and motivational enhancement, prolonged stabilization and 

relapse prevention, rehabilitation and growth) and stages of change. Treatment must be 

matched not only to diagnosis, but also to phase of recovery and stage of change. 

Appropriately matched interventions may occur at almost any level of care. 

7. Consequently, there is no one correct dual diagnosis program or intervention. For each 

individual, the proper treatment must be matched according to quadrant, diagnosis, 

disability, strengths/supports, problems/contingencies, phase of recovery, stage of change, 

and assessment of level of care. In a CCISC, all programs are dual diagnosis programs that 

at least meet minimum criteria of dual diagnosis capability, but each program has a 

different “job”, that is matched, using the above model, to a specific cohort of clients. 

8. Similarly, outcomes also must be individualized, including reduction in harm, movement 

through stages of change, changes in type, frequency, and amounts of substance use or 

psychiatric symptoms, improvement in specific disease management skills and treatment 

adherence. 

D. CCISC—Four Core Characteristics 

Using these principles, all organizations signing this memorandum of understanding agree to 

work toward implementing a CCISC in Maine with the following four core characteristics: 

1. The CCISC will be implemented initially within the context of existing treatment operational 

resources by maximizing the capacity to provide integrated treatment proactively. 

2. The CCISC will promote participation from all components of the mental health and 

substance abuse systems with the expectation of achieving, at minimum, dual diagnosis 

capable standards and, in some instances, dual diagnosis enhanced capacity. 

3. The CCISC will incorporate utilization of a full range of outcome-based best practices and 

clinical consensus best practices. 

4. The CCISC will promote an integrated treatment philosophy and common language, and 

develop specific strategies to implement clinical programs, procedures, and practices 

throughout the system of care. 

E. Statewide Priority Issues 

Page 2

All organizations signing this memorandum of understanding agree to work on the action steps 

listed in this section over the next year in order to support the implementation of a welcoming 

system for individuals with co-occurring disorders. 

Stakeholders from the three regions of the department have identified the priority issues that 

they believe need to be addressed first as they plan for and implement a welcoming system for 

individuals with co-occurring disorders in their region. In the first year of implementation, all 

participating organizations agree to the tackle the following statewide priority issues: 

1. Make sure the system is welcoming (with no wrong doors) for adolescents and adults with 

co-occurring disorders, through a process of examining resources and identifying service 

needs within the continuum of care to improve system integration. 

2. Identify and advocate for removing barriers to access to and engagement in services for 

adolescents and adults with co-occurring disorders, particularly crisis, case management, 

and, in those areas where they currently exist, Assertive Community Treatment (ACT) Team 

services. 

3. Assign staff to contribute to the development of regulations indicating how Medicaid funds 

for either mental health or substance abuse services can be used flexibly to reimburse 

services for individuals with co-occurring disorders. 

4. Assign staff to comment on the content of, and contribute to the adoption of, proposed new 

licensing regulations for the provision of welcoming, accessible, integrated services for 

adolescents and adults with co-occurring disorders. 

5. Develop regional training steps that will facilitate intra/inter-agency coordination to enable 

substance abuse and mental health agencies to provide services that are, at minimum, 

dual diagnosis capable and, in some instances, dual diagnosis enhanced. 

F. State Government Action Planning 

Over the next year, the department agrees to carry out the action planning steps listed in this 

section in order to support the implementation of a welcoming system for individuals with cooccurring 

disorders. 

1. The department will review all of its initiatives, including requests for proposals, and 

ensure their alignment with all sections of the memorandum of understanding. 

2. To support the statewide priorities identified in Sections E-1 and E-2, the department will 

move toward the collection of co-occurring disorders data for all the relevant services that it 

funds by: 

a) Reviewing the Enterprise Information System for its compatibility with data collection 

by the Office of Substance Abuse, with the aim of developing an infrastructure to 

support the collection of co-occurring disorders data; and 

b) Determining what data should be collected through grants and contract reporting and 

an infrastructure to support the collection of this data. 

3. To support the statewide priority identified in Section E-3, the department will convene a 

group representing providers, consumers, and family members to work toward the 

adoption of regulations that indicate how Medicaid funds for either mental health or 

substance abuse services may be used flexibly to reimburse services for individuals with 


4. To support the statewide priorities identified in Sections E-1, E-2, and E-3, the department 

will advocate for funding parity by all mental health and substance abuse funding sources. 

5. To support the statewide priority identified in Section E-4, the department will engage 

Page 3

participating organizations in the promulgation of licensing regulations for the provision of 

welcoming, accessible, integrated services for adolescents and adults with co-occurring 

disorders. 

6. To support the statewide priority identified in Section E-5, the department will develop 

clinical pathways and ways to support co-occurring mental health and substance abuse 

professional competencies. 

7. To support all five statewide priorities identified in Section E, the department will: 

a) Streamline documentation and paperwork requirements related to services for 

individuals with co-occurring disorders; and 

b) Provide technical assistance to participating organizations participating as they develop 

and implement policies and protocols to support a welcoming system of services for 

individuals with co-occurring disorders. 

G. Region I Action Planning 

Over the next year, the participating organizations located in BDS Region I agree to address 

the issues and implement the action steps listed in this section as they plan for and implement 

a welcoming system in their region. 

1. Region I organizations will carry out the following action planning steps to implement the 

statewide welcoming priority stated in Section E-1: 

a) Adopt this memorandum of understanding as the guiding principles of the co-occurring 

disorders initiative. Circulate the approved memorandum of understanding to all staff, 

and provide training to all staff regarding the principles and the CCISC approach. 

b) Develop and implement screening protocols for co-occurring mental health and 


c) Participate in regional planning for the collection of a minimal data set that is 

compatible with state-wide data collection planning on mental health, substance abuse 

and co-occurring disorders in the individuals they serve. 

d) Participate in a self-survey of their organization or department using the COMPASS 

annually to evaluate the current status of dual diagnosis capability. 

e) Each agency will develop an action plan that addresses co-occurring capacity and share 

action plan with other regional agencies participating in the initiative and with other 

stakeholders as appropriate. 


statewide barrier removal priority stated in Section E-2. 

a) Create an integrated planning process in Region I that will include current planning 

groups. 

b) Participate in regional meetings hosted by the Co-Occurring Collaborative of Southern 

Maine to identify barriers and gaps and plan for the expanded access in crisis services 

including emergency rooms, case management, outpatient services, residential services 

and ACT teams for individuals with co-occurring mental health and substance use 

disorders. 

c) Agencies and the department will develop plans to incorporate consumer and family 

stakeholder co-occurring voice in the planning and delivery of crisis, case management, 

and ACT team services and appropriate peer recovery activities. 

Page 4

3. Region I organizations will assign knowledgeable staff to participate in the development of 

Medicaid regulations as described in the statewide priority in Section E-3. 

4. Region I organizations will assign knowledgeable staff to comment on new licensing 

regulations as described in the statewide priority in Section E-4. 


statewide training priority stated in Section E-5: 

a) Review the curriculum that is being developed and, in addition to the overall review, 

enhance the curriculum to address the training needs of adolescent providers. 

b) Work in conjunction with other regions to maintain consistency in developing a 

knowledge base. 

c) Identify appropriate clinical and administrative staff to participate as trainers in the 

system-wide train-the-trainer initiative and to assume responsibility for implementation 

of the training plan of the organization and department. 

H. Region II Action Planning 

Over the next year, the participating organizations in BDS Region II agree to address the issues 

and implement the action planning steps listed in this section: 

1. Region II organizations will carry out the following action planning steps to implement the 

statewide welcoming priority stated in Section E-1: 

a) Adopt this memorandum of understanding as the guiding principles of the co-occurring 

disorders initiative. 

b) Develop and implement screening protocols for co-occurring mental health and 


c) Participate in regional planning for the collection of a minimal data set that is 

compatible with statewide data collection planning on mental health, substance abuse, 

and co-occurring disorders in the individuals they serve. 

d) Participate in a self-survey of their organization or department using the COMPASS 

annually to evaluate the current status of dual diagnosis capability. 

e) Based upon the findings of the COMPASS evaluation, each agency will develop an 

action plan that strengthens the delivery of services for co-occurring conditions. 

Agencies may share their plan with stakeholders and agencies participating in the 

initiative. 


statewide barrier removal priority stated in Section E-2: 

a) Examine and review policies and procedures that present barriers to a welcoming 

system for individuals with co-occurring disorders. When necessary and as resources 

allow, agencies may assign staff to participate in system-wide efforts to develop 

systemic policies and procedures to support welcoming access in both emergency and 

routine situations. 

b) Include co-occurring disorders case discussions in existing inter-agency and intraagency 

clinical care meetings. 

3. Region II organizations will assign knowledgeable staff to participate in the development of 

Medicaid regulations as described in the statewide priority in Section E-3 and will: 

Page 5

a) Advocate within their provider association groups (such as the Maine Association of 

Mental Health Providers, Maine Association of Substance Abuse Providers, and the 

Maine Hospital Association) to work collaboratively with the department to impact 

regulatory changes that will enhance services for individuals with co-occurring 

disorders. 

b) Promote periodic meetings among all participants and stakeholders to share current 

information on regulatory activities. 

4. Region II organizations will assign knowledgeable staff to comment on new licensing 

regulations as described in the statewide priority in Section E-4; and will: 

a) Advocate within their provider association groups (such as the Maine Association of 

Mental Health Providers, Maine Association of Substance Abuse Providers, and the 

Maine Hospital Association) to work collaboratively with the department to impact 

licensing changes that will enhance services for individuals with co-occurring disorders. 

b) Promote periodic meetings among all participants and stakeholders to share current 

information on licensing activities. 



a) Work with the department to develop training opportunities focused on knowledge, 

skills, values, and attitudes necessary for staff to deliver services to individuals with cooccurring 

disorders. 

b) Review the curriculum that is being developed and, in addition to the overall review, 

enhance the curriculum to address the training needs of adolescent providers. 

c) Work in conjunction with other regions to maintain consistency in developing a 

knowledge base. 

d) Identify appropriate clinical and administrative staff to participate as trainers in the 

system-wide train-the-trainer initiative and to assume responsibility for implementation 

of the training plan of the organization and department. 

I. Region III Action Planning 

Over the next year, the participating organizations located in BDS Region III agree to address 

the issues and implement the action planning steps listed in this section as they plan for and 

implement a welcoming system in their region. 

1. Region III organizations believe that the statewide welcoming priority described in Section 

E-1 will be accomplished as a result of the completion of all the action planning steps in 

this memorandum of understanding. 

2. Region III organizations have combined two priorities—to examine resources and identify 

service needs to improve system integration, which is part of Section E-1—with the 

statewide priority to remove barriers described in Section E-2. They will carry out the 

following action planning steps pursuant to these combined priorities: 

a) Develop a resource guide, to be updated yearly, that addresses such service as mental 

health, substance abuse, housing, crisis, legal, case management, medical services, 

self-help groups, vocational education, SSI/SSDI, TANF, etc. 

b) Provide organizations with the resource guide. 

c) Advocate for mental health and substance abuse training for medical providers. 

d) Have a resource list of Region III on the State Website. 

Page 6

e) Link organizations with websites to the State Website for the resource list. 

3. Region III organizations also have combined two other statewide priorities—assigning staff 

to participate in the development of Medicaid regulations, as described in the statewide 

priority in Section E-3, and assigning staff to comment on new licensing regulations, as 

described in the statewide priority in Section E-4. They will carry out the following action 

planning steps pursuant to these combined statewide priorities: 

a) Establish a group composed of members who are well grounded in both the mental 

health and substance abuse regulatory environment. 

b) Know what the regulations are, identify the barriers to service (disconnects), and 

provide cross-training to mental health and substance abuse providers. 

c) Appoint two individuals (one mental health and one substance abuse representative) as 

co-chairs of this group to act as a receptacle for and conduit to BDS Central Office and 

to keep larger regional work group informed. 

d) Determine where State is regarding dual licensing and other changing policy. 

e) Streamline paperwork so there can be single oversight. 

f) Measure improvement in quality of care with improved services. 

g) Explore the idea of “single release of information”— 

‣ Ask community-affiliated Information Management Specialists to have a dialogue 

about barriers to single release. 

‣ Consider asking for help to facilitate this dialogue, if necessary. 

‣ Explore issues of informed consent and release of information. 

4. Region III organizations will carry out the following action planning steps to implement the 


a) Use COMPASS as a tool to evaluate providers’ status around dual diagnosis treatment 

capability and to identify program strengths and system gaps. Using this data, 

providers that identify strengths areas can develop presentations to offer to other 

programs. 

b) Conduct an assessment of staff training needs, based on use of CODECAT, to evaluate 

clinician dual diagnosis competencies and areas in need of development. 

c) Identify training resources available to regional providers, locally, regionally, and 

nationally. Agencies will collaborate to co-sponsor particular trainings, or may invite 

other providers to join in training sessions they are holding. 

d) Survey the types of training that are being done nationally, to identify the core 

competencies that are generally accepted as “best practices” in the treatment of cooccurring 

disorders. Use this information to plan for Maine-based training. 

e) Provide staff training, based on “dual diagnosis best practices model,” in the areas of: 

‣ Screening. 

‣ Assessment. 

‣ Diagnosis. 

‣ Treatment planning. 

‣ Discharge planning. 

‣ Aftercare. 

Page 7

f) Train staff in the principles of teamwork communication and in understanding their 

roles within a multidisciplinary team. 

J. Other Actions to Create a Welcoming System 

Nothing in this memorandum of understanding should be construed to stop any regional group 

of stakeholders or any organization from addressing additional priorities and taking additional 

action steps in order to promote and support a welcoming system for adolescents and adults 

with co-occurring disorders. 




Statewide Memorandum of Understanding 

Signature Sheet 

Signature: 

Name & Title: 

Organization: 

Date: 

Page 8




Statewide Memorandum of Understanding 

Signature Sheet 

Signature: 

Name & Title: 

Organization: 

Date: 

Page 9

T56: Needs of Recovery Community for Supportive Services 

Johnny W. Allem, President, Johnson Institute 


Description: 

This workshop focuses on the types of supportive services needed by those in recovery. Treatment services 

may be a first step in educating oneself about specific disorders, but recovery is a lifelong process. The 

workshop gives participants a perspective from the recovering person’s view of how the treatment community 

can appropriately support a person’s recovery plan. 


• Describe and choose appropriate recovery support services; 

• Distinguish between all avenues of recovery supports, i.e., 12-step and other mutual aid groups; 

• Apply new information in aftercare plans for those in treatment. 

NOTES:

Welcome to the Johnson Institute 

http://www.johnsoninstitute.org/ 

Page 1 of 2 

4/26/2006 

April 24, 2006 

Paul Williams Chairs 2006 

Recovery Honors Event 

Third Annual Washington, DC 

Luncheon Honors Six Americans 

For Service To Addiction Recovery 

Cause 

March 15, 2006 

In Memory: Joel Hernandez 

An Ordinary Man Doing 

Extraordinary Things 

March 13, 2006 

Johnson Institute Partners With 

Argosy University/Twin Cities To 

Choose Scholarship Winner For 

Education Research Project 

Event to be held on Thursday, 

March 16, 2006 in Eagan, 

Minnesota 

All individuals and families experiencing the 

harmful effects of alcohol or other drug addictions 

will find a path to recovery through early 

intervention, appropriate care, family involvement 

and community support. 

For over 40 years, the Johnson Institute led the 

field in delivering effective prevention, treatment 

and recovery programs. We have been a strong 

beacon of hope for alcoholics, their families and 

communities. 

February 13, 2006 

Recovery Advocate Calls for End 

of Addiction “Treadmill,” Calls for 

“Marshall Plan” to Develop 

Responsible Treatment 

Johnson Institute President/CEO 

Allem Tells Join Together Policy 

Panel That Timely Recovery 

Programs Are a “Bargain” for 

Nation 

The America Honors Recovery Luncheon was 

designed to honor those in recovery from alcohol 

and other drug addiction who are making a 

difference for future generations! 

Nomination Information 

Nominations are now being accepted for the 2006 

America Honors Recovery Luncheon. To request a 

nomination packet, please email 

ingridfaust@johnsoninstitute.org. Please provide 

your name and complete mailing address.

johnsoninstitute.com - History 

http://www.johnsoninstitute.org/about/index.php?DocID=5 

Page 1 of 2 

4/26/2006 

President's Message 

Vision & Mission 

History 

Board/Advisory 

Council/Staff 

Contact Information 

A Guiding Light for Four Decades 

A History of the Johnson Institute 

The Johnson Institute (JI) represents 

a long history of encouraging and 

perfecting more appropriate and 

timely responses to alcoholism and 

drug addiction. Its leadership in the 

chemical dependency field spans 40 

years and is continuing to eliminate 

barriers to recovery today. 

In 1966, the Johnson Institute was 

formed and dedicated to designing 

treatment programs as well as 

educating individuals, families, 

professionals, and entire communities 

about addiction disease. The Johnson 

Institute is named after Rev. Vernon Johnson, an Episcopal priest 

who convened a Minnesota church study group to figure out how to 

convince alcoholics to accept help before incurring tragic 

consequences of their drinking. 

The result was the first application of the intervention concept that 

would become the standard approach for getting alcoholics into 

treatment. From that first historic new insight came “Minnesota 

Model” programs that have helped hundreds of thousands of 

recovering alcoholics around the world. 

The Johnson Institute produced and published a variety of 

educational books, including Vernon Johnson’s seminal and still 

popular book, I’ll Quit Tomorrow. The Johnson Institute continues to 

publish numerous books, pamphlets and videos. 

By 1990, treatment techniques advanced by the Johnson Institute 

had become standard practice in the chemical dependence field. In

johnsoninstitute.com - History 

http://www.johnsoninstitute.org/about/index.php?DocID=5 

Page 2 of 2 

4/26/2006 

1992, Johnson Institute transferred distribution of its training media 

to Hazelden Information and Educational Services and refocused its 

attention on removing barriers to effective treatment. 

Today, Johnson Institute identifies, nurtures, and supports initiatives 

to reach individuals and families early in their difficulties with 

chemical dependency. From its beginnings with a Minnesota church 

study group, JI now comprises four centers dedicated to fresh 

policies and new awareness of addiction disease. 

The Center for Education and Advocacy supports such initiatives 

as Recovery Ambassadors, Faces and Voices of Recovery, Advancing 

Help and Hope Workshops, National Recovery Month and Sports 

Salute to Recovery. 

The Center for Resource Development is dedicated to changing 

America’s attitudes and opinions about addiction recovery. It finds 

links between JI’s mission and projects and the goals of funding 

institutions. This center also holds the highly successful America 

Honors Recovery Luncheon in September to recognize recovering 

citizens who have made major contributions to recovery efforts. 

The Center for Policy and Communication provides platforms for 

discussion and strategic planning. It brings together more than 80 

organizations for biannual National Forum on the latest in the 

recovery field and continues JI’s publishing tradition of excellence, 

including the latest Speaking Out for Addiction Recovery, by Johnny 

Allem, president of the Johnson Institute. 

The Rush Center for Congregational Action recognizes the 

special opportunity that bringing science and faith perspectives 

together can have in benefiting congregations of all faith traditions. 

Its highly successful Faith Partners program uses a team approach to 

allow recovery to happen within congregations of all faiths. It also 

publishes a new quarterly publication, Faith Partners Journal. 

Johnson Institute’s approach has evolved over more than 40 years 

yet its commitment to advancing understanding of alcoholism and 

chemical dependency is unwavering. 

© 2006 Johnson Institute. All rights reserved.

johnsoninstitute.com - President's Message 

http://www.johnsoninstitute.org/about/ 

Page 1 of 2 

4/26/2006 


Vision & Mission 

History 

Board/Advisory 

Council/Staff 



By Johnny W. Allem 

The High Profit of Doing 

The Right Thing 

Helping people get well 

from alcohol and other 

drug addiction makes good 

sense. It also makes good 

"cents." Recovery is a 

bargain for society. When 

fully available to everyone afflicted or affected by addiction disease, 

millions of dollars will be saved. 

Individuals and families who have survived addiction are not 

surprised that recovery saves money. Their experience is 

documented by research – most studies showing that every dollar 

spent on treatment saves from seven to twelve dollars in health 

care, social and criminal justice costs. 

It is a shock, however, to see a government pay for treatment and 

recovery support – expecting a return by saving money on primary 

health care. 

The State of Washington just made this landmark decision: to fund 

everyone eligible for Medicaid for addiction treatment when 

diagnosed. They boosted their treatment budget to $39 million for 

each of the next three years -- $32 million for adults and $7 million 

for youth. They expect $31 million return each year in reduced 

claims for other health issues. If this savings happens, they will keep 

on paying for treatment when diagnosed after 2007. 

Their official "Treatment Philosophy" posted on their website, should 

be placed over the door of every managed care office in the United 

States. In part, it says:

johnsoninstitute.com - President's Message 

http://www.johnsoninstitute.org/about/ 

Page 2 of 2 

4/26/2006 

"Research demonstrates that treatment results in a marked 

reduction in negative consequences for the addicts, their families, 

friends, and society at large, as measured by domestic violence, 

disrupted families, employment histories, and public costs for law 

enforcement and the courts, welfare dependence, medical and 

hospital costs, and admissions to psychiatric hospitals." 

Because they expect real savings, the treatment and support offered 

is not stingy. Up to six months of care (half in residential) is offered 

within a two-year window. There are four reasons this tremendous 

development is important to the recovery community that is now 

organizing and working to change policies about how society 

responds to alcohol and drug issues: 

First, here is an example of a major government making decisons 

based on research and fact, not emotion and prejudice. Standing on 

the facts, the real problems can be addressed to the satisfaction of 

the entire community. 

Second, this action proves that progress against discrimination and 

prejudice can be made at the state level. 

Third, this public demonstration of the savings generated when 

addiction is appropriately addressed will bring pressure on private 

healthcare providers. Society will not be freed from the addiction 

epidemic until private insurance money returns to treat addiction. 

And fourth, state government policies are good targets for successful 

local advocacy by the recovery community. 

At the Johnson Institute, we advocate for policies that promise to 

"conquer addiction in our lifetime." The science to reduce our rolling 

epidemic to a manageable health threat already exists. It is our 

policies that discriminate, replacing science with prejudice. As a 

result, America’s response to addiction disease includes the largest 

jail-building effort in the history of civilization. 

With the example of the State of Washington, perhaps we can 

recognize the high cost of prejudice and the savings that happen by 

"doing the right thing." 

© 2006 Johnson Institute. All rights reserved.

T61: The Pilot Takes Flight: An Approach to Continuity of Care in the Mental Health and Drug and 

Alcohol System in Washington County, PA 

Carl H. Stopperich, BA, CCDP, CCJP, Bethany Bowman, MS, CAC-D, CCDP-D, 

Judy Klimcheck, MA, CCDP-D, Gregg Thomas, BA, CAC, CCDP & Tracey Osman, BSN 


Description: 

The Co-Occurring Disorders Pilot Program in Washington County, PA, consists of an array of services that 

include a residential program, a halfway house, partial hospitalization, intensive outpatient and outpatient 

services, and case management. The goal was to blend mental health and drug and alcohol service systems 

to meet the needs of the person with CODs. The result is that a person can now get all of his/her treatment 

needs met by one provider with staff trained to support the person’s continued progress. 


• Identify beginning conditions and barriers in the county system’s ability to integrate services; 

• Describe implementation strategies for changing agency and staff practices; 

• Discuss current system capacity and future directions for providing integrated services. 

NOTES:


Washington County Co- 

Occurring Disorders 

Pilot 

A Pilot Approach for Continuity of Care 

through Mental Health and Drug & 

Alcohol systems in Washington County 

COD CONFERENCE Flight Intro 

Airport: 

April – December, 2005: 

Washington County COD Pilot Integration Project 

30% completed flight 

70% no shows/refusing further treatment/unable 

to locate (take a parachute) 

Terminal/Gates: Gate A- Greenbriar (Check-in Point) 

Begin @ Airport: 66% severe mental illness (SMI), 85% COD 

72% with drug use disorder 

• Axis II, serious personality disorders 

21.8% serious suicidal ideations 

FLIGHT MENU: 

Welcoming/intakes/engage/re-engage (49% began @ this LOC) 

Physical/psych evaluation (assess MH & D&A) (72% on 

psychotropic meds) 

Medications (nurses on site, med education groups) 

Treatment plans/d/c plans with COD competent staff (increase 

COD staff) 

Case management services (continuity with treatment @ all 

levels, and other agencies involved)/housing issues/ 

transportation 

Gate B- Lighthouse (Layover Until Take-off) 

Remain in Hanger: More intense treatment and longer stays 

FLIGHT MENU: 

• Welcoming/pre-admit assessment (Consumers skills extremely low) 

• Onsite psychiatrist/nurse weekly 

• Medications 

Need continuity of services for COD females 

All clients have co-occurring disorders 

49% have depressive disorders 

68% unemployed 

• Comprehensive treatment plans, discharge plans, re-engagin 

COD - ICM involvement, 100% pilot consumers 

Gate C- Wesley Spectrum service (12 Steps for Boarding) 

Preflight preparation: Onsite COD – ICM (12 domains critical) 

Ed. groups, + staff changes, 

more staff 

COD Partial/IOP/OP, DRA group 

• 24% began @ Partial LOC, 1/3 complete 

• 40% Self/family referral 

FLIGHT MENU: Welcoming/COD assessments (25 COD pilot slots) 

• Engaging/re-engaging (74% living with someone/independent) 

• Onsite psychiatrist weekly (Potential immediate access to Dr) 

• Medication accessible (Nearly ¾ of COD consumers on meds) 

• Increased COD competent staff, groups with MH component 

• COD – ICM for continuity of treatment/housing/transportation 

• Onsite self-help groups 

Gate D- SPHS D&A Outpatient, Monessen (Preparation for Landing) 

In-flight Necessities: 

• Competent psychiatric time/meds 

• Mobile medication delivery, 

• Multiple agency involvement 

• COD documentation/chart 

FLIGHT MENU: 

• Welcoming from D&A, MH/COD evaluations (25 COD pilot slots) 

• Engaging/re-engaging 

• Onsite psychiatrist weekly 

• Mobile medication, (72% on psychotropic meds) 

• COD staff with COD partial hospitalization program (79% high 

severity) MH partial hospitalization accessible 

• COD – ICM availability (100%) 

1


Gate E- SPHS Case Management, Charleroi (Destination to Independence) 

Earning Their Wings: MH – ICM with COD caseload 

COD Case management chart (with MH case 

management availability) 

Personal touch with consumers 

Mental Health CM at its BEST. 

FLIGHT MENU: 

• Welcoming/COD opening & ISS 

• Engaging/re-engaging, (100% services at Halfway House) 

• Meeting consumers every need,( Psych meds/ housing/ 

transportation 

• In last 30 days, 70% were ‘totally unable to work or do normal 

activities’ 

• Very mobile (dealing with using client at their residents/treatment) 

• 27 MH staff are COD Core Competent (trained or in training), 

including director and 3 supervisors. 

• Linking necessary services, especially with family members 

• COD ready, willing & capable 

“You are now free to move about the 

country” 

AS THEY PASS LIFE’S SECURITY CHECK-POINTS, THEY 

CONTINUE TO EARN 

‘WINGS OF RECOVERY’ 

2

MISA PILOT TAKES FLIGHT: A PILOT APPROACH FOR 

CONTINUITY OF CARE THROUGH MENTAL HEALTH 

AND DRUG & ALCOHOL SYSTEMS IN WASHINGTON 

COUNTY 

AIRPORT: WASHINGTON COUNTY COD PILOT PROGRAM 

MAIN FLIGHT 777: Co-Occurring Disorder Integration 

TERMINAL/GATES: 

GATE A - DESTINATION: GREENBRIAR TREATMENT CENTER 

(‘Check-in Point’) 

GATE B - DESTINATION: LIGHT HOUSE FOR WOMEN 

(‘Layover Until Take-Off’) 

GATE C – DESTINATION: WESLEY/SPECTRUM SERVICES 

(’12 Steps for Boarding’) 

GATE D – DESTINATION: SPHS – MON VALLEY (D&A) 

(‘Preparation for Landing’) 

GATE E – DESTINATION: SPHS – CHARLEROI (CM) 

(‘Destination to Independence’) 

ETA (Estimated Time of Arrival): 2004-2007 (federal time), On time? 

More passengers are passing security check points! 

Integration is making take offs and landings a smooth process. First flight 

available is replacing stand bys and less luggage and less overbooking 

verifies the BLACKBOX recording: 

PASSENGERS ARE EARNING THEIR WINGS OF RECOVERY 

THIS IS YOUR PILOT SPEAKING: “Final Approach, God 

Grant Me …?”

Flight times of Pennsylvania MISA Pilot Project 

Flight Origin # 1997: Statewide MISA Consortium 

Pennsylvania Department of Public Welfare, Office of Mental Health and Substance 

Abuse Services (OMHSAS), and Department of Health Bureau of Drug and Alcohol 

Programs (BDAP) sponsored consortium 

Flight Confirmation # 1999: Consortium Formal Report 

Service and systems integration, establishment of courses and core competencies 

Flight Takeoff # 2001: OMHSAS and BDAP Issued Letter of Interest 

• 29 counties responded/solicitation announced/18 proposals received 

• 5 counties selected, Beaver, Berks, Blair, Mercer and Washington 

• 4 adult, 1 child and adolescent proposal selected for funding 

• Evaluation by Center for Mental Health Policy and Services Research (CMHPSR) 

• at University of Pennsylvania 

Flight Instruction Manifest: MISA Pilot Expectations 

• ideas for policy, program development and funding for services 

• create integrated services and systems of care 

• models for welcoming clients 

• create level of care criteria 

• assure availability of MISA case management 

• develop structures for inter-agency care coordination 

In Flight Changes for COD in Washington County: 

Passengers Served: Adults with co-occurring psychiatric and substance 

Security Checkpoints: Greenbriar Treatment Center, Lighthouse for Women, Wesley-Spectrum Services, SPHS – 

Monessen/Charleroi 

Current Bookings for COD: SPHS – CARE Center, Turning Point I & II, Catholic Charities and Gateway South 

Luggage Includes: detoxification, inpatient treatment, residential treatment, partial hospitalization, intensive outpatient, 

outpatient, case management and intensive case management 

Redeye: 75 COD-Trained) Professionals (or currently in training 

Page 1 of 2

In Flight Changes for COD in Washington County (continued) 

Standby: Psychiatrist services, medical needs care, nursing availability, credentialed COD therapists, social workers, 

and all levels of case management. All integrated services at All locations/entry of care 

Ongoing Turbulence Correction: billing, medications, transportation, housing, funding sources and communication 

Arrival Needs: More education, employment, stressor reduction, harm reduction (includes decreased substance use), 

cognitive behavioral changes, proactive not reactive changes and Life With a Safe Landing 

Estimated Time of Arrival: (ETA) 2007, Co-Occurring Capable and Co-Occurring Enhanced 

Criteria at Destination Checkpoints 

• Landing: All destinations currently meet Co-Occurring Capable Criteria 

• Have developed COD programs, and funding resources 

• Integrating services and systems 

• All Destinations have ‘Welcoming’ ability 

• Criteria for level of care quadrants 

• Full continuum of integrated care, ‘One Stop Shop 

• All COD clients have availability of case management 

• Structural changes at COD providers 

• Weekly and monthly meetings to ensure Appendix 5 

• Clinical and case management meetings weekly 

• Ongoing COD Cross-training 

• Co-Occurring abilities for Treatment Court clients 

• Dual Recovery Groups 

Next Flight: Have All D&A and MH services Co-Occurring Capable in 

WASHINGTON COUNTY 

TO ALL, HAVE A SAFE FLIGHT ! 

Page 2 of 2

T62: Crossroads Program – Intensive Co-Occurring Probation Services 

Linda Tucci Teodosio, JD, & Dawn R. Jones, BA 

1.5 hours Focus: Children and Adolescents & Forensic Involvement 

Description: 

Crossroads is an intensive supervision probation program (diversionary) working with co-occurring substance 

abusing/dependent and mentally ill youth in the juvenile justice system. Treatment services are provided from 

numerous community providers, and a small number of youth receive integrated substance abuse and mental 

health services in a home-based setting provided by a single treatment provider. This workshop reviews the 

4-phase program that uses graduated sanctions and incentives, having a minimum of one year’s attendance. 

Handling of charges, any new charges, and parent/guardian involvement are also discussed. 


• Describe the eligibility criteria and phase progression of the program; 

• Explain the advantage of co-occurring treatment service delivery and intensive probation services; 

• Identify the process used to develop a specialized docket for youth with CODs in the community. 

NOTES:


Crossroads Program 

Summit County Court of Common Pleas 

Juvenile Division 

Summit County, Ohio 

The Honorable Linda Tucci Teodosio, Judge 

What is Crossroads? 

• Diversionary Program 

• Post Adjudication 

• Voluntary 

• Intensive Probation 

• For children who have either a diagnosis 

of a mental illness, substance 

dependence, or both 

• A Gateway to existing services 

Why Crossroads? 

• Need for early mental health assessment, identification, 

intervention, and services 

• Provide support for families dealing with children with 

mental health issues and/or substance dependence 

• Community Safety: Children are at risk to be a danger to 

themselves or others 

• Need to reduce recidivism 

• Value of keeping child with family 

• Treatment for both conditions simultaneously 

• Community collaboration to allow for most appropriate 

treatment options 

Eligibility Criteria 

• Youth 12 to 17 years of age 

• No current charge or previous conviction for an offense of violence, 

except for Domestic Violence charges 

• Gang members and sex offenders are excluded 

• No current charge or previous conviction for drug trafficking 

• Must have a mental health diagnosis in the major affective disorders 

category (major depression, bi-polar disorder, schizophrenia, 

dysthymia, or Severe post traumatic stress disorder) and/ or 

substance dependence. 

• Youth with mild mental retardation (or more severe mental 

retardation) or youth participating in programming for the 

developmentally handicapped are ineligible 

• All first-degree felonies and most second-degree felonies are 

excluded 

Identification of Participants 

• GRAD (Graduated Risk Assessment Device) 

• V-DISC (Voice Diagnostic Interview Schedule 

For Children) for youth whose 

Personality/Behavior or Sociability scores on the 

GRAD are elevated 

• SASSI (Substance Abuse Subtle Screening 

Inventory) 

• SPPI (Structured Pediatric Psychological 

Interview) or interview with the Court 

psychologist 

How Does a Referral Occur? 

• Detention 

• Intake 

• Defense Attorney, Prosecutor or Family 

Request 

• Disposition 

• Traditional Probation 

• Upon the failure of less intensive 

supervision to achieve the desired result 

1


Suitability Process 

• Purposes of the Committee: 

– To ensure youth meet eligibility criteria 

– To ensure Crossroads is the most suitable 

placement for the child 

– To make recommendations for the case plan 

Suitability Committee Composition 

• Crossroads Administrator 

• Felony Disposition Coordinator 

• Akron Health Department Representative 

• Court Psychologist 

• Referring Court Worker 

• Crossroads Magistrate 

Suitability Considerations 

• SASSI results 

• GRAD results 

• V-DISC results 

• SPPI results 

• Parent Interview Results 

• Willingness and ability of child and family 

to comply with the program requirements 

Acceptance Process 

• Magistrate or Judge is notified of 

acceptance and recommendations for the 

case plan 

• Magistrate or Judge orders youth into 

Crossroads 

• Probation rules, house arrest rules, parent 

guidelines, and drug use contract rules are 

reviewed immediately prior to the Youth’s 

first Crossroads hearing 

Programming 

• Youth, parent, probation officer, and community 

providers meet within the first two weeks to 

develop a case plan 

• The Crossroads probation officer serves as the 

case manager 

• Youth and parent report to Court periodically for 

a review (frequency depends upon phase and 

compliance) 

• Youth, parent and probation officer develop 

contract goal sheets which record all required 

activities for each period until the next Court 

review 

Treatment Team 

• Representatives from County Agencies meet every two 

weeks to review each child and make recommendations 

for appropriate care. 

• Team consists of the Crossroads Probation Officers, 

Administrator, Magistrate & Social Worker; Court 

Psychologist; Representatives from the County Alcohol 

Drug Addiction and Mental Health Services Board, 

Community Health Center (Substance Abuse), Akron 

Health Dept. (Substance Abuse), Greenleaf Family 

Services (Mental Health Services), ICT, Oriana House 

(Halfway House for adolescent males); Representative 

from other agencies having contact with a particular child 

or family 

2


Some Treatment Options: 

• Intensive Outpatient Treatment 

• Short Term Placement at the Halfway 

House or other treatment facility 

• Individual and/or group counseling 

• Medical Evaluation and compliance 

• Continuation with family’s private 

treatment provider 

• Institutional or residential placement 

Intensive Co-occurring 

Treatment 

• Short term intensive counseling for child 

and family 

• On call 24/7 for crisis intervention 

• In home services 

• Counselors are qualified to provide both 

substance abuse and mental health 

counseling 

• Community funded 

Court Hearings 

• All scheduled Participants and Parents are 

present for all hearings 

• Probation Officer, Parents and Child report to 

Court on progress since last Review 

• Court provides encouragement and suggestions 

• Rewards and sanctions are given 

• School progress is discussed 

• Contempt Track for probation violations or new 

charges while on probation 

Program Advancement 

• Five Phases 

• Contact with the Court decreases as the 

child progresses through the Program 

• The responsibility of the child and the 

family increases 

• Child works on achieving his or her 

individualized 

• Mental Health treatment compliance and 

sobriety are monitored 

Phase One 

– Minimum of 30 days 

– Assessed for and engaged in substance abuse treatment; attend 

required AA meetings 

– Assessment for and engaged in mental health treatment 

– Develop case plan 

– Attendance at school 

– House Arrest 

– Complete Phase One Wellness Plan 

– Submit negative urine drug screens for a minimum of one month 

– Comply with all case plan and contract goal sheet requirements 

– Attend weekly Court review 

Phase Two 

– Participate in recommended substance abuse and 

mental health counseling 

– Abide by curfew 

– Attend school (monitor performance, attendance, and 

behavior) 

– Submit negative urine drug screens a minimum of two 

months 

– Complete phase two wellness plan 

– Comply with all case plan and contract goal sheet 

requirements 

– Attend bi-weekly Court review 

3


Phase Three 

– Comply with substance abuse treatment requirements 

– Comply with mental health treatment requirements, 

including medication compliance 

– Attend school daily 

– Comply with all case plan and contract goal sheet 

requirements 

– Obtain a sponsor 

– Complete Phase Three Wellness plan 

– Attend Court review every three weeks 

Phase Four 

– Engage in all recommended substance abuse and 

mental health counseling 

– Obtain and maintain employment 

– Abide by curfew 

– Attend school daily 

– Select a home group 

– Complete Relapse Prevention Plan 

– Submit request for graduation to the probation officer 

– Attend monthly Court review 

Successful Completion and 

Graduation 

Youth who successfully complete the program 

requirements : 

Pass a “hair test” 

Participate in a graduation ceremony and celebration 

Give a speech and are recognized at the ceremony for their 

achievements by the staff, family and friends 

Obtain a certificate of completion 

Receive a graduation gift from program staff 

Receive an expungement of the admitting charge (and 

subsequent probation violations) 

Court and Community Benefits 

• Services providers have open lines of communication with the Court 

to assure that the best treatment options are being considered 

• Court provides assistance in making appropriate referrals 

• Children are not punished simply because they are mentally ill: 

Focus is on wellness 

• Delinquent behavior and/or the severity of the behavior is 

diminished 

• Children and families become connected to community treatment 

providers that can continue to work with the family long after Court 

involvement ceases 

• Savings to the community and the juvenile justice system as a result 

of reduced commitments to the Ohio Department of Youth Services 

(Ohio’s equivalent to prison for youthful offenders) 

• Increased satisfaction in dealing with troubled youth for Judge, 

Magistrate and Court Personnel 

SUMMARY 

The number of days youth spends in detention is decreased significantly. 

This is an indication of improved functionality in the society. 

Youth’s substance use is reduced significantly while in the program. 

Substance use is eliminated at the end of Crossroads Program. 

Youth’s GPA is improved significantly. 

Significant increase in the employment rate at discharge, achieved the 

goal to increase youths’ productivity and functionality in the society. 

The higher the positive reinforcement at home in phases 1 and 2, the more 

likely the youth will successfully complete the Crossroads Program. 

Crossroads 

Summit County Court of Common Pleas 

Juvenile Division 

650 Dan Street 

Akron, Ohio 44310 

Judge Linda Tucci Teodosio 

330-643-2995 

lteodosio@cpcourt.summitoh.net 

4


Other Sources 

• Dawn Jones, Crossroads Administrator 

330-643-2910 

Djones@cpcourt.summitoh.net 

• Global Risk Assessment Device – 

http://projectgrad.osu.edu/about.cfm 

• V-DISC – Diagnostic Interview Schedule 

for Children – www.teenscreen.org 

5

T63: Using Motivational Interviewing Skills to Facilitate Readiness for Change in Persons with 

Co-Occurring Disorders (related to T53) 

Carol Auerbach, MA 


Description: 

This workshop builds on the one before (use of change theory) to explore the uses and skills needed for the 

practice of Motivational Interviewing as a means of helping persons prepare to move to the next stage of 

change and to fully engage with the interviewer. Basics will be reviewed and resources for additional skillbuilding 

will be discussed. 


• Describe the basic components of Motivational Interviewing and their relationship to change theory; 

• Discuss how this interviewing approach is useful both in fully engaging the person and in creating the 

context in which positive change may more readily occur; 

• Identify additional resources for skill-building in one’s own program/practice. 

NOTES:


TR63: Using Motivational 

Interviewing Skills to Facilitate 

Readiness for Change in Persons 


4:30PM – 6:30PM, May 16, 2006 

Carol J. Auerbach, MA 



Educational Objectives 

By the end of this workshop, participants will be 

able to: 

• Describe the basic components of Motivational 

Interviewing and their relationship to change 

theory; 

• Discuss how this interviewing approach is useful 

both in fully engaging the person and in creating 

the context in which positive change may more 

readily occur; 

• Identify additional resources for skill-building in 

one’s own program/practice. 

The Source of Change 

According to MI (Miller, 1998) 

“The route out of 

addiction involves 

finding alternatives 

that are more 

motivating.” 

The Basic Concepts of 


• Motivation is a state of readiness or 

eagerness to change 

• Ambivalence is a normal state of mind in 

which a person has coexisting but 

conflicting feelings about changing 

• Motivation can be defined as the 

probability that a person will enter into, 

continue and adhere to a specific change 

strategy 

Definition of Motivational 

Interviewing (Miller, 1995) 

“Motivational interviewing is a 

directive, client-centered 

counseling style designed to 

elicit behavior change by 

helping people to explore and 

resolve ambivalence.” 


(Prochaska & DiClemente, 1984) 

II. Contemplation: 

Person is aware that a problem exists 

and is in the process of evaluating 

whether to do anything about it. 

- The “not quite ready stage” 

- Ambivalence is the hallmark; the 

person is usually thinking about change 

but is ambivalent and refuses to make a 

commitment 

1


Motivational Interviewing & The 

Transtheoretical Model of Change 

(Prochaska and DiClemente, 1984) 

In Motivational Interviewing, 

movement from Contemplation to 

Preparation is most likely to occur 

when the individual: 

1. Identifies a desired goal that 

cannot be met if current behavior 

continues (Readiness) 

2. Sees the possibility of attaining it 

(Self-efficacy) 

The Goal of Motivational 

Interviewing 

To help the individual arrive at 

a decision to change based on 

his or her own reasons 


• A person-centered, strength-based 

approach 

• Originally developed to reduce 

“resistance to treatment” among 

individuals with substance use 

disorders 

• Successfully being applied to other 

issues which involve behavioral 

change: 

– Mental Illness 

– Medical Disorders 

We found that…drinkers would 

not take pressure in any form, 

excepting from John Barleycorn 

himself. They always had to be 

led, not pushed…We found we 

had to make hast slowly. 

- Bill Wilson, 1955, quoted in Ernest Kurtz, 

Not-God: A History of Alcoholics 

Anonymous 

Resistance According to 


“A mismatch 

between the 

individual’s 

readiness and 

willingness to do 

something and the 

staff’s expectations 

& approach.” 


Motivational Interviewing (MI) 


Is normal and to be expected during 

counseling but must be kept at lowlevels 

for change to occur 

Is a state that can fluctuate according 

to the interpersonal interaction of 

counselor and consumer 

2



Motivational Interviewing (MI) 

(Cont’d.) (Miller & Rollnick, 1991) 

Is increased by confrontational 

strategies 

Is responded to in MI using 

specific, non-confrontational 

strategies 

MI Practice Guidelines 

for Staff 

Listening is more than just 

paying attention…it is also 

suspending judgment… 

listening means we are 

trying to understand, not 

getting ready to reply.” 

- Gardner Hanks 

Staff Attitude: 

“The Spirit” 

•Trust the client 

• Be curious; learn from the 

individual 

• Accept ambivalence 

• See change as an individual 

process which occurs over 

time 

• Have hope 

Key Staff Behavior 

• Provide a “safe place” 

•Engage 

• Promote autonomy and 

empowerment 

Key Staff Behavior 

•Negotiate 

• Allow risk 

• Inspire hope 

• Listen, listen, listen… 

3


The Four General Principles of 



1. EXPRESS EMPATHY 

– Acceptance (vs. debate) 

facilitates change 

• Appreciate the person’s 

dilemma 

• Understand that ambivalence 

is normal 

• Reflect back their position 




2. DEVELOP DISCREPANCY 

– The person rather than staff should 

present the arguments for change 

• Help the individual minimize or 

counterbalance the incentives for 

continuing current behavior by 

helping them identify positive 

incentives for alternate behaviors 




3. ROLL WITH RESISTANCE 

- Resistance is increased by 

confrontational strategies 

• Avoid arguing for change 

• Invite new perspectives rather than 

impose them 

• See the individual as the primary source 

of answers and solutions 

• See resistance as a signal to respond 

differently. 




4. SUPPORT SELF- EFFICACY 

- A person’s belief in their ability to 

change is an important motivator 

• The individual, not staff, is responsible 

for choosing and carrying out the 

change 

• The staff’s own belief in the individual’s 

ability to change becomes a selffulfilling 

prophecy 

Fundamental MI Techniques 

1. O –Ask Open-ended 

questions; 

2. A – Affirm the person 

through non-verbal and 

verbal behaviors; 

3. R –Use Reflective listening 

skills throughout; 

4. S – Occasionally Summarize 

the conversation. 

***Avoid Traps 

Adaptations for Individuals with 


(Bellack & DiClemente, 1999) 

Four modules: 

1. Social skills and problem solving training 

2. Education about reasons and dangers of 

substance use 

3. Motivational interviewing, goal setting for 

decreased substance use 

4. Behavioral skills for coping with urges 

and high risk situations 

4


Traps to Avoid 

• Question/Answer Trap 

• Confrontation/Denial 

Trap 

• Expert Trap 

• Labeling Trap 

• Premature Focus Trap 

• Blaming Trap 

Resources for Additional Skill 

Building 

• William R. Miller & Stephen Rollnick.(1998). 

Motivational Interviewing: Professional Training 

Series (video). 

• Public Training Courses, Behavioral Healthcare 

Education, Drexel University College of Medicine 

• Bellack, A. & DiClemente, C. “Treating 

Substance Abuse Among Patients with 

Schizophrenia.” Psychiatric Services 50:75-80, 

1999 

• www.motivationalinterview.org 

Short Bibliography 

• Amador, X. & Johanson, A. (2000). I Am Not Sick, I Don’t Need Help!; Helping the 

seriously mentally ill accept treatment. Peconic, NY: Vida Press 

• Bellack, A. & DiClemente, C. “Treating Substance Abuse Among Patients with 

Schizophrenia.” Psychiatric Services 50:75-80, 1999 

• Miller, W.R., & Rollnick, S. (Eds.). (1991). Motivational interviewing: Preparing people 

to change addictive behavior. NY:Guilford Press. 

• Miller, W. (1998). Toward a motivational definition and understanding of addiction. 

[On-line]. Available: http://motivational.interview.org/mint/Mint5_3.PDF . 

• Miller, W. (1999). Toward a theory of motivational interviewing. [On-line]. Available: 

http://motivationalinterview.org/clinical/theory.html . 

• Miller, W. R., & Rollnick, S. (Eds.). (2002). Motivational interviewing: Preparing 

people for change (2nd .Ed). NY: Guilford Press. 

• Miller, W.R. (2003). Motivational Interviewing: Training for new trainers (2ndE.d.) 

Resource book given to participants in the Training for Trainers workshop (not 

available to the public domain). University of New Mexico, Department of Psychology. 

• Prab, K.J. (1998). Alternative diagram of the stages of change. In K.J. Drab, Brief 

interventions with substance use disorders. [On-line]. Available: 

http://users.erols.com/kjdrab/PNH . 

• Rollnick, S. & Miller, W.R. (1995). What is motivational interviewing? Behavioural and 

Cognitive Psychotherapy, 23, 325-334. 

5

T65: Creating Co-Occurring Centers of Excellence in Maine: The Experience of Two Agencies 

Catherine S. Chichester, MSN, APRN, Andrew B. Loman, LCSW, LADC, CCS, 

Michael Mitchell, LCSW & Peter Wohl, MA, LADC, CCS 


Description: 

Two agencies - a large hospital network and a rural agency that provides outpatient/crisis services - explore 

their agencies’ experiences and lessons learned in applying the CCISC model to advance integrated cooccurring 

services and systems. Practical “how to” steps to create a welcoming system of care for individuals 

with co-occurring disorders are highlighted. Topics explored include how to: organize an agency-wide 

initiative; engage and motivate leadership and staff; support cultural shifts; restructure organizational 

structures; develop quality improvement indicators; adapt policies and procedures; and develop a competent 

workforce. 


• Describe “how to” steps in developing an agency change initiative; 

• Critique ways to change organizational structures to support best practice protocols; 

• Apply lessons learned from two agencies to their own agency change initiatives for enhancing cooccurring 

disorders services; 

• Use integrated specific tools to assess performance outcomes. 

NOTES:

Crisis & Counseling Centers 

Co-occurring Integration 

Process 

•Structural Re-organization 

•Clinical Practice Changes 

•Individual Practice Changes 

C&C Organizational Structure as 

seen by Minkoff, 2004 

• CRISIS 

SERVICES 

• Clinical 

Director/Director of 

Operations 

The Chasm 

• OUTPATIENT 

SERVICES 

• OP Director 

While C&C had this particular 

idiosyncratic 

structural problem 

• Encountering idiosyncratic 

obstacles is common in most 

systems! 

Minkoff, 2005 

Reorganization 

System Redesign 

Clinical Director/Chief Operating Officer 

Senior Clinical Team 

MH Director CRISIS Director CRU Director OUTREACH Director SA Director 

Senior Clinician Residential Team Leader Senior Clinician 

1

Senior Clinical Team 

• Fosters spirit of collaboration between 

programs 

• Facilitates coordination of services 

• Promotes a unified clinical philosophy and 

clinical practice standards 

• Reviews (multi-program) cases 

• Reviews OP and IOP 

intake/assessment/clinical dispositions 

Clinical Practice Changes 

• Integrated assessment in all programs- 

MH,SA,COD 

• Eliminating barriers- 

• Crisis program assessing clients under the 

influence; 

• CRUs accepting clients under the influence. 

• Increasing inter-program collaboration. 

BARRIERS 

Solutions? 

• Maine Licensing (both agency and clinician) and Billing 

Structures maintain distinct bifurcation. 

• Increasing fiscal pressures, 

• requiring higher clinician productivity; 

• limiting time for clinical collaboration (such as team meetings); 

• limiting time and funds available for training to support 

technology transfer. 

• Pockets of resistance supported by long-held and 

resilient cultural myths and reactions to personal history. 

• Result: Tendency for some levels of the system 

to stall half-way, implementing parallel rather 

than integrated treatment. 

• Utilize group and individual supervision as a 

primary cost and time effective means of 

technology transfer and integration; 

• Identify resistance and apply strategies to 

enhance motivation and increase readiness to 

change. 

• Further organizational change- Redefining MH 

and SA Director roles to further collaboration 

and minimize distinctions between services. 

C&C Today, Having Achieved a 

Smooth, Seamless, Continuous 

System of Care 

2


Problem: 

Lack of integrated psychiatric & 

substance abuse (SA) treatment 

Maine Mental Health Network 

Co-Occurring Treatment 

Improvement Initiative 

• Substance abuse (SA) was prevalent in 

patient population and complicated 

patients’ psychiatric issues 

• Discrete psychiatric and SA programs were 

delivered in silos, without formal alignment 

or organizational structure 

• Less-than-optimal outcomes 

March, 2006 

Plan for Improvement 

• Adopted State’s evidence-based treatment 

philosophy & care model for co-occurring 

psychiatric & SA issues 

• Mission, vision revised to reflect the philosophy 

& model 

• Launched pilot program (Centers of Excellence 

for Integrated Treatment) 

• Received private foundation support and federal 

funds to offset start-up costs 

• Five-year planning & implementation timeline 

Improvement Design 

• Developed infrastructure to oversee, support 

& implement program 

– Champion model: 22 champions represent 

24 programs 

– Steering Committee 

• Created process for independent audits of 

patient charts 

• Redesigned assessments/treatment plans to 

reflect stages of change 

• Created systematic staff training program & 

orientation process 

• Solicited consumers to facilitate self-help 

groups 


• Pre-contemplation 



• Action 


Outcome Measures 

• Patient survey data 

– % of SA and psychiatric issues treated 

concurrently 

– % self-reported improvement in condition 

• % Increase in chart audits that demonstrate 

caregivers’ consistent presentation of 

treatment model to patients 

• % of caregivers/treatment teams reporting 

improved knowledge, skills, values & 

attitudes concerning the model 

1


2


Improvement Objectives for 

September, 2006 

• Increase % of charts indicating consistent cooccurring 

treatment philosophy used 

• Increase % of charts indicating consistent 

recording of ‘stages of change’ 

• Upgrade computer system to capture 

secondary diagnoses & automate data 

collection 

• Implement patient-reported symptom-reduction 

checklist across continuum 

• Expand resources to enhance staff training 

process & chart audit integrity 

Questions? 

3


History of Evidence Based Practice 

Toolkits 

INTRODUCING EVIDENCE 

BASED CARE TO A 

CONTINUUM OF CARE 

Andrew B. Loman, LCSW, LADC 

Program Manager 

Co-occurring Disorder Treatment Services 

Maine Medical Center and Spring Harbor 

Hospital 

• SAMHSA Initiates EBP Toolkit project 

• Six EBP Toolkits developed 

• Website for EBP’s Developed Mentalhealthpractices.org 

• Co-occurring Disorders Toolkit developed by staff of the 

New Hampshire-Dartmouth Psychiatric Research 

Center. 

• NHDPRC staff authored book on Integrated Treatment- 

Integrated Treatment for Dual Disorders, A Guide to 

Effective Practice, Guilford Press 2003. 

INTEGRATED TREATMENT 

• Shared Decision making 

• Integration of Services 

• Comprehensiveness 

• Assertiveness 

• The reduction of negative consequences 

• A long-term perspective (time-unlimited 

services) 

• Motivation based treatment 

• Availability of multiple psychotherapeutic 

modalities 

What does this mean? 

• Integration means services for both illnesses same staff, same 

organization. 

• Comprehensiveness refers to total client functioning- Housing, 

vocational services, self help etc. 

• Assertiveness addresses outreach to clients in creative ways. 

• Reduction of negative consequences represents a philosophy of 

harm reduction 

• Long-term perspective refers to sticking it out clients offering what 

they need when they require it. 

• Motivation based approaches are based upon clients motivation to 

change and the stage of change that they are determined to be in. 

• Multiple psychotherapeutic modalities means that treatment is 

tailored to the client not designing treatment programs to fit clients 

into. 

SHARED DECISION MAKING? 

• Are you really saying what I think you are 

saying? 

• Clients and families often know better 

what is best for them. 

• Client and helper as co-conspirators 

STAGES OF 

TREATMENT/STAGES OF 

CHANGE 

• Engagement- Precontemplation 

• Persuasion- 

Contemplation/Preparation 

• Active Treatment- Action 

• Relapse prevention- Maintenance 

1


Treatment Matching 

• Treatment must match the stage 

• Interventions must be fluid 

• Services must be comprehensive 

How do you get an 800 pound 

Gorilla to listen to you? 

• Empower staff to think out of the box 

• Develop a philosophy that guides your 

system 

• Create a management structure that 

really, really believes in this work. 

• Identify program champions 

Memorandum of Understanding 

• Ken Minkoff, M.D. and the MOU 

• Comprehensive, continuous, integrated 

system of care model (CCISC) 

• Eight principles 

• Four core characteristics 

The Holy Grail 

• Dual Diagnosis is an expectation, not an exception 

• The core of treatment success in any setting is the availability of 

empathic hopeful treatment across multiple treatment episodes. 

• Consensus model of treatment based on severity of illnesses. 

• Care must be balanced in a comprehensive manner. 

• When both illnesses are present, each must be considered primary. 

• Treatment must be matched to phase of recovery and stage of 

change. 

• There is no correct intervention or program 

• Outcomes must be individualized. 

Four Core Characteristics 

• The CCISC will be implemented within existing 

treatment resources. 

• The CCISC will promote participation from all 

components of the system. 

• The CCISC will utilize a full range of outcome 

based best practices. 

• The CCISC will promote an integrated treatment 

philosophy, common policies, procedures and 

language throughout the system of care. 

How do you know what your doing 

really works? 

• The COPASS Instrument 

• The CODECAT 

• Program specific action planning 

• Pre test 

• Post test 

2


Who are we? 

A 600 Bed teaching hospital with a large 

psychiatric department which offers a 

comprehensive array of services including 

inpatient, partial hospital, IOP, outpatient, ACT 

teams, research, residency training, acute 

psychiatry, consultation and liaison, 

and vocational services. 

A 100 bed psychiatric and substance abuse 

inpatient facility with eight units. 

A staff of 600 individuals who are very smart and 

opinionated. 

How are we doing this? 

• Very carefully 

• Very cautiously 

• Very deliberately 

• Very plan fully 

What of the future? 

• Constant review and feedback via quality 

management. 

• Satisfaction surveys 

• Community focus groups 

• COMPASS, CODECAT, COMPASS 

3

Fact Sheet 

A Project to Establish A More Welcoming System of Integrated Treatment* 

for People with Co-occurring Disorders (COD) in 

Mental Health and Substance Abuse Treatment Centers in Maine 

A two-year project of the Co-occurring Collaborative of Southern Maine funded by the Maine Health Access Foundation and the Office of Substance Abuse 

*Integrated treatment is a model in which one clinician or treatment team provides mental health and substance abuse 

services without prioritizing treatment for one disorder over the other. It promotes individualized interventions, 

inspiring a clinician to advance beyond traditional approaches to treat effectively both mental health and substance use 

issues at the same time. 

Project Summary 

This two-year project establishes the Institute for Quality Behavioral Health Care, a collaboration of 

mental health and substance use providers, administrators, payors, and advocates which will focus 

concurrently on two areas: 

1) Removing structural barriers to integrated treatment for co-occurring disorders (COD) including at the 

policy, funding, regulatory, contracting, training, and program levels. 

2) Developing or enhancing integrated programs for co-occurring disorders (COD) in ten treatment centers 

throughout Maine through technical assistance, support, and evaluation. 

This project expands on a federal community action grant awarded in 2002 by the Substance Abuse and 

Mental Health Service Administration (SAMHSA) to the Maine Department of Behavioral and 

Developmental Services. That grant was used to build consensus for the integration of substance abuse and 

mental health services among key stakeholders using a model called the Comprehensive Continuous 

Integrated Systems of Care (CCISC) Model. 

Funding 

The two-year-project is funded with approximately $200,000 by the Maine Health Access Foundation and 

$60,000 from the Office of Substance Abuse through training sub-contracts with AdCare Educational 

Institute of Maine and the CCSME, for a total of $260,000. The grants are matched by significant in-kind 

contributions from project partners. 

Problem statement 

Co-occurring disorders are common, they affect from 7 to 10 million adults in the US each year. Youth also 

may experience co-occurring disorders. According to the US Surgeon General report “Forty-one to 65 

percent of individuals with a lifetime substance abuse disorder also have a lifetime history of at least one 

mental disorder, and about 51 percent of those with one or more lifetime mental disorders also have a 

lifetime history of at least one substance abuse disorder.” 

When one co-occurring disorder goes untreated, both usually worsen. Complications arise which result in 

serious medical, psychological and social problems such as HIV, Hepatitis B and C, and cardiac and 

pulmonary disease, suicide, unemployment, homelessness, incarceration, and alienation from help and 

support of family and friends. Consequently, people with COD often require high cost services such as 

emergency room care, hospitalization, and a range of social services. 

People with co-occurring disorders need complex, comprehensive, integrated treatment which most do not 

receive. They historically have received parallel or sequential treatment from separate mental health and 

substance abuse services.

The need for integrated services 

Maine’s behavioral health service delivery system continues to struggle with the needs of those with cooccurring 

disorders. Service providers consistently identify the need for integrated substance use and mental 

health services in behavioral health. 

A 2001 survey of Maine professionals in substance abuse and mental health treatment centers found that 89 

percent identified substantial structural barriers to establishing integrated treatment for co-occurring disorders 

including separate administrative structures, funding disparities, differing treatment philosophies, differing 

clinician abilities, and differing eligibility criteria. 

The CCISC Model 

The project uses the Comprehensive Continuous Integrated Systems of Care (CCISC) Model, a systems change 

model developed by Kenneth Minkoff, MD, to establish integrated treatment within the Centers for Excellence. The 

model has four basic characteristics: system-level change, efficient use of existing resources, incorporation of best 

practices and integrated treatment philosophy. Integrated treatment is established by implementing change in 

treatment philosophy, policy, procedures and practices. 

The Centers of Excellence 

Four treatment centers established in year one represent diverse services and geographic distribution. Those 

agencies and their administrative offices include: 

• Aroostook Mental Heath Services, Inc. (d.b.a. AMHC), Caribou 

• Day One, Cape Elizabeth 

• Maine Medical Department of Psychiatry and Spring Harbor Hospital, Portland 

and Westbrook 

• Crisis and Counseling Centers, Augusta 

The initial four treatment centers will mentor and support four additional treatment centers in year two. Additional 

treatment centers in year two include: 

• Wellspring, Bangor 

• Community Health and Counseling Services, Bangor 

• MaineGeneral Health, Waterville 

• Spurwink, Portland 

System Change Strategies/Tools 

• Agency Commitment through MOU 

• Use of agency assessment tool: COMPASS 

• Development of Action Plans for change 

• Encouragement to utilize agency Continuous Quality Improvement processes 

• Biannual visits of national experts Doctors Minkoff and Cline with follow up reports 

• Additional consultant services from Dorothy Farr and NAMI ME 

• Monthly tele-video conferences among Centers of Excellence lead change agents 

• Chart audits 

• Mentoring across Centers 

• Evaluation/Outcomes through Hornby Zeller Associates, Inc. 

Contact 

Catherine Chichester, Co-Occurring Collaborative of Southern Maine, tel. 207-878-6170, 

cchichester@ccsme.org, www.ccsme.org 

Partners of the Institute for Quality Behavioral Health Care 

National Alliance for the Mentally Ill-Maine (NAMI Maine) ● AdCare Educational Institute of Maine 

Aroostook Mental Health Services, Inc (AMHC) ● Drug Rehabilitation Incorporated (also known as Day One) 

Anthem Blue Cross Blue Shield ● Maine Primary Care Association (MPCA) 

Maine DHHS, Bureau of Medical Services (BMS) ● Dept. of Health and Human Services (HHS) 

Office of Substance Abuse (OSA)

Mental Health Network Co-Occurring Champions Organizational Chart 

SPRING HARBOR 

HOSPITAL BOARD OF 

TRUSTEES 

MMC positions in Red boxes 

Spring Harbor positions in Blue boxes 

CEO 

King 

Chief Financial Officer 

Chief Operating Officer 

Hanley 

Chief Medical Officer 

Dept. of Psychiatry 

Psych Director of Nursing/ 

Chief Clinical & Nursing Officer 

Chief Planning & 

Development Officer 

Information Systems 


Director, OP 

Director Quality 

Management 

Program Manager 

Adult Partial Program 

Managed Care 

Chemical Dependency 

Andy Loman 

Adult OP 

Beth Largey 

Odyssey 

David Tompkins 

Medical Director, OP 

Cindy Boyack 

Medical Director, IP 

Consult & Liaison 

Physicians 

Patrice Roy 

Research 

In-Patient Services 

2E- Nancy Ashbaugh 

2NE - Karl Buckley 

1NW - Linda Chance 

1NE- Marina Eddy 

2W - Scott Letourneau 

2NW - Susan Ginnett 

P-6 - Lu Hutchinson 

Dietary 

Child 

Kristen Frazier 

Geriatric 

Maureen Callnan 

Residency Training 

Daniel Holliday 

Associate Chief of 

Nursing 

Joyce Cotton 

Admission Nurses 

Addictions Counselor 

Access/ICI/ 

Jail Diversion 

Marie Turco 

Psych Central Services 

Stacy Manning 

ANCHOR 

Curtis Scribner 

PIER 

Phil Collin 

Outpatient Social Work 

Revised - November 2005

Random Chart Audit Results 

(year 1) 

100% 

80% 

60% 

40% 

20% 

0% 

Screened for SA & MH Diagnosed with co-occurring Treated with integrated model

100% 

Treatment Team Improvement in 

Knowledge/ Skills/ Values/ Attitudes 

80% 

Compass Data 

Percentages by 

Program 

60% 

40% 

20% 

0% 

SHH IP 

5 Units 

MMC IP 

2 Units 

McGeachey 

OP 

3 Programs 

Other 

Programs 

6 Programs 

2005 

2004

T66: Co-Occurring Disorders from a Personal Perspective 

David F. Wooledge & Pauline Hoffman 

1.5 hours Focus: Recovery Supports; Family 

Description: 

In this workshop, a person in recovery from co-occurring disorders and a person in recovery who is also a 

family member discuss their own journeys. They also examine the complexities involved in living with cooccurring 

mental and substance use disorders and factors that help and that hinder dual recovery. This 

workshop is particularly useful for those providing treatment and support services to persons with co-occurring 

disorders and their families. 


• Examine factors that affect recovery from co-occurring disorders; 

• Discuss useful and non-useful approaches to providing treatment and support services; 

• Explore issues important to family members and means of helping them effectively support their family 

member. 

NOTES:

T67: Antisocial Personality Disorder and Co-occurring Substance-related Disorders 

Sam K. Gully, III, MS 


Description: 

This workshop describes some of the clinical modifiers a practitioner needs to use to engage the person with 

Antisocial Personality Disorder. It also examines why this form of character pathology is very heavily marked 

by Substance/Dependence. Recovery is very different with this combination of diagnoses. In this particular set 

of co-occurring disorders, progress in treating one of the disorders rarely leads to progress in the other – an 

integrated, specialized approach is needed. 


• Summarize the DSM-IV (TR) criteria for this Disorder; 

• Examine Conduct Disorder and its onset as a prerequisite for Adult ASP; 

• List possible neurological and developmental deficits and their implications for treatment; 

• Explain how the lack of attachments can lead to even deeper psychopathology; 

• Discuss newer treatment options. 

NOTES:


History of Antisocial Personality 

Disorder 

• 1801, Phillipe Pinel worked with people whom he called 

mad but not confused (“manie sans delire) 

• Benjamin Rush- the disorder was life time irresponsibility 

without remorse 

• 1835, J.C. Pritchard-”moral insanity” 

• 1878, Lombroso and Gouster-born juvenile delinquents 

with recognizable criminal faces 

• 1891, J.L. Koch-”psychopathic inferiority” 

• 1941, Hervey Cleckley-developed the first coherent 

description of the antisocial personality in his book, The 

Mask of Sanity 

Demographics of ASP 

• 3% of Males in the general population meet 

the DSM IV criteria for ASP. 

• 1% of Females in the general population 

meet the DSM IV criteria for ASP. 

• If the census numbers for the population of 

the U.S. are correct, i.e. approximately 300 

million–that equates to 12 million persons in 

our society meet the criteria for ASP. 

Central Features of APD 

• Inadequate conscious or superego 

• Emotional Immaturity-Egocentricity- 

Impulsivity 

• Stunted Capacity for Love and Emotional 

Involvement 

• Distress in Functional Life Areas 

Associated Features 

(DSM IV 1994) 

• People with ASP frequently lack empathy, 

tend to be callous, and contemptuous of 

feelings, rights, and sufferings of others. 

• They may have an inflated and arrogant selfappraisal(e.g. 

feel that ordinary work is 

beneath them or lack a realistic concern 

about their current problems or their future). 

• They may be excessively opinionated, selfassured, 

or cocky. 

• They may express a glib, superficial charm 

and can be quite voluble and verbally 

facile...or in other words–great bull-shitters.. 

• May be irresponsible as parents. 

• May become impoverished or even 

homeless. 

• Are more likely than people in the general 

population to die prematurely by violent 

means. 

• May experience dysphoria, complaints of 

tension, inability to tolerate boredom, and 

depressed mood. 

1


• They often meet the criteria for other Cluster 

B Personality Disorders such as Borderline, 

Histrionic, and Narcissistic PDO’s. 

• The likelihood of developing ASP in Adult 

Life is increased dramatically if the individual 

experienced an early onset of Conduct 

Disorder (before the age of 10 years) and 

accompanying ADHD . 

• Child abuse or neglect, unstable or 

erratic parenting, or inconsistent 

parental discipline may increase the 

likelihood that Conduct Disorder will 

evolve into ASP. 

Theories of Etiology 

• Heredity and Environment 

• “Abnormal Brain”/Neurological Impairment 

• Decreased activity in the Autonomic 

Nervous System 

• Lower Arousal Levels 

• Developmental Impairments 

Antisocial Personality 

Disordered Offender 

• The ASP disordered offender generally 

responds negatively to traditional engagement 

techniques, disrupts treatment efforts, and has a 

higher rate of recidivism. 

• They have higher rates of co-occurring SUD 

• There is a pervasive pattern of disregard for and 

violation of the rights of others (DSM IV, 1994) 

Cont’d 

• ASP’s know the difference between right 

and wrong, however they do not care. 

• Over 43% of the prison population has 

ASP 

• Some have all the traits of ASP, childhood 

onset of conduct disorder, and more 

bizarre behavioral characteristics which 

enter the realm of psychopathy (as 

measured by the Hare Psychopathy 

Checklist-R). 

Cont’d 

• Clinical, Correctional, and Psychosocial 

(Psychiatric) Rehabilitation approaches 

may have to address the dynamics of 

power, social disdain, impulsivity, and 

eroticized violence (sexual sadism). 

• ASP’s do not respect rules or social norms 

but they can learn to abide by them if there 

is a perception that something is in it for 

me 

2


Violence Risk Appraisal Guide 

(VRAG) 

• Psychopathy Checklist Score 

• Elementary school maladjustment 

• Age at index offense 

• DSM IV personality disorder 

• Separation from parents before age 16 

• Failure on prior conditional release 

Cont’d 

• History of nonviolent offenses 

• DSM IV schizophrenia 

• Victim injury in index offense 

• History of alcohol abuse 

• Male victim in index offense 

Does Mandatory Treatment Work? 

(Winick, B.J., 1997) 

• What does not work…Negative Pressure 

Tactics such as Threats and Force!! 

• Variables affecting client’s perception of force: 

– Motivation of the treatment provider--or is the 

provider acting out of concern for the client? 

– Respect--was there a degree of respect for the client 

by the provider? 

– “Voice”--or the tolerated expression of opinion 

• What is perceived to work: 

– Others act out of concern. 

– Others act out of a sense of fairness/respect. 

– Others act without deception. 

– Others provide an opportunity for “voice”. 

– Others take what “I” say seriously. 

• These factors are highly correlated with treatment 

outcomes. 

Gathering the right information to 

detect Co-occurring Disorders (Gains, 

2001) 

• There are several signs and symptoms of 

MH and SUD disorders that indicate the 

need for further screening and 

assessment. 

• These provide subtle indicators that can 

supplement self-report and archival 

information used in screening, diagnosis, 

and assessment 

• Goals of Screening, Dx, & and 

Assessment: 

Screening: 

• Detect current MH and SUD disorders 

• Identify people with a history of violent 

offenses/behavior or severe medical 

problems 

• Identify people who have severe cognitive 

deficits 

• Identify people without co-occurring d/o’s 

3


Diagnosis (Dx): 

• Identify the presence of specific DSM-IV 

Mental Health (MH) and Substance Use 

Disorders (SUD) 

• Develop plans for psychosocial 

assessment 

Assessment: 

• Assessment provides a comprehensive 

examination of bio-psycho-social needs 

and problems including the severity of MH 

and SUD D/O’s, conditions associated 

with the occurrence of these D/O’s, other 

problems, individual motivation, & areas 

for appropriate interventions, & is 

conducted through interview & specialized 

instruments 

Goals of Assessment 

• Examine the scope of MH & SUD 

problems 

• Assess the full spectrum of biopsychosocial 

problems that may need to 

be addressed in 

corrections/treatment/rehab. 

• Provide a foundation for treatment 

planning that incorporates successful and 

satisfactory outcomes. 

Screening for Co-occurring Disorders-- 

Signs and Symptoms: 

• Unusual affect, appearance, thoughts, or 

speech (e.g. confusion, disorientation, 

rapid speech). 

• Suicidal thoughts or behavior. 

• Paranoia. 

• Impaired judgment and risk-taking 

behavior. 

• Prescription drug-seeking behavior. 

Cont’d 

• Agitation and tremors. 

• Impaired motor skills (unsteady gait). 

• Dilated or constricted pupils. 

• Elevated or lower vital signs. 

• Hyperarousal or drowsiness. 

• Muscle rigidity. 

Cont’d 

• Needle track marks/injection sites. 

• Inflamed or eroded nasal septum. 

• Burns on the inside of the lips. 

– An integrated screening approach should be 

used to examine relevant criminal justice 

information, along with networking between 

multiple systems to establish ongoing 

professional contacts. 

4


Risk Assessment: 

• Need to find out the answer to a series of 

questions-- 

– Was the individual on medications at the time 

of the offense? 

– Since being in prison has the individual been 

receiving MH treatment? 

– Was the offense committed against family, 

close friends, or randomly? 

Cont’d 

• Was the offense sexual in nature? 

• Is there any remorse? 

• Are the individual and other participating 

parties agreeable to the conditions for 

entry? 

• Were drugs and/or alcohol used prior to 

the offense? 

• Is this a repeat offense? 

Ongoing concerns for working with 

people who have been imprisoned: 

• Considerations re: how people learn, 

adapt, and recover…including those who 

are physically disabled. 

• Considerations re: recovery from multiple 

disorders and incarceration. 

• Considerations re: MH / SUD/Correctional 

technologies that facilitate recovery and 

transition into the Community. 

Social Skills Training 

• A review of the literature indicates that all 

people learn idiosyncratically, but with 

some commonalities that include: 

– Visual Components 

– Auditory Components 

– Tactile Components 

– Interactive Components, particularly in adults. 

Cognitive-Behavioral-Treatment 

Approaches,CBT- (Beck, A.T., 1999) 

• The negative frame of “The Enemy”. 

• Applications of CBT: 

– Applying Rules of Evidence 

– Considering Alternative Explanations 

– Problem Solving 

– Examining and Modifying Beliefs 

– Modifying the Rules and the Imperatives 

Borderline Personality Disorder 

5


DSM-IV BPD CRITERIA 

ARE ALSO GENERALLY SEEN IN CLUSTERS 

• IMPULSE CLUSTER 

– Impulsivity in two or more areas. 

– Repetitive self-destructive behavior 



(Cont’d) 

• AFFECT CLUSTER 

– Uncontrolled anger 

– Unstable interpersonal relations 

– Labile moods 

– Stress-related paranoia or Dissociative 

symptoms 



(Cont’d) 

• IDENTITY CLUSTER 

– Identity diffusion 

– Feelings or emptiness and boredom 

– Intolerance of being alone 

CULTURAL FACTORS 

(Paris, 1996) 

• BPD highly sensitive to sociocultural context 

• Rare in traditional societies 

• Maybe a byproduct of rapid change/ 

modernization 

• Need to consider a late-age onset that meets 

DSM-IV criteria 

A NEW DIAGNOSIS 

COMPLEX POST-TRAUMATIC STRESS 

DISORDER 

• A history of subjection to totalitarian 

control over a prolonged period 

• Alterations in affect regulation 

• Alterations in consciousness 

A NEW DIAGNOSIS 

COMPLEX POST-TRAUMATIC STRESS 

DISORDER (Cont’d) 

• Alterations in self-perception 

• Alterations in perception of perpetrator 

• Alterations in relations with others 

• Alterations in system of meaning 

(Herman, 1992) 

6


EXAMPLES OF ASSESSMENT 

DOMAINS 

• Does individual meet DSM-IV criteria for 

BPD? 

• Identify any barriers to services/treatment. 

• What is the individual's subjective 

experience? 


DOMAINS (Cont’d) 

• Perceptions by others in personal and human 

services networks? 

• Assess etiology 

• Functional Assessment 

• Risk Assessment 


DOMAINS (Cont’d) 

• Assessment of the nature, role and function of 

non-lethal behaviors such as self-mutilation 

• Biomedical Assessment 

• Assessment/Evaluation of Practitioner/Team 

Responses to Individuals Being Served 

THE IMPACT OF TRAUMA 

• Trauma, related to early abuse and/or 

neglect, is in the histories of consumers of 

public MH and D & A programs. 

• They are frequently self –harming, high 

users of costly services who carry multiple 

diagnosis- BPD, DID, PTSD and 

substance abuse. 

GENERAL POPULATION 

• 10% of the women and 5% of the men are 

likely to suffer from PTSD 

• 33.3% +will have symptoms lasting 

several months 

• Those most vulnerable-inadequate social 

support, survivors of childhood sexual 

abuse 

Public mental health 

consumer 

• 98% of 275 consumers had exposure to 

severely traumatic events 

• 43 % suffered from PTSD 

• Chart reviews revealed only 2% had 

diagnosed PTSD in their chart 

• Another study-34% admitted to psychiatric 

state hospitals had PTSD- secondary to 

CSA 

7


Substance abuse and trauma 

• PTSD 5 times more likelihood with alcohol 

abuse and dependence 

• PTSD and veterans-75% met the criteria 

for alcohol abuse 

• 60% women & 20% of men in alcohol 

recovery programs-childhood sexual 

abuse 

The Oregon study 

• The highest use of acute psychiatric were 

individuals with BPD 

– In one county 69 individuals with BPD were 

hospitalized 412 times-average 6 days 

– 60% had 353 hospitalizations-total 2,634 days 

– estimated cost 1.3 million dollars 

– 21 accounted average 308 hospitalization 

average length stay 7.7 days 

Blackshaw,1999 

SUICIDE AND BPD 

• A diagnosis of personality disorder is 

found in 9% to 28% of completed suicides. 

• A diagnosis of personality disorder is 

found in 55% of persons who attempt 

suicide. 

SUICIDE AND BPD (Cont’d) 

• Borderline personality disorder is the only 

personality diagnosis that includes suicidal 

behavior as a criterion. 

• Many suicide attempts by people with BPD 

appear to arise from a background of 

anger or impulsivity (impulsiveaggression). 

SUICIDE AND BPD (Cont’d) 

• There is wide consensus of the predictive 

importance of prior attempts in both 

retrospective and prospective studies of 

attempters and completers in a wide variety of 

studies and across diagnoses. 

• Number of prior attempts relates to prediction of 

present attempt; seriousness of intent; and to 

degree of medical lethality. 

(Adapted from Soloff, P.H., et al., 1994). 

PARASUICIDAL BEHAVIORS 

• Nonfatal acts in which an individual deliberately 

causes self-injury or ingests a substance in 

excess of any prescribed or generally 

recognized dose. 

• 3/4 of BPD clients have committed at least one 

parasuicidal act. 

• Parasuicidal acts are never accepted as 

therapeutic choice 

(Adapted form Linehan, 1993.) 

8


Co-occurring APD and other 

Personality Disorders 

• Narcissistic 

• Histrionic 

• Paranoid 

• Borderline 

Specific Features In Cooccurring 

APD and BPD 

• Meet the criteria for APD and the following 

seven features: 

– Quasi-psychotic thought (transient) 

– Self-mutilation 

– Manipulative suicide efforts 

– Concerns with abandonment, engulfment, or 

annihilation 

Cont’d 

– Treatment regression 

– Demandingness or entitlement 

– Countertransference difficulties 

• People with both disorders report being 

more symptomatic than those individuals 

with APD alone. 

Cont’d 

• Persons with BPD, APD, or both often 

exhibit strong antisocial personality trends 

• There is an overlap in their family patterns 

of psychopathy 

Other Similarities (Cloninger, 1993; 

Siever and Davis, 1991)) 

• Pathological childhood experiences 

• The course of the disorders 

• Basic underlying temperaments 

– Both rate high on Novelty Seeking Scale 

– Those with APD are much lower on Harm Reduction 

Scale 

– Both have a strong personality dimension of anger 

and impulsivity which is tied to a disturbed 

neurophysiological regulation of serotonin 

APD and BPD (Zanarini & Gunderson, 1997) 

• Common Symptomatology: 

– Sexual deviance (usually promiscuity) 

– Other impulsive patterns 

– Interpersonal problems (devaluation, 

manipulation, and sadism) 

10


Numbers and Statistics 

• Persons with “pure” BPD significantly 

more female—86% 

• Persons with “pure” APD significantly 

more male—81% 

• Persons with both or “mixed” APD and 

BPD—55% female and 45% male 

Therapy Implications (Zanarini & 

Gunderson, 1997) 

• Persons who meet the criteria for both 

disorders may be better understood and 

treated if the Borderline diagnosis is 

considered the dominant, or hierarchically 

significant, designation. 

• This honors the basic principle that people 

deserve a treatment trial that may be 

beneficial. 

Other Therapeutic 

Considerations 

• Does the individual show evidence (not 

primarily in words) of a desire for getting 

attached to others? 

• Does the person have a capacity to 

tolerate unpleasant feelings (sadness, 

shame, guilt, envy)? 

• Are there social supports that reflect some 

positive social values? 

11

WEDNESDAY 

May 17 th , 2006

Wednesday Morning Plenary Session 

“Cultural Clashes in Co-Occurring Disorders: 

Clinical Dilemmas in Assessment and Treatment” 

David Mee-Lee, MD

Cultural Clashes in Co-Occurring Disorders: 

David Mee-Lee, M.D. 

Clinical Dilemmas in Assessment and Treatment 

___________________________________________________________________________________ 




Davis, CA 

(530) 753-4300; Voice Mail (916) 715-5856 

DAVMEELEE@aol.com www.DMLMD.com 

May 17, 2006 

Hershey, PA 

A. Terminology 

• MICA, CAMI: MISA, SAMI: MICD; ICOPSS; dual disorders; dual diagnosis; double trouble; coexisting; 

co-morbid; co-occurring; multiple vulnerabilities 

In “A Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders 

and Mental Disorders”, SAMHSA defines people with co-occurring disorders as “individuals who have at 

least one mental disorder as well as an alcohol or drug use disorder. While these disorders may interact 

differently in any one person…at least one disorder of each type can be diagnosed independently of the 

other”. The report also states, “Co-occurring disorders may include any combination of two or more 

substance abuse disorders and mental disorders identified in the Diagnostic and Statistical Manual of 

Mental Disorders-IV (DSM-IV). There are no specific combinations of….disorders that are defined 

uniquely as co-occurring disorders.” 

(www.samhsa.gov/reports/congress2002/foreword.htm) 

I. Cultural Clashes 

B. Philosophical Clashes in the Behavioral Health Field 

1 Polarized Perspectives about Presenting Problems 

3 D’s Deadly Disease – consider addiction in differential diagnosis; ask questions to screen, diagnose 

Denial – conscious lying; amnesia of blackouts; unconscious survival mechanism 

Detachment – healthy distance; don’t pin your professional self esteem to client’s success or not 

3 P’s Psychiatric Disorders – not all mental health problems are symptoms of addiction and withdrawal 

Psychopharmacology – medications often necessary; can prevent psychiatric & addiction relapse 

Process – often no quick, easy answer to decide addiction versus psychiatric versus dual diagnosis 

2. Different Theoretical Perspectives; Different Treatment Methodologies 

1. Addiction System versus Mental Health System 

• 3 D’s and 3 P’s - implications for medication, staff credentials, attitudes towards physicians, role of staff and team, 

programs 

2. Integrated Treatment versus Parallel or Sequential Treatment 

• hybrid programs - staffing difficulties; numbers of patients and variability, but one-stop treatment 

• parallel programs - use of existing programs and staff, but more difficult to case manage 

1 

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3. Care versus Confrontation 

• mental health - care, support, understanding, passivity 

• addiction - accountability, behavior change 

4. Abstinence-oriented versus Abstinence-mandated 

• treatment as a process, not an event 

• respective roles in both approaches 

5. Deinstitutionalization versus Recovery and Rehabilitation 

C. Dilemmas in Definition, Diagnosis and Disposition 

• Definition - diagnosis or diagnoses; “multiproblem” 

- any client who presents with significant alcohol and/or other drug use and active psychiatric Sxs 

• Diagnosis - substance use disorder or psychiatric diagnosis or both?; primary or secondary disorder, 

or doesn’t it matter? 

• Disposition - where to treat? - addiction treatment settings; mental health settings; or special dual 

diagnosis services; use treatment-priority to determine placement 

- how to treat? - medications; motivation; meetings 

D. Why Diagnostic Confusion? - Diagnostic Confusion due to: 

• Alcohol/drugs can cause psychiatric symptoms in anyone (acute toxicity) 

• Prolonged alcohol/drug use can cause short or long-term psychiatric illness 

• Alcohol/drug use can escalate in episodes of psychiatric illness 

• Psychiatric symptoms and alcohol/drug use can occur in other psychiatric disorders 

• Independent addiction and psychiatric illnesses (“Dual Diagnosis”) 

(Marc A. Schuckit: Am. J. Psychiatry, 143:2 p. 141 - modified) 

E. Why Lack of Consensus? 

• Lack of consistency in research findings; research methodologies; prevalence rates 

• Different training and experience 

• Different patient populations 

• Different research methodologies 

2 

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II. What to do about Philosophical Clashes 

F. Person-Centered Assessment and Individualized Treatment 

1. Multidimensional Assessment 

• Because mental and substance-related disorders are biopsychosocial disorders in etiology, expression 

and treatment, assessment must be comprehensive and multidimensional to plan effective care. The 

common language of six assessment dimensions of the ASAM Criteria (modified for mental disorders 

in Second Edition, Revised, ASAM PPC-2R, 2001) are used to focus assessment and treatment. 

1. Acute intoxication and/or withdrawal potential 

2. Biomedical conditions and complications 

3. Emotional/behavioral/Cognitive conditions and complications 

4. Readiness to Change 

5. Relapse/Continued Use/Continued Problem potential 

6. Recovery environment 

2. Individualized Treatment 

PATIENT/PARTICIPANT ASSESSMENT 

Data from all 

BIOPSYCHOSOCIAL 

Dimensions 

PROGRESS 

Response to Treatment 

BIOPSYCHOSOCIAL Severity (SI) 

and Level of Functioning (LOF) 

PRIORITIES 

BIOPSYCHOSOCIAL Severity (SI) 

and Level of Functioning (LOF) 

PLAN 

BIOPSYCHOSOCIAL Treatment 

Intensity of Service (IS) - Modalities and Levels of Service 

3. Biopsychosocial Treatment - Overview: 5 M’s 

* Motivate - Dimension 4 issues; intervention; “raising the bottom”; motivational enhancement 

* Manage - the family, significant others, work/school, legal 

* Medication - detox; anti-craving meds; Antabuse; opioid antagonists; methadone and 

buprenorphine; psychotropic medication 

* Meetings - AA, NA, Al-Anon; Smart Recovery, Dual Recovery Anonymous, etc. 

* Monitor - continuity of care; relapse prevention; family and significant others 

4. Treatment Levels of Service - levels of care/service to match severity of problems: 

I Outpatient Services 

II Intensive Outpatient/Partial Hospitalization Services 

III Residential/Inpatient Services 

IV Medically-Managed Intensive Inpatient Services 

3 

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___________________________________________________________________________________ 

III. 

People and Personnel Clashes and Solutions 

• collaborative, concurrent interdisciplinary team 

• vulnerabilities inhibiting team cohesiveness e.g., recov. vs non-recov.; M.D. vs counselor; psych. vs addictiontrained; 

biomedical vs psych. orientation; education vs. life experience; ambiguity tolerance 

• team communication - documentation skills; use of jargon and technical terms e.g., “confused”, “disoriented”, 

“delusional” 

• staff-program match 

• stress of working with multiproblem patients - need to be in control; countertransference; overwhelmed with the 

needs and lack of resources; group supervision and conflict resolution 

Incorporate the following into your personal approach to care: 

• Tolerance: To listen to another professional’s opinion 

• Open-mindedness: To give up old views of addiction or psychiatric problems 

• Patience: To explore the history and treatment progress carefully before jumping to 

diagnostic conclusions 

• Education: To learn more about addiction & mental illness; meds.; motivating strategies 

• Serenity: To realize that professionals cannot always know the answers immediately. 

IV. 

Policy and Program Clashes and Solutions 

G. Program Issues 

• mission of the program, department, institution or agency 

• equal emphasizes both mental health and addictions issues 

• admission criteria and patient mix - what can staff/program mange 

• terminology and treatment tools e.g., “alcoholism vs “addiction 

• non-cognitive, activity groups e.g., time use charts; collages 

• groups - education about dual identity; feelings group to learn about relapse cues, signs and symptoms 

• family involvement; systems work and continuing care 

• self/mutual help groups - preparation for AA/NA mainstreaming; Dual Recovery Anonymous 

• staff composition reflects training proportionate to program’s clientele 

H. Payment Issues 

• Person-centered funding of services based on the specific priorities guided by the level of functioning in all six 

ASAM Criteria assessment dimensions 

• Moving from medical necessity being defined by withdrawal, biomedical and psychiatric severity, to 

multidimensional severity requiring interventions in any or all of the six dimensions 

• Fund case management to allow proactive treatment planning rather than reactive services 

• Turf battles between mental health and alcohol/drug services with addiction services frequently being the more 

neglected of the two systems due to fewer numbers of clients and/or stigma 

4 

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I. Gathering Data on Policy and Payment Barriers 

• Policy, payment and systems issues cannot change quickly. However, as a first step towards reframing frustrating 

situations into systems change, each incident of inefficient or in adequate meeting of a client’s needs can be a data 

point that sets the foundation for strategic planning and change 

• Finding efficient ways to gather data as it happens in daily care of clients can help provide hope and direction for 

change: 

PLACEMENT SUMMARY 

Level of Care/Service Indicated - Insert the level of care and/or type of service that offers the 

most appropriate level of care/service that can provide the service intensity needed to address the 

client’s current functioning/severity. 

Level of Care/Service Received - If the most appropriate level/service is not able to be utilized, 

insert the most appropriate placement/service available and circle the Reason for Difference 

between Indicated and Received Level/service 

Reason for Difference - Circle only one number -- 1. Level of care or Service not available; 2. Provider 

judgment; 3. Client preference; 4. Client is on waiting list for appropriate level/service; 5. Level of care or 

Service available, but no payment source; 6. Geographic inaccessibility; 7. Family responsibility problems e.g., 

no childcare; 8. Language; 9. Not applicable; 10. Not listed. 

LITERATURE REFERENCES AND RESOURCES 

Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-Occurring 

Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 05-3992. 

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005 

(TIP 42 should be available online within the next couple of weeks. It will be posted to the Health 

Services/Technology Assessment Text (HSTAT) section of the National Library of Medicine Web site at 

the following: URL: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.part.22441) 

Davis KE, O’Neill SJ (2005): “A Focus Group Analysis of Relapse Prevention Strategies for Persons with 

Substance Use and Mental Disorders”. Psychiatric Services 56:1288-1291 

Drake RE, Wallach MA, McGovern MP (2005): “Future Directions in Preventing Relapse to Substance 

Abuse Among Clients With Severe Mental Illness” Psychiatric Services 56:1297-1302 

Mee-Lee, D., Shulman, G.D., Fishman, M., Gastfriend, D.R., & Griffith J.H. (Eds.) (2001). ASAM Patient 

Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised (ASAM 

PPC-2R). Chevy Chase, MD: American Society of Addiction Medicine, Inc. 

American Society of Addiction Medicine - 4601 Nth. Park Ave., Arcade Suite 101, Chevy Chase, MD 

20815. (301) 656-3920; Fax: (301) 656-3815; (800) 844-8948. Web page: www.asam.org 

Mueser KT, Noordsy DL, Drake RE, Fox L (2003): “Integrated Treatment for Dual Disorders – A Guide to 

Effective Practice” The Guilford Press, NY. 

Prochaska, JO; Norcross, JC; DiClemente, CC (1994): “Changing For Good” Avon Books, New York. 

5 

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RESOURCES FROM SAMHSA 

1. In 2002, the Substance Abuse and Mental Health Services Administration (SAMHSA) presented 

“A Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse 

Disorders and Mental Disorders”. It provides a summary of practices for preventing substance use 

disorders among individuals who have mental illness and also a summary of evidence-based practices for 

treating co-occurring disorders. Resource: www.samhsa.gov/reports/congress2002/foreword.htm 

2. A 2003 publication, “Strategies for Developing Treatment Programs for People with Co-Occurring 

Substance Abuse and Mental Disorders” is also available on the SAMHSA website or though the 

SAMHSA National Mental Health Information Center at (800) 789-2647. SAMHSA Publication No. 

3782, SAMHSA 

3. Center for Substance Abuse Treatment. “Substance Abuse Treatment for Persons With Co- 

Occurring Disorders” Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 

05-3992. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005 




4. Co-Occurring Dialogues is an Electronic Discussion List that specifically focuses on issues related to 

dual diagnosis. A subscription to the Co-Occurring Dialogues Discussion List is free and unrestricted and 

can be done simply by sending an e-mail to dualdx@treatment.org. 

5. The Co-Occurring Center for Excellence (COCE) 

In September 2003, the Substance Abuse and Mental Health Services Administration (SAMHSA) launched 

the Co-Occurring Center for Excellence (COCE) with a vision of its becoming a leading national resource 

for the field of co-occurring mental health and substance use disorder treatment. The mission of COCE is 

threefold: (1) Receive, generate and transmit advances in substance abuse and mental health that address 

substance use and mental disorders at all levels of severity and that can be adapted to the unique needs of 

each client, (2) Guide enhancements in the infrastructure and clinical capacities of the substance abuse and 

mental health service systems, and (3) Foster the infusion and adoption of prevention, treatment, and 

program innovations based on scientific evidence and consensus. 

COCE consists of national and regional experts who serve to shape COCE’s mission, guiding principles, 

and approach. (For more information on the COCE, see: www.coce.samhsa.gov. You can contact the 

COCE at (301) 951-3369, or e-mail: coce@samhsa.hhs.gov.) 

FREE MONTHLY NEWSLETTER 

“TIPS and TOPICS” – Three sections: Savvy, Skills and Soul and additional sections vary from month to 

month: Stump the Shrink; Success Stories and Shameless Selling. Sign up on www.DMLMD.com or here 

at the workshop. 

6 

______________________________________________________________________________

W71: The OK-COD Screen: Rapid Detection of People with the Co-Occurring Disorders of 

Substance Abuse, Mental Illness, Domestic Violence & Trauma 

L.D. Barney, MA, LADC & Todd Crawford, MS, LPC, LADC 


Description: 

A small percentage of persons with co-occurring disorders are actually identified. Until now, no integrated tool 

has been available. This workshop will introduce participants to a screen that can be quickly administered and 

requires little training. As part of its COSIG grant, Oklahoma developed a statistically reliable instrument to 

identify the likelihood of mental and substance use disorders as well as the existence of trauma and domestic 

violence issues. The OK-COD Screen is copyrighted, and commercial use is prohibited, but it will be made 

available at no charge to clinicians and agencies serving those with co-occurring disorders. 


• Use an integrated screening instrument proven to identify persons with a co-occurring disorder; 

• Employ a co-occurring screening instrument that is quickly administered and requires little or no 

training to use; 

• Document the need for further assessment for co-occurring disorders to provide early intervention for 

problems that, if ignored, present themselves later in expensive crisis situations. 

NOTES:


Co-Occurring Disorders in Those 

Seeking Services Were Under 

Recognized 

The OK-COD Screen: 

Rapid Detection of People 

with Co-Occurring Disorders of 

Substance Abuse, Mental Illness and 

Trauma 

• Nationwide information led to expectation 50 % 

or more of those seeking services would have 


• Less than 8% of those presenting for service in 

Oklahoma were being identified as needing 

COD treatment 

Recognition Needed To Be a Priority 

• Data from 1999 Mortality Review in New Mexico 

made it clear that deaths by accident, suicide, 

homicide, illness or natural causes were a high 

probability of under recognizing COD 

• Under recognition at best leads to low retention 

rates, inefficient coordination of services, 

inefficient use of resources, poor treatment 

matching, discharge planning and follow up. 

How to Increase the Number of Service 

Recipients Assessed for COD 

• Statewide Committee of Mental Health, 

Substance Abuse and Domestic Violence 

Clinicians, Consumers, and Advocacy 

Groups Formed Through COSIG Process 

• Decision Made to Utilize “Hot Button” 

Screen to Broaden the Number of People 

Assessed for COD 

• Screen Would Simply Determine Whether Client 

Warranted Assessment for a Possible Co- 

Occurring Mental or Substance Use Disorder 

• Screen Process Would Seek a “Yes” or “No” 

Answer to Questions About Possible Problem, 

Including Trauma. 

• Screening Process Would Not Attempt to 

Identify or Determine Seriousness of any 

Problem Service Recipient Might Have 

• A Yes Answer Results in Automatic Referral for 

Assessment 

• All Persons Seeking Services Would Receive an 

Integrated Screen, SA for Those Seeking MH 

Services and MH for Those Seeking SA 

Services. Everyone Would Receive Trauma 

Screening. 

• Screening Would be Brief, Require A Bare 

Minimum of Training and Collect Only Enough 

Information to Determine Immediate Need for a 

Full, More Sophisticated Assessment 

1


What Was Available 

• A Literature Search Revealed Most Promising 

Scales Were Time Consuming and Required 

Clinical Skills and Training to Administer 

• No Instrument Available Designed to Tentatively 

Identify People With COD That is Quickly 

Administered and Requires Little or No Training 

to Utilize 

• OK-COD Screen Designed to Fill the Void 

OK-COD Screen 

• Collects Self-Report Information 

• Purpose is Not to Determine Mental Health or 

Substance Use Profile but to Identify Possibility 

of A Problem That Justifies a More 

Comprehensive Assessment 

• Goal Was to Develop an Instrument That Is 

Succinct But Does Not Identify an Unacceptably 

High Proportion of False Positives 

OK-COD Screen 

• Demonstrated Reliability and Validity 

• Easy to Interpret 

• Administered in a Few Minutes Whether in 

Person or Telephone 

2

W72: Use of Animal Assisted Therapy with Adolescents in Substance Abuse and Co-occurring 

Disorders Treatment 

Alanna Lassiter, MA 

1.5 hours Focus: Children and Adolescents 

Description: 

One of the major barriers experienced by adolescents in treatment often involves their overall difficulty with 

attachment and connectedness. This connectedness usually interferes with major functioning in interpersonal 

settings and is often at the core of identified triggers for substance use and other maladaptive coping. Since 

interpersonal attachment is often the conduit to change, this workshop reviews means of implementing an 

AAT program into an existing milieu, discussed criteria for participant selection and examines strengths and 

limitations of AAT. 


• Summarize important factors to consider in the implementation of an AAT program in an existing 

milieu; 

• Discuss and analyze diagnostic criteria for participant selection; 

• Examine and discuss strengths and limitations to the AAT model. 

NOTES:

W73: Suicide by Cop: A Volatile Formula for Law Enforcement and Co-occurring Disorders 

Suzanne M. Elhajj, BA 

1.5 hours Focus: Systems Integration & Forensics Involvement 

Description: 

Unsuspecting police officers have only seconds to make life-altering decisions and can become a lethal 

instrument used by a person with a neurobiological disorder who is “under the influence” and suicidal. Such a 

shooting then brings about a “ripple effect,” often traumatizing the police officer, the officer’s family, the 

family of the decedent and the community at large. This workshop, which includes videotaped interviews of 

consumers and police, provides valuable information for professionals and persons using their services on the 

phenomenon of “suicide by cop” and present innovative ways in which police and mental health providers are 

working together to address this issue and its aftermath with care and compassion. 


• Define and describe Suicide by Cop (SBC) - what it is and how it is determined; 

• Evaluate risk factors associated with SBC; 

• Develop preventative measures to assess individuals at risk; 

• Partner with Police to provide/assist with training on this subject; 

• Provide support for all involved in a SBC incident. 

NOTES:


Suicide by Cop 

Suicide By Cop 

• Definitions and concepts 

• Personal/family perspectives 

• Post-incident Response 

– Psychological Concerns (PTSD) 

– Intervention Techniques 

– Resources and referrals 

Suicide by Cop (SBC): 

DEFINED 

• Suicide-by-cop: A form of “victim 

precipitated homicide” in which a 

suicidal individual engages in 

calculated, life threatening and 

criminal behavior in order to compel 

the police to use deadly force 

(a.k.a. Police-assisted suicide) 

CA Peace Officer Standards and Training (POST) 


DEFINED 

• “Victim Precipitated Homicide” 

– a person’s actions whether knowingly 

or unknowingly cause his or her own 

death by another 

Richard Parent, PhD, Delta, BC Police Department and Simon 

Frasier University 


DEFINED 

• “Death by Indifference” 

– people who engage in self-destructive 

conduct with no apparent regard for 

the consequences of their actions 

• “Victim Precipitated Homicide” or “Death 

by Indifference” may or may not be SBC 

Incident Dynamics 

• May be ambiguous, OR 

• Overt expression of a wish to die by the 

hands of police 

• Existence of some other type of written, 

verbal or behavioral suicidal 

communication 

• Acts which, by their very nature, would 

cause law enforcement to use deadly 

force 

CA POST and Dr. Barry Perrou 

1


Mechanics 

• Planned or Spontaneous 

• Outrageous act to draw attention, provoke 

confrontation or escalate an incident to 

elicit law enforcement response 

• Actions are those which a reasonable law 

enforcement officer would view as 

dangerous, unusual or out of the ordinary 

Actions 

• Desire to provoke a deadly confrontation 

with officers 

• Non-compliant, reckless, threatening or 

aggressive, despite the likely 

consequences of that behavior 

• 0ften deliberately manipulate officers into 

a position of confrontation (sets a “trap”) 

CA POST and Dr. Barry Perrou 

• 96% of the subjects 

were male. 

• Ages ranged from 18-54 

• Weapons ranged from 

firearms (46%), stabbing 

instruments (46%) and 

firearm replicas (8%). 

• 58% asked to be killed 

by police 

• 58% had a 

psychiatric history 

• 8% had previously 

attempted suicide 

• 50% were 

intoxicated 

• 42% had a history of 

domestic violence 

• 38% had a criminal 

history 

(1998, “Annals of Emergency Medicine“; Dr. Barry Perrou, forensic psychologist and former 

commander of the LA County Sheriff's Hostage Negotiations Unit; officer involved shootings 

investigated by the Los Angeles County Sheriff's Department between 1987 and 1997.) 

SBC 

• All but one of the victims were male. 

• All possessed an apparent handgun or other 

weapon and threatened to kill the officers with 

these weapons. 60% of the subjects USED 

their weapons. 

• 40% were intoxicated 

• 50% had made previous suicide attempts 

• 40% had a history of mental illness with 60% 

showing compelling evidence of depression. 

1998 study analyzed 15 shooting deaths of suicidal persons by law 

enforcement personnel in Oregon (Marion County) and Florida (Dade County) 

SBC 

• 63% were armed with guns, 24% had knives, 3 had 

other objects ; 3 had no weapon or other weapon. 

• More than 50% were under the influence of alcohol 

• 45% were experiencing family problems or the end of 

a relationship 

• Almost 40% talked about homicide and suicide with 

officers involved 

• In 46% of the cases, the incidents began as a 

domestic argument. 

• Two-thirds appeared unplanned. 

Dr. Vivian Lord; University of North Carolina – Charlotte; a study of 54 cases in 

which people attempted "suicide by cop" in North Carolina between 1992 and 1997. 

SBC 

• In roughly half the cases, the police reacted with 

deadly force to despondent individuals suffering 

from suicidal tendencies, mental illness or 

extreme substance abuse acting in a manner to 

elicit such force. He found that 10-15% of these 

cases could be considered pre-meditated 

suicides. 

Constable Rick Parent, M.A. of the Delta, British Columbia Police Department, a Doctoral Student at 

Simon Fraser University, 1996 research of municipal police and Royal Canadian Mounted Police. 

2


SBC 

• Out of the 437 shootings studied, 46 events (11%) 

were classified as "suicide by cop.“ (1998, “Annals of 

Emergency Medicine“; officer involved shootings investigated by the 

Los Angeles County Sheriff's Department between 1987 and 1997.) 

• 10% of officer involved shootings involved suicide 

attempts. The method of suicide was to entice a 

police officer, in a self-defensive action, to shoot the 

decedent. (Dr. Karl Harris, former Deputy Medical Examiner of Los 

Angeles County, Richard Brian Parent of Simon Fraser University and 

Dr. H. Range Huston of Harvard University School of Medicine, 1983.) 

Indicators 

•Male 

• Weapons (gun, knife) 

• Relationship Problems 

• Substance Use or Abuse (alcohol) 

• Predisposition to Violence 

• Mental Illness 

• Previous Suicide Attempts 

• Major life change (income, terminal illness) 

• Statements of homicide or suicide 

Psychological 

Autopsy 

• Investigation into individuals behavior to 

determine if death was suicide, homicide 

or accidental. 

– Statements and behaviors 

– Compare with everyday life 

– Interviews with witnesses, family, ambulance 

or hospital staff 

– Psychological history 

– Outlook on precipitators future 

A Personal Perspective 

• A survivor’s story 

• 20/20 video 

Suicide by Cop 

3


Understanding Officer 

Reactions 

“War in the Streets: Memphis PD” HBO 

Above 175 bpm: 

•Irrational fight or flee 

•Freezing 

•Submissive behavior 

•Voiding of bladder or 

bowels 

•Running/charging etc.. 

220 

200 

180 

160 

175 bpm 

•Cognitive processing 

Deteriorates 

•Tunnel vision 

•Loss of depth percept. 

•Loss of near vision 

•Auditory exclusion 

Condition 

Black 

5 Areas of Stress Indicators 

Cognitive (thinking) 

Emotional 

Hormonal or 

Fear Induced 

Heart Rate. 

140 

120 

100 

80 

145 bpm complex 

motor skills deteriorate 

115 bpm fine motor 

skills deteriorate 

60-80 bpm normal 

resting rate 

Condition 

Red 

Condition 

Yellow 

Condition 

White 

Behavioral 

Physical 

Spiritual 

• 20/20 video 

Police Perspective 

4


Time Frame 

• 70% of SBC shootings occur within 30 

minutes of the officer’s arrival 

• 30% occur within 5 minutes of the 

officer’s arrival 

Types of Incidents 

• Sudden on-set without information 

• Sudden on-set with information 

• Staged “trap” 

• Note: Robert Woodward shooting 

(Brattleboro,VT) occurred within the 

first minute of police arrival on scene 

Who Are The Victims? 

• The suicidal person (victim of their illness) 

• The police officer 

• The suicidal person’s family members 

Police Shootings 

NEVER FORGET…… 

The “ripple effect”….. 

Police shoot to_____________ LIVE! 

(fill in the blank) 

Family Perspective 

• A mother’s story 

CIT 

Response 

5


CRISIS INTERVENTION TEAMS 

• A community partnership to set a standard 

of excellence with respect to the treatment 

of people with mental illness, improving 

the quality of life in an entire community. 

Connecticut CIT 

CT Alliance to Benefit Law Enforcement, Inc. 

(CABLE) 

In conjunction with 

CT Department of Mental Health and Addiction 

Services (DMHAS) 

National Alliance on Mental Illness of CT 

(NAMI) 

CT Criminal Law Foundation, Inc. (CCLF) 

PROGRAM OVERVIEW 

• Officer selection 

– All CIT officers are volunteers / not all 

volunteers are selected. 

– Volunteers are selected based on 

communication skills, problem solving, and 

their ability to perform under pressure. 

TRAINING 

• 40 Hour – multidisciplinary 

• Find the most respected experts in the 

field. 

• Co-train with mental health providers. 

• Create specialists within your police force 

– not a special unit. 

Training areas 

• Overview of the Mental Health System. 

• Co-occurring Disorders 

• Mental Health & the Law 

• Requests for Emergency Evaluations (17a-503) 

• Hearing Voices (Living w/ schizophrenia) Role Play 

• Less Lethal Overview 

• Suicide assessment 

• Suicide by Cop 

• Post Shooting Trauma 

• Children / Adolescent Mental Health 

• Management of Aggressive Behavior 

• Implementation pitfalls & successes 

• Families (NAMI) 

Training Partners 

• NAMI-CT 

• DMHAS (Department of Mental Health and 

Addiction Services) 

• Yale University 

• Connecticut Criminal Law Foundation 

• West Haven Police Department 

• New London Police Department 

• Waterbury Police Department 

• University of New Haven 

6


HOW IT WORKS 

• Dictated by policy. 

• Dispatcher screens call. 

• CIT Officer sent if available. 

• CIT Officer uses his special training and 

increasing experience to obtain positive 

outcomes. 

• Rapport and partnerships built between 

police, consumers and mental health 

professionals. 

What type of call? 

• “Family member out of control” 

• “Man acting bizarre” 

• “Woman threatening suicide” 

• “Man threatening his case worker” 

• “Mother not eating or taking meds.” 

BACKGROUND 

• Started in Memphis TN in May 1988 

• As the direct result of a shooting. 

• The mandate for the program was for it to 

provide safety for the officers, consumers 

and their families. 

• Partnership w/ University of TN Medical 

Center. 

• Of the 900 MPD Officers – 213 are CIT 

trained. 

• 7,000 CIT calls a year. 

CITED BY 

• US Justice Department 

• National Alliance for the Mentally Ill 

• Amnesty International 

• Amer. Society for Sociology 

• Police Executive Research Forum 

CIT in Connecticut 

• Started in January of 2000 in New London by 

Capt. Kenneth Edwards Jr. who took the 

Memphis training 

• Trained 14 New London Officers 

• Developed in partnership with a local providers 

• Recognized by Police Executive Research 

Forum as a “Best Case Practice” 

• Expanded on Model (CIT Plus) now supported 

by DMHAS in four urban police departments. 

• Thirteen additional departments including three 

college campuses now have CIT training and 

are working with their local mental health service 

providers 

BENEFITS 

• Low cost 

• Saves manpower 

• Reduce officer injuries 

• Reduce consumer injuries 

• Excellent tool for pre-arrest jail diversion 

• Links consumers to community services 

• Reduced use of restraints 

• Increased tactical, communications and negotiation skills 

in managing a wide range of crisis situations. 

• Reduce liability and litigation 

7


What CIT is not. 

• It is not a cure-all for police problems 

involving mentally ill persons. 

• It is not a guarantee that there will not be a 

use of force (even deadly force) situation. 

• It does not promote bad or unsafe tactics. 

Partnerships are the KEY 

• Interdisciplinary focus 

• Working together to solve problems and 

create solutions 

• Who Wins? 

– The police 

– The mental health system 

– The mental health consumer 

– The whole community 


• Suzanne Elhajj: NAMI Pennsylvania 

– (717) 238-1514 x109 

– selhajj@nami.org 

• Louise C. Pyers: NAMI Connecticut 

(860)882-0236 x 24 

(203)848-0320 C.A.B.L.E. 

lcp@cableweb.org 

8

W74: Therapy for Women Facing Trauma and Substance Abuse 

Derenda Edmondson, EdD 

1.5 hours Focus: Clinical Integrated Intervention 

Description: 

The syndromes of psychological trauma and substance abuse have been linked among women. The 

psychological disorder directly related to, and highly associated with substance use disorders, is Posttraumatic 

Stress Disorder. The goal of this workshop is to introduce an integrated model, “Seeking Safety,” developed by 

Dr. Lisa Najavitis to treat both disorder simultaneously. 


• Recognize factors that impact women’s psychological trauma; 

• Describe the interconnectedness of both the trauma and substance use among women; 

• Integrate the Seeking Safety Model to treat both disorders simultaneously. 

NOTES:


Objectives 

THERAPY FOR WOMEN 

FACING TRAUMA AND 

SUBSTANCE ABUSE 

• Provide a general overview of 

psychological trauma that impact women 

• Discuss the inter-connectedness of trauma 

and substance use among women 

• Provide a brief introduction of the “Seeking 

Safety Model” developed by Dr. Lisa 

Najavits 

What is Psychological Trauma 

• Is the unique individual experience of an 

event or condition in which: 

– 1. The individual’s ability to integrate their 

emotional experience and it becomes 

overwhelming or 

– 2. The individual’s experience (subjectively) a 

threat to life, bodily integrity, or sanity 

(Pearlman & Saakvitine, 1995) 

Psychological Trauma For Women 

• Risk Factors • Rape


Posttraumatic Stress Disorder 

• Psychological Disorder directly related to 

trauma 

• Highly associated with substance abuse 

Trauma and PTSD in Substance 

Use/Abuse 

• More than 80% of women seeking 

treatment for a substance use disorder 

report experiencing physical/sexual abuse 

during their lifetime. (Centers for Innovation in Health, Mental 

Health and Social Services). 

Prevalence of Trauma and PTSD in 


• The diagnosis of PTSD and Substance 

Abuse is: 

–


Seeking Safety 

Principles 

• Safety as the Priority of Treatment 

• Discontinue substance use 

• Reducing suicide 

• Minimizing exposure to HIV risk 

• Letting go of dangerous relations 

Integrated Treatment of PTSD and 


• To continually integrate attention to both 

disorders 

• To recognize their relationship 

• To fall prey less often to each disorder 

triggering the other 

A Focus on Ideals 

• Restore ideals that have been lost 

Four Content Areas 

• Cognitive 

• Behavioral 


• Case Management 

Attention to Therapist Processes 

• For more information on the model see 

• www.seekingsafety.org 

3


Workshop 

Summary 

• The syndromes of PTSD and Substance 

Abuse/Use are linked 

• The reality is that women have greater 

psychological risk factors such as rape, 

domestic violence, sexual/physical abuse in the 

development of PTSD and Substance 

Abuse/Use 

• Trauma figures importantly in the development 

of PTSD and Substance Abuse/Use 

• Research supports an integrated model in the 

treatment of both PTSD and Substance Abuse. 

4

Article 

Promising Treatments for Women With Comorbid PTSD 

and Substance Use Disorders 

Denise A. Hien, Ph.D. 

Lisa R. Cohen, Ph.D. 

Gloria M. Miele, Ph.D. 

Lisa Caren Litt, Ph.D. 

Carrie Capstick, M.A. 

Objective: The authors’ goal was to compare 

the efficacy of a manualized cognitive 

behavior therapy that addresses both 

posttraumatic stress disorder (PTSD) and 

substance abuse (seeking safety) with a 

manualized cognitive behavior therapy 

that addresses only substance abuse (relapse 

prevention) and with standard community 

care for the treatment of comorbid 

posttraumatic stress disorder (PTSD) 

and substance use disorder. 

Method: One hundred seven women 

from an urban, low-income population 

who had comorbid PTSD and substance 

use disorder were randomly assigned to 

receive the two kinds of cognitive behavior 

therapy or received standard community 

treatment. Participants were recruited 

from both community and clinical populations 

and evaluated with structured clinical 

instruments. Forty-one women received 

seeking safety therapy, 34 received 

relapse prevention therapy, and 32 received 

standard community care. 

Results: At the end of 3 months of treatment, 

participants in both cognitive behavior 

therapy conditions had significant 

reductions in substance use, PTSD, and 

psychiatric symptoms, but community 

care participants worsened over time. 

Both groups receiving cognitive behavior 

therapy sustained greater improvement 

in substance use and PTSD symptoms at 

6-month and 9-month follow-ups than 

subjects in the community care group. 

Conclusions: Seeking safety and relapse 

prevention are efficacious short-term 

treatments for low-income urban women 

with PTSD, substance use disorder, and 

other psychiatric symptoms. 

(Am J Psychiatry 2004; 161:1426–1432) 

Substance abuse is a substantial problem among 

women, who represent up to 30% of the patients in substance 

abuse treatment (1–3). Gender-specific risk factors, 

including having experienced interpersonal trauma and 

violence, underscore the need for tailored interventions 

for women in addiction treatment programs. Up to 80% of 

women seeking substance abuse treatment report lifetime 

histories of sexual and/or physical assault, and many of 

these women have symptoms of posttraumatic stress disorder 

(PTSD) (4–7). Women with comorbid PTSD and substance 

use disorders have poor treatment retention rates 

and outcomes (7). 

An ongoing controversy exists in both the trauma and 

addictions fields regarding which disorder to treat first. A 

commonly held belief is that addressing PTSD in early 

treatment would “open Pandora’s box” and worsen 

progress in addiction treatment, interfering with achieving 

and maintaining abstinence. In contrast, proponents 

of the “self-medication” hypothesis (8) challenge the suggestion 

that trauma should be left untreated, even in the 

earliest phases of recovery. As an alternative, an integrated 

model that addresses PTSD and addictions may be more 

likely to succeed, more cost-effective, and more sensitive 

to the unique needs of these patients (9–12). To date, however, 

few integrated approaches have been empirically 

tested and demonstrated as efficacious. 

One exception is seeking safety (13), a short-term, manualized 

cognitive behavior treatment that simultaneously 

addresses trauma and substance abuse. Smaller-scale 

studies and open trials indicate that seeking safety may 

significantly decrease substance use, trauma-related 

symptoms, and depression and may also improve social 

adjustment and coping (14, 15; unpublished 2000 paper 

by L. Najavits et al.). These preliminary findings indicate 

that instead of exacerbating symptoms, treatment that addresses 

both disorders can benefit women with comorbid 

PTSD and substance use disorders. 

The main objective of the current trial was to further 

evaluate the impact of seeking safety treatment on substance 

use and PTSD symptoms by comparing it with a 

standard manualized substance abuse treatment that 

does not directly address trauma-related symptoms (relapse 

prevention treatment, as described by Carroll et al. 

[16]) and with standard community care. Relapse prevention, 

often considered the gold-standard addiction treatment, 

is an empirically validated cognitive behavior therapy 

focusing on the identification of triggers and coping 

strategies for managing substance cravings and relapse 

(16). Demonstrating that seeking safety is superior to 

community care as well as equivalent or superior to relapse 

prevention would provide further empirical support 

1426 http://ajp.psychiatryonline.org 

Am J Psychiatry 161:8, August 2004

HIEN, COHEN, MIELE, ET AL. 

for the efficacy of integrated models that address traumarelated 

issues in substance-abusing populations. 

Method 

Design 

All subjects were recruited through advertisements requesting 

participants for a study about trauma and addiction. Eligible patients 

were randomly assigned to one of two active treatment 

conditions: seeking safety or relapse prevention. Treatments were 

conducted in twice-weekly 1-hour individual sessions for 12 consecutive 

weeks. A nonrandomized community care comparison 

group served as a nonspecific comparison condition. This design 

follows the criteria of stage IB behavioral therapies research (17), 

which allows for a preliminary stage efficacy trial with a nonrandomized, 

quasi-experimental comparison group. The community 

care comparison condition strengthened our design by 

allowing us to examine whether seeking safety and relapse prevention 

were more effective than other routinely sought out substance 

abuse treatments. 

The 32 women in the community care group met the same diagnostic 

criteria and were recruited in the same manner as those 

in the two cognitive therapy groups but were not offered either of 

the two manualized therapies. If interested, they were given the 

same list of treatment referrals as those in the manualized therapy 

groups. They were followed longitudinally for the same pretest-posttest 

assessment periods. Over the 3-month active treatment 

phase, seven (22%) of the subjects in the community care 

group received outpatient psychological treatment, seven were 

prescribed psychiatric medication, and two (6%) were hospitalized 

for psychiatric reasons. Nine (28%) reported receiving any 

drug or alcohol treatment, and five (16%) reported attending selfhelp 

meetings. 

The patients in the two manualized study treatments (seeking 

safety and relapse prevention) received standard care in the community 

similar to the care received by the community care group. 

Over the 3-month study period, 22 (29%) received outpatient psychological 

treatment, 14 (19%) received prescription medications, 

four (5%) were hospitalized for psychiatric reasons, 15 

(20%) received any drug or alcohol treatment, and 18 (24%) reported 

attending self-help meetings. Neither active treatment 

group statistically differed from the community care group in this 

comparison. 

Participants 

Participants were treatment-seeking women who responded to 

an advertisement or were referred from substance use treatment 

programs in a major metropolitan area. Women met screening 

criteria for the presence of a lifetime traumatic event (defined as 

positive response to items from the Lifetime Trauma Events Scale 

adapted from Fullilove et al. [5]). 

Screening inclusion criteria were as follows: 1) age 18 through 

55 years, 2) female, 3) diagnosis of substance use disorder, 4) a 

history of at least one DSM-IV-defined trauma event, and 5) English-speaking. 

Patients who met these initial eligibility criteria 

received further diagnostic screening. 

Exclusion criteria were as follows: 1) advanced-stage medical 

disease (e.g., AIDS, tuberculosis) as indicated by global physical 

deterioration and incapacitation, 2) organic mental syndrome 

(associated with chronic drug abuse), and 3) psychiatric exclusions, 

defined below. 

All women who met screening eligibility criteria (N=207) were 

asked to participate in a diagnostic interview. Interviewers obtained 

written informed consent before the interview. Each participant 

received $10. 

Patients met criteria for final eligibility (and received an additional 

$20 voucher for their additional interview time) if they were 

diagnosed with current or subthreshold PTSD (defined as DSM-IV 

criteria A, B, and E and the presence of either C or D) and current 

DSM-IV substance dependence; if they reported using substances 

at least three times a week on the Substance Use Inventory (18); 

and if their Mini-Mental State Examination score was greater than 

21. Psychiatric exclusion criteria included 1) current active suicidality, 

2) current axis I diagnoses other than atypical bipolar, depressive, 

or anxiety disorders, and 3) history of psychosis. 

Of the 128 women who met full study eligibility criteria, 115 

(90%) agreed to participate, and 96 of these women were randomly 

assigned to active treatment. Thirty-two of the 128 women 

became the community care comparison group. Baseline data 

were available for 115 of the women entered into the study. Of the 

96 women randomly assigned to active treatments, 75 (78%) attended 

at least one psychotherapy session and were included in 

the intent-to-treat group. Thus, the total number of subjects was 

107 (75 in active treatment and 32 in community care). There 

were no significant differences in demographics, treatment history, 

or baseline symptom severity between those who entered 

treatment and those who did not, suggesting that dropouts were 

random rather than attributable to any systematic bias. 

Ninety-four (88%) of the 107 subjects met full criteria for current 

PTSD; 13 (12%) met “subthreshold” criteria. Comparative 

analyses of those with full and subthreshold PTSD yielded no differences 

in substance use, PTSD, and psychiatric symptom severity. 

There were no differences in distribution of subthreshold 

PTSD across the three study groups. 

Table 1 presents the subjects’ demographic characteristics. The 

groups differed significantly only in age: the seeking safety group 

was significantly older than the relapse prevention group (Table 

1). Therefore, age was entered as a covariate in all analyses. 

Study participants in all three conditions received repeatedmeasures 

assessments at baseline, end of treatment (3 months after 

baseline), 6 months after baseline, and 9 months after baseline. 

The primary outcomes assessed were substance use and 

PTSD symptoms. The secondary outcomes were global psychiatric 

symptoms. Additionally, for patients in the two active treatment 

groups, feasibility and acceptability were examined through 

adherence and dropout rates. 

Measures 

To reduce the possibility of Type I error, standardized composite 

scores were created for the two primary outcome domains of 

substance use and PTSD severity, as well as for the secondary outcome 

domain of global psychiatric symptoms. Intercorrelation 

matrices of all standardized measure total scores relevant to a 

specific outcome were created to determine which had reliability 

coefficients (alpha) of at least 0.85. Composite scores for each 

construct (substance use, PTSD, and global psychiatric symptoms) 

were then created by using a mean of all standardized 

scores meeting reliability criteria. Standardized scores range from 

–1 to 1. A score approaching –1 can be interpreted as low severity 

relative to a score approaching 1, whereas a score close to 0 falls at 

the midpoint. Individual measures that were used to create the 

respective outcome composites are described below. 

Substance use severity composite individual measures. 

The Substance Use Inventory (18), which consists of self-report 

questions, was used to determine quantity (i.e., dollars spent per 

day) and frequency (i.e., days) of substance use over the past 

week. Substances included opiates, cocaine, alcohol, marijuana, 

amphetamines, sedatives, phencyclidine, and prescription medications. 

Outcomes were based on the mean rating of use over the 

previous 4 weeks. 

The Clinical Global Impression (CGI) (19), a series of 7-point, 

interviewer-rated scales, was used to measure substance abuse. 

Am J Psychiatry 161:8, August 2004 http://ajp.psychiatryonline.org 1427

PTSD AND SUBSTANCE USE DISORDERS 

TABLE 1. Characteristics of 107 Women With Comorbid PTSD and Substance Use Disorder Assigned to Two Types of 

Cognitive Behavior Therapy or Receiving Standard Community Care 

Active Treatment With Cognitive Behavior Therapy 

Characteristic 

Seeking Safety a (N=41) Relapse Prevention (N=34) Community Care (N=32) 

Mean SD Mean SD Mean SD 

Age (years) b 38.2 9.1 33.8 8.3 39.7 0.7 

Education (years) 13.6 2.5 13.5 3.1 13.5 2.3 

N % N % N % 

Ethnicity 

African American 20 48.8 12 35.3 13 40.6 

Hispanic 10 24.4 5 14.7 6 18.8 

Caucasian 10 24.4 17 50.0 13 40.6 

Other 1 2.4 0 0.0 0 0.0 

Drug of choice 

Alcohol 13 31.7 13 38.2 13 40.6 

Crack 6 14.6 6 17.6 3 9.4 

Cocaine 8 19.5 6 17.6 8 25.0 

Heroin 3 7.3 3 8.8 3 9.4 

Cannabis 11 26.8 6 17.6 5 15.6 

Affective disorders 

Major depressive disorder 

Lifetime 37 90.2 24 70.6 27 84.4 

Current 21 51.2 17 50.0 23 71.9 

Dysthymia 14 34.1 11 32.4 10 31.3 

a Addresses both trauma and substance abuse. 

b The seeking safety group was significantly older than the relapse prevention group (F=5.17, df=2, 104, p


TABLE 2. Severity of PTSD and Substance Use Over Time of 107 Women With Comorbid PTSD and Substance Use Disorder 

Assigned to Two Types of Cognitive Behavior Therapy or Receiving Standard Community Care a 

Standardized Composite Score 

Baseline End of Treatment 6-Month Follow-Up 9-Month Follow-Up 

Measure and Treatment Group b Mean SD Mean SD Mean SD Mean SD 

PTSD severity 

Seeking safety (N=41) 0.03 0.81 –0.11 0.59 –0.10 c 0.67 –0.02 c 0.63 

Relapse prevention (N=34) –0.14 0.59 –0.17 0.65 –0.24 0.78 –0.25 0.86 

Community care (N=32) 0.12 0.73 0.25 c 0.61 0.31 c 0.79 0.39 c 0.86 

Substance use severity 

Seeking safety (N=41) –0.08 0.68 –0.15 0.65 –0.12 c 0.61 –0.08 c 0.54 

Relapse prevention (N=34) –0.22 0.60 –0.26 0.52 –0.30 0.58 –0.18 c 0.76 

Community care (N=32) 0.19 1.0 0.36 c 0.78 0.19 0.72 0.21 c 0.76 

a Negative numbers indicate fewer symptoms, and positive numbers indicate more symptoms, ranging from possible standardized scores of 

–1.0 (no symptoms) to 1.0 (most severe symptoms). 

b Seeking safety refers to the treatment addressing both trauma and substance abuse. 

c Worsening symptoms from the previous assessment time point. 

Data reduction strategies and multivariate testing were used to 

minimize the number of statistical tests. Post hoc tests were conducted 

to examine predicted differences between seeking safety 

and relapse prevention and between relapse prevention and 

community care only when main effects were found to be significant 

at p


TABLE 3. Raw Scores on Individual PTSD Measures Over Time for 107 Women With Comorbid PTSD and Substance Use 

Disorder Assigned to Two Types of Cognitive Behavior Therapy or Receiving Standard Community Care 

Raw Score 

Baseline End of Treatment 6-Month Follow-Up 9-Month Follow-Up 

Measure and Treatment Group a 

Mean SD Mean SD Mean SD Mean SD 

Clinician-Administered PTSD Scale 

Frequency and intensity 

Seeking safety (N=41) 72.17 19.70 57.15 22.33 59.85 21.12 55.34 20.85 

Relapse prevention (N=34) 70.38 16.84 51.21 25.21 52.65 24.08 47.82 27.73 

Community care (N=32) 73.88 19.16 68.00 24.20 64.79 23.81 66.00 23.99 

Global severity 




Revised Impact of Event Scale 




CGI of PTSD 




a Seeking safety refers to the treatment addressing both trauma and substance abuse. 

community care (Table 2). There was a main effect for 

treatment type (F=5.51, df=2, 100, p


TABLE 4. Intent-to-Treat Analyses of Variance of PTSD and Substance Use Severity Over Time for 107 Women With Comorbid 

PTSD and Substance Use Disorder Assigned to Two Types of Cognitive Behavior Therapy or Receiving Standard Community 

Care a 

Interaction of Treatment Group and Baseline Symptom Severity 

End of Treatment 6-Month Follow-Up 9-Month Follow-Up 

Variable 

F df p F df p F df p 

PTSD severity 

Group 4.71 2, 100


Received July 24, 2002; revisions received Jan. 13 and Aug. 11, 

2003; accepted Nov. 18, 2003. From the Women’s Health Project 

Treatment and Research Center, St. Luke’s/Roosevelt Hospital Center. 

Address reprint requests to Dr. Hien, Women’s Health Project Treatment 

and Research Center, St. Luke’s/Roosevelt Hospital Center, 411 

West 114th St., Suite 3B, New York, NY 10025; dhien@chpnet.org (email). 

Supported by National Institute on Drug Abuse grant R01 DA- 

10843-02 as a part of the National Institute of Justice Violence 

Against Women and Families Consortium. 

The authors thank Teresa Leite, Ph.D., Laurie Weber, Ph.D., and Lisa 

Najavits, Ph.D., for their support and collaboration. 

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1432 http://ajp.psychiatryonline.org 

Am J Psychiatry 161:8, August 2004

W75: The MISA/COD Pilot Projects: Lessons Learned 

Cynthia Zubritsky, PhD, (Convenor), Stacy Colbert, MA, CAC-D, CCDP-P, 

Nancy Jaquette, LSW, ACSW, Michele A. Ruano-Weber, MA, Theresa Rudy, BSW, 

Lora Shrock, MA, Carl Stopperich, BA, CCDP, CCJP 


Description: 

In 2001, the Commonwealth of PA awarded five grants for pilot projects. One of the goals was to develop 

integrated systems of care for identifying, treating and supporting persons with CODs. The five projects 

review the models they developed and present their results. The challenges of developing an integrated 

system of care for COD services are also discussed. 


• Identify key services necessary for developing an integrated system of care for individuals diagnosed 

with a co-occurring psychiatric and substance use disorder; 

• Discuss the challenges of developing integrated COD services; 

• Examine the model developed by each county; 

• Review the results of each project. 

NOTE: See T51 for a copy of the Mercer County slides and T61 for a copy of the Washington County slides. 

NOTES:

The Beaver County 

COD Pilot Project 

Presented To: 

2006 COSIG Conference 

May 17, 2006 

Presented by: 

Nancy Jaquette 

Beaver County MH/MR/D&A Office 

Beaver County 

• Located in Southwestern Pennsylvania, 

north of Pittsburgh 

• Semi-rural 

• Population of 180,000 

Former Beaver County Jail 

Jail History 

• Jail Task Force 

• Annual Report to Prison Board 

• Jail Requirements Related To 

Outsiders Providing Service In 

The Jail 

Current Beaver County Jail 

MISA/COD History 

• July 2001- Funding 

awarded through the 

Office of Mental 

Health and Substance 

Abuse Services and 

Bureau of Drug and 

Alcohol Programs 

• Only forensic model 

• Gateway 

Rehabilitation Center 

–jail based treatment 

provider 

• Services commenced 

the end of May 2002 

1

THE BEAVER COUNTY MODEL 

• Targets the Incarcerated Offender 

• Provides Treatment in the County 

Jail/Community 

• Utilizes a Forensic Case Manager 

• Promotes Systems Change 

• Evaluates Performance 

SYSTEMS WORKING 

TOGETHER 

• Drug and Alcohol 


• Criminal Justice 

• Support Services 

MISA VISION 

Systems change 

regarding delivery of 

services to the MISA 

client in a Forensic 

Setting and in the 

Community 

Integration of 

Services-Dually 

Licensed Provider 

Network 

Standardized 

screening process 

for improved 

identification (SIIP) 

Collaboration and 

training across 

systems 

(MH/D&A/Criminal 

Justice) 

TRAINING STRATEGY 

‣ Provider Staff trained by Western 

Psychiatric Institute (OERP) on Co- 

Occurring Disorders. 

‣ Cross-Training of Staff on Agency Systems 

and Continuum of Care. 

‣ Jail Staff trained in how to work with 

prisoners who are Mentally-ill/Substance 

Abusers. 

‣ Scholarships awarded to promote agency 

involvement 

• 23 agency staff have received the COD 

credential 

STAKEHOLDER 

INVOLVEMENT 

‣Quarterly Meetings with the MISA 

Network Committee. 

‣Quality Improvement Committeeto 

Oversee Outcomes Data. 

‣CST Committee Involvement in 

Client Satisfaction. 

MISA 

CONTINUUM OF CARE 

Dually Licensed Providers 

‣Outpatient community setting 

‣Outpatient jail setting 

‣(2) Inpatient non-hospital 

providers 

‣Halfway house provider 

Other Levels of Care are Available 

That are Not Dually Licensed 

2

BEAVER COUNTY MISA 

PROJECT – JAIL MODEL 

• Intake and Social 

Services Assessment by 

Jail Staff 

• SIIP 

• Place in D&A only, MH 

only, or MISA 

• Receive treatment and 

support services 

• Service planning by 

Forensic CM 

• Upon release, community 

based treatment/self help 

supports and CM 

follow-up 

Beaver County Jail: 

Gateway Treatment Components 

for MISA Clients/Inmates 

Individual Assessment: S.I.I.P.’s/Bio-Psycho-social 

Psychiatric Histories 

Psychiatric Consults 

Group Counseling 

Relapse Education and Prevention Groups 

Life Skills Education and Training 

Discharge/Continuing Care Planning: Transition Team 

Planning: Daily/Weekly 

Post Release Support: F.C.M./I.C.M./Outpatient 

Contacts/Services, Psychiatric Follow-up from the 

Beaver Co. Jail, Community Liaison: Probation Update 

Gateway System of Services 

for MISA Clients 

Beaver County Jail 

Gender Profile of COD Clients 

Compared to Jail Population 

Aliquippa Ambridge Beaver Falls 

All MISA trained clinicians in Gateway 

Rehabilitation Center system providing services 

to MISA consumer/clients. 

Psychiatric follow-up on site. 

Use of supportive housing designed for MISA 

population: D.D.U./Stone Harbor/Specific units 

at GRC: half-way house. 

Percent 

100 

80 

60 

40 

20 

0 

75% 

74% 

60% 

55.8% 

44.2% 

40% 

25% 

21% 

Male Female African American Caucasian 

COD Population Jail Population 


Enhancements to Existing Model 

• Identification and 

placement of over 400 

individuals in the jail 

based treatment program 

• 100% of clients entered 

the jail based treatment 

program 

• 36.7% were High/High 

• 41.4% were Low/High 

• Average Length of Stay is 

8.0 weeks 

• 50% of those clients 

entering community 

based treatment entered 

a COD program 

• 60% of clients who were 

involved in the jail based 

program did not return to 

jail 

• Efforts to sustain a treatment program in 

the jail 

• Retention in the treatment which is being 

addressed through other initiatives, i.e. 

Beaver County Re-Entry Program 

• Brief Intervention for those receiving early 

release 

• Evidenced treatment for individuals with 

PTSD or a history of abuse 

3

Additional Information 

Contact: 

Nancy Jaquette 


njaquette@bcbh.org 

(724) 847-6225 

4


Project Administration 

Berks County 

MISA Services 

Mental Illness & Substance Abuse 

WORKING TOWARD A SINGLE SOLUTION TO MULTIPLE 

DISORDERS 

Berks County MH/MR 

Program 

(County Agency) 

Council On Chemical Abuse - 

Drug and Alcohol SCA 

(Private Non-Profit Agency) 

Joint Projects- Collaboration of staff and funding 

Adult Dual Outpatient Treatment 

Student Assistance Programs 

CASSP 

HealthChoices 

Dual Adult Transitional Living 

Outpatient Satellite Project 

Parent Partner 

MISA 

Berks County MISA Project 

Collaborative Effort between the Berks 

County Mental Health/Mental Retardation 

Program and the Council On Chemical 

Abuse 

Only Child/Adolescent Program Proposal 

funded by the State 

Comprehensive care including integrated 

treatment and case management services 

Berks County MISA Project Key 

Components 

Berks County MISA Program Coordinator 

MISA Training 

MISA Workgroup 

Implementation of Targeted MISA Services 

Development of MISA Continuum of Care 

MISA Program Coordinator 

Serve as liaison between county administration, 

state and service providers 

Monitor Current MISA service providers and 

pursue expansion of the MISA Continuum of 

Care within the County 

Develop and organize trainings for advanced 

MISA competencies and integrate core 

curriculum as a college course offering 

Facilitate the MISA Work Group 

Coordinate the collection and submission of 

MISA project evaluation data 

MISA Work Group 

Family, consumer and community involvement. 

Encourage Providers to become involved in system 

integration. 

Forum for discussion on issues related to the 

treatment of co-occurring disorders and services in 

the community. 

Workgroup operates as a subcommittee of the 

CASSP Advisory Committee. 

1



Treatment 

Assessment 

Intensive Outpatient 

Outpatient 


Challenges 

Although MISA is an integrated project, 

funding streams remain distinct between 

mental health and drug/alcohol. This affects 

provider billing practices, data collection, and 

analysis of outcomes. 

MISA continuum is limited due to dual 

licensing requirement for providers. 

Few Board certified Child/Adolescent 

Psychiatrists available to provide direct 

services. 

Resource Coordination 


Intensive 

Challenges 

Medical Assistance requires ASAM for 

drug/alcohol treatment authorization and 

placement despite mental health 

diagnosis/classification. 

Formulating procedures to insure 

simultaneous assessment of psychiatric 

and addictive disorders. 


Providing Integrated services for adolescents within the 

framework of Mental Health and Drug and Alcohol 

Confidentiality Regulations. 

– Successful implementation of the targeted MISA Services 

– Expansion of MISA continuum 

– Integrated Assessment Protocols at CIU and BSU 

– Integrated SAP assessments 

– Integrated assessments at Youth Center as part of County 

Integrated Children’s Services Plan (ICSP) 

Development and implementation of appropriate, 

comprehensive continuing care plans, despite limited 

MISA provider network. 


Partnership with the Berks County Medicaid 

managed care entity for enhanced rates and 

inclusion of MISA screen in CCBHO contracts. 

Solidified the relationship between the Single 

County Authority, The Council On Chemical 

Abuse, and the Berks County Mental 

Health/Mental Retardation Program. 

Increased public and provider awareness of 

co-occurring disorders and integrated 

treatment models. 

2


History 


CO-OCCURRING MENTAL HEALTH AND 

SUBSTANCE USE DISORDERS INITIATIVE 

Project Activities 

2006 

• Project planning began in early 2000 

• Application submitted in May 2001 

• Funding awarded in August 2001 

• Became part of the SAMHSA CO-SIG 

Grant in 2003 

Project Vision 

Project Mission 

• Persons with mental health & substance 

use disorder have the opportunity to 

exercise choice & control in their lives, 

supported by a system of recovery that 

integrates mental health & drug & alcohol 

services into a behavioral health system of 

care. 

• “Blair County stakeholders” will implement 

a plan to integrate mental health & drug & 

alcohol services into a behavioral health 

system of care for “persons with cooccurring 

disorders”. 

Phase I: Acquire an understanding of the 

Comprehensive, Continuous, Integrated System 

of Care (CCISC) Model which describes: 

System Level Change 

Efficient Use of Existing Resource 

Incorporation of Best Practice Principles 

Use of an Integrated Treatment Philosophy 

Phase II: Contracted with ZiaLogic, Dr. Ken 

Minkoff and Dr. Chris Cline, to provide advice 

& training on the implementation of the CCISC 

Model through consultation site visits: 

Training on the COD Services Enhancement 

Toolkits; COMPASS, CODECAT, CO-FIT 

Training on Principles, Consensus Document, Sample 

Case Studies and General Consultation 

on County Work Plan & Provider Action Plans, Use of the 

COMPASS Toolkit, Live Assessment Interview, Train-the 

Trainers, Pharmacology Presentation 

1


Altoona Regional Health System, Home Nursing 

Agency, Pyramid HealthCare, White Deer Run/Cove 

Forge Site Visits, Staff Education, Case Study, 

Discussion of Data & Prevalence Work 

Training on the ILSA (Integrated Longitudinal 

Strength- Based Assessment) 

Negotiated and endorsed the Consensus 

Document which included: 

• Brief background & history of project 

• 8 Best Practice Principles 

• CCISC Implementation characteristics 

• Agreed upon action plans for the County and the 

Providers 

Signature on Concensus Document indicated: 

• Support and participation as a partner in the 

initiative 

• Commitment of the organization to adopting the 

CCISC model 

• Commitment to participating in a change 

process consistent with the 8 best practice 

principles 

Using the Co-occurring Disorder Consensus 

Document, developed a work plan which included 

the following actions: 

• Design a process & framework to document 

implementation issues and barriers. 

• Improve welcoming access and reduce barriers. 

• Collect & disseminate data & information gathered by 

project participants. 

• Evaluate providers co-occurring disorder capability. 

- the COMPASS tool is used to assess program competencies & 

develop provider & system level action plans that focus on 

strategic, incremental, measurable, and sustainable change 

toward the goal of COD capability. 

Using the Co-occurring Disorder Consensus 

Document, developed a work plan which included 

the following actions (continued): 

• Develop a short and long term plan to improve the systems ability to 

provide co-occurring disorder services & supports. 

- use the CO-FIT tool to monitor and measure system change in 

implementation of the CCISC. 

• Assess clinician training needs around the CCISC Best Practice 

Principles and the core competencies which include Attitudes and 

Values, as well as Knowledge and Skills. 

- the CODECAT is used for either supervisory evaluation or 

clinician self-evaluation of these Competencies. 

• Accurately identify & report prevalence of co-occurring disorder. 

In order to implement the work plan, Blair County 

established the following committee structures: 

• The Performance Improvement Committee to 

provide overall management & direction to the 

project. 

• The Trainers Group to assure long term viability 

of the project by offering ongoing provider-level 

training & support. 

• The MISA Team to address the clinical & 

system issues of individuals receiving treatment. 

2


To accomplish the work plan activities, the 

Performance Improvement Committee: 

• Monitored the completion of the Consensus Document. 

• Developed Job Scopes for singly licensed agencies. 

• Designed the communication process between all 

parties. 

• Reviews & takes action on issues & barriers identified. 

• Managed the completion of the COMPASS & reviewed 

the summary results. 

• Developed a survey to assess welcoming practices & 

gather prevalence data. 

To accomplish the work plan activities, the 

Trainers Group: 

– Manages a listing of provider level issues & concerns. 

– Developed staff & supervisory training opportunities 

within each provider agency. 

– Assisted in the completion of the COMPASS. 

– Plans the process for completion of the CODECAT in 

each agency. 

– Uses CDs & VCRs of all trainings offered by ZiaLogic 

as internal organization training tools. 

For persons with Co-occurring Disorders, the 

MISA Team: 

– Develops service plan recommendations & ongoing 

consultation 

– Manages utilization of services for persons with COD 

– Provide advise & consultation to providers 

– Identify system barriers to accomplishing the mission 

& referring those issue to the Performance 

Improvement Committee. 

Next Steps 

• Continue to implement Performance 

Improvement Committee work plan: 

– Establish process to assess prevalence 

– Analyze system’s screening & assessment process 

• Continue to implement Trainers Group work 

plan: 

– Provide ongoing internal training for providers 

– Establish systemic use of the 8 best practices during 

regular supervisory situations. 

Next Steps 

Update the Consensus Document to include the 

new partnership with CBHNP (HealthChoices 

MCO). The revised document will define how 

the County MH/D&A, Agencies, & CBHNP will 

work together to implement a quality 

improvement process that includes the CCISC 

model, best practice principles, and tools to 

support on-going incremental system change in 

the future. 

3

W76: Friends Connection Peer Support: An Evidence-Based Means for Reducing Hospitalization 

Jeannie Whitecraft, MEd, CAC, CCS, CPRP & Ted Dawson 

1.5 hours Focus: Recovery Supports and Community Integration 

Description: 

This program, promoting recovery in persons with co-occurring disorders since 1989, has demonstrated, in 

research conducted through the University of Pennsylvania, a significant reduction in hospitalization (among 

other benefits for persons receiving services from this Peer Support Model). This workshop reviews 

effectiveness data for Peer Support, the history of the Friends Connection program, and discusses its daily 

operational and supervision structures and the reciprocating benefits for both staff and program participants. 


• Define Peer Support and describe the reciprocating benefits for staff and participants; 

• List the benefits of peer support for people with co-occurring disorders; 

• Describe Friends Connection and its history; 

• Discuss the implementation in three current programs. 

NOTES:


FRIENDS CONNECTON PEER SUPPORT 

Mental Health Assoc. of SEPA 

An Evidence-Based Means for Reducing Hospitalization 

2006 Pennsylvania 

COSIG Conference 

May 15 – 17 

Hershey PA 

Presenters, Jeanie Whitecraft M.Ed,CAC,CCS,CPRP 

Ted Dawson 

FRIENDS CONNECTION 

OVERVIEW 

Community Integration/Recovery 

Peer Support/Recovery/outcomes 

History of Friends Connection Program 

Operational and Supervisory Program Structure 

Outcomes and reciprocating benefits for staff 

UPENN COLLABORATIVE ON 

COMMUITY INTEGRATION 

Mark Salzer, Ph.D., Director 

(www.upennrrtc.org) 

Salzer@mail.med.upenn.edu 

COMMUNITY INTEGRATION 

Provides the Roadmap to Recovery 

The opportunity to live in the community and be valued for abilities and unique 

qualities like everyone else 

• Housing 


• Spirituality 

• Health Status 

• Self Determination 

• Leisure/Recreation 

Citizenship and civic engagement 

Valued Social Roles (marriage/parent) 

Self -Determination 

PEER SUPPORT 

UPENN COLLAORATIVE 

ON COMMUNITY INEGRATION 

DEFINING PEER SUPPORT 

Shery Mead 

Peer support is a system of giving and receiving help 

founded on key principles of respect, shared responsibility, 

and mutual agreement of what is helpful. Peer support is not 

based on psychiatric models of diagnostic criteria. It is about 

understanding another’s’ situation empathically through the 

shared experience of emotional and psychological pain. 

When people find affiliation with others whom they feel are 

“like” them, they feel a connection. 

PEER SUPPORT AS A 

BEST/EMERGINING/PROMISING 

PRACTICE 

Evidence based 

Policy Support 

--Surgeon General’s report, New Freedom Commission 

“The value of Peer Support is highlighted as a valuable 

approach for promoting consumer recovery 

1


PEER SUPPORT RESEARCH 

• Utilization 

• Psychological benefits 

• Cost-savings benefits 

• Benefits to Peer Providers 

• Two Key Issues to Keep in Mind 

--Participation in peer support reflects a person-environment fit 

Rather than universal appeal 

--Professional-Centrism undermines support for peer support 

PEER SUPPORT EVIDENCE BASE 

• Humphrey’s (1997) individual and social benefits of mutual – aid Self-Help 

groups social policy 

• Davidson et.al. (1999) Peer Support among individuals with severe mental illness: 

A Review of the evidence. Clinical Psychology: Science and Practice 

• Van Tosh and delVecchio (200) consumer operated self-help programs: A 

Technical report. 

• Solomon and Draine(2001) The state of Knowledge of The effectiveness of 

Consumer Provided Service Psychiatric Rehabilitation Journal 

UPENN COLLABORATIVE ON COMMUNITY INTEGRATON 

UPENN COLLABORATIVE ON 


EXAMPLE 

SELF-HELP/MUTUAL-HELP GROUPS 

• Double-Trouble in Recovery (DTR) 

Greater participation in this self-help group associated 

with increased medication adherence (Magura et al., 2002) 

• Greater participation in DTR associated with greater perceived social 

support. Greater support associated with less substance use. (Laudet 

et al., 2000) 

DROP-IN CENTERS 

Peer-Run Drop-in Centers: High satisfaction and increased 

quality of life enhanced social support and problem solving 

(Chamberlin, Rogers,& Ellison, 1996; Mobray & Tan, 1992). 

• Self-help groups improve symptoms, increase participants social 

networks 

And quality of life 

UPENN COLLBORATION ON 


FRIENDS CONNECTION 

Peer Support for Co-occurring Disorders 

Is associated with; fewer crisis events 

Fewer hospitalizations 

Improved social functioning 

Greater reduction in substance use, and improvement in quality of life 

Compared to the non-matched comparison group over a 6 month period 

(Klein, Cnaan,Whitecraft, Research on Social Work Practice vol.8 no.5 September 1998) 

FRIENDS CONNECTION PROGRAM 

HISTORY 

• 1980 Closing of Philadelphia State Hospital/Byberry 

• Early 1980’s 

• Need for creative, effective solutions co-occurring 

• Oasis Program – Ohio (black males small 1 to 1 

• Funding came from closing 

2


FRIENDS CONNECTION MOBLE PEER 

SUPPORT PROGAM 

Mission 

The mission of the Mental Health Association of Southeastern 

Pennsylvania’s Friends Connection Program is to provide social support 

and healthy community connections in a culturally competent manner for 

people with co-occurring disorders of mental illness and substance abuse 

who aspire to a fuller life in a supportive community environment that is 

free of drug and alcohol abuse 

FRIENDS CONNECTION MOBILE 

PEER SUPPORT PROGRAM 

Philosophy 

Loneliness, isolation, stigmatization 

Recovery begins with HOPE 

Each person has intrinsic interest 

Non-punitive/non-judgmental 

Do not spend time with participant when “high” 

People do better when something to look forward 

to 

PROGRAM GOALS 

Peer Counselors 

• Provide intensive one on one support 

• Help a develop clean/sober support network 

• In vivo peer counseling (self-disclosure) 

• Empower participants to design their own social rehabilitation recovery 

plans, activities and supports to enable independent living. 

• Help participants to reach their full potential for recovery through 

exploration of social, educational, vocational and leisure interest and by 

developing necessary social support pursue goals. 

• Build self-esteem and self-confidence by engaging participants in 

community based social, educational, and leisure activities of their choice. 

• Improve the quality of life and alternative for recovery by enabling a broad 

range of diverse opportunities for community integration for individuals 

who desire to establish natural community support systems as an option to 

traditional clinical treatment programs 

CRITERIA PROGRM PARTICIPANTS 

• Must have a co–occurring diagnosis 

• Actively using/or major changes in life 

• Referral from Case Manager or Resource 

Coordinator 

• Desire to participate in program/Not mandated 

• Length of stay 3 to 18 months 

STAFFING CRITERIA 

• Recovery from mental health and or D/A 

• Two years work experience 

• High School Diploma or GED 

3


STAFF TRAINING 

Orientation 6 months 

Peer Specialist Training 

Psychiatric Rehabilitation Training12 to 24 hours 

Drug and alcohol Training 

Behavioral Health Training Network 

Drexel 

Supervision weekly 

Staff meeting 2x week peer review and support 

Documentation/Accountability 

MAKING MATCHES 

PARTICIPANTS WITH STAFF 

• Level of skill 

• Culturally 

• Personality 

• Back ground in chemical of choice 

STAGES/LEVELS OF PROGRAM PROCESS 

PROCESS: LEVEL I 

• Engagement phase, developing a rapport and relationship building 

between Peer Support Counselor and Program Participant 

• One on one interactions between PSC and PP 

• Relationship building and identifying interests and activity preferences 

• Participation in various chosen activities 

• Identification of recovery supports in PP’s community (e.g., 12 step 

meetings) participation in recovery support related activities – 12 step 

meetings 

• Identify and expand leisure options for PP encouragement to try new 

things 

• Attend weekly scheduled FC group activities (e.g., bowling, billiards, 

etc. 

• Travel Training 

• Identifying resources 

STAGES/LEVELS OF PROGRAM PROCESS 

PROCESS: LEVEL II 

• Focus on expansion of recovery support network, continued 

development of social skills and leisure skills through participation 

in group activities 

• Focus on developing peer relationships with other Peers 

• Focus on PP involvement in group activities planning and 


• Continue identifying resources such as College campus, 

newspapers, and other publications advertising community activities 

Stages/Levels of Program Process 

PROCESS: LEVEL III 

• Encouragement of the independent assessing of 

community recovery supports and continued 

participation in ongoing FC group activities as 

the PSC decreases face-to-face contact 

• Focusing on and encouraging to continue and 

participate in activities, etc., independently 

• Gradually reducing face-to-face time with 

participant 

• Encourage participation in FC Alumni program 

TRANSITION TO ALUMNLI PROGRAM 

• THE ALUMNI PROGRAM serves as an important function 

for many graduates of the program 

• Continued mutual support and sense of belonging. 

• The alumni holds fund raisers, trips and activities of their 

own and act as role models for the program participant by 

attending FC ongoing weekly and monthly activities in the 

community. 

4


OUTCOMES 

BENEFITS OF STAFF (Salzer & Liptzin Shear, 2002) 

Helper Therapy Principle 

Interviews with 14 peer staff: 

Great feeling of helping others 

They benefited from being able to practice their own recovery, and 

mentioned explicit features that helped them prentice recovery, such as 

learning about things to do when bored other than using drugs or 

alcohol, building their own positive support networks, improving their 

ability to behave responsibly, being active in the community as an 

antidote to boredom, and dealing with personal problem through selfdiscovery 

and skill development. “Embrace life and enjoy things” 

“Taught me to enjoy recovery” 

Keep Coming Back, Keep 

Trying A New Way 

Research Slides will be attached at 

presentation 

Juntos Podemos 

(Together We Can) 

COSP STUDY 

5

W77: Treatment for Older Adult with Co-Occurring Disorders: Importance of Collaboration 

Across Systems 

Tod R. Marion, PhD, MPH, CAC 

1.5 hours Focus: Aging Adults with CODs 

Description: 

This workshop will provide an overview of the problems and conditions associated with substance use misuse 

and abuse among older adults. It will identify the problems and opportunities of service delivery to older 

substance abusers within various environments. 


• Identify the problem of substance misuse, abuse and dependency within the older adult population; 

• Identify collaborative opportunities among professionals and organizations for addressing the problem 

of substance abuse in older adults; 

• Become familiar with resources and strategies for program development. 

NOTES:


Substance Abuse Among 

Older Adults 

By: 

Tod Marion, Ph.D., M.P.H., CAC 

Treatment Improvement 

Protocol 

TIP # 26 

Substance Abuse among Older 

Adults 

What is TIP 

• Treatment Improvement Protocols 

• Are best practice guidelines for the treatment of 

substance abuse, provided as a service of the 

Substance Abuse and Mental Health Services 

Administration’s Center for Substance Abuse 

Treatment (CSAT). 

• This TIP is aimed at substance abuse treatment 

providers, primary care clinicians, social 

workers, senior center staff, and anyone with 

contact with older adults. 

Introduction 

• Older adults comprise individuals 60 years 

of age and older 

• Substance abuse continues to be a 

problem among this age group, but is 

undetected or overlooked. 

• Importantly, alcohol and prescription drug 

misuse and abuse affects 17% of older 

adults. 

Reasons Abuse Not Detected 

• Health care providers overlook the 

problem. 

• Health care providers mistake the 

symptoms as being—dementia, 

depression, and other common problems 

among these age groups. 

• Older adults are more likely to hide their 

problem and are less likely to seek help. 

• Children of older adults with substance 

abuse are ashamed and don’t want to 

address it. 

The Invisible Epidemic 

• One of the fastest growing health problems in this 

population is addiction to alcohol and prescription drugs. 

• It affects 17% and these numbers are underestimated 

and under diagnosed. 

• Many symptoms may be similar to diabetes, dementia, 

or depression, etc. 

• The older cohort’s disapprove and feel shame about the 

use of substances (they believe it’s a personal matter). 

• Ageism (beliefs such as: “it is not worth treating older 

adults for substance abuse” or “what else do they have 

to look forward to”. 

1


Under lying factors 

• Those who “self-medicate” are more likely to 

characterize themselves as “lonely”. 

• Lower life satisfaction. 

• Retirement and other loses 

– Death of a spouse 

– Disabilities 

– Chronic and painful illnesses 

• Older women who drink are more likely to have 

a problem-drinker spouse. 

• .Depression. 

Problem in the Future 

• 1994’s older adult population of 33 million will 

double to 80 million by 2050. 

• Life expectancy is 79 years for women and 72 

years for men. 

• More will face chronic, limiting illnesses, or 

painful health conditions (arthritis, diabetes, 

etc.). 

• The overall increase in alcohol problems 

throughout the population coupled with the aging 

of the Baby Boomers and their unique 

relationship to drugs 

Alcohol Problems 

• Far out number any other substance 

abuse problems among this age group. 

• 3-25% are considered “heavy users”. 

• 2.2-9.6% are considered those with 

“alcohol abuse”. 

• 15% of men and 12% of women have 

problems with alcohol. 

• Clinicians only detected one-third of 

patients with the disorder. 

Prescription Drugs 

• Abuse of narcotics is rare except for those 

who used opiates in their younger years. 

• Concern of those using benzodiazepines, 

sedatives, and hypnotics. 

• This population is prescribed 

benzodiazepines more than any other age 

group. 

• 17-23% are prescribed the above 

medication. 

Dangers of Benzodiazepines 

• Have longer half-lives and they result in side 

effects that influence the functioning and 

cognition of these individuals. 

• A greater risk for falling when under the 

influence. 

–Ataxia 

• Excessive daytime sedation. 

• Cognitive Impairment 

• Attention, memory, physiological arousal and 

impaired psychomotor abilities. 

Barriers to Identifying Problem 

• Ageism (negative stereotypes). 

• Lack of awareness—denial that elderly 

can be addicted. 

• Clinician Behavior—Not being aware of 

prescribing addictive prescriptions, or not 

spending enough time with their patients 

to detect the problem. 

• Comorbidity 

2


Specific Barriers to Women 

• Have less insurance coverage and 

pension (not being able to afford treatment 

when necessary). 

• More likely to live in poverty. 

• Drink less in public places and are less 

likely to drive so they may not reveal a 

problem to others. 

• Prescribed and consume more 

psychoactive drugs and are more likely to 

be long-term users. 

Barriers to Minorities 

• More vulnerable to late-life drinking 

problems. 

• Live in urban areas with busy health-care 

programs so their problem may be less 

likely to be detected among clinicians. 

• Language barriers 

Homebound Adults 

• Identification and treatment harder to 

detect. 

• No means of transportation or 

handicapped accessibility. 

•Isolation 

• Health problems that limit mobility (heart 

disease, etc.) and daily living. 

• Isolated socially so abuse may be 

undetected and dependence may 

increase. 

Alcohol and Age-Related Changes 

• Decrease in body water (alcohol is water 

soluble) so concentration in blood system 

is greater. 

• Increased sensitivity and decreased 

tolerance. 

• Decrease in metabolism of alcohol in the 

gastrointestinal tract (stomach is less 

actively involved in metabolism so there’s 

an increased strain on the liver). 

Health Problems from Alcohol 

• Increased Risk for hypertension, cardiac 

arrhythmia. 

• Increased risk of hemorrhagic stroke. 

• Cirrhosis and liver diseases. 

• Decreased bone density. 

• Gastro Intestinal Bleeding. 

• Depression, Anxiety, and Mental Health 

problems. 

• Malnutrition. 

• Sleep Disturbances 

• Alcohol-Related Dementia (ARD) 

Problems with Classifying 

• DSM-IV-may not apply to elderly because 

of lower legal, social, or psychological 

problems (their usually retired with limited 

family responsibility). 

• Tolerance may be set too high for older 

adults because of their altered sensitivity 

to alcohol (may take less to produce the 

effects it would on younger adults). 

3


Age-Appropriate Levels of 

Distribution 

• No more than one drink per day. 

• Maximum of two drinks per occasion. 

• Lower limits for women. 

• “Safety zone”- foster sensible drinking that 

avoids health risks, while allowing 

beneficial effects that may occur from 

drinking. 

Types 

• Early On-Set drinkers compromise the 

majority of those receiving treatment. 

Plus, psychiatric comorbidity is common. 

• Late On-Set drinkers may appear 

healthier, and are more likely to have 

begun drinking due to recent losses 

(death, divorce, and decreased health). 

Easily overlooked by health care 

providers. 

Patterns of Drinking 

• Continuous is ongoing drinking. 

• Intermittent-is regular, daily, heavy 

drinking after a period of abstinence of 

three to five days. 

• Binge- for older adults drinking four or 

more per occasion. 

Prescription Drugs 

• Those age 65+ consume more 

prescription drugs and over-the-counter 

medications than any other age group in 

the U.S. 

• Older adults comprise 13% of the 

population but received 25-30% of all 

prescriptions. 

• Experienced more than ½ of all reported 

adverse drug reactions leading to 

hospitalization. 

Facts 

• 80-86% of those 65+ suffer from one or more 

chronic diseases or conditions. 

• 83% of those 60+ take at least one medication. 

• 30% of those aged 65+ take eight or more 

prescriptions daily. 

• Usually, prescriptions are for psychoactive, 

mood-changing drugs that carry potential for 

misuse, abuse, or dependence. 

• More likely to continue use for longer periods 

than younger adults. 

Patterns of Use 

• Elderly’s abuse usually fall within the 

“misuse” category of the DSM-IV 

(unintentional misuse). 

• Usually because they are more likely to 

misunderstand the directions for 

appropriate use. 

• Overdose, addictive effects, and adverse 

reations are more likely to occur from 

combining drugs. 

4


Unintentional Misuse 

• Poly-Pharmacy 

• Doctor shopping 

• Sharing medication 

• Compliance issues 

– “If one works two will work better” 

– Not taking enough 

– Forgot if taken on and then take another 

– Taking the wrong drug (confusing the bottle) 

Unintentional Misuse 

• Can progress to a person using for the 

“desirable effects”. 

• Can become physiologically dependent on 

psychoactive mediations without meeting 

dependence. 

• Tolerance and psychological dependence can 

develop when taken regularly. 

• An abstinance symptom or withdrawal effects 

may occur if a drug stopped immediately. 

• Can become dependent without knowing it. 

Risk Factors 

• The aging process (needing more medications because 

of physiological changes, accumulating physical health 

problems and psychosocial stressors. 

• Female gender 

• Middle/Late life divorce 

• Widowhood 

• Lack of education 

• Chronic somatic Problems 

• Increased Stress 

• Lower income 

• Depression, Anxiety 

System and Environmental 

Influences 

Health care systems: 

• Order medications without adequate 

diagnosis. 

• Prescribe medications for too long without 

adequate diagnosis. 

• Prescribe drugs with a high potential for 

side-effects in older adults. 

• Prescribe drugs without reviewing whether 

they interact adversely with other 

medications. 

• Diminished nervous system. 

• Impaired reaction time. 

• Loss of coordination 

• Ataxia 

• Falls 

• Excessive daytime drowsiness 

• Confusion/Rage 

• Amnesia/Delirium 

• Constipation 

• Dry mouth 

• Urinary difficulty 

• Withdrawal seizures 

• Development of dependence 

Adverse Effects 

Withdrawal of Benzodiazepines 

• Anxiety 

• Agitation 

• Lethargy 

• Nausea/Loss of Appetite 

• Insomnia 

• Dizziness 

• Tremor 

• Depersonalization 

• Confusion 

• Disappear within 3-5 weeks because they have longer 

half-lives (up to 200 hours). But some report side effects 

for several months. 

5


Sedatives/Hypnotics 

• Are usually prescribed for insomnia (which 

is common among the elderly). 

• Sleep patterns change due to aging. 

• Deep sleep lessens and they are more 

likely to awake during the night more 

often. 

• Plus, other medications may cause 

insomnia (e.g. MAO and SSRI’s). 

Ways to Treat Sleep Problems 

• Keep a sleep diary (times take naps, 

awake during the night, etc.). 

• Educate about sleep hygiene. 

• Educate about sleep patterns (naps). 

• Relaxation Techniques. 

Withdrawal from 

Sedatives/Hypnotics 

• Increased pulse rate 

• Hand Tremors 

• Insomnia 

• Nausea/Vomiting 

•Anxiety 

• Hallucinations 

•Seizures 

Opiates 

• Estimated that 2-3% of noninstitutionalized 

older adults receive 

prescriptions for opioid analgesics. 

• Use for the management of severe pain. 

• Treatment for cancer-related pain. 

Problem with Elderly Taking 

Opiates 

• The duration of action is longer (due to 

decreased metabolism and liver 

functioning). 

• More adverse side effects because of 

changes in receptor sensitivity. 

• May cause impairment of psychomotor 

performance. 

• More potent ones may cause impairment 

of vision, attention and motor coordination. 

Withdrawal from Opiates 

• Restlessness/dysphonic mood 

• Nausea/Vomiting 

• Tearing and Yawning 

• Insomnia 

• Diarrhea/Fever 

• However, not life-threatening like 

benzodiazepines. 

6


Interactions with Drugs and Alcohol 

• Some combinations may be deadly (e.g. 

alcohol and diazepam). 

• Increases lithium toxicity and enhances 

CNS depression and those taking tricyclic 

antidepressants. 

• Can be extremely dangerous to mix. 

Identification, Screening and 

Assessment 

• 87% see physicians regularly but 40% of 

those at risk do not self-identify or seek 

services for substance abuse on their own. 

• Are unlikely to be identified by physicians. 

Who Should Identify Problem 

• Health care workers 

• Friends/Family 

• Staff of senior centers (drivers/volunteers) 

• Therapists 

•Clergy 

• Anyone involved with this age group. 

Barriers to Screening 

• Ageist assumptions—failure to recognize 

symptoms. 

• Lack of knowledge about screening. 

• Family members may be biases about the 

problem. 

• Symptoms may be confused with other 

medical conditions. (psudodementia) 

• Inappropriate screening procedures 

(amount and frequency levels). 

Who and When to Screen 

• Every 60+ year-old as a part of regular physical 

examinations. 

• As older patients experience life transitions, stress, or 

loss. 

Or those who complain about: 

• Sleep (changes, fatigue, drowsiness) 

• Cognitive impairments (memory, concentration) 

• Seizures, or malnutrition 

• Liver Function abnormalities 

• Poor hygiene 

• Blurred vision/Dry mouth 

• Slurred Speech 

• Frequent Falls/Unexplained bruising. 

Introduction of Screening 

• Depending on the setting, the topic of 

screening can be introduced in a number 

of ways. 

• Self-Administered and self-scored mass 

screenings 

• Self-administered but machine-scored 

computerized screens 

• Nurses, home-health aides, etc. can give a 

brief screen by asking typical questions. 

7


Direct Questioning for Alcohol Use 

• Do you ever drink alcohol? 

• How much do you drink? 

• Do you ever drink more than four on one 

occasion? 

• Does drinking help you feel better? 

• Have you ever wandered if your drinking 

interferes with your health or other areas in your 

life? 

• The CAGE questions are very useful. 

CAGE 

The CAGE assessment tool can help assess alcohol 

dependence. The questions are: 

• Cut down: Have you ever felt that you should cut down 

on your Annoyed: drinking? 

• Annoyed: Have other people annoyed you by criticizing 

your drinking. 

• Guilty: Have you ever felt guilty about your drinking? 

• Eye-Opener: Have you ever taken a drink in the Morning 

to steady your nerves or get rid of a hang-over? 

*yes to two or more indicates alcohol dependence. Accurate 

85% of the time. 

In-Direct Questions for Prescription 

Abuse 

• Are you having any medical or health 

problems? 

• What prescription drugs are you taking? 

• Are you having any problems with them? 

• Do you use any over-the-counter 

medications. 

• Remember, many elderly are unaware that 

they have a problem with prescription 

drugs (unintentional use). 

Signs of Abuse During 

Conversation 

• Excessive worrying about whether 

prescriptions are “really working”. 

• Detailed knowledge about a specific drug. 

• Worrying about having enough pills or 

whether it’s time to take them. 

• Request of refills when not time or 

resisting the decreasing of doses. 

• Eating only at restaurants that serve 

alcohol. 

Asking Screening Questions 

Michigan Alcoholism Screening Test - 

Geriatric 

• Should be asked in a confidential setting. 

• Asked in a nonthreatening, 

nonjudgemental manner. 

• Avoid using stigmatizing terms like, 

alcoholic or drug abuser. 

• Use active listening (non-verbal behavior, 

understanding verbal communication, 

etc.). 

• 1.After drinking have you ever noticed an increase in your heart 

rate or beating in your chest? 

• 2. When talking with others, do you ever underestimate how 

much you actually drink? 

• 3. Does alcohol make you sleepy so that you often fall asleep in 

your chair? 

• 4. After a few drinks, have you sometimes not eaten or been 

able to skip a meal because you didn't feel hungry? 

• 5. Does having a few drinks help decrease your shakiness or 

tremors? 

• 6. Does alcohol sometimes make it hard for you to remember 

parts of the day or night? 

• 7. Do you have rules for yourself that you won't drink before a 

certain time of the day? 

• 8. Have you lost interest in hobbies or activities you used to 

enjoy? 

• 9. When you wake up in the morning, do you ever have trouble 

remembering part of the night before? 

• 10. Does having a drink help you sleep? 

• 11. Do you hide your alcohol bottles from family members? 

• 12. After a social gathering, have you ever felt embarrassed 

because you drank too much? 

• 13. Have you ever been concerned that drinking might be 

harmful to your health? 

14. Do you like to end an evening with a nightcap? 

15. Did you find your drinking increased after someone close to 

you died? 

• 16. In general, would you prefer to have a few drinks at home rather 

than go out to social events? 

17. Are you drinking more now than in the past? 

18. Do you usually take a drink to relax or calm your nerves? 

19. Do you drink to take your mind off your problems? 

20. Have you ever increased your drinking after experiencing a loss 

in your life? 

21. Do you sometimes drive when you have had too much to drink? 

22. Has a doctor or nurse ever said they were worried or concerned 

about your drinking? 

23. Have you ever made rules to manage your drinking? 

• 24. When you feel lonely, does having a drink help? 

YESNOScoring: Five or more "yes" responses are indicative of an 

alcohol problem. For further information, contact Frederic C. Blow, 

Ph.D., at University of Michigan Alcohol Research Center, 400 E. 

Eisenhower Parkway, Suite A, Ann Arbor, MI 48108; (734) 998-7952. 

Source: Blow, F.C.; Brower, K.J.; Schulenberg, J.E.; Demo- 

Dananberg, L.M.; Young, J.P.; and Beresford, T.P. The Michigan 

Alcoholism Screening Test - Geriatric Version (MAST-G): A new 

elderly-specific screening instrument. Alcoholism: Clinical and 

Experimental Research 16:372, 1992. 

© The Regents of the University of Michigan, 1991. 

8


Difference Between Instruments 

• CAGE is most effective in identifying more 

serious problem drinkers. 

• But, it’s less effective for women (have 

different drinking patterns). 

• MAST-G was developed specifically for 

older adults. 

• Can be used for those from a wide variety 

of settings. 

AUDIT 

• Alcohol Use Disorders 

• Has not been evaluated for use with older 

adults but is validated cross-culturally. 

• May prove useful for identifying problems 

among older adults of ethnic minorities 

Common Positive Screening 

Results 

In order to ease the process one should: 

• Describe the impact that alcohol or 

prescription drugs is having on the 

person’s health or functional status (e.g. 

“The screening results indicate that 

alcohol may be having a negative effect on 

your blood pressure”). 

• Immediately follow up by noting that this is 

very treatable. 

Positive Screening Results 

(cont.) 

• Present the options for addressing the 

problem if the problem seems severe, “I’d 

like to do a complete assessment so we 

know how to proceed” or “We’ll monitor 

your progress over the next couple weeks 

to see if this helps with your hypertension”. 

• If the situation seems dire, a 

recommendation to detoxification may be 

appropriate. 

Substance Abuse Assessment 

Instruments 

• DSM-III-R (SCID) 

• Diagnostic Interview Schedule (DIS) which 

covers: Substance use disorders, Mood 

disorders, Somatoform Disorders, 

Adjustment disorders, Psychotic 

Disorders, Anxiety Disorders, Eating 

Disorders, and Personality Disorders. 

Special Assessments 

• Sometimes it may be impossible to understand 

the true impact of their alcohol and drug use 

without a full assessment of physical, mental, 

and functional health. 

• Functional health is assessed by a person’s 

ability to perform activities of daily living (e.g. 

bathing, dressing, feeding) and instrumental 

activities of daily living (e.g. managing finances, 

shopping, taking medications, using the phone). 

• Instruments that measure ADL’s and IADL’s 

include the Medications Outcome Study 36-Item 

Short Form Health Survey (SF-36). 

9


What Else to Assess 

• Comorbid Disorders 

• Physical Comorbidities 

• Psychiatric Comorbidities 

– Cognitive Impairments 

– Dementia-is chronic, progressive, and 

irreversible impairments. 

– Delirium-is a potentially life-threatening illness 

that requires acute intervention. 

Guidelines for Interviewing 

• Areas that are most likely to motivate the 

client are their physical health, loss of 

independence, and financial security. 

• Decisions must include the patient in order 

to be successful. 

• May be important to include family. 

• Treatment strategies must be culturally 

competent. 

Appropriate Treatment 

• After screening and assessment have identified 

a problem the clinician and patient must choose 

an appropriate treatment. 

• The least intensive treatment options should be 

explored first. 

• Less intensive options will not resolve issues for 

some people but can move them by helping 

them overcome resistance and ambivalence 

about changing. 

• Pretreatment activities can be conducted in a 

client’s home (ideal for homebound clients). 

Brief Intervention for At-Risk 

Drinkers 

• 10-30% of dependent problem drinkers 

decrease their drinking to moderate levels 

following a brief intervention by clinicians. 

• Consists of one or more sessions (may 

include motivation for change, education, 

assessment, direct feedback, 

contracting/goal setting, and behavioral 

modification). 

Conducting Brief Interventions 

• Since many older at-risk and problem drinkers 

are ashamed, initial strategies need to be 

nonconfrontational and supportive. 

• Provide feedback 

• Discuss types of drinkers and where the 

patient’s pattern’s fit into the population norms 

for their age. 

• Consequences for heavier drinking and reasons 

to cut down or quit. 

• Setting agreed upon limits and having the 

patient sign them. 

FRAMES Approach 

•FEEDBACK for risk of problem. 

•RESPONSIBILITY for change. 

•ADVICE to change 

•MENU for change options 

•EMPATHIC counseling style 

• Enhanced client SELF-EFFICACY 

10


Beyond Brief Intervention 

• Use an intervention which occurs under 

the guidance of a skilled counselor and 

several significant people in abusers’ life 

which confront the individual. 

• Use no more than 1 to 2 relatives or close 

associates. 

• Having too many people may be 

overwhelming or confusing. 

• Inclusion of grandchildren is discouraged. 


• Acknowledges differences in readiness to 

change, so it “meets people where they 

are”. 

• Intensive process that enlists patients in 

their own recovery by avoiding labels, 

avoiding confrontations, accepting 

ambivalence, and placing responsibility for 

change on the client. 

Patient Placement and Patient 

Matching 

• Triage-the process of organizing and prioritizing 

treatment service. 

• Patient placement-process by which a 

recommendation is made for placement in a 

specific level (intensity) of care that ranges from 

medication managed (high intensity) inpatient 

services to outpatient services (low intensity. 

• Triage process is influenced by other factors like 

physical accessibility of facility, types of therapy 

used, etc. 

Levels of Treatment Services 

• Inpatient/Outpatient Detoxification Treatment 

(first, one must consider whether detoxification 

management is needed because it’s riskier for 

the elderly). 

• Inpatient Rehabilitation (those who are fail or 

acutely suicidal) 

• Residential Rehabilitation (slower paced and 

range from high to low intensity). 

• Outpatient Services (may include partial 

hospitalization, daytime treatment that requires a 

patient to attend day-long for 5 days a week). 

Program Philosophy 

• Supportive and nonconfrontational 

• Cope with loneliness, depression, or loss 

• Rebuilds social support network 

• Acceptance 

• Provides links with medical services and 

community programs 

Treatment Approaches 

• Cognitive-Behavioral 

• Group-Based approaches 

• Individual counseling 

• Medical/Psychiatric approaches 

• Marital/Family Therapy 

• Case-Management/Community Linked 

Services 

• A.A./N.A./Self-Help Groups 

• Educational programs 

11


Discharge Plans and Aftercare 

• Encourage A.A., Pills Anonymous ageappropriate 

support groups. 

• Tell about services among the community 

• Ongoing medical monitoring 

• Involvement of case-manager to ensure 

services are provided. 

Specialized Treatment for 

Prescription Drug Abuse 

• Since this type of abuse stems from 

unintentional misuse, issues that need to 

be addressed include: Misconceptions 

about drugs, inability to manage the 

medications (too complex/memory 

impairments), and intentional misuse to 

obtain results other than for those 

prescribed (sleep). 

Outcomes and Cost Issues 

• Addresses alcohol treatment costs only because 

there are no outcome studies of prescription 

drug use among the older adults. 

• Studies showed that age-specific programming 

improved treatment completion and resulted in 

higher rates of attendance at meetings. 

• Also, older alcoholics were more likely than 

younger adults to complete treatment. 

• For older patients, the number of days abstinent 

was higher and those treated with a focus on 

self-efficacy had fewest heavy drinking days 

Problem with Outcome Studies 

• Have bias and provide no information on 

treatment drop-outs or on short/long term 

outcomes for treatment. 

• Exclusion of women in studies. 

• Use unstructured techniques for assessing 

drinking patterns. 

Measurement of Multidimensional 

Outcomes 

• Consumption levels, drinking patterns, 

alcohol-related problems, physical and 

emotional health, and quality of life can be 

used to assess treatment outcomes. 

• Initial evaluation should take place at the 

beginning of the treatment to obtain 

baseline data. 

• The first follow-up evaluations should be 

conducted after 2 weeks to 1 month. 

Measures of Alcohol Use 

• Drinking patterns can be assessed using 

approximations like the average number of 

drinks per week or the average number of 

drinks per occasion. 

• Alcohol Use Disorders Identification Test 

(AUDIT) and the Health Screening Survey 

(HSS). 

• Most accurate is the Time Line Follow 

Back Procedure (TLFB). 

12


Cost of Treatment 

• Estimated to be over 100 billion dollars a 

year. 

• Those with alcohol disorders are among 

the highest cost users of medical care in 

the U.S. 

• For those who underwent treatment—their 

mean monthly medical care costs declined 

immediately after treatment and continued 

to decline 2 years following treatment. 

Reimbursement Issues 

• Only a small minority of those who needed 

treatment have received it. 

• Medicare programs are turned over to 

managed care companies (Medicare used 

to cover 12 days of inpatient services but 

managed care eliminated coverage and 

cut services altogether to keep costs 

down). 

Areas for Future Research 

• Life course variations among alcohol, illicit drug 

and prescription drug use patterns. 

• Gender and ethnic variability 

• Reasons for changes in drinking and drug use 

patterns with aging. 

• Early/Late onset of the Problem 

• Valid screening instruments 

• Under representation of older adults in treatment 

settings 

13

W81: The Pennsylvania COSIG Evaluation 

Cynthia Zubritsky, PhD & Aileen Rothbard, ScD 


Description: 

The federal Co-Occurring Systems Improvement Grants were established in 2002 to assist states in 

transforming their infrastructures to support co-occurring service delivery. Pennsylvania received one of these 

initial COSIG grants in 2003. The goal of the PA COSIG project is to transition from the five MISA county pilot 

projects that were initiated in 1999 to permanent statewide infrastructure and service delivery. For the past 

three years, the Center for Mental Health Policy and Services Research has been evaluating the effectiveness 

of this project. Evaluation activities, including infrastructure development and data collection in the pilot 

counties, are described in this session. 


• Examine the current national COD prevalence rates and discuss implications for the current treatment 

system; 

• Describe the framework for developing a Pennsylvania infrastructure to support COD services; 

• Assess the evaluation outcomes for the Pennsylvania COSIG pilot programs. 

NOTES:


Co-Occurring State Incentive 

Grant Evaluation 

Pennsylvania COD Conference 

Hershey, PA 

May 17, 2006 

University of Pennsylvania 

Center for Mental Health Policy and Services Research 

Cynthia D. Zubritsky, PhD 

cdz@mail.med.upenn.edu 

Aileen Rothbard, ScD 

rothbard@mail.med.upenn.edu 

COSIG System Goals 


existing resources, to support COD service delivery 

• To create, test and establish an approval process for 

providers to deliver COD services 

• To develop a reimbursement mechanism to support 

COD treatment 

• To identify COD screening and assessment 

instruments 

• To develop a process for data integration for 

behavioral health services to track clients across 


• To ensure that a COD training curriculum is available 

to support workforce development 

COSIG System Evaluation Goal 

Evaluation Goal: To describe the processes 

and measure the impact of the COSIG 

initiative through qualitative and quantitative 

evaluation techniques. 

Evaluation Aims 

• Aim #1. Infrastructure: to monitor and measure 

changes in the COD infrastructure 

• Aim #2. Service Intervention: To document and 

measure system and consumer change in COD 

treatment programs 

• Aim #3. COD Treatment Impact: To describe 

COD clients and document and measure client 

change in COD treatment programs. 

COSIG Evaluation Methods 

COSIG System Goals 

• Qualitative methods: 

– Stakeholder Interviews 

– Focus Groups 

– Town Meetings 

– Surveys 

– Conference Calls 

– Regional Meetings 

– County Meetings 

– Provider Meetings 

• Quantitative Methods: 

– Pilot County Provider 

Data Collection for 

Two Years 


existing resources, to support cod service delivery 

• To create, test and establish an approval process for 

providers to deliver co-occurring services 

• To develop a reimbursement mechanism to support 

co-occurring treatment 

• To identify screening and assessment instruments for 


• To develop a process for data integration for 

behavioral health services for tracking clients across 


• To ensure a co-occurring training curriculum is 

available to support workforce development 

1


Infrastructure Development 

Evaluation 

• Focus Groups 

– Consumers 

– Providers 

– Family members, caregivers 

– Community members 

• Surveys 

• Town Meetings 

• Review Policies and Practices 

• Review of Meeting Documents 

Focus Groups 

• Focus Groups were held in each county before 

and 12-18 months after the pilot projects were 

implemented to determine program perception. 

Questions included the following: 

– What challenges will the project need to overcome in 

order to be successful? 

– What resources/services exist in your community that 

may help the project to succeed? What services are 

missing that might help the project to succeed? 

Provider Focus Group Themes 

• Access to COD services by consumers improved 

as a result of the pilot projects 

• Participation in COD services increased as a result 

of the pilot projects 

• County providers expressed interest in developing 

more dual recovery groups 

• Collaboration between mental health and 

substance abuse providers increased significantly 

as a result of the pilot programs 

• More COD housing services needed 

Purpose of Pilot Service 

Integration Programs 

• Increase identification of individuals with 

COD through screening 

• Increase retention in treatment 

• Reduce utilization of high-end services 

• Reduce involvement with corrections, 

juvenile justice an child welfare 

• Increase satisfaction with services 

Town Meetings 

• Purpose: 

– To obtain feedback on existing programs from 

consumers, providers, family members and 

community members (stakeholders) 

– To obtain recommendations for future COD 

development from stakeholders 

– To educate communities about the COD 

program 

Service Integration Pilot – 

Beaver County 

• Case Management/training model 

• Provides integration for COD services for 

adults diagnosed with COD disorders 

while in a correctional program and who 

are reentering the community. 

2


Service Integration Pilot – Berks 

County 

• Case Management model 

• Provides COD services to adolescents 

• Integrates services across mental health, 

substance abuse and education 

Service Integration Pilots: 

Butler, Mercer & Washington 

Counties 

• Case Management Model 

• Provides COD services to adults 

Data Integration Pilots – 

Dauphin & Philadelphia 

Counties 

• Dauphin County: Development and 

testing of software for consumer data 

collection across the substance abuse and 

mental health systems. 

• Philadelphia County: Development and 

testing of methods for consumer data 

collection across the corrections, mental 

health, and substance abuse systems. 

Evaluation Design for Service 

Intervention Projects 

• Describe treated population 

• Describe referral patterns 

• Describe admission patterns 

• Describe program perception of consumers, 

providers and family members 

• Describe outcome 

• Monitor extent that projects met program 

criteria. 

Evaluation Elements for 

Service Intervention 

• Descriptive elements collected at baseline, 6 and 

12 months 

• Descriptive elements included: 

– Client Tracking Measures, 

– Client Demographic Variables 

– Prior Services for 12 months 

– Current Services 

– Program Outcomes 

Adult Summary Data 

University of Pennsylvania Evaluation 

• 1195 Adults served 

• Average Age – 35 

• 34% - Alcohol Use Disorders 

• 68% - Drug Use Disorders 

• 79% - Mood Disorders 

• 10% - Schizophrenia 

• 42% - Medical Co-morbidity 

• 67% - Psychotropic Medication 

3


Adolescent Summary Data 

• 124 Adolescents served 

• 15 – Average Age 

• 6% - Alcohol Use Disorder 

• 94% - Drug Use Disorder 

• 73% - Mood Disorder 

• 25% - ADHD 

• 2% - Schizophrenia 

• 24% - Medical Co-morbidity 

• 74% - Psychotropic Medication 

Population Characteristics 

• COD Quadrant: 

• 69% - High/High 

• 10% - High/Low 

• 13% - Low/High 

• 7% - Low/Low 

Project Outcomes 

• Adult and Adolescent Co-occurring Core 

Curriculum is available to all clinicians 

• 250 clinicians have received the Certified Co- 

Occurring Disorders Professional Credential since 

May of 2004 

• GAF scores increased by 85% for individuals 

receiving integrated treatment 

• There was a 75% reduction in substance use for 

individuals 

• 15% of the individuals in the project were selfreferred 

• Need for housing supports, & other lessons 

learned…. 

Problems Encountered 

• Difficulty following up prospectively on cohorts 

once they leave treatment 

• Coordination of care difficult when SA and MH 

providers are in different locations and have 

conflicting regulations 

• Communication across counties sometimes 

difficult- COD services not always in same county 

• Lack of common definitions for data elements 

across systems 

PPGs/Outcome Measures 

• Federally Required 

• Collection will be in September, 2005 

COSIG PPGs Outcome/Performance Measures 

• Measure #1 -not a performance measure but a 

precondition to measurement of outcome: 

A) count of persons identified with cod 

B) count of persons identified with cod that have been 

served… 

• Measure #2 % of programs that screen for cod 

% of programs that assess the need for both su and mh 

tx. 

% of programs that provide tx for cod. 

• Measure #3 specific outcomes to include: 

–alcohol use 

–substance use 

–mental health status 

–employment 

–living arrangements 

–involvement in the criminal 

justice system 

4

W82: Evidenced-Based Approaches in the Engagement African-American Youth, Families, and 

Subsystems (continued as W92) 

Angelo Adson, MSS, MLSP, MBA, LSW 

3 hours Focus: Family, Children and Adolescents & 

Cultural Competency 

Description: 

What are the factors that influence African-American youth, families and sub-systems to engage in substance 

abuse and co-occurring disorders treatment? This seminar is focused on how evidenced-based practice, 

applied from a systemic and strength-based approach, engages African-American youth and their families in 

the treatment process. 


• Recognize, assess and apply factors of resiliency and its importance in the engagement process; 

• Perform systemic assessments to analyze strengths and barriers to community sub-system 

involvement; 

• Examine relevant evidenced-based approaches for the engagement of African-American family 

systems. 

NOTES:

W83: Beaver County Forensic COD Initiatives 

Nancy Jaquette, LSW, ACSW, Holly Wald, PhD, Karen Florence, Med & 

Raymond Grabowski, MHS, FACMHA 

1.5 hours Focus: Systems Integration and Forensics Involvement 

Description: 

This project was begun in May 2002 as one of five Pilot Projects funded by the Pennsylvania Department of 

Public Welfare and Pennsylvania Department of Health and was further funded through the Pennsylvania Cooccurring 

State Incentive Grant (COSIG). This model initially targeted adults in the Beaver County Jail. Based 

on this experience, the model has been expanded to include a Re-Entry Initiative to support continuation of 

treatment in the community, and into the juvenile justice systems, through BC-SCORES. This workshop will 

highlight the county’s vision, progress to date, efforts to support retention and participation in treatment, and 

how the model is being adapted for the adolescent population. 


• List the components of the models developed in Beaver County; 

• Describe how to use data collected for program enhancements; 

• Identify the supports needed to help clients to continue with treatment in the community; 

• Summarize the outcomes of the projects; 

• Discuss opportunities for program enhancement and expansion. 

NOTES:


System Integration and 

Forensic Involvement 

Presented to: 

2006 COSIG Conference 

May 17, 2006 

Presented by: 

Nancy Jaquette, LSW, ACSW 


Holly Wald, Ph.D. 

HPW Associates, LLC 

Karen Florence, M.Ed. 

Gateway Rehabilitation Center 

Ray Grabowski, MHS, FACMHA 

Synergy Behavioral Health Care 

Former Beaver County Jail 

Jail History 

• Jail Task Force 

• Annual Report to Prison Board 

• Jail Requirements Related To 

Outsiders Providing Service In 

The Jail 

Current Beaver County Jail 

MISA/COD History 

• July 2001- Funding 

awarded through the 

Office of Mental 

Health and Substance 

Abuse Services and 

Bureau of Drug and 

Alcohol Programs 

• Only forensic model 

• Gateway 

Rehabilitation Center 

–jail based treatment 

provider 

• Services commenced 

the end of May 2002 

1


MISA/COD Aims 

MISA/COD VISION 

• Collaboration among systems (Network) 

• Comprehensive training (Core 

competency, advanced training and COD 

related topics) 

• Appropriate identification of individuals 

with COD 

• Client outcomes related to retention in 

treatment, sobriety, stabilization, et. al. 

Systems change 

regarding delivery of 

services to the MISA 

client in a Forensic 

Setting and in the 

Community 

Integration of 

Services-Dually 

Licensed Provider 

Network 

Standardized 

screening process 

for improved 

identification (SIIP) 

Collaboration and 

training across 

systems 

(MH/D&A/Criminal 

Justice) 

SUCCESSFUL ASPECTS OF 

SYSTEM INTEGRATION 

•Development of continuum of 

care 

•Dual licensure 

•Participation in comprehensive 

training 

•23 individuals received the COD 

credential 

MSOff 

BEAVER COUNTY MISA/COD PROJECT – JAIL MODEL 

Incarceration 

Medical Intake –Jail Staff 

Social Services Assessment 

D&A 

Only 

SIIP 

MH 

Only 

Pre-Release Planning 

Community Based Treatment/ 

Self Help Supports 

Inmate Completes 

Sentence 

MISA/ 

COD 

Service Planning- 

Forensic CM 


Follow-Up 

Multi Disciplinary Transition Team 

PROGRESS TO DATE 

• Psychiatrist 

• Jail Treatment Teams 

• Forensic Case Manager 

• Intensive Case Managers 

• Mental Health and Drug & Alcohol Advocates 

• Beaver County Jail Staff 

• Probation Officer 

• Stone Harbor 

• Outpatient Representatives 

2

Slide 9 

MSOffice1 Collaboration with CJ 

, 3/30/2006


Beaver County-MISA/COD Model 

Identification of potential clients by jail staff : 

Gender Profile of COD Clients 

Compared to Jail Population 

100 

80 

75% 

74% 

• 92.6% of the referrals originated from the criminal 

justice system during the first three years 

• 57.7% are MISA 

Percent 

60 

40 

20 

55.8% 

44.2% 

25% 

21% 

60% 

40% 

• 100% of those identified actually entered treatment 

0 

Male Female African American Caucasian 

COD Population 

Jail Population 

Quadrant Profile 

Quadrant Profile by Gender 

100 

80 

Percentage 

60 

40 

43.3% 

(65) 

31.4% 

(59) 

43.6% 

(82) 

38.7% 

(58) 

15.4% 

20 

(29) 

10.7% 

(16) 

9.6% 

(18) 

7.3% 

(11) 

0 

High/High High/Low Low/High Low/Low 

Male (N=188) 

Female (N=150) 

GAF Scores* 

Primary Drugs Of Choice 

*GAF scores were not indicated for six clients over all three years. 

3


Types of Charges Leading to 

Incarceration* 


Incarceration by Gender* 

* It is important to note that most of the clients had more than one charge leading to incarceration. 

* It is important to note that most of the clients had more than one charge leading to incarceration. 

Primary Behavioral Health 

Diagnoses* 

Community Based Treatment 

*The “Other” category consisted of Schizophrenia and Attention-Deficit Hyperactivity Disorder (ADHD). 

Enrollment in Community Based Treatment* 

Gender Distribution of MISA/COD 

Clients 

100 

Percentage 

80 

60 

40 

53.1% 

(34) 

39.3% 

(53) 

46.9% 

(30) 

60.7% 

(82) 

20 

0 

Female 

Year 3 Communiity Based (N=64) 

Male 

Year 3 Jail-Based (N=135) 

*There were none of the following combinations: 1) D&A only, 2) COD and D&A or 3) COD, D&A and MH. 

4


Ethnic Distribution of MISA/COD 

Clients 

Profile of GAF Scores * 

Percentage 

100 

80 

60 

40 

20 

18.8% 

(12) 

16.3% 

(22) 

76.6% 

(49) 

76.3% 

(103) 

4.7% 

(3) 

7.4% 

(10) 

Percentage 

100 

80 

60 

40 

20 

0 

91.7% 

(121) 

56.7% 

(34) 

25% 

(15) 

18.3% 

(11) 

8.3% 

(11) 

30-40 41-50 51+ 

0 

Year 3 Community-Based (N=60) 


African American Caucasian Other 



* GAF scores were not indicated for two community-based clients and three clients 

in jail-based treatment during this same time. 

Behavioral Health Diagnoses 

Primary Drugs of Choice* 

100 

100 

80 

72.7% 

70.5% 

(224) 

(31) 

88.6% 

85.6% 

(39) 

(113) 

56.1% 

66.7% 

(88) 

80 

Percentage 

60 

40 

20 

0 

(74) 

47.7% 

(21) 

29.5% 

(13) 

21.2% 21.2% 

(28) 

18.2% 

(28) 

(8) 

22.7% 

(10) 

15.9% 

(7) 

2.3% 

(3) 

Percentage 

60 

40 

20 

23.2% 23.6% 

(13) (26) 

12.7% 

(14) 

3.6% 

(2) 

41.1% 

(23) 

31.8% 

(35) 

1.8% 1.8% 

(1) (2) 

30.4% 30% 

(17) (33) 

Alcohol Drug Major 

Depressive 

Bipolar Anxiety Personality Other 

0 

Alcohol Cannabinoids Crack/Cocaine Nicotine Heroin & Other 



Opiates 

Year 3 Community-Based (N=56) Year 3 Jail-Based (N=110) 

* Primary drugs were not indicated for eight clients in the community-based 

population and twenty-five clients in the jail-based population. 

Mean Number of Services by Type 

of Service 

Profiles of Reasons for 

Discharge 

15 

14.2 14.3 14.3 

100 

Mean Number of Sessions 

12 

9 

6 

3 

6.3 

4.8 

4.3 

3 

5.1 

Percentage 

80 

60 

40 

20 

0 

37.5% 

(15) 

22.1% 

(29) 

15% 

(6) 

3.1% 

(4) 

47.5% 

(19) 

12.2% 

(16) 

62.6% 

(82) 

Completed Tx 

Left Against Medical 

Other 

Released from jail 

Advice 

0 

Treatment Groups Education Groups Training Groups Individual Sessions 





5


Overall Recidivism 

• 60% of the clients served during the first 

three years did not return to the Beaver 

County Jail. 

Beaver County Re-Entry 

Initiative 

Background 

• In May 2004 the Beaver County MH/MR/DA 

office received funding from the Pennsylvania 

Center for Crime and Delinquency (PCCD) to 

develop a Re-Entry Initiative program. 

• Its aim is to: 

– Increase the number of individuals completing jailbased 

and community-based treatment, 

– Enhance coordination and cooperation among the 

criminal justice system, the courts and treatment 

providers 

– Decrease the jail population by reducing recidivism. 

Target Population 

• Inmates released 

early from jail due to 

being: 

– Paroled 

– Making bond 

– Sentenced 

– Paid domestic 

relations costs 

Aims 

• Connect inmates to services 

• Prevent individuals from “falling through the 

cracks” through liaison follow-up 

• Share treatment recommendations with the 

appropriate criminal justice system 

representatives 

• Reduce recidivism 

• Save costs 

Types of Information 

• All information gathered during treatment 

including evaluations and recommendations for 

continued treatment. 

• May include: 

– Psychiatric evaluations 

– Treatment plans 

– Recommendations 

– Medications 

– Certificates of completion 

– Discharge plan 

6


Liaison Role 

BEAVER COUNTY MISA/REENTRY MODEL 

Incarceration 

• Track and support the client 

• Maintain communication with probation, 

the courts and other criminal justice 

agencies 

• Serve as a link between the treatment 

provider, case manager, client and courts 

Jail Based TX 

In jail support through 

Liaison and Pre-Release 

Planning through 

Transition Team 

Assessment 

including SIIP 

TX Recommendations 

from Psychiatrist and 

Liaison shared with CJ 

system 

Ineligible or 

Refuses Tx and 

Inmate Completes 

Sentence/ 

Community Based TX 

Liaison/Case Management 

Community Based Tx Self Help Supports 

Eligibility Criteria 

Overall Liaison Activities (N=516) 

• Non-violent offenders in Beaver County 

who have been screened by, enrolled in or 

have completed the MISA/COD program 

in the jail 

• Or who have been released from jail due 

to being paroled, making bond, completing 

sentence, or having paid domestic 

relations costs. 

100 

80 

60 

40 

20 12% 11.5% 10.5% 10.3% 

(62) (59) 

8.1% 

(55) (53) 

(42) 

0 

Treatment Probation Service Jail Staff Transition 

Staff Consultation Agency Consultation and 

Consultation 

Consultation 

Treatment 

Team 

5.2% 

(27) 

Re-Entry 

Group 

7.2% 

5% 

(37) 

(25) 

1.7% 

(9) 

Case Attorney Court 

Managers Consultation Attendance 

and 

Advocates 

16.1% 

(83) 

Other 

Meetings 

Type of Contact 

• 65.4% of the contacts were in person 

Client Related Liaison Activities 

(N=344) 

100 

80 

• 34.6% conducted via telephone 

60 

• The average length of contact is one 

hour. 

40 

14.2% 14% 12.8% 

20 

11.6% 

(49) (48) 

9.6% 9.3% 

(44) (40) 

7% 6.1% 

(33) (32) 

(24) 

2.6% 

(21) 

(9) 

0 

Treatment One on One Social Probation Case Jail Staff Attorney Transition Court 

Staff Session Service Consultation Managers Consultation Consultation and Attendance 

Consultation 

Agency 

and 

Treatment 

Consultation 

Advocates 

Teams 

12.8% 

(44) 

Other 

7


Criminal Justice Status of Reentry 

Clients 

Gender Distribution (N=30) 

• 30 clients have been placed on liaison caseload between 

December 2004 and April 2005. 

• 70% were court ordered to treatment. 

• The types of treatment stipulated were: 

– 20% were required to attend jail based treatment only 

– 13.3% community based treatment only 

– 36.6% were ordered to attend both jail and community based 

treatment. 

• 90% were incarcerated and 10% were on 

probation/parole/house arrest. 

73.3% 

(22) 

26.7% 

(8) 

Male 

Female 

Distribution Clients by Ethnicity 

(N=30) 

Mean Age 

• 33.9 years, ranging from 18 to 47 

16.7% 

(5) 

African American 

Caucasian 

83.3% 

(25) 

Primary Drugs of Choice (N=30) 

Behavioral Health Diagnoses 

(N=30) 

100 

100 

100% 

(28) 

80 

80 

71.4% 

(20) 

Percentage 

60 

40 

20 

42.9% 

(12) 

25% 

(7) 

21.4% 

(6) 

10.7% 

(3) 

Percentage 

60 

40 

20 

42.9% 

(12) 

35.7% 

(10) 

17.9% 

(5) 

0 

Crack/Cocaine Other Heroin and Other 

Opiates 

Primary Drug of Choice 

Alcohol 

0 

Drug Use 

Disorders 

Alcohol Use 

Disorders 

Personality 

Disorders 

Depressive 

Disorders 

Other 

Diagnoses 

8



Incarceration (N=30) 

Successes 

Percentage 

100 

80 

60 

40 

20 

36.7% 

(11) 

13.3% 

(4) 

40% 

(12) 

76.7% 

(23) 

6.7% 

(2) 

• Education of judges, attorneys and probation officers 

• Appropriate screening and identification of clients 

• Provision of treatment to the individuals identified and 

enrolled in the program 

• Encouragement of all eligible inmates to participate in 

the program 

• Facilitation of a pre-release transition team meetings and 

development of a written plan for continuing care for all 

participating inmates 

0 

Drug Related Violent Nonviolent Other F = Family 

Type of Charge 

BC-SCORES 

BC SCORES 

Beaver County System of Care: 

Optimizing Resources, 

Education and Services 

• 25 system of care awards in FFY 05-06. 

• 2 in Pennsylvania (Beaver and Allegheny) 

• Currently 60 funded system of care communities 

throughout the continental US, Hawaii and Alaska. 

• 6 year project, totaling approximately $6,000,000.00 

• National Collaborative including: 

– National Technical Assistance Center at Georgetown 

– ORC Macro 

– Federation of Families for Children’s Mental Health 

– American Institutes of Research 

BC-SCORES 

• A collaborative effort to establish a System of Care for adolescents 

and young adults ages 14-21 with co-occurring disorders who have 

been identified through the Juvenile Justice System. 

• Funded through a cooperative grant from SAMHSA to Beaver County 

MH/MR/DA 

• Collaboration of several agencies and organizations: 

– Synergy Behavioral Healthcare Management, LP Project and 

Clinical Direction 

– HPW Associates, LLC Local Evaluator 

– The Prevention Network Family and Youth 

Coordination 

– BC-CAN Social Marketing and TA 

– Pressley Ridge Enhanced Family Based 

MH 

– Adelphoi Village MST 

– Children and Youth Services FGDM 

– Juvenile Services Target Population 

Facilitator 

BC SCORES Intended Outcomes 

• Creation and continuation of a system of care for the 

targeted population 

• Increased awareness of the impact cultural issues have 

on treatment 

• Timely and accurate screening for co-occurring disorders 

• Integrated service planning 

• Improved clinical outcomes related to mental health 

status and substance use; 

• Reduced involvement with the juvenile justice systems 

• Reduced incarceration and out-of-home placement and 

• Improved school success as indicated by attendance, 

school performance, and rates of suspension. 

9


SPOC - Juvenile Justice 

System of Care Principles 

System 

In Detention (10 day 

Disposition) 

BC-SCORES Referral 


Screening and Assessment 

OR 

BC-SCORES Systems 

Coach Assigned 

At Home (14 day 

Disposition) 

Family Meeting 

• Families as partners 

Review rights, responsibilities, obtain 

consents and schedule FGDM/IAPM 

• Cultural competence 

YES 

Meets FGDM Eligibility 

NO 

• Interagency collaboration 

Family Group 

Decision Making 

Inter-Agency 

Planning Meeting 

• Home, community, and school-based 

Process 

Process 

BC-SCORES SERVICE SYSTEM 

• Individualized strength-based care 

• Accountability to Self, Each Other and Community 

F 

A 

M 

I 

L 

Y 

Low Intensity/ 

Community Based 

Education and 

Prevention Svcs 

Family Education 

and Supportive 

Svcs 

Medium Intensity/ 


Outpatient & 

Intensive OP 

Svcs 

Partial 

Hospitalization 

School-Based 

High Intensity/ 


Multi-Systemic 

Therapy (MST) 

Enhanced 

Family-Based 

Mental Health 

High Intensity/ 

Facility Based 

Residential 

Treatment 

Treatment Foster 

Care 

Group Home 

P 

E 

E 

R 

G 

R 

O 

U 

P 

Services 

COMMUNITY, SCHOOL, CHURCH and IDENTIFIED NATURAL SUPPORTS 

10

W84: Improving Assessment and Treatment Planning for Persons Having Co-Occurring Disorders 

(continued as W94) 

David Mee-Lee, MD 


Description: 

It is difficult to change clinician attitudes and skills to provide truly integrated services. This double workshop 

focuses on ways to change assessment and treatment planning processes that help practitioners deliver 

individualized, person-centered treatment for all disorders. Sensitivity to the person’s change readiness for 

each disorder and continued engagement and motivational enhancement are also discussed. 


• examine ideological differences that present barriers to integrating treatment interventions; 

• identify unifying principles and strategies for improving integration and outcomes; 

• discuss essential assessment data and means to organize it to individualize service planning; 

• review ways to create more flexible interventions that better meet the needs of persons with cooccurring 

disorders and their families; 

• describe how sensitivity to a person’s stage of change readiness can improve both engagement and 

practitioner/program strategies and supports. 

NOTES:

Improving Assessment and Treatment Planning for 


Persons Having Co-Occurring Disorders 

_____________________________________________________________________________ 




Davis, CA 

(530) 753-4300; Voice Mail (916) 715-5856 

DAVMEELEE@aol.com www.DMLMD.com 

May 17, 2006 

Hershey, PA 

A. Assessment Guidelines 

• Pharmacological and psychosocial aspects of addiction can mimic psychiatric disorders 

• Decision tree for “Addiction versus Psychiatric Diagnoses: Either or Both?” 

• Take a good history - A definitive psychiatric diagnosis by history requires the psychiatric symptoms 

to have occurred during drug-free periods of time 

• Observe the client for a sufficient time drug-free - shorter time for objective, psychotic symptoms; 

longer for subjective, affective symptoms; non-drug ways of coping; addiction is a biopsychosocial 

disorder, so encourage active involvement in a recovery program; incorporate meetings, tools, 

techniques, and a wide variety of non-drug coping responses to help client deal with the stresses of 

everyday living; diagnosis as a process, not an event 

• Strategies for severely and persistently mentally-ill 

B. Treatment Dilemmas 

• For dual diagnosis patients, treat vigorously every diagnosis you are reasonably sure of, but only if the 

assessment steps have excluded the mimicking effects of addiction. 

• Because mental and substance-related disorders are biopsychosocial disorders in etiology, expression 

and treatment, assessment must be comprehensive and multidimensional to plan effective care. The 

common language of the six assessment dimensions of the ASAM Criteria (modified in Second 

Edition, Revised, ASAM PPC-2R, 2001) are used to focus assessment and treatment. 

1. Acute intoxication and/or withdrawal potential 

2. Biomedical conditions and complications 

3. Emotional/behavioral/Cognitive conditions and complications 

4. Readiness to Change 

5. Relapse/Continued Use/Continued Problem potential 

6. Recovery environment 

• Regardless of the particular setting and client population, there are “generic” treatment strategies: 

5 M's: 

Motivate - dual diagnosis clients can have denial, resistance and passivity about their addiction and mental 

health problems; deal with resistance at a pace that keeps the patient engaged in treatment; family and 

healthcare workers may also need “motivating” to deal with both addiction and psychiatric issues equally. 

(Dimension 4) 

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Manage - because dual diagnosis clients easily present to both addiction and mental health programs, 

treatment is more case management across the addiction and mental health treatment systems, social 

welfare, legal, and family systems and significant others, than individual therapy; case management 

especially important for high risk, multiproblem and chronic relapsing clients; take a total systems 

approach; to improve outcomes, alternative services may be necessary e.g. educational or vocational 

services, child care and parenting training, financial counseling, coping with feelings and dual relapse 

groups, daily living skills, tutoring or mentoring services, transportation. (Dimensions 1 - 6) 

Medication - for a diagnosed co-morbid psychiatric disorder, but only after sufficient assessment strategies 

exclude addiction mimicking; also for detoxification if necessary; educate clients about their medication 

and interaction with alcohol/drugs; prepare them on how to deal with conflicts about medication at AA/NA 

meetings; anti-craving medication; Antabuse; methadone; opioid antagonists. (Dimensions 1, 2, 3, 5) 

Meetings - mainstream into AA and NA as much as possible, but prepare clients on how to not alienate 

themselves eg. too readily discussing medication and mental health issues unless with an understanding 

member or group; help clients deal with their “dual identity”; help identify appropriate meetings in the area 

and locate or develop special support groups for those unable to be “mainstreamed”. (Dimensions 3, 4, 5, 

6) 

Monitor - to ensure continuity of care, be alert to missed appointments; hospitalizations and professionals 

unfamiliar with dual diagnosis and the treatment goals eg. drug-free diagnostic trial; promote 

accountability for an ongoing treatment plan, rather than fragmented response to crises; recognize 

treatment as a process, not an event. (Dimensions 1 - 6) 

Different Approaches for Different Dual Diagnosis Clinical Situations 

Past abuse: help patient stay in recovery, but don't dig and uncover traumatic experiences until sufficient 

non-drug coping skills developed; 

Verbally aggressive and challenging: empathize with the fear or the mistrust but don't patronize nor 

verbally spar with the patient; 

Intellectualizing, obsessing: allow discussion of ideas for five minutes at the end of session, but don't 

discount patient by saying, "don't analyze" or “get out of your head", provide action or doing tasks to 

communicate; 

Withdrawn and reluctant to verbalize: provide action or writing tasks to facilitate discussion eg. reading to 

group from a homework or action assignment; 

Hypomanic or manic: separate from the group if overstimulated or withhold from group or activity if 

escalating; 

Psychotic or paranoid: empathize with the concern, but don't agree with or condone the delusion or 

misperceptions. 

Criminal code and criminal thinking: help client develop the responsible code and reverse criminal thought 

processes. Feelings are signals to start thinking it through by going inside oneself and choosing 

responsible, accountable behavior. Criminal thinking goes outside and blames people, places and things 

using feelings to define the thought process, thus choosing irresponsibility and lack of accountability e.g., 

client awakes and feels bored and like skipping work; allows the feeling to form the thoughts and says 

“they’re jerks”, or “it’s a stupid job”, or “they don’t pay me enough” - and then chooses not going to work 

or being responsible and accountable. 

A responsible code person awakes with the same feeling of boredom and of not wanting to go to work, but 

then thinks: “they’re relying on me”, or “I’ve got a family to support”, or “they pay me for this job” - and 

then chooses to go to work and be responsible and accountable. (David Koerner’s training in corrective 

thinking and criminal thought process). 

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C. Medication Treatment Adherence Problems – Differential Diagnosis and What 

to Do About It 

• It is important to diagnose why the person does not adhere to medication, otherwise the strategy 

may be counterproductive: 

1. Cognitive – (a) client had a bad side effect or felt meds have not worked before and so won’t take 

medication anymore – treat the fear of side effects and/or the lack of confidence in medication. 

(b) readiness to change issues – client not ready to accept medication as necessary for an 

illness which s/he may accept or about which is still ambivalent – motivational 

enhancement, stages of change work. 

(c) wants to use natural substances rather than psychotropic medication. 

2. Cultural – believes the medication is dangerous from his/her cultural perspective – get a bicultural 

outreach worker. 

3. Unconsciously non-adherent; somatic complaints; sick role; characterological; the more the 

therapist is involved, the more it shows they care and the more the sick role pays off; love 

Assertive Community Treatment (ACT) for example, because the more you go to their home to 

count pills, the more they are non-compliant to keep you coming back. 

4. Drug addict – overusing pills due to an addiction. 

5. Psychotic – delusional – maintain the relationship and don’t struggle over the diagnosis; ACT is 

appropriate in such situations. 

6. Malingering external incentives for the behavior e.g., keep getting workers compensation. 

D. Engaging Client and Families into Participatory Treatment 

1. Stages of Change and How People Change 

* 12-Step model - surrender versus comply; accept versus admit; identify versus compare 

* Transtheoretical Model of Change (Prochaska and DiClemente): 

Pre-contemplation: not yet considering the possibility of change although others are aware of a 

problem; active resistance to change; seldom appear for treatment without coercion; could benefit from 

non-threatening information to raise awareness of a possible “problem” and possibilities for change. 

Contemplation: ambivalent, undecided, vacillating between whether he/she really has a “problem” or 

needs to change; wants to change, but this desire exists simultaneously with resistance to it; may seek 

professional advice to get an objective assessment; motivational strategies useful at this stage, but 

aggressive or premature confrontation provokes strong resistance and defensive behaviors; many 

Contemplators have indefinite plans to take action in the next six months or so. 

Preparation: takes person from decisions made in Contemplation stage to the specific steps to be taken 

to solve the problem in the Action stage; increasing confidence in the decision to change; certain tasks that 

make up the first steps on the road to Action; most people planning to take action within the very next 

month; making final adjustments before they begin to change their behavior. 

Action: specific actions intended to bring about change; overt modification of behavior and 

surroundings; most busy stage of change requiring the greatest commitment of time and energy; care not to 

equate action with actual change; support and encouragement still very important to prevent drop out and 

regression in readiness to change. 

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Maintenance: sustain the changes accomplished by previous action and prevent relapse; requires 

different set of skills than were needed to initiate change; consolidation of gains attained; not a static stage 

and lasts as little as six months or up to a lifetime; learn alternative coping and problem-solving strategies; 

replace problem behaviors with new, healthy life-style; work through emotional triggers of relapse. 

Relapse and Recycling: expectable, but not inevitable setbacks; avoid becoming stuck, discouraged, 

or demoralized; learn from relapse before committing to a new cycle of action; comprehensive, 

multidimensional assessment to explore all reasons for relapse. 

Termination: this stage is the ultimate goal for all changers; person exits the cycle of change, without 

fear of relapse; debate over whether certain problems can be terminated or merely kept in remission 

through maintenance strategies. 

* Readiness to Change - not ready, unsure, ready, trying. Doing what works: 

Motivational interviewing (Miller and Rollnick) 

2. Principles of Motivational Interviewing (MI) - Miller and Rollnick 

* Express empathy - “accurate empathy” (Carl Rogers) and acceptance. 

* Develop discrepancy - between present behavior and goals of what the patient wants. 

* Avoid argumentation - avoid head-to head confrontations. (This principle has been folded into 

the next principle in Second Edition “Motivational Interviewing - Preparing People for Change, 2002) 

* Roll with resistance - “psychological judo” (Jay Haley); patient as a valuable resource in finding 

solutions; perceptions can be shifted. 

* Support self-efficacy - client is responsible for choosing and carrying out personal change; belief 

in the possibility of change is powerful motivator. 

3. Client-Therapist Relationship - Solution-Focused Therapy (Berg): 

• Visitor-type relationship: patients see their involvement in treatment as voluntary with therapeutic 

tasks, goals, and solutions being imposed on them against their wishes; labeled and behave as if they 

are “unmotivated” or “resistant”; the “real problem: is “having to come” to treatment. 

• Complainant-type relationship: this relationship involves persons who have goals for others, but not 

for themselves; parents, spouse, employer or probation officer etc., present another person’s substance 

use as a problem to the complainant; these persons often labeled “co-dependent”, “caretaker” and 

“unhealthy”. 

• Customer-type relationship: patients express a treatment goal that is related to themselves and 

demonstrate many ways in which they are ready to change their behaviors of their own volition; for 

most addiction patients, this is not the usual presentation and very few have “hit bottom”, nor should 

be expected to for treatment eligibility. 

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4. Developing the Treatment Contract 

Client Clinical Assessment Treatment Plan 

What? What does client want? What does client need? What is the Tx contract? 

Why? Why now? Why? What reasons are Is it linked to what client 

What's the level of revealed by the assessment wants? 

commitment? 

data? 

How? How will s/he get there? How will you get him/her to Does client buy into the 

accept the plan? 

link? 

Where? Where will s/he do this? Where is the appropriate Referral to level of care 

setting for treatment? 

What is indicated by the 

placement criteria? 

When? When will this happen? When? How soon? What is the degree of 

How quickly? What are realistic expectations? urgency? 

How badly does s/he What are milestones in the What is the process? 

want it? process? What are the expectations 

of the referral? 

E. Improving Treatment Systems - ASAM PPC-2R 

(a) Description of Services 

The ASAM PPC-2R takes a step in this direction by defining program capabilities as being of three types: those 

that offer Addiction-Only Services (AOS), those that are Dual Diagnosis Capable (DDC), and those that are 

Dual Diagnosis Enhanced (DDE). Programs capabilities are defined as follows: 

1. Programs that offer Addiction-Only Services (AOS) 

• Cannot accommodate patients with psychiatric illnesses that require ongoing treatment, however stable 

the illness and however well functioning the individual. Such programs are said to provide Addiction- 

Only Services (AOS). 

• The policies and procedures typically do not accommodate co-existing mental disorders: for example, 

individuals on psychotropic medications generally are not accepted, coordination or collaboration with 

mental health services is not routinely present, and mental health issues are not usually addressed in 

treatment planning or content. 

2. Dual Diagnosis Capable (DDC) Programs 

• Dual Diagnosis Capable (DDC) programs routinely accept individuals who have co-occurring mental 

and substance-related disorders. 

• DDC programs can meet such patients' needs so long as their psychiatric disorders are sufficiently 

stabilized and the individuals are capable of independent functioning to such a degree that their mental 

disorders do not interfere with participation in addiction treatment. 

• DDC programs address dual diagnoses in their policies and procedures, assessment, treatment 

planning, program content, and discharge planning. 

• They have arrangements in place for coordination and collaboration with mental health services. 

• They also can provide psychopharmacologic monitoring and psychological assessment and 

consultation on site; or by well-coordinated consultation off-site. 

5 

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3. Dual Diagnosis Enhanced (DDE) Programs 

• DDE programs can accommodate individuals with dual diagnoses who may be unstable or disabled to 

such an extent that specific psychiatric and mental health support, monitoring and accommodation are 

necessary in order for the individual to participate in addiction treatment. 

• Such patients are not so acute or impaired as to present a severe danger to self or others, nor do they 

require 24-hour, psychiatric supervision. 

• DDE programs are staffed by psychiatric and mental health clinicians as well as addiction treatment 

professionals. Cross-training is provided to all staff. Such programs tend to have relatively high ratios 

of staff to patients and provide close monitoring of patients who demonstrate psychiatric instability 

and disability. 

• DDE programs typically have policies, procedures, assessment, treatment planning and discharge 

planning that accommodate patients with dual diagnoses. 

• Dual diagnosis-specific and mental health symptom management groups are incorporated into 

addiction treatment. Motivational enhancement therapies are more likely to be available (particularly 

in outpatient settings) 

• Ideally, there is close collaboration or integration with a mental health program that provides crisis 

back-up services and access to mental health case management and continuing care. 

(b) Risk Domains. A Risk Domain is an assessment subcategory within Dimension 3: 

• Dangerousness/Lethality. This Risk Domain describes how impulsive an individual may be with 

regard to homicide, suicide, or other forms of harm to self or others and/or to property. The 

seriousness and immediacy of the individual's ideation, plans and behavior—as well as his or her 

ability to act on such impulses—determine the patient's risk rating and the type and intensity of 

services he or she needs. 

• Interference with Addiction Recovery Efforts. This Risk Domain describes the degree to which a 

patient is distracted from addiction recovery efforts by emotional, behavioral and/or cognitive 

problems and, conversely, the degree to which a patient is able to focus on addiction recovery. (Note 

that high risk and severe impairment in this domain do not, in themselves, require services in a Level 

IV program.) 

• Social Functioning. This Risk Domain describes the degree to which an individual's relationships 

(e.g., coping with friends, significant others or family; vocational or educational demands; and ability 

to meet personal responsibilities) are affected by his or her substance use and/or other emotional, 

behavioral and cognitive problems. (Note that high risk and severe impairment in this domain do not, 

in themselves, require services in a Level IV program.) 

• Ability for Self Care. This Risk Domain describes the degree to which an individual's ability to 

perform activities of daily living (such as grooming, food and shelter) are affected by his or her 

substance use and/or other emotional, behavioral and cognitive problems. (Note that high risk and 

severe impairment in this domain do not, in themselves, require services in a Level IV program.) 

• Course of Illness. This Risk Domain employs the history of the patient's illness and response to 

treatment to interpret the patient's current signs, symptoms and presentation and predict the patient's 

likely response to treatment. Thus, the domain assesses the interaction between the chronicity and 

acuity of the patient's current deficits. A high risk rating is warranted when the individual is assessed 

as at significant risk and vulnerability for dangerous consequences either because of severe, acute 

life-threatening symptoms, or because a history of such instability suggests that high intensity services 

are needed to prevent dangerous consequences. 

6 

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For example, a patient may present with medication compliance problems, having discontinued 

antipsychotic medication two days ago. If a patient is known to rapidly decompensate into acute 

psychosis when medication is stopped, his or her rating is high. However, if it is known that he or she 

slowly isolates without any rapid deterioration when medication is stopped, the risk rating would be 

less. Another example could be the patient who has been depressed, socially withdrawn, staying in 

bed and not bathing. If this has been a problem for six weeks, the risk rating is much higher than for a 

patient who has been chronically withdrawn and isolated for six years with a severe and persistent 

schizophrenic disorder. 

F. Case Presentation Format 

I. Identifying Client Background Data 

Name 

Age 

Ethnicity and Gender 

Marital Status 

Employment Status 

Referral Source 

Date Entered Treatment 

Level of Service Client Entered Treatment 

Current Level of Service 

Stated or Identified Motivation for Treatment 

II. Current Placement Dimension Rating Has It Changed? 

1. 

2. 

3. 

4. 

5. 

6. 

(Give a brief explanation for each rating, note whether it has changed since the client entered 

treatment and why or why not) 

III. What problem(s) with High and Medium severity rating are of greatest concern at this time? 

Specificity of the problem 

Specificity of the strategies/interventions 

Efficiency of the intervention (Least intensive, but safe, level of service) 

7 

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G. Case Consultation and Systems Issues 

There are many systems boundaries that work against effective continuity of care: 

• Excessive boundaries, exclusion, and territoriality - policy, funding and practice ignore and sacrifice the 

complexity of individual needs to achieve and maintain bureaucratic simplicity; continuity of care is nearly 

impossible under these circumstances. 

• Inadequate assessment and diagnosis - on an individual basis, addiction and mental illness are often not diagnosed; 

inadequate assessment of community needs affects system planning and development of services. 

• Lack of trained staff - the polarization of the mental health and addictions fields, historically, has resulted in 

knowledge gaps only now beginning to improve; lack of experience in both addiction and mental health fields results 

in fear and resistance to learn and broaden counseling knowledge 

• Inadequate array of services - dual diagnosis services either do not exist, or represent a few model programs; 

even in states where it is more of a priority, there are too many gaps. 

• Rigid funding streams - there still are inadequate resources, turf battles and reluctance to pool resources for training, 

research or service delivery. 

• Lack of a strong shared constituency - because there is little common ground between the addictions and mental 

health constituencies, the ability to influence policy and service delivery is greatly limited. 

• Limited dissemination of effective program models - too little is done to publicize what works in model programs; 

programs are too infrequently evaluated, or if evaluated, the findings are often not applied in future funding or 

program planning 

• Fragility - when barriers have been overcome, it is usually due to individual efforts that are too fragile and dependent 

on that person’s leadership; positive changes are therefore not sustained by basic structural changes in the mental 

health and addiction service systems. 

(Wayne Thacker, MSW., Leslie Tremaine, Ed.D: “Systems Issues in Serving the Mentally Ill Substance Abuser: Virginia’s Experience” 

Hospital and Community Psychiatry, Vol. 40, No. 10 pp. 1046-1049, Oct. 1989.) 

H. Gathering Data on Policy and Payment Barriers 

• Policy, payment and systems issues cannot change quickly. However, as a first step towards reframing frustrating 

situations into systems change, each incident of inefficient or in adequate meeting of a client’s needs can be a data 

point that sets the foundation for strategic planning and change 

• Finding efficient ways to gather data as it happens in daily care of clients can help provide hope and direction for 

change: 

8 

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PLACEMENT SUMMARY 

Level of Care/Service Indicated - Insert the level of care and/or type of service that offers the 

most appropriate level of care/service that can provide the service intensity needed to address the 

client’s current functioning/severity. 

Level of Care/Service Received - If the most appropriate level/service is not able to be utilized, 

insert the most appropriate placement/service available and circle the Reason for Difference 

between Indicated and Received Level/service 

Reason for Difference - Circle only one number -- 1. Level of care or Service not available; 2. Provider 

judgment; 3. Client preference; 4. Client is on waiting list for appropriate level/service; 5. Level of care or 

Service available, but no payment source; 6. Geographic inaccessibility; 7. Family responsibility problems e.g., 

no childcare; 8. Language; 9. Not applicable; 10. Not listed. 

COMMENTS: 

Stephen 

Stephen is 51 years old and is accompanied by his wife. He wants help, but is depressed. During his 

intake interview for this, his second DUI arrest, he looks disconsolate and he speaks in a monotone as he 

wonders if his wife will leave him. His alcohol use has resulted in alienation from his children, guilt 

feelings and his job may now be threatened, as he has been warned by his supervisor about his poor 

attendance and performance. Most of his friends drink, but none of them think he is an alcoholic. 

He has not had any previous addiction treatment other than DUI classes after his first DUI four years ago. 

He attended AA for six months on and off and did have a sponsor, but felt more and more that he wasn't as 

bad as others at AA and gradually stopped going. 

Stephen has been alcohol-free for three weeks. He has used cocaine (snorting) about three times per month 

over the past four years, but stopped two months ago. He has had no legal or financial problems related to 

cocaine. Stephen has continued on diazepam (Valium) 5 mg. qid which he has taken for five years to relax 

him because of mild hypertension. He has no other chronic physical problems but has lost 10 pounds 

weight over the past month and has been sleeping poorly. He wishes he could sleep and get away from all 

his problems but denies any organized suicidal plans and says he wants help. 

February 18 

C.W. 

The following is a report on C.W. The consultation issue involved the question of whether primary alcohol 

dependence or primary psychiatric interventions were needed; and also recommendation for level of care 

and treatment plan given this patient’s three hospitalizations since age 15 with the current admission 

involving high risk suicidal behavior. CW is a 19 year-old, white, single, unemployed tire worker who was 

admitted 2/13 intoxicated on alcohol and also positive for marijuana in his drug screen. He was depressed 

and suicidal and had cut his chest; written “Die” on his chest; and taken an overdose of Prozac. 

9 

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LITERATURE REFERENCES AND RESOURCES 

“Co-Occurring Psychiatric and Substance Disorders in Managed Care Systems: Standards of Care, Practice 

Guidelines, Workforce Competencies, and Training Curricula” Report of The Center for Mental Health 

Services Managed Care Initiative: Clinical Standards and Workforce Competencies Project, Co-Occurring 

Mental and Substance Disorders Panel. Kenneth Minkoff, M.D., Panel Chair; Cynthia Ajilore, Project 

Coordinator. January, 1998. 

(University of Pennsylvania Health System, Dept. of Psychiatry, Center for Mental Health Policy and 

Services Research, 3600 Market St., 7 th Floor, Philadelphia, PA 19104-2468 Tele: 215.662-2886). 

Daley, CD, Howard BM (2002): “Dual Disorders – Counseling Clients with Chemical Dependency and 

Mental Illness”, Third Edition. Hazelden, Center City, MN 

Davis KE, O’Neill SJ (2005): “A Focus Group Analysis of Relapse Prevention Strategies for Persons with 

Substance Use and Mental Disorders”. Psychiatric Services 56:1288-1291 

Drake RE, Wallach MA, McGovern MP (2005): “Future Directions in Preventing Relapse to Substance 

Abuse Among Clients With Severe Mental Illness” Psychiatric Services 56:1297-1302 

Evans K, Sullivan JM (2001): “Dual Diagnosis – Counseling the Mentally Ill Substance Abuser” Second 

Edition. Guilford Press. 

“Manual of Adolescent Substance Abuse Treatment” Edited by Todd Wilk Estroff, M.D. American 

Psychiatric Publishing, Inc. Washington, DC. 2001 

Mee-Lee, David: "Managed Care and Dual Diagnosis" in "Treating Coexisting Psychiatric and Addictive 

Disorders -- A practical Guide," Norman S. Miller, editor, Hazelden Educational Materials, Center City, 

MN., 1994. 

Mueser KT, Noordsy DL, Drake RE, Fox L (2003): “Integrated Treatment for Dual Disorders – A Guide to 

Effective Practice” The Guilford Press, NY. 

CLIENT WORKBOOKS AND INTERACTIVE JOURNALS 

1. “Successful Living with a Dual Disorder” – Motivational, Educational and Experiential (MEE) Journal 

System. Interactive journaling for clients. This Journal is designed specifically for individuals who are 

suffering with a dual disorder. It provides important information that allows clients to understand the facts 

and challenges regarding their addiction and mental disorder. 

To order: The Change Companies at 888-889-8866. www.changecompanies.net. 

2. Foundations Co-Occurring Disorders Series Co-Occurring - The Recovery Workbook Series 

Workbook series on treating addictions and mental health conditions. 

To order: Foundations Associates at 888.869.9230. www.dualdiagnosis.org 

RESOURCES FROM SAMHSA 

1. In 2002, the Substance Abuse and Mental Health Services Administration (SAMHSA) presented 

“A Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse 

Disorders and Mental Disorders”. It provides a summary of practices for preventing substance use 

disorders among individuals who have mental illness and also a summary of evidence-based practices for 

treating co-occurring disorders. Resource: www.samhsa.gov/reports/congress2002/foreword.htm 

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2. A 2003 publication, “Strategies for Developing Treatment Programs for People with Co-Occurring 

Substance Abuse and Mental Disorders” is also available on the SAMHSA website or though the 

SAMHSA National Mental Health Information Center at (800) 789-2647. SAMHSA Publication No. 

3782, SAMHSA 

3. Center for Substance Abuse Treatment. “Substance Abuse Treatment for Persons With Co- 

Occurring Disorders” Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 

05-3992. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005 




4. Co-Occurring Dialogues is an Electronic Discussion List that specifically focuses on issues related to 

dual diagnosis. A subscription to the Co-Occurring Dialogues Discussion List is free and unrestricted and 

can be done simply by sending an e-mail to dualdx@treatment.org. 

5. Evidence-Based Practices: Shaping Mental Health Services Toward Recovery 

Tool Kits are currently in production. Please download materials as needed. 

The Substance Abuse and Mental Health Services Administration (SAMHSA) and its Center for Mental 

Health Services (CMHS) are pleased to introduce six Evidence-Based Practice Implementation Resource 

Kits to encourage the use of evidence-based practices in mental health. The Kits were developed as one of 

several SAMHSA/CMHS activities critical to its science-to-services strategy. We expect to identify 

additional practices for future Kits. 

• www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/about.asp 

The Kits contain many useful resources, including: 

* Information Sheets for all stakeholder groups 

* Introductory videos 

* Practice demonstration videos 

* Workbook or manual for Practitioners 

Each of the six Resource Kits is described below. 

The Illness Management and Recovery program strongly emphasizes helping people to set and pursue 

personal goals and to implement action strategies in their everyday lives. The information and skills taught 

in the program include: 

* Recovery strategies 

* Practical facts about mental illness 

* The Stress-Vulnerability Model and strategies for treatment 

* Building social support 

* Using medication effectively 

* Reducing relapses and coping with stress 

* Coping with problems and symptoms 

* Getting needs met in the mental health system 

The Medication Management Approaches in Psychiatry program focuses on using medication in a 

systematic and effective way, as part of the overall treatment for severe mental illness. The ultimate goal is 

to ensure that medications are prescribed in a way that supports a person's recovery efforts. The program 

includes: 

* Guidelines and steps for medication decision making, based on current Evidence and outcomes 

* Systematic monitoring and record keeping of medications 

* Consumer and family member Involvement 

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The goal of Assertive Community Treatment is to help people stay out of the hospital and to develop skills 

for living in the community, so that their mental illness is not the driving force in their lives. Assertive 

community treatment offers services that are customized to the individual needs of the consumer, delivered 

by a team of practitioners, and available 24 hours a day. The program addresses needs related to: 

* Symptom management 

* Housing 

* Finances 

* Employment 

* Medical care 

* Substance abuse 

* Family life 

* Activities of daily life 

Family Psychoeducation involves a partnership among consumers, families and supporters, and 

practitioners. Through relationship building, education, collaboration, problem solving, and an atmosphere 

of hope and cooperation, family psychoeducation helps consumers and their families and supporters to: 

* Learn about mental illness 

* Master new ways of managing their mental illness 

* Reduce tension and stress within the family 

* Provide social support and encouragement to each other 

* Focus on the future 

* Find ways for families and supporters to help consumers in their recovery 

Integrated Dual Diagnosis Treatment is for people who have co-occurring disorders, mental illness and a 

substance abuse addiction. This treatment approach helps people recover by offering both mental health 

and substance abuse services at the same time and in one setting. 

This approach includes: 

* Individualized treatment, based on a person's current stage of recovery 

* Education about the illness 

* Case management 

* Help with housing 

* Money management 

* Relationships and social support 

* Counseling designed especially for people with co-occurring disorders 

6. The Co-Occurring Center for Excellence (COCE) 

In September 2003, the Substance Abuse and Mental Health Services Administration (SAMHSA) launched 

the Co-Occurring Center for Excellence (COCE) with a vision of its becoming a leading national resource 

for the field of co-occurring mental health and substance use disorder treatment. The mission of COCE is 

threefold: (1) Receive, generate and transmit advances in substance abuse and mental health that address 

substance use and mental disorders at all levels of severity and that can be adapted to the unique needs of 

each client, (2) Guide enhancements in the infrastructure and clinical capacities of the substance abuse and 

mental health service systems, and (3) Foster the infusion and adoption of prevention, treatment, and 

program innovations based on scientific evidence and consensus. 

COCE consists of national and regional experts who serve to shape COCE’s mission, guiding principles, 

and approach. 

(For more information on the COCE, see: www.coce.samhsa.gov. You can contact the COCE at (301) 951- 

3369, or e-mail: coce@samhsa.hhs.gov.) 

12 

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_____________________________________________________________________________ 

RESOURCES FOR ASAM PPC 

American Society of Addiction Medicine - 4601 Nth. Park Ave., Arcade Suite 101, Chevy Chase, MD 

20815. (301) 656-3920; Fax: (301) 656-3815; www.asam.org; e-mail: asamoffice@aol.com. (800) 844- 

8948. 

RESOURCE FOR ASSESSMENT INSTRUMENTS 

Level of Care Index (LOCI-2R): Checklist tool listing ASAM PPC-2R Criteria to aid in decision-making 

and documentation of placement. 

Dimensional Assessment for Patient Placement Engagement and Recovery (DAPPER): Severity ratings 

within each of the six ASAM PPC-2R dimensions. 

A variety of proprietary assessment instruments for identifying substance use disorders, psychiatric 

diagnoses for adults and adolescents. 

To order: The Change Companies at 888-889-8866. www.changecompanies.net. 

For clinical questions or statistical information about the instruments, contact Norman Hoffmann, Ph.D. at 

828-454-9960 in Waynesville, North Carolina; or by e-mail at evinceassessment@aol.com 

RESOURCE FOR HOME STUDY AND ONLINE COURSES 

1. “Dilemmas in Dual Diagnosis Assessment, Engagement and Treatment” By David Mee-Lee, M.D. 

This home study or online course (with CEU’s) is designed to improve practitioners’ abilities to assess, 

engage, and treat people with co-occurring mental health and substance use problems. Practical strategies 

and methods are offered to help change interviewing methods, treatment planning and documentation, 

program components, range of services, and policies to better engage the dually diagnosed client. 

Professional Psych Seminars, Inc. Agoura Hills, CA Toll-free phone: (877) 777-0668. Website: 

www.psychsem.com 

2. “ASAM 101: Basics on Understanding and Using ASAM Patient Placement Criteria, Revised Second 

Edition (ASAM PPC-2R)” 

A 3-hour course that will introduce students to key concepts and issues of the ASAM Patient Placement 

Criteria. Clinicians involved in planning and managing care often lack a common language and systematic 

assessment and treatment approach that allows for effective, individualized services. The Patient Placement 

Criteria of the American Society of Addiction Medicine (ASAM) first published in 1991, provided 

common language to help the field develop a broader continuum of care. They were updated and the 

second edition (ASAM PPC-2) was published in April 1996. A revised second edition was published in 

April 2001. 

The Distance Learning Center for Addiction Studies (DLCAS) is an internet based educational service that 

provides comprehensive training and information in the field of addiction studies. It is a joint presentation 

of the Betty Ford Center and the Distance Learning Center, LLC. Toll-free phone: 866 471-1742. Website: 

www.dlcas.com/course59.html 

FREE MONTHLY NEWSLETTER 

“TIPS and TOPICS” – Three sections: Savvy, Skills and Soul and additional sections vary from month to 

month: Stump the Shrink; Success Stories and Shameless Selling. Sign up on www.DMLMD.com or here 

at the workshop. 

13 

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RESOURCE FOR TRAINING VIDEOTAPE 

“Enhancing Motivation: How to Engage People into Addiction Treatment” By David Mee-Lee, M.D. 

This training album is designed to improve practitioners’ abilities to assess and engage people into 

participatory treatment. Treatment programs can use this training to orient new staff or refresh current 

clinicians. Practical strategies and methods are offered to help change interviewing methods, treatment 

planning and documentation, program components, range of services, and policies to better engage people 

into treatment 

Available at www.DMLMD.com from DML Training and Consulting, Davis, CA (530) 753-4300 

Fire Starters 

1. Addictive and psychiatric disorders are both significant chronic conditions characterized by 

episodes of exacerbation, remission and relapse. 

2. All clients should be retained in treatment and treated with great respect in spite of non-follow 

through with treatment plan recommendations, including failure to take prescribed medication or 

return to use of their drug of choice. 

3. Addiction and mental illness are both no-fault disease categories. 

4. No behavioral health problem is so grave that the client cannot be engaged in the recovery 

process. 

5. It is more important to convey caring and concern than to avoid being manipulated or conned – 

even at the cost of “enabling”. 

6. Medication can be an effective strategy in the treatment of both disorders. 

7. Can someone on methadone be in recovery? 

8. Evaluating and monitoring how a client is functioning in their living environment with significant 

others is equally as important as to whether they go to AA or other recovery groups. 

(Some modified or added from original Fire Starters developed by Mike Boyle, M.A., Executive Vice President, 

Fayette Companies www.BHRM.ORG E-mail: mboyle@fayettcompanies.org) 

14 

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W85: The Co-Occurring Competency Bulletin: Preparing for a Response 

Taylor B. Anderson, MSW, LSW, CPRP 

1.5 hours Focus: Systems Integration & 

Clinical Integrated Interventions 

Description: 

Pennsylvania DOH and DPW have jointly issued a bulletin to certify programs with either license to provide 

certain services to persons with co-occurring mental and substance use disorders. This workshop presents an 

overview of all clinical criteria set needed and recommended by the bulletin to give programs a clear picture of 

the type and level of skills required for certification. Additional resources will be provided. 


• Describe the necessary and recommended clinical competencies needed by staff of COD competent 

programs; 

• Assess program and staff strengths and needs given these areas of clinical competencies; 

• Identify resources and sources for increasing skills in needed areas. 

NOTES:


Co-Occurring Disorder 

Competency Criteria Exploration 

A Seminar for Practitioners and 

Programs That Will Request 

Certification Under This Bulletin 

Shared Concerns 

The Departments of Health and Public 

Welfare, since 1997, have worked 

collaboratively to develop a statewide 

system of care for persons having cooccurring 

psychiatric and substance use 

disorders, with the objective of providing 

the most appropriate care, understanding 

that neither set of disorders is primary or 

secondary to the other. 

Background (COSIG Executive Report) 

• 1997-99 Mental Illness & Substance Abuse 

Consortium (joint participation by OMHSAS and 

DOH) 

• 5 county pilot projects with 2 year evaluation 

• Co-occurring State Incentive Grant (COSIG) 

– Develop permanent statewide infrastructure to 

support co-occurring service delivery 

– Co-occurring State Advisory Committee (CODAC) 

• 5 sub-committees (Screening & Assessment; Provider 

Approval; Workforce Development; Data Integration; 

Reimbursement) 

Objectives in Bulletin: to… 

• Move the entire BH system toward achieving 

core competencies for serving persons with 

CODs who are already in facility programs; 

• Provide the framework for delineating objective 

criteria for defining COD Competency; 

• Describe the process for licensed facilities to 

achieve COD Competency; 

• Provide direction for County MH/MR programs 

and SCAs in supporting development of COD 

Competent programs in all facilities. 

1


CO-OCCURRING DISORDER(S) 

‣A term used when a person is found to 

have one or more DSM-IV-TR diagnosed 

psychiatric disorders as well as one or 

more substance use disorders. 

‣Both disorders are considered primary, 

meaning that one does not cause the 

other and that both require interventions 

that assist the person in overcoming the 

negative effects of these disorders. 

COD Professional Credential 

(CCDP) 

‣ A competency-based credential now granted by 

the Pennsylvania Certification Board for 

professions who provide co-occurring mental 

health and substance use treatment. 

‣ The grandfathering period for this credential has 

now expired and an examination is required. 

There are about 1000 practitioners currently 

approved. 

‣ Not the only acceptable credential that indicates 

dual competency. 

*COD Competent Facility* 

‣ A licensed facility (by one or both) that: 

Addresses co-occurring psychiatric and substance 

use disorders in its policies and procedures; 

Provides integrated screening and assessment to 

determine interventions needed and engage in an 

integrated care planning process; 

Provides education on co-occurring disorders in both 

individual and group programming; 

Establishes appropriate crisis intervention protocols; 

Develops interagency coordination for co-occurring 

services and ensures COD discharge planning; 

If singly licensed, does NOT provide treatment for the 

other disorder. 

COD Enhanced Facility 

‣A dually-licensed facility that: 

Has programmatic capacity to provide 

integrated substance use and psychiatric 

treatment to persons presenting with 

symptomatic and/or functional impairments as 

a result of their co-occurring disorders; and 

Address CODs using an integrated 

philosophy and treatment model in a single 

setting. 


“Any mechanism by which treatment 

interventions for CODs are combined 

within the context of a primary treatment 

relationship or service setting with an 

individual clinician or clinical team.” 

• Recognizes the need for a unified 

treatment approach for person or family 

• This approach is characteristic of the 

standard of care in a COD enhanced 

facility 

2


Evidence-Based Practice 

‣Practices are referred to as being 

“evidence-based” or “promising” (not 

“best”). 

‣Some definitions: 

• “Evidence-based practices are interventions for which 

there is consistent scientific evidence showing that 

they improve client outcomes” (Drake et al, 2001) 

• “Evidence-based practice is the integration of best 

research evidence with clinical expertise and patient 

values….” (Crossing the Quality Chasm, Institute of Medicine, 2001) 

POLICY AND CRITERIA 

FOR CO-OCCURRING 

DISORDER COMPETENT 

PROGRAMS 

POLICY 

To be approved as a co-occurring disorder 

capable facility, in addition to meeting the 

following criteria, the facility must: 

• Have a current license or certificate of compliance 

from the Department of Health, Division of Drug and 

Alcohol Program Licensure; OR 

• Have a current license or certificate of approval from 

the Department of Public Welfare, Office of Mental 

Health and Substance Abuse Services. 

CRITERIA SECTIONS 

A. COD Mission and Philosophy 





F. Medication 

G. Crisis Intervention Procedures 

H. Communication, Collaboration & Consultation 



Approval Procedure 

APPROVAL 

PROCESS 

• The licensed facility desiring to be 

approved as a COD competent program 

requests approval from DOH or OMHSAS 

in writing*, indicating that the facility meets 

all criteria in the bulletin; 

• The licensing division/office conducts an 

on-site survey to assess compliance as 

soon as possible after request is received. 

3


Approval Procedure (continued) 

• Within 90 days of the site visit, either: 

– A certificate of approval effective for no longer 

than one year will be issued that indicates the 

facility has met the criteria and is able to 

provide co-occurring competent services; 

– OR a letter is sent that specifies any areas not 

in compliance with the criteria with an 

explanation of the corrections required for 

compliance. 


– Within 3 weeks (15 working days), if in noncompliance, 

the facility must submit a plan of 

correction, including the action [to be] taken, 

timeframe for accomplishment, and person(s) 

responsible for ensuring correction, to the appropriate 

Department. 

– A re-inspection may be conducted for verification. 

Following inspection or upon approval of the plan of 

correction, the certificate of approval may be issued, 

with a letter sent to the facility and to the other 

licensing entity for their records. 


• The licensing entity will visit the facility at least 

annually to conduct a program and clinical 

record review for renewal of the certificate of 

approval. 

• If the facility is licensed by both Departments, a 

joint on-site visit may be conducted; if possible, 

they will include existing licensing surveys. 

• Each approved co-occurring competent facility 

listing will be listed in both Department’s Facility 

Directory and both Departments’ websites. 

DETAILS OF 

PROGRAM 

APPROVAL 

CRITERIA 

A. COD Mission & Philosophy 

1. Mission statement & program philosophy 

which incorporates an understanding of 

the provision of effective COD services 

approved by the governing body of the 

facility. 

‣ The facility should have written 

statements that reflect the ideas found in 

the “Background” section of the bulletin. 

COD Mission & Philosophy (continued) 

2. Description of intervention strategies that 

include consensus & evidence-based 

practices for age and culturally 

appropriate co-occurring treatment. 

‣ The facility should describe the treatment 

approaches it is using and provide a 

written rationale based in current clinical 

research for using these approaches. 

4



3. Quality improvement plan that monitors 

compliance with program philosophies, 

treatment modalities, and consumer 

satisfaction with services. 

‣ The facility should have a written QI plan that 

describes its purpose and how it involves all 

level of staff in identifying problems, creating 

proposed solutions, and evaluating the effect 

of corrective actions taken. 


4. Co-occurring program performance 

measures linked to the quality 

improvement activities. 

‣ The QI efforts need to document 

attention to assessing and treating 

persons with CODs, outcomes achieved, 

problems identified, actions taken to 

improve results, evaluation of such 

actions, satisfaction or continued actions. 



1. Develop written procedures for screening for cooccurring 

issues. (should be available) 

2. Utilize population appropriate screening instruments 

that identify both psychiatric and substance use 

disorders. (designated instruments with written 

instructions for use) 

3. Identify staff qualified to provide screening. 

(documented qualifications for each staff member) 

4. Document staff training on screening procedures. 

(evidenced by dates, times, topics, attendance) 

All of these must apply to an adolescent population when 

that is the population served by the facility. 



1. Develop written procedures for a strengthbased 

assessment process for co-occurring 

disorders. (should be available) 

2. Utilize assessment instruments that gather 

both psychiatric and substance use disorders, 

including information re: symptoms of either 

set of disorders when the other is at baseline. 

(should have rationale for instrument use) 

COD Assessment Process (continued) 

3. Identify how assessment findings are 

incorporated into the treatment planning 

process. (written description of process) 

4. Identify staff qualified to complete the 

assessment process for individuals with CODs. 

(staff qualifications documented) 

5. Document staff training on the co-occurring 

disorder assessment process. (dates, times, 

outline of training, attendance sheets) 


In addition to current licensed activities, the 

program shall identify and describe 

specific co-occurring disorder services 

that, at a minimum, include: 

1. Individual and Group Interventions, 

2. Skill-Building Interventions, 

3. Mental Health and/or Addiction 

Education, 

4. Medication Education, 

5


COD Program Content (con’t.) 

5. COD Education for Individuals & Families 

6. COD Relapse Prevention, and 

7. Access to Peer Support Services and Self- 

Help Recovery Resources. 

Also recommended, in addition, are: 

8. Stage of Change Matched Interventions, 

9. Motivational Enhancement Interventions, 

10. Contingency Management. 

1. Individual and Group Interventions are 

being used appropriately… 

‣when the P&P/Operations Manual 

describes how the assessment process 

leads to a careful decision about which 

forms of intervention to use under what 

conditions; 

‣when each form of intervention is 

described in sufficient detail in the P&P/ 

Operations Manual; 

‣when each individual record describes the 

rationale for the current choice of 

interventions. 

1. Choice of Individual & Group 

Interventions 

• Interventions targeted to individual and 

scope of program (types of diagnoses, 

ages, cultural groups, etc.) 

• Choice dictated by diagnostic symptoms, 

stage of change, program efficiencies 

• Cognitive behavioral strategies generally 

used in helping people alter thinking habits 

• See COD IDDT Workbook, pp. 69-79 & 87-92 

2. Skill-Building Interventions are 

being used… 

‣when the types of skills groups and the 

criteria for their use are described in the 

P&P/Operations Manual; 

‣when the rationale for teaching specific 

skills is described in individual plans; 

‣when the person learning the skills can 

describe the skills being learned and their 

particular use to him/her. 

2. Choosing Skill Building 

Interventions 

‣Skills tend to be of two types: 

• Specific activity skills 

• Social skills (reference p. 84 of IDDT Workbook) 

‣Persons with CODs often need skill 

development 

‣Skills related to desired goals need to be 

further assessed in the “Preparation” stage 

‣Skills teaching needs to relate the skills to 

the person’s own desired goals 

3. Education about disorders is 

occurring … 

‣when the types of educational offerings 

and criteria for their use are described in 

the P&P/Operations Manual; 

‣when the educational intervention and its 

rationale is described in individual plans; 

‣When people in the program can describe 

what they are learning in their own words. 

6


3. MH & SUD Education 

• Designed to help people acquire 

knowledge about what we have learned 

from research so far about the various 

psychiatric disorders, their symptoms, and 

what may work to manage symptoms well 

• Designed to help people learn about the 

various chemical substances used, their 

biological effects and risks, fact from myth, 

benefits and cost ratios, and alternatives 

to use 

4. Medication Education is 

occurring when… 


and criteria for their use are described in 

the P&P/Operations Manual; 

‣when medication education is documented 

as occurring individually and in groups; 

‣When the people in the program can say 

what medication(s) they are taking and 

why, report on side effects, and are 

satisfied that their issues are heard and 

responded to. 

4. Medication Education 

• One of the 6 adult EBPs on SAMHSA 

website: “Medication Management 

Approaches in Psychiatry” (algorithms for 

schizophrenia-MedMAP) involves the 

person, family members & supporters and 

facilitates adherence by partnering with 

the person in shared decision-making. 

• Medication is a first line treatment for 

many psychiatric disorders and should not 

be denied because the person is using. 

5. Co-occurring Education for 

Persons and Families is occurring… 


and the expectation that family members 

will also be invited and involved is 

described in the P&P/Operations Manual; 

‣when recovering persons and family 

members are involved as presenters in 

educational groups; 

‣when discussion about potential need for 

some form of education is documented in 

individual charts. 

5. COD Education-People/Families 

• Workbook defines family interventions: 

– Education 

– Involvement in treatment planning 

– Family therapy 

– Family support groups 

– Organizations such as NAMI 

• Educational topics include: psychiatric dx.; 

medications; stress-vulnerability model; role of 

family; basic facts about alcohol/drugs; cues or 

triggers for & consequences of SU; treatment of 

dual disorders; good communication 

6. COD Relapse Prevention is 

occurring… 

‣when relapse prevention interventions 

(individual/group) are described in the 


‣when the rationale for initiating these 

interventions is indicated in the 


‣when individual strengths and skills in 

constructing a relapse prevention plan are 

described in individual charts. 

7


6. COD Relapse Prevention 

• See Chapter 12 (pp. 80-86) of the COD- 

IDDT Workbook. 

• Some interventions listed include: 

– Make a relapse prevention plan 

– Support & reinforce previously learned skills 

for sobriety 

– Facilitate social skills for making sober friends 

– Facilitate social and leisure activities 

– Explore job opportunities* 

– Encourage & facilitate participation in selfhelp 

groups 

7. Access to Peer Support Services 

and Self-Help Recovery Resources 

have been discussed and used… 

‣when some types of resources available 

locally and the expectation that staff will 

facilitate their use is described in the 

P&P/Operations Manual; AND 

‣resources used are part of the assessment 

process documented in the chart; 

‣resource use discussion is documented in 

the individual’s chart prior to discharge; 

‣Chosen resources are included in the 

person’s Relapse Prevention Plan. 

10. Access to Self-Help Recovery 

Resources 

Depending upon the person’s needs and 

preferences, some resources are: 

Peer counselor or case manager to model 

12-Step program: 

• Alcoholics Anonymous 

• Narcotics Anonymous 

• Dual Recovery/Double Trouble 

Specific focus (such as “Pink and Blues”) 

8. A Program Uses Stages of Change… 

‣when the program P&P/Operations 

Manual documents how stage of change 

readiness is incorporated into the 

assessment and planning process; 

‣when a change rating for each major 

diagnosis or issue is documented in the 

chart at assessment and throughout the 

intervention process; 

‣when the type of intervention being used 

documents a match to the person’s stage 

of change readiness level. 

8. Matching Stages of Change 



Contemplation & 

Preparation 

Action 

Maintenance 

Stages of Treatment 

Engagement 

Persuasion 

[then a good plan] 

Active Treatment 


9. MI Strategies are being used… 


Manual documents the values and 

approaches of MI strategies in its Mission 

and Philosophy section; 

‣the program documents use of MI 

approaches with persons in the 

Precontemplation and Contemplation 

stages of change readiness; 

‣When the chart documents movement to 

different stages of change. 

8


9. The Spirit of Motivational 

Interviewing (Miller & Rollnick, 2002, p.35) 

Fundamental approach of 

motivational interviewing 

Collaboration. Counseling involved a 

partnership that honors the client’s 

expertise and perspectives. The 

counselor provides an atmosphere that 

is conducive rather than coercive to 

change. 

Evocation. The resources and motivation 

for change are presumed to reside 

within the client. Intrinsic motivation 

for change is enhanced by drawing on 

the client’s own perceptions, goals, 

and values. 

Autonomy. The counselor affirms the 

client’s right and capacity for selfdirection 

and facilitates informed 

choice. 

Mirror- image opposite approach to 

counseling 

Confrontation. Counseling involves 

overriding the client’s impaired 

perspectives by imposing awareness 

and acceptance of “reality” that the 

client cannot see or will not admit. 

Education. The client is presumed to lack 

key knowledge, insight, and/or skills 

that are necessary for change to occur. 

The counselor seeks to address these 

deficits by providing the requisite 

enlightenment. 

Authority. The counselor tells the client 

what he or she must do 

10. Contingency Management is being used… 


Manual documents the value and use of 

Contingency Management principles; 

‣when positive reinforcement strategies are 

documented in individual treatment plans; 

‣when people in the program can describe 

the use of reinforcers in active groups. 

10. Contingency Management 

• Based in animal models of chemical use 

demonstrating neurobiological and 

environmental factors 

• Based on operant conditioning principles 

• Four essential principles (Higgins & Petry, 1999): 

- regular testing to detect targeted use; 

- tangible reinforcers provided for abstinence; 

- incentives withheld when use is detected; 

- person assisted to establish alternate, healthier 

activities that become reinforcing themselves 


1. The individual’s full participation in the 

development of his/her integrated treatment 

plan. (Documented by the program’s having a written 

description of the manner in which the person is 

involved throughout the process – not just by the 

person’s signature on the plan - & by evidence of this 

involvement in the plan itself.) 

2. Input from the multidisciplinary treatment team, 

collaborating agencies & practitioners and 

family, if appropriate. (Documented by a written 

description of how this process is to occur within the 

program and evidence of this involvement in the plan 

itself.) 


3. Goals and measurable learning and skillbuilding 

objectives that reflect the presence of 

both disorders and how treatment interventions 

may vary to meet the needs of the individual. 

(Documented by a written description explaining the 

process of goal selection, how the steps toward goal 

achievement are to be written within a treatment plan 

and evidence of steps toward achievement.) 

4. Individualized goals that are stage-specific 

based upon the assessment of co-occurring 

needs. (Evidence of use of assessment of stage and 

goals that are clearly THIS person’s – not a “cookie 

cutter” plan) 


5. Identification and incorporation of the 

individual’s strengths and supports needed to 

accomplish the identified goals. (Evidence of 

use of strengths-based assessment data, 

including supports needed, in formulating 

steps for reaching the goal) 

6. Reviews and revisions based upon additional 

clinical information obtained through the 

ongoing assessment and evaluation process. 

(Evidence of additional assessment data 

added to chart and additions to plan as shortterm 

goals are accomplished) 

9



7. Recovery supports for both disorders. 

(Evidenced by assessment data of what 

person has used before that has been 

helpful and person’s preferences and by 

documentation of provision of education 

activities that provide information about 

both/all diagnosed disorders in the chart) 

F. Medication 

The facility shall develop medication policies 

regarding prescription medications that 

address the following: 

1. Documentation that includes medication, 

dose, frequency, and prescribing 

physician. (written documentation) 

2. Monitoring medication adherence, 

including self-report. (written 

documentation in specific format) 

Medication (continued) 

3. Access to medication, if not available 

within the facility. (written protocol for 

how to access, including payment 

sources) 

4. Documentation of communication and 

coordination of care among all programs 

providing treatment services and 

medications to the individual. 

5. Education about the medications, 

including side effects. (written 

documentation in record) 


Procedures 

The program shall develop policies and 

procedures to address the following*: 

1. Psychiatric emergencies 

2. Withdrawal emergencies 

3. Medication emergencies 

4. Medical emergencies 

5. Intoxication 

6. Social Safety emergencies (e.g., Child Abuse, 

Domestic Violence, Unexpected 

Homelessness 


Procedures Documentation 

‣ Evidenced by written P&P and by clear 

documentation of how any of these 

situations is handled when they occur 

H. Communication, Collaboration 

& Consultation 

1. Written agreements to maintain linkages with 

practitioners and organizations necessary to 

support co-occurring service needs. 

(Evidenced by the presence of such 

agreements, including procedures for access 

and collaboration) 

2. Policies and procedures for integrating input 

from collaborating agencies and family 

members, if appropriate. (Evidenced by their 

presence and by evidence of collaboration in 

the assessments and treatment records 

themselves) 

10


Communication, Collaboration & 

Consultation (continued) 

3. Procedures for obtaining written consent from 

the individual receiving services for all 

communication and collaboration with other 

agencies. (Evidenced by copies of these 

procedures [usually approved by the facility’s 

legal council] and evidence of their use in 

individual records) 

4. Procedures for identifying situations requiring 

consultation. (Evidenced by written documents 

and their use in individual cases) 

Communication, Collaboration & 

Consultation (continued) 

5. Protocols for referrals to integrated cooccurring 

services or ancillary treatment 

services, when indicated. 


1. Documentation of credentialed staff, 

including the CCDP. (Establish # or %) 

(Evidenced by written roster of all staff 

with their credentials listed) 

2. Number of staff who have completed the 

approved co-occurring core training 

curriculum. (Evidenced by completion 

certificate in staff personnel file) 

Staff Competencies (continued) 

3. Program training plan addressing co-occurring 

issues. (Evidenced by written plan, preferably 

linked to QI activities) 

4. Documentation of credentialed supervisors, 

including the CCDP. (see #1) 

5. Documentation of ongoing supervision to 

address co-occurring services. (Evidenced by 

supervisory log of individual and group 

supervision and topics addressed) 


The facility shall demonstrate they can provide: 

1. Transition, Discharge, and Aftercare needs 

planning commencing upon admission to the 

program. (Evidenced by written instruction in 

the Policies and Procedures/Operations 

Manual, assessment information noting 

aftercare needs, and attention to follow-up 

needs in treatment plans) 

2. Referral for psychiatric access and medication 

management. (Evidenced by all listed in #1 

above) 

Transition/Discharge/Aftercare (continued) 

3. Identification of and referral to 

community support services including 

peer support services, recovery self-help 

groups, co-occurring self-help groups, 

and other individualized support 

services. (Evidenced by all listed in #1 

above plus evidence that staff have 

worked collaboratively with the person to 

find the right “fit” that the person finds 

acceptable) 

11


Transition/Discharge/Aftercare (continued) 

4. Instructions for accessing crisis services for 

both psychiatric and substance use needs. 

(Evidenced by written instructions in the 

P&P/Operations Manual and by notes in 

record – a written instruction sheet is 

preferable, or relapse prevention plan) 

5. Linkage with case management services for 

community resources, if appropriate and 

available. (Evidenced by written detail of when 

and how to refer in P&P/Operations Manual, 

including type/level of CM services needed) 

RECOVERY IS THE FOCUS 

OF ALL CO-OCCURRING 

DISORDERS CAPABLE 

TREATMENT & SUPPORTS 

For additional references on any 

clinical areas described in this 

bulletin contact : 

Taylor.Anderson@Drexelmed.edu 

She can be reached toll-free at: 

1-877-243-3033 

Or locally at 215-831-3574 or -6331 

12

W86: Fairweather Lodge - An Evidence-Based Practice 

Kim Stucke 


Description: 

This workshop presents the Fairweather Lodge concept; reviews the fidelity standards as developed in 

Pennsylvania; describes the Lodge principles and characteristics; and examines the Lodge program as one 

evidenced-based practice that fully supports recovery in a population of adults with co-occurring disorders. 

Participants view a video and hear directly from co-presenters who are Lodge members from Erie, 

Pennsylvania. 


• Describe the Lodge as an evidence-based practice for persons with co-occurring disorders; 

• Explain how the Lodge concept supports personal recovery; 

• Describe the current OMHSAS contract with Stairways to promote creation of a Lodge program on a 

statewide basis; 

• Explore funding opportunities for Lodge development. 

NOTES:

FAIRWEATHER LODGE FIDELITY 

Principles, Practices, Outcomes and Satisfaction 

Fidelity to the principles and practices of the Fairweather Lodge is important for a number of 

reasons. But participant outcomes and participant satisfaction are a test of fidelity at least as 

important to the spirit of the Fairweather Model as any checklist of programmatic elements. A 

comprehensive assessment of Lodge success, therefore, involves: 1) Adherence to the Lodge 

Principles; 2) Implementation of Lodge Practices; 3) Demonstrated Outcomes; and 4) Participant 

Satisfaction (see page 6). 

Principles 

In his ground-breaking 1963 book, Community Life for the Mentally Ill, Dr. Fairweather 

established thirteen principles for successfully integrating people with mental illness into the 

community. Although all thirteen were valid at the time, the eight principles updated for this 

assessment tool are those which remain relevant to distinguishing the unique values of a 

Fairweather Lodge. A program which is at odds with these principles might be a wonderful 

program, but it is not a Fairweather Lodge. 

Practices 

Over the last forty years, as practitioners have experimented with the Lodge Model, a wide 

variety of practices have been implemented with various degrees of success. The sixteen 

practices selected for this assessment are those which have enjoyed the greatest success. We 

recognize that conditions vary from one setting to the next, and that the most successful 

practitioners are those who can adapt to local conditions, but these sixteen practices are highly 

recommended, especially for new programs. 

Outcomes 

We presume that anyone associated with a Fairweather Lodge will have a philosophical affinity 

for the values defined by the eight Principles and sixteen Practices. And it is easy to get 

engrossed in implementing the principles and practices while at the same time struggling to 

obtain/maintain funding, hire/supervise staff, recruit/ screen participants. But hopefully, the 

reason practitioners choose the Lodge Model in the first place is because of the potential 

outcomes, and any assessment of Lodge success needs to examine the outcomes produced.

Housing, Employment, Social and Autonomy 

Although a Fairweather Lodge is understood to be a package of highly-integrated services, we 

have broken the assessment into four domains for the purpose of evaluation. Surveys of the 

needs/wants/desires of people with serious mental illness provide three obvious domains -- 

housing, employment, and a social life. To this we add the uniquely Fairweather perspective of 

group autonomy. A successful Fairweather Lodge should score well across all four domains. 

Housing 

Principle I. The lodge must provide a safe, healthy and caring environment, which reinforces 

the recovery process. 

Practice A. Lodges should be located in a safe and accepting neighborhood. 

Practice B. Lodges should be attentive to exercise and nutrition. 

Practice C. Lodges should control the use of alcohol and street drugs 

Proposed Outcome Measures: 

1. Number of undesirable interactions (e.g., getting mugged, name-calling) in the 

neighborhood per participant-year, (or versus desirable interactions). 

2. Percentage of participants eating healthy. 

3. Percentage of participants exercising regularly. 

4. Percentage of participants using drugs or alcohol. 

OR 

4.a Undesirable incidents related to drugs or alcohol. 

Principle II. The Lodge must be part of the plan for managing symptoms and promoting good 

mental health. 

Practice D. Good quality psychiatric care (implying a doctor-patient partnership) should 

be available. 

Proposed Outcome Measure #5: 

Average length of wait for non-routine psych visit. 

Practice E. Lodges should have a standard mechanism for ensuring medication 

compliance (This mechanism should be adjustable in response to variance in earned 

autonomy.) 


Percentage of medications taken as prescribed. 

2

Principle III. Services must be available as long as the participant wants and needs them. 

Practice F. (Except as established by the Lodge) There should not be any minimum or 

maximum time limits on participation. 

Employment 

Principle IV. People with psychiatric disabilities increase their community success and raise 

their social status through employment, through accumulating wealth, and through direct (not 

third-party) consumerism. 

Practice G. Everyone of working age should be employed (except in the event of 

temporary incapacity) and employment should begin immediately upon entry into the 

lodge. 


Average weekly wages per participant. 

Practice H. Employment (and costs related to participation in the Lodge) should be 

structured so as to ensure financial reward for increasing participation in employment. 


Percentage of participants earning more than the cost of their room and board. 

Practice I. Employment may be offered in the form of a (affirmative) business operated 

by the lodge. If employment through an affirmative business is provided: 

1. Work opportunities should include a range of tasks from simple to complex, 

with appropriate accommodations for the illness; 

2. Participants should be paid commensurate with their contribution to the 

business; 

3. There should be frequent and realistic evaluation of performance and an 

opportunity to advance; and 

4. Participants should have a choice between working in the affirmative business 

and outside employment, especially if the affirmative business does not provide 

opportunities commensurate with the participant’s skills and experience (but not 

working should not an option, and neither should prolonged job-search). 

Social 

Principle V. Above and beyond economic roles, participants need to perceive (and to have) 

meaningful social roles in both the Lodge and the larger community. 

Practice J: Every participant should contribute to the collective good to the limit of 

his/her ability. (Equity of contribution and autonomy from one participant to the next is 

of secondary importance). 


Social adjustment/level of functioning . 

3

Principle VI. Successful Lodges resemble a healthy family. 

Practice K. Participants should share at least one meal a day. 

Practice L. Participants should share at least one social/recreational event a week. 

Proposed Outcome Measures 10 & 11: 

Number of meals per week shared by at least 75% of members. 

Number of social/recreational event per month shared by at least 75% of members 

Autonomy 

Principle VII. In order to progress, people with psychiatric disabilities need autonomy 

commensurate with their behavioral performance, with the ultimate goal of full autonomy. 

Similarly, the Lodge needs autonomy commensurate with its behavioral performance, with total 

autonomy being the ultimate goal. (Peer support is ultimately more powerful than assistance 

from paid service providers.) 

Practice M. The lodge participants, through some form of collective decision-making, 

should be responsible (to the extent that the skills are present) for all aspects of Lodge 

management including but not limited to finance, maintenance, meal planning and 

preparation, social life, transportation, rules related to interaction between members and 

symptom management including the taking of medications. Professionals serve as 

advisors to the Lodge, never managers. 


Average # of hours/week paid service providers are present in the Lodge. 

Practice N. If the skills required for certain tasks are not available within the 

membership, the advisors should provide these skills temporarily. Training should be 

provided so as to help one or more participants to acquire these skills and advance 

individual and group autonomy. 

Practice O. Lodges typically need assistance and feedback on how they are doing; this 

need should decrease over time, but may never disappear. It is advisable, especially 

during the training phase, to have a special communication system which facilitates this 

assistance and feedback while simultaneously promoting autonomous group decisionmaking. 

Principle VIII. Lodges must not be dependent on resources from any single entity. 

Practice P: Lodges and Lodge Programs require strong leadership, committed to all 8 

principles and focused on long-term success. 

Proposed Outcome Measures 13 & 14: 

Number of “engaged” community partners providing on-going resources. 

Largest single source of revenue as a percentage of total revenue. 

4

Implementation of Lodge Practices 

Housing: 

The Lodge has a plan for controlling the use of alcohol and street drugs. 

Participation in the Lodge guarantees good quality psychiatric care, available in a 

timely manner. 

The Lodge has a standard mechanism (adjustable in response to earned 

autonomy) for ensuring medication compliance. 

There are no minimum or maximum time limits on participation in the Lodge. 

Employment 

All participants are employed at least 15 hours per week. 

Employment begins immediately upon entry into the lodge. 

The more participants work, the more disposable income they have. 

Yes No 

Yes No 

If employment through an affirmative business is provided: X X 

1. Work opportunities include a range of tasks from simple to complex, 

with appropriate accommodations for the illness. 

2. Participants are be paid commensurate with their contribution to the 

business. 

3. There are frequent and realistic evaluation of performance and an 

opportunity to advance. 

4. Participants should have a choice between working in the affirmative 

business and outside employment. 

Social 

Yes No 

Every participant contributes to the collective good of the lodge. 

Equity of contribution from one participant to the next is of secondary importance. 

The Lodge (or the members) contribute to society. 

Autonomy 

Yes No 

Lodge participants, as a group, make decisions about: X X 

Finances 

Home maintenance 

Meal planning and preparation 

Social life 


Rules related to interaction between members 

Symptom management, including the taking of medications 

Training is available to develop individual and group skill related to: X X 

Finances 

Home maintenance 

Meal planning and preparation 

Social life 


Rules related to interaction between members 

Symptom management, including the taking of medications 

A special communication system is used during training. 

This system provides feedback to individuals and group at least once per week. 

This system promotes autonomous group decision-making. 

5

Fidelity to Autonomy Principles 

1. Both the Lodge and the Sponsoring Agency endorse full autonomy as the 

ultimate goal. 

2. A system is in place which adjusts autonomy commensurate with Lodge 

performance. 

3. The Lodge is dependent on resources from a single source. 

a. If yes, a plan exists to diversify. 

Yes No 

Satisfaction 

Although choices are often limited by an under-developed community mental health system, the 

Fairweather philosophy is based on the assumption that Lodge members participate voluntarily. 

One of the implications of voluntary participation is that adherence to the principles, 

implementation of the practices, and even the production of desirable outcomes, are meaningless 

unless the participants are satisfied that their basic needs are being met. 

Most surveys of the needs/wants/desires of people with serious mental illness produce the same 

general results with respect to the BIG 3 (not always in the same order): a “nice place to live,” a 

“good job,” and friends. It is a given that a Lodge provides housing, but is it a “nice place to 

live?” Does the employment provided meet the standard of a “good job?” Are the other 

participants really “friends?” And does allegiance to the autonomy principles and a low staffing 

ratio actually produce empowerment? The most direct way to answer these questions is to ask 

the participants. 

However, one limitation of satisfaction surveys is that some people always express satisfaction, 

even while planning to leave the program, and others will complain bitterly for years but never 

contemplate leaving. (This phenomenon is not exclusive to mental illness.) It is important, 

therefore, to measure retention -- a less direct, but potentially more telling strategy for measuring 

satisfaction. So we add: 


The percentage of participants, at a given starting point, still participating at a certain benchmark. 

Public Interest 

The taxpaying public has a legitimate interest in the cost-effectiveness of any program supported 

with public funds. So even though it is an imperfect measure of Lodge success, and not 

necessarily tied to the Lodge mission, we add: 


Number of days of in-patient psych hospitalization as percentage of participant-days. 

6

Lodge Member Satisfaction Survey 

Housing Yes No 

1. My lodge is in good repair. 

2. I feel safe in my lodge. 

3. I feel healthier than before I joined the Lodge. 

4. The meds I take help me maintain my mental health. 

5. The use of alcohol and /or street drugs is causing trouble in my lodge. 

Employment Yes No 

6. I like my job. 

7. I have more spending money than before I came to the lodge. 

8. I think more about work than about having mental illness. 

Social Yes No 

9. I enjoy group meals. 

10. I enjoy group social/recreational events. 

11. I have at least one good friend in the lodge. 

Autonomy Yes No 

12. I am increasingly responsible for my own future. 

13. I have a voice in the decisions my lodge makes. 

14. My lodge-mates and I are increasingly responsible for the future of our lodge. 

The attached Fairweather Lodge Fidelity Standards were adopted by the Coalition for 

Community Living on September 10, 2004, during a meeting held in Erie, PA. 

7

W87: Physical Disorders and Persons with Co-Occurring Mental and Substance Use Disorders 

Kenneth Thompson, MD 

1.5 hours Focus: Clinical Integrated Interventions & Axis III 

A focus on recovery and wellness must include the whole person, including any other conditions that need 

treatment and management. This workshop focuses on the need for assessment of physical disorders, 

including HIV status, and for engaging the person in a process of finding and using services and supports that 

promote total health. 


• Review common physical disorders that persons with CODs may have; 

• Examine engagement and assessment strategies for identifying all illnesses/ disorders; 

• Discuss the need for collaboration among all those providing treatment and support services, including 

physical medicine, for persons with CODs. 

NOTES:


Juggling Recoveries: 

Physical 

Disease 

Psychiatric 

Disorder 

•Coping with Addiction, Psychiatric 

Disorders and Physical Disease 

Kenneth Thompson MD 

University of Pittsburgh 

Addiction 

The way I used to think 

How I have 

learned to think 

Healthy 

Illness 

Health 

Ill 

Not Ill 

Not Healthy 

SAMHSA Consensus Statement on 

Recovery 

Mental health recovery is a journey of 

healing and transformation enabling a 

person with a mental health problem to 

live a meaningful life in a community of 

his or her choice while striving to 

achieve his or her full potential. 

Ten Points on Recovery 

(I - V) 

• I. Recovery is a Process 

• II. It is based on strength and dignity 

• (There is much waste if we do not focus on 

recovery strengths.) 

• III. It requires connection 

• (Individuals are powerful. Groups based 

on mutual support, shared identity and 

affirmation are more powerful.) 

• IV. It is based on learning from history. Insight 

into patterns is critical. 

• V. It takes discipline. It is discipline. 

1


Ten Points on Recovery 

VI - X 

• VI. Helping others is a crucial part of the process. 

• VII. It is difficult work. Reassembling personal 

worlds is daunting. 

• VIII. Meaning is critical 

• IX. Emotions in recovery are powerful and 

unpredictable. 

• All in contact with emotions are changed. 

• X. There can be health in illness. 

Recovery Domains 

validated person-hood 

person centered decision making and choice 

connection-community integration and 

relationships 

basic life resources 

self care, wellness, and meaning 

rights and informed consent 

Recovery Domains 2 

peer support and self-help 

participation, voice, government, and advocacy 

treatment services 

worker availability, attitude and competency 

addressing coercive practices 

outcome evaluation and accountability 

Recognizing Illness- 

Learning to look: 


Substance Misuse 

Medical Illness 

2


Factors Associated with Success 

Medication 72% 

Community Support Service/ 

Case Management 67% 

Self-Will, Self-Monitoring 63% 

Vocational Activity (including school) 46% 

Spirituality 43% 

Knowledge about the Illness/Acceptance 

of the Illness 35% 

Mutual Aid Groups - Support Friends 33% 

Significant Others 30% 

The Hero’s Adventure: 

Recovery and Metaphor for 

Ourselves and Our 

Profession 

• Departure 

• Initiation 

•Return 

n=46 

3

W91: Collaborative Care for Concurrent Disorders: The Central Okanagan Experience 

Jamie Marshall, MEd 


Description: 

This workshop reviews the experience of the Central Okanagan Collaborative Care Project, a Canadian 

initiative begun in April 2005 that demonstrates effective partnerships and planning for effective service 

delivery with persons having CODs. It uses the skills of Physicians, Psychiatrists, Alcohol and Drug Clinicians 

and Mental Health Clinicians, all working together at one of three family practitioner sites in the Kelowna area. 

Positive outcomes have been reported and data are available. The project is one of three supported through 

University of British Columbia and Health Canada. 


• Explore a working model of collaborative care service delivery for concurrent disorders; 

• Identify links between collaboration and positive outcomes for persons with cods; 

• Examine tools used to develop a concurrent disorders program using the principles of collaborative 

care. 

NOTES:


Collaborative Care 

in the Central Okanagan 

A Little bit of History! 

• Shared care – collaboration between psychiatrist and 

physician – program started in Hamilton, Ontario in 1992 

• Expanded to include mental health workers shortly after. 

• National movement with connections to many disciplines 

• “Collaborative Care describes a collaboration between 

providers from different services or disciplines who share 

the responsibility for the care an individual receives. 

Working together they will be able to pool their resources 

according to the needs of the individual client, service 

availability and their respective skills.” (Vancouver Think 

Tank June 2004) 

• This project started in 2004 with application for funds 

from Health Canada by UBC to fund 3 sites (North Shore 

Vancouver, Yukon, & Central Okanagan). 

A Little bit of Geography! 

Kelowna 

• City situated in the Central Okanagan Valley, 

• Surrounded by the Monashee Mountians 

• Okanagan Lake running down the centre, between 

Vancouver (West 400 km/240 miles) and Calgary 

(East 602 kms/307 miles) 

Part of Interior Health Authority (approx. 

300,000 sq miles = size of Germany) 

Known for Seasonal Tourism (Summer and 

Winter), Fruit Growing, Wine 

Central Okanagan 

• Population of Kelowna = 105,621 

• Population of Area = 162,555 

• Aboriginal Population = 3,950 

(2.7%) 

• Area = 2904 Sq. Km. 

• Average income (2000) = $60,047 

• Life expectancy at Birth = 81.3 

Evolution of a Project 

• Solicit Key Partners 

• Develop Felt Need 

• Train to Project Needs 

• Define Project 

Partners and 

Parameters 

• Set Time Lines and 

Implement 

• Support 

• Evaluate 

Solicit Key Partners at All Levels 

Partners in Care 

Advisory Group with 

Direct Contact with 

– Substance Abuse 

Clinicians 

–Mental Health 

Clinicians 

– Psychiatrists 

– Primary Care 

Physicians 

1


Develop Felt Need 

& Train to Project Needs 

Workshops and Training 

(Highlights) 

Define Project Partners 

Psychiatrists Sites Clinicians 

Site A 

Aurora 

Candice Rae 

Dr. Jim Allison 

(MH) 

Dr. Grant Smith 

Wed PM 

1 – 4:30 

Thursday 1 – 4:30 

Crystal Meth. Dr. Daryl Inaba 

Shared-Care: Concept to Practice - Dr. 

T. Isomura 

Screening Tools - Dr. Brian Rush 

Dual Diagnosis: Integrated Models for 

Treatment - by Dr. Ken Minkoff 

Motivational Interviewing - Dr. Linda 

Sobell 

Cognitive Behavior Therapy - Dr. Donald 

Meichenbaum, 

Helping People Change: Motivating 

Engaging and Attracting Clients into 

Treatment –Dr. David Mee Lee 

Dr. James Chin 

Wed 11:00 – 3:00 

Site B 

Tutt St 

Dr. Jan McIntosh 

Mon AM 

9:00 – 12:30 

Site C 

Group 1 

Dr. Gail Plecash 

Dawn (Office 

Manager) 

Sheila Crosby 

(A&D) 

Elaine Beyeler 

MH 

Wed 1 - 5 

Marg Noble 

Mon 9 - 1 

Define Partner Tasks 

• Physicians – 

– case finding 

– Use of primary and 

secondary screening 

tools 

– Referral to Clinicians 

– Attendance at case 

conferences 

Define Partner Tasks (continued) 

• Clinicians – 

– Review PDSQ 

– Conduct concurrent assessment 

– Create Treatment Plan 

– Report findings back to physician 

– Refer or treat as necessary 

Define Partner Tasks – (continued) 

• Psychiatrists – 

– Be available for consultation 

– See clients as directed 

– Complete assessments and treatment plans as 

necessary 

– Conduct case reviews and training as 

appropriate. 

Screening for Concurrent 

Disorders - Primary 

Primary Screening – 3 MH and 3 SA Questions 

3 questions for MH (Health Canada Best Practice Report): 

• Have you ever been given a mental health diagnosis by a qualified health 

professional? 

• Have you ever been hospitalized for a mental health related illness? 

• Have you ever harmed yourself or thought about harming yourself but not as a 

direct result of alcohol or drug use? 

3 questions for A&D (Health Canada Best Practice Report): 

• Have you ever had any problem related to your use of alcohol or other drugs? 

• Has a relative friend, doctor or other health worker been concerned about your 

drinking or other drug use or suggested cutting down? 

• Have you ever said to another person “No, I don’t have (an alcohol or drug) 

problem”, when around the same time you questioned yourself and felt, maybe I 

do have a problem? 

2


Screening for Concurrent Disorders - 

Secondary 

If the index of suspicion is high for MH and/or 

Substance Abuse then ask the client to fill 

out either: 

• GAIN Short Screener (SS) – 15 questions with 

3 screening areas of focus 

Or 

• Modified MINI - 

Screening for Concurrent Disorders - 

Tertiary 

If the index of suspicion is still high: 

• Give Client Psychiatric Diagnostic 

Screening Questionnaire (PDSQ) to fill out 

• Book appointment with Clinician. 

• Have client return to appointment with 

PDSQ filled out! 

Set Timelines and Implement 

Implementation 

• Training and 

selection of partners 

by January 2005 

• Late start on 

implementation due 

to hiring of Project 

manager (Feb 2005) 

• Full schedule of 

clinicians in all sites 

by mid April 2005 

• Evaluation 

component set for 

Spring 2006 

To: 

• Clinicians 

• Physicians 

• Psychiatrists 

• Administrators 

From: 

• Partners 

• Project Manager and 

Admin 

• Mheccu/CARMA 

Support 

• Format based on Program 

Logic Model 

• Client/Physician/Clinician 

satisfaction surveys 

• Test re-test on PDSQ 

• Capacity of system 

• Client and referral 

characteristics 

• To be used as part of a 

Quality Assurance program 

for improvement 

Evaluation 

3


One Year Evaluation 

• Data to be presented at conference 

• Will be available on Project website 

• www.collaborativecare.ca 

Where to from Here? 

• Sustainability in the Central 

Okanagan 

– Capacity 

– Support of Partners 

– Improvements to the model 

• Roll out to other communities and 

age groups 

– Following similar models of approach 

– Adolescent concurrent collaborative 

care 

• Use of other technologies 

– Video conferencing 

– Touch screen terminals to other sites 

Happy Birthday to 

Collaborative Care! 

A gracious “Thank 

You!” to all of our 

friends, partners and 

associates who have 

assisted in this 

journey. 

Resources 

• Resources available at conference. 

4

W93: Fostering Recovery: Meeting People Where They Are “At” 

Steven Sawicki, MHSA 

1.5 hours Focus: Clinical Integrated Interventions & Recovery Supports 

Description: 

The workshop focuses on community stabilization, engagement and recovery. Co-occurring disorders are often 

wrapped around homelessness, joblessness and other difficulties. The addition of substance use/abuse also 

often raises legal and moral issues when it comes to finding treatment and services. Staff training in providing 

integrated services and in ways to work with people in a variety of circumstances and situations is necessary, 

as is using evidence- and stage-based interventions. Learn the initial steps needed to start down the path of 

person-centered service provision and to be part of a recovery-centered process. 


• Identify roadblocks often put in the path of recovery; 

• Name three critical steps to community integration; 

• Distinguish between the stages of stabilization and engagement; 

• Discuss means of truly meeting people where they are “at.” 

NOTES:


CO-OCCURRENCE is COMMON 

MI/SA Disorders—51%-53% Nationally 

*Individuals tend to be multiply impaired 

Fostering Recovery 

Meeting People Where They Are At 

Higher rates of: 

Hospitalization Homelessness 

Relapse Violence 

Suicide Crisis 

Incarceration 

Baseline Population 

• Symptomatic in their Mental Illness 

• Actively Using—Polysubstance 

• Homeless or at risk of homelessness 

• History of Trauma—PTSD 

• Various Medical Issues 

• Dys or Non Functional Support System 

• Criminal Justice Involvement 

ENGAGEMENT 

• The act, or art, of making connections. 

• The first steps in relationship building 

• To become involved 

Recovery 

• Movement of an individual towards 

homeostasis 

MASLOW 

Hierarchy of Needs 

Transcendence 

Self Actualization 

-------------------------------------------- 

Aestetic Needs 

Need to Know and Understand 

------------------------------------------------------------ 

Esteem Needs 

Belongingness & Love Needs 

Safety Needs 

Physiological Needs 

1


STAGE or PHASE BASED 

Provide services to people that are specific 

to a particular moment in time 

STAGE or PHASE BASED 

Keep yourself out of the process 

Meets the immediate need of a person 

Meets people figuratively where they are at 

Meets people literally where they are at 

Individualized services 

Comprehensive/Integrated services 

You are not there to work on your goals, 

plans or expectations, regardless of 

how wonderful they may be. 

The focus must always be on the 

person in need—the client. 

TOOLS OF COMMUNITY 

STABILIZATION/ENGAGEMENT 

MORE TOOLS OF COMMUNITY 

STABILIZATION/ENGAGEMENT 

Provide for Basic Needs 

Develop the Relationship 

Outreach Aggressively 

Respect Individual Choice 

Provide Concrete Assistance 

Carry Hope 

Integrate Treatment 

Accept People for who and what they are 

Acknowledge the Skills and Abilities that the 

People you serve have and use daily 

PROBLEMS 

TRICKS 

Staff want to always be ahead 

Not enough time from funding sources 

Objectives/Results are few and far between 

or don’t match funding 

You get blamed for client’s behaviors 

Moral model of substance abuse clash 

The legal card 

Keep and Review Histories 

Ask who’s Working Harder 

Assess, Assess, Assess 

Forget What You Know 

Don’t always believe the paper 

2


TRICKS (More) 

Discharge is Failure 

Prison/Jail can be your Friend 

Go Everywhere 

Begin Discharge Planning Immediately 

3

W95: Systems Integration within a Behavioral Health System 

Smittie J. Brown, Mike Filanowski, Katrina Kyle & Brian Kapp 


Description: 

This workshop explores the challenges of developing an integrated system in a county in central Pennsylvania, 

including common problems and their solutions. It examines the benefits for various groups (including 

persons receiving services and their families, clinicians and administrators) and the creation of outcome 

measures for an integrated system. An analysis and creation/adaptation of technological supports needed and 

the cost benefits of integrating systems are also presented. 


• Examine the challenges in developing an integrated system; 

• Explore benefits of an integrated system for various constituent groups; 

• Review data needs of, and available technologies for supporting, an integrated system. 

NOTES:


Data Systems Integration 

Smittie J Brown 

Michael Filanowski 

Katrina Kyle 

Brian Kapp 

Data Integration 

• The development of uniform data 

definitions for selected data elements 

across different information systems and 

the establishment of a methodology to 

share selected data collected by state, 

county, managed care, mental health, and 

substance use disorder service providers. 

Department of 

Public Welfare 

OMHSAS 

Medicaid $ 

- FFS 

- Managed Care 

ACT 152 

BHSI 

CMHS Block Grant 

MH Licensing 


SCAs 

MH/MR 

Department of 

Health 

BDAP 

SAPT Block Grant 

D&A Licensing 

Challenges 

• The multiple data systems used are not integrated; 

they are complex and inefficient. 

• The BDAP database CIS tracks limited outcome and 

process information. 

• HealthChoice data is primarily encounter data. 

• A separate database is utilized depending on the 

funding stream. 

• Lack of common terminology limits the ability to 

compare data across systems. 

• Some data is bundled and cannot be separated. 

• Confidentiality Regulation 

Why Integrate Data? 

• Generate measures to evaluate the impact of 

service provision for individuals and their 

families 

• Needs Assessment and Planning 

• Legislative interests. 

• PPG requirements set forth by SAMHSA for 

the COSIG grant and Federal Block Grant 

requirements 

SAMHSA Co-occurring 

Outcome/Performance Measures 

Measure #1 -not a performance measure but a precondition to 

measurement of outcome: 

A) count of persons identified with cod 

B) count of persons identified with cod that have been served…. 

Measure #2 % of programs that screen for cod. 

% of programs that assess the need for both su and mh tx. 

% of programs that provide tx for cod. 

Measure #3 specific outcomes to include: 

alcohol use 

substance use 

employment 

living arrangements 

involvement in the criminal justice system 

1


What is the current system? 

“Indicators should be developed with a clear 

definition of the purpose of this data from a 

policy perspective, and how the data are 

supposed to guide useful decision making at the 

State level… 

…to inform regarding how it will be most 

valuable for the states to collect information 

about prevalence, screening, assessment, and 

outcomes in a way that will be programmatically 

meaningful based on each states situation. Since 

we are developing a data set that will influence 

the activity of every clinician in the nation for 

years to come, it is extremely important that we 

approach this in a way that helps us collect 

meaningful and useful information based on each 

states capacity to do so.” 

The current behavioral health system 

consists of multiple, disparate systems that: 

• do not talk to each other 

• collect different information 

• use different definitions 

• collects information per payer source. 

• cannot track individual service recipients 

longitudinally across payers. 

These issues are long standing and well 

documented (LBFC, KPMG) 

Current System 

• BDAP CIS collects info on BDAP dollars- (Phila 20% 

of clients) 

• OMHSAS HC’s is a claims payment system 

• CCRS POMS- collects info for MH dollars for 

individuals registered in county MH programs (MA 

FFS, County $, etc) (POMS limited- good reporting 

not occurring) 

• Promise- MA FFS claims payment system 

• HCSIS- substantial investment- $50 millioncostly/difficult 

to upgrade. 

• Corrections has separate data bases. 

Result 

The result is that we can’t answer the most 

simple and important questions: 

• what are we getting for our $, 

• how is the system performing, 

• what is the outcome for the client? 

What should the system look like? 

Different Levels 

• The systems should be integrated, or at least 

have the ability to talk to each other (based on 

the premise that we will have separate systems 

forever). Data should easily flow from providercounty-state-to 

federal level. Data generated 

should be meaningful. 

• Reduce paperwork burden 

• Real time trends for planning 

FEDERAL 

Funding 

STATE 

LOCAL 

MH, D&A Admin Units & Programs 

Federal Agencies 


Payers 

Admin and 

Provider Agencies 

2



• Develop a method to link client demographic and 

service utilization data across treatment systems in a 

manner that meets state and federal confidentiality 

requirements. 

• Submit a request to the Governor’s Office of 

Administration to obtain a legal opinion addressing 

the ability to share specific client data elements 

across the various Commonwealth Departments’ 

data systems. 

Recommendations continued 

• Develop a common language that incorporates, at a minimum 

the following activities. 

– unique identifiers. 

– descriptors and client service categories used in both 

treatment data systems, to determine whether they can be 

defined identically and whether the services can be 

measured in identical units. 

– Patterns of services for clients with mental health, substance 

use disorders, and/or COD should be reviewed. 

– A set of shared, common outcome measures, standard 

measures of the service episode, and common performance 

indicators should be identified for mental health, substance 

use and COD programs. 

– A method should be identified to track clients across an 

entire episode of care, regardless of the payer source. 

– Develop rules and protocols to share information that 

includes the ability to track service recipients across funding 

streams. 

Recommendations continued 

• New data system that will be flexible enough to 

incorporate the recommendations of the Sub-Committee. 

• Minimize burden to providers in acquiring and supporting 

the technology 

• BDAP/DOH must move forward in the acquisition of a 

new data system that will be flexible enough to 

incorporate the recommendations of this Sub- 

Committee. 

Benefits of Web-Base Reporting 

• Accountability 

• Time & Money 

• Improved Client Care 

• Complete list in handout 

Process Improvement 

• Eliminate redundancy – Administrative Burden 

• Authorizations 

• Automated SCA Fund Management 

• Electronic Billing 

• Standardized Processes 

3


Tracking 

• Track costs for all types of treatment 

– What are funds being spent on ? 

– What’s working? 

– What’s not? 

– Where is more funding needed? 

• Track Co-occurring data for clients 

Tracking 

• Track statistics for all clients – not just 

public funded 

• Track clients throughout the State 

(regardless of Provider) 

• Track across all Levels of Care 

• Outcome tracking is available 

Reporting 

• Available Immediately 24/7/365 

• Beneficial for all levels (Provider, SCA, 

BDAP) 

Questions - Discussion 

• Standardized - meaningful 

• No more waiting 

For more information… 

sbrown@dcdat.org 

kkyle@dcdat.org 

mfilanowski@dcdat.org 

www.pa-co-occurring.org 

4

W96: Stigma & Co-occurring Disorders 

Cheryl Floyd LSW, CCDP & Suzanne Elhajj, BA 

1.5 hours Focus: Forensics Involvement & Recovery Supports 

Description: 

This workshop provides an overview of co-occurring mental illness and substance use disorders, as well as 

examining how stigma plays a significant role in the treatment and recovery of individuals suffering from these 

disorders. The role of family and community treatment is highlighted as a key component in recovery and 

eradicating stigma. 


• Identify and define co-occurring mental and substance use disorders; 

• Define and recognize stigma in the treatment and recovery of these disorders; 

• Apply the knowledge gained in this workshop to assist in accessing treatment and aid in recovery for 

individuals affected by these disorders.


STIGMA AND CO-OCCURRING 

DISORDERS 

Suzanne Elhajj, BA - NAMI PA 

National Alliance on Mental Illness, PA 

Objectives - Understanding 

Stigma 

• In relation to addiction 

• In relation to mental illness 

• In relation to co-occurring disorders 

• In relation to the workplace 

Cheryl Floyd, LSW, CCDP - PRO-A 

PA Recovery Organizations Alliance, Inc. 

MAY 17, 2006 

Pre-test 

Addiction 

Addiction is a brain disease expressed in the 

form of compulsive behavior. It is the 

uncontrollable, compulsive drug craving, 

seeking and use even in the face of negative 

health and social consequences. 

Addiction Recovery Guide, www.addictionrecoveryguide.org/articles/article151.html 

Addiction – Brain Disease 

• Is a biological, brain disorder and public 

health problem for which treatment is 

available; 

• Confusion surrounds behaviors from 

symptom of underlying illness; 

• Should be understood as chronic recurring 

illness; 

• Includes some behavioral and social 

aspects; 

• Just as clinically depressed patients 

cannot voluntarily control their moods, 

addicted individuals cannot control their 

use. 

Addiction Facts 

• Some studies place the figure as high as 85% 

maintaining sobriety when completing treatment 

as well as attendance in recovery groups. 

• There are an estimated 26.8 million COA in the 

U.S.; 17% of COA’s will become addicted. 

• 80% of people with heroin addiction are 

employed. 

• Treatment of addiction meets or exceeds 

success rates for treatment of other chronic 

illness. 

1


Addiction Facts 

• Addiction has most successful 

treatment. 

• Cocaine addiction does not have a 

lower rate of recovery. 

• People can find recovery even if they 

are not seeking it. 

• Coerced treatment does work. 

• The rate of drug abuse among 

Caucasians is 8 times higher than 

African Americans. 

Myths about addiction 

• Belief that people should be ready, willing, 

and able to do whatever it takes to get 

clean & sober. 

• Addiction is NOT a brain disorder. 

• An addict can never recover from active 

use. 

•Alladdicts are criminals-they steal to 

support their habit. 

• Addicts cannot maintain steady 

employment. 



•Mental Illnesses are biologically-based 

disorders of the brain that profoundly disrupt a 

person’s ability to think, feel and relate to 

others. 

• Mental Illnesses are not caused by 

environment, bad parenting, nor are they 

“character flaws” or related to intelligence. 

•Cannot be overcome through “will power.” 

The person with a mental disorder has 

NO CHOICE about having it, just as a 

person who has heart disease or cancer 

has no choice in getting ill. 


Treatment 

• In the U.S., people 18 and older--about 1 in 4 

adults--suffer from a diagnosable mental 

disorder in a given year. 

• 4 of the 10 leading causes of disability in the 

U.S. and other developed countries are mental 

disorders, namely major depression, bipolar 

disorder, schizophrenia and obsessivecompulsive 

disorder. 

• According to a poll conducted by 

Psychology Today, an estimated 59 

million people, or 1 in 4 U.S. adults, have 

received some form of mental health 

treatment in the past 2 years. 

• The vast majority, 48 million, are being 

treated with prescription medication. 

2


Co-occurring Disorder 

• Co-occurring disorder is also known as 

dual diagnosis, co-morbid disorder, comorbidity, 

concurrent disorders, and 

double trouble. 

• It is a mental illness co-existing with a 

substance use disorder. 


According to a report published by the 

Journal of the American Medical 

Association: 

• 37% of people with an alcohol disorder 

and 53% of people with a substance use 

disorder also have at least one serious 


• Of all people diagnosed with mental 

illness, 29% misuse either alcohol or drugs. 

National Mental Health Association 

It is estimated that 50-75% of patients in 

addiction treatment programs have co-occurring 

mental illness, while 20-25% of those treated in 

mental health settings have co-occurring 


Substance Abuse and Mental Health Services Administration, February 2005 


Parallels (K. Minkoff) 

• Biological illness 

• Genetic predisposition 

• Chronic 

• Leads to lack of control of behavior & 

emotions 

• Positive and negative symptoms 

• Affects the whole family 


Parallels (continued) 

• Progression of disease without treatment 

• Symptoms can be controlled with proper 

treatment/involvement in 12 step recovery 

programs. 

• Disease of denial 

• Facing the disease can lead to depression 

and despair 

• Disease is often seen as “moral issue”- due 

to personal weakness rather than biological 

causes 


Parallels (continued) 

• Feelings of guilt and failure 

• Feelings of shame and stigma 

• Physical, mental and spiritual disease 

3




Each disorder has symptoms that 

interfere with that person’s ability to 

function effectively and how they relate to 

themselves and others. 

• The disorders may exacerbate each 

other, and each disorder predisposes to 

relapse in the other disease. 

• The symptoms can overlap and even 

mask each other, making diagnosis and 

treatment more difficult. 


• A person may sincerely try to recover 

from one illness and not acknowledge the 

other. 

• As a person neglects his or her mental 

illness, that illness may recur. 

• This recurrence may lead an individual 

to use or misuse alcohol or drugs. 

Consequences of 

No Treatment/No Recovery 

• Unnecessary disability 

• Unemployment 

• Marital/family problems 

• Chemical dependence 

• Homelessness 

• Continued instability 

• Incarceration 

•Suicide 

Costs 

• The economic cost of untreated mental 

illness is more than 100 Billion dollars each 

year in the United States. (NIMH) 

• Estimated direct (hospitalization, medication) 

and indirect (family care-giving, lost wages) 

cost of severe mental illness is 

$81,000,000,000 annually. 

• The economic cost of untreated chemical 

dependency was $276 billion dollars in 1995 in 

the U.S. (NIDA, 1998) 

Costs 

• Left untreated, depression is as costly as heart 

disease or AIDs to the the U.S. economy, 

costing over $43.7 billion in absenteeism from 

work (over 200 million days lost from work each 

year), lost productivity and direct treatment 

costs. 

• The annual economic cost of depression in 

1995 was $600 per depressed worker: one third 

of these costs are for treatment, and 72% are 

related to absenteeism and lost productivity. 

• Almost 15% of those suffering from severe 

depression will commit suicide. (DSM-IV, 1994) 

4


Barriers to Treatment 

• Failure to recognize disorders 

• Failure to access treatment due to stigma 

• Inability to pay for available treatment 

• Inadequate treatment resources in some 

areas 

• Inadequate insurance coverage 

• Inadequate resources & organizational care 

• Lack of coordination of public & private sectors 

Barriers to Treatment 

State law mandates 7 days of detox and 

30 days of residential rehab per year, 

with lifetime benefits. (Act 106) 

• In September 2003, the Pennsylvania 

Insurance Department issued notice to 

Health Insurance companies doing 

business in PA that Physicians, not a 

managed care firm, have final 

determination regarding referrals for 

inpatient and outpatient treatment services 


• Taboo topic 

Recovery 


Discrimination 

• National Policy Panel 

• Silence perpetuates stigma 


Discrimination toward individuals in 

recovery 

– Fifth Circuit Court Ruling 

– Insurance Companies/HMOs 

– Uniform Individual Accident and Sickness 

Policy Provision 


– Drug-Free Student Aid 

– Welfare Reform Provision 

– Public Housing 

– Medication while in treatment 

5


What has the power to: 

• Isolate individuals and families; 

• Encourage people to deny a fatal illness and 

ignore its symptoms; 

• Keep desperately ill people from seeking help; 

• Block funding for treatment for all but a small 

fraction of those who need it; and 

• Persuade society to choose far more expensive 

alternatives – like imprisonment, costs of 

accidents and secondary illnesses, and loss of 

human lives, productivity, and potential? 

Answer: STIGMA 

• The deep and sometimes hidden belief 

that addiction is something shameful and 

that people with addictions are somehow 

weak willed or morally inferior. 

What is stigma? 

• Erving Goffman, a sociologist well-known 

for his analyses of human interaction and 

traditionally the best-respected authority 

on the subject of stigma, defined stigma 

as: 

“an attribute that is deeply discrediting” and 

described the stigmatized individual as a 

“discredited person facing an unaccepting 

world”. (1963). 

Stigma 

• something that detracts from the 

character or reputation of a person, group, 

etc.; mark of disgrace or reproach 

• a mark, sign, etc. indicating that 

something is not considered normal or 

standard 

• any sign characteristic of a specific 

disease 

Stigma and Addiction 

• Because of shame, stigma feeds into the 

forces of isolation and denial that push 

people deeper into the addictive process 

and farther away from recovery. 

• Social justification of the stigma pushes 

the medical response to punishment of the 

addiction. 

Stigma Exists 

• Stigma is deep rooted in society. 

• Has profound effect on ability to help 

people find and hold onto recovery. 

• The first step is finding a deeper 

knowledge that the problem exists and a 

broader awareness of all the ways in 

which it shows itself. 

6


Effects of Stigma 

• Name five examples of the effects of 

stigma seen during the past month. 

1. 

2. 

3. 

4. 

5. 

Stigma Associated with Cooccurring 

• Moral weakness 

• Impression that treatment does not work 

• People often suffer from compounding 

stigmas 

• Drug use is illegal 

Stigma in the Media 

• People consciously or unconsciously let 

the popular media influence their images 

and opinions. 

• Media depends on sales and that depends 

on level of attention. 

• Few things grab our attention as 

effectively as drama, accusations and 

exaggerated stereotypes. 

Stigma Quiz 

• Examples of stigma in media 

“Crazy for You” 

The Vermont Teddy Bear Co. 

plans to continue selling its 

"Crazy for You Bear" through 

Valentine's Day, despite 

protests from mental health 

advocates. The bear, wrapped 

in a white straitjacket with a 

red heart on the front, comes 

with commitment papers and 

is meant to convey out-ofcontrol 

love, 

the company says. 

January 13, 2005 

7


Stigma 

Hello, and welcome to the mental health hotline..... 

If you are obsessive-compulsive, press 1 repeatedly. 

If you are co-dependent, please ask someone to press 

2 for you. 

If you have multiple personalities, press 3, 4, 5, and 6. 

If you are paranoid, we know who you are and what 

you want. Stay on the 

line so we can trace your call. 

Stigma 

If you are delusional, press 7 and your call will be 

transferred to the other ship. 

If you are schizophrenic, listen carefully and a small voice 

will tell you which number to press. 

If you are manic-depressive, it doesn't matter what number 

you press, no one will answer. 

If you have bi-polar disorder, please leave a message after 

the beep or before the beep or after the beep. Please 

wait for the beep. 

If you have short-term memory loss, press 9. 



Challenge and Educate 

• Media to provide complete, accurate information. 

• Balanced responses to public situations that involve 

addiction. 

• Multi-dimensional portrayal of people with addictions. 

• More widespread and accurate portrayal of people in 

recovery. 

Stigmatizing language 

• Drunk, junkie, lush, dope fiend, pot-head, etc. 

• Alcoholic, addict, substance abuser 

• These terms carry society’s anger and disgust 

toward people with addictions even the anger 

people with addiction direct toward themselves. 

• When words are linked with toxic situations, they 

grow toxic. 

• Addiction creates painful situations that raise 

intense shame, fear, anger and guilt. 

• How many words linked with addiction have 

grown toxic because of their association. 

Stigmatizing language 

• Crazy, psycho, psychopath, loony, 

loony-tune, loony bird, maniac, 

maniacal, nuts, nutty, fruitcake, 

schizo, 

cuckoo, demented, twisted, insane. 

Cycle of Stigma and Isolation 

•Stigma 

• Worthlessness 

•Isolation 

• Fear 

• Hopelessness 

•Pain 

• Addictive Use 

8


Opposite of Stigma 

• Widespread acceptance of truth. 

• Acceptance that human beings have 

limitations. 

• Honest compassion. 

• Recognition that people in recovery are 

normal, everyday people who live, love, 

work, play, pay taxes and vote. 

Combating Stigma 

• Speak on addiction as other conditions 

and illnesses. 

• Educate to overcome attitudes. 

• Encourage research. 

• Assist those needing treatment to obtain it. 

• Provide support and services. 

• Eliminate discrimination in all areas. 

Stigma Busters 

The best medication and treatment in the 

fight against mental illness and addiction 

have come about in the past 15 years, as 

have public awareness, education and 

training about these disorders. 

Stigma 

• The idea that psychiatric disorders 

have something to do with the 

supernatural. 

• The association between mental 

illness and the supernatural in films 

such as “The Snake Pit” and “One 

Flew Over the Cuckoo’s Nest”. 

Stigma 

• The media often feature one-sided, 

negative coverage of those with mental 

illness. 

• The focus is usually on those who are 

not taking their medication and whose 

actions result in involvement with 

police. 

Employment 

• According to the President’s New 

Freedom Commission on Mental Health, 

people with mental illnesses and/or 

co-occurring disorders have one of the 

lowest rates of employment of any group 

with disabilities – only about 1 in 3 is 

employed. 

9


Employment 

In a survey of those with mental illness: 

• 39% denied employment 

• 34% forced to resign 

• 69% unwilling to apply for job due to 

fear of discrimination 

(www.openmindsopendoors.com) 

Employment 

• Employment is a very important 

element of recovery for those with 

serious mental illness as a means of 

economic support, as well as a 

significant contributor to self-esteem. 

Yet only 10-15% of those with severe 

mental illnesses are in the workforce. 

Employment 

Stigma can lead to discrimination - 

not getting a job or being turned down for 

a promotion because of a mental illness, 

addiction or co-occurring disorder –stigma is 

wrong, but discrimination is ILLEGAL. 

Employment 

• It was only recently that questions about 

an individual’s history of nervous 

breakdowns were eliminated from 

required applications for federal 

Government jobs. 

• Past alcohol/drug use and past history of 

mental illness should be considered only 

when relevant to the job. 

Employment 

• In 2000, an estimated 70% of people 

needing treatment for drug or alcohol 

disease were employed. 

• More than 1 in 5 insured employees 

believe they would face “negative 

consequences” if they simply asked about 

their coverage for treatment. 

•Experts estimate that when someone tells a 

prospective employer that he or she is in 

recovery, 75% of the time they will not get 

the job. 

Employment & other issues 

• Employees who voluntarily seek treatment 

for addictive disorders or mental illness 

are subject to discriminatory actions or 

dismissal. 

• People with drug convictions but no 

current drug use face obstacles getting 

student loans, grants, scholarships or 

access to government training programs. 

• People disabled as a result of their dual 

diagnosis sometimes are not eligible for 

SSDI and SSI. 

10


Employment 

• Approximately 20% of all voluntary 

referrals to the EAP involve chemical 

dependency. 

• When a supervisor or manager refers 

an employee for concerns related to 

job performance, between 50 and 

78% involve chemical dependence. 

www.jointogether.org/discrimination 

Employee attitudes 

Employees will not seek treatment because: 

• Fear of being fired 

• Losing a license or promotion 

• Lack of insurance coverage 

• Concern about confidentiality 

• Shame 

•Denial 

Mental health conditions are actually 

the second leading cause of 

absenteeism. 

National Mental Health Association 

Relapse 

• Employers need to understand that 

relapse can be part of the recovery 

process. Just as a diabetic may 

experience problems if they don’t follow 

their doctor’s instructions for diet and 

medication, people who have an addictive 

disorder or a mental illness may also 

relapse. But with support from employers 

and others, the potential for relapse 

decreases as time in recovery increases. 

www.jointogether.org/discrimination 

“I won’t turn my back on Doc (Gooden), and I 

won’t turn my back on Darryl (Strawberry), 

and I’ll tell you why. These fellas—it’s a 

sickness. And if we don’t go at the root of the 

thing and cure that, how can you blame the 

user? How can you blame the kids who get put 

upon and don’t have the will to resist?” 

George Steinbrenner, owner, New York Yankees 

Information 

National Alliance on Mental Illness, PA 

1-800-223-0500 

http://namipa.nami.org 

www.nami.org 

Pennsylvania Recovery Organizations 

Alliance 

1-800-858-6040 

www.pro-a.org 

11


Information 

• Bureau of Drugs and Alcohol Programs 

Department of Health 

www.state.health.pa.us 

717-783-8200 

•IRETA 

http://www.ireta.org 

Information 

• Substance Abuse & Mental Health 

Services Administration (SAMHSA) 

www.samhsa.gov 

www.health.org 

• Office of Mental Health & Substance 

Abuse Services (OMHSAS) 

www.dpw.state.pa.us/omhsas/dpwmh.asp 

http://www.pa-co-occurring.org/ 

Information 

• Capitol Area Narcotics Anonymous 

717-233-FREE 

http://www.na.org 

• Alcoholics Anonymous 

www.alcoholics-anonymous.org 

12

W97: The Pennsylvania Community Support Program 

Glenn Koons 


Description: 

This interactive presentation provides an orientation to the Pennsylvania Community Support Program - a 

grassroots coalition made up of mental health consumers, family members and mental health professionals. 

Recent revisions to CSP and a general understanding of CSP principles are highlighted. The Southeast PA CSP 

Coordinator also discusses the role of CSP Coordinators and provides handouts that include information related 

to all facets of the Pennsylvania Community Support Program. The “Open Minds Open Doors” CD is also 

shown. Recovery is the focus of everything that the Community Support Program is about! 


• Describe the history, principles, and wheel components of the Community Support Program (CSP); 

• Discuss ways that formal services and support programs can be partners and components essential to 

recovery; 

• Identify their Regional Community Support Program contact person and use their local Community 

Support Program to help empower the consumers they serve. 

NOTES:


PENNSYLVANIA 

COMMUNITY SUPPORT 

PROGRAM 

CSP 

COMMUNITY 

• Where We Live 

• People 

• Common Interests and Backgrounds 

Presented by the Southeast Region 

Community Support Program 

Training Team 

SUPPORT 

Assistance and comfort in times of distress 

Encouragement and help 

Social Network 

Material Assistance 

"Don't walk in front of me, I may 

not follow; don't walk behind me, I 

may not lead; walk beside me, and 

just be my friend.” 

Albert Camus 

PROGRAM 

• A plan of action for achieving a goal. 

• A System of procedures or activities that has 

a specific purpose 

• A system to develop or provide something 

IT’S A WAY OF DOING THINGS!!! 

WHO ARE WE ? 

• Consumers 

• Family Members 

• Professionals 

We Focus On: 

A Common Vision 

Improving the Mental Health System 

Let’s take a closer look. 

1


 

 

 

 

 

WHAT DO WE BELIEVE? 

Creating Opportunities 

vs. 

Dependency & Disability 

Treating Individuals with Dignity and 

Respect 

People First 

Looking Beyond a Person’s Disability 

Aspirations - Experience - Potential 

Skills - Accomplishments 

 

 

 

 

BACKGROUND 

Birth of CSP in 1977 by the 

National Institute of Mental Health (NIMH) 

Response to Deinstitutionalization 

Holistic Approach 

Goals: 

• To move from institutional to 

community services 

• To Improve quality of life vs. 

management of symptoms 

EVOLUTION 

• NIMH Community Support System (CSS) 

was a national model created to reach the goals 

of deinstitutionalization and improving quality of 

life 

• The model included a philosophy, principles, 

and a group of consumers, family members, 

and professionals committed to realizing the 

goals. 

• CSP describes how the model is implemented 

CSP IN PENNSYLVANIA 

CSP Encompasses: 

Housing 

Training/Education 

Work 

Community Integration 

Rehabilitation Peer Run Services 

Income Assistance Medical/Psychiatric Care 

• Began in 1984 as a state committee 

• Developed into four regional 

committees 

• Regional CSP supports development 

of local committees 

CSP is designed to facilitate the 

Recovery of consumers 

2


VISION STATEMENT 

Every adult with a serious mental illness 

including persons with co-occurring 

disorders will enjoy the highest quality of 

life. Quality of life consists of inclusion in 

community, easy access to and choice of 

comprehensive services and supports, and 

multiple opportunities to enhance personal 

growth and recovery. 

MISSION STATEMENT 

The State CSP Advisory Committee advises 

the Pennsylvania Office of Mental Health 

and Substance Abuse Services (OMHSAS) 

on improving the quality of communitybased 

behavioral health services and 

supports systems by advocating the use of 

CSP Principles and exemplary practices. 

1. ADVOCACY 

GOALS 

To review and make recommendations 

regarding county, regional, state and 

national services, policies, legislation 

and regulations that impact consumers 

and families. 

2. COALITIONS 

To foster communication, collaboration 

and partnerships among consumers, 

families, professionals and community 

groups. 

3


3. COMMUNITY INTEGRATION 

To support the recovery of consumers by 

advocating for equal access, opportunities, 

and choices in education, health care, 

housing, meaningful work and 

relationships, transportation and spiritual 

and leisure activities that represent the 

character of the community. 

4. COMPREHENSIVE SERVICES 

To ensure that community-based 

behavioral health services and 

support systems are comprehensive, 

available, accessible, appropriate and 

accountable. 

5. CSP COMMITTEES 

To establish grass roots support and 

ensure effectiveness of County, 

Regional and State CSP Committees. 

4


6. EDUCATION 

To influence and create positive attitudes, 

behaviors and knowledge about 

consumers, families and services. To 

ensure that training and technical 

assistance in CSP Principles and exemplary 

practices is provided to consumers, family 

members, professionals, community 

decision-makers and the general public. 

Pennsylvania 

Community Support Program 

A Recovery Model 

for People with Mental Illness 

and Co-Occurring Disorders 

The CSP Recovery Model 

CSP Model Components 

• Template for service and 

recovery planning 

• Template for meeting people’s 

needs, to improve quality of life & 

to promote best practices 

 

 

 

Centered on Recovery and a 

holistic view of the person 

Surrounded by CSP Principles 

Incorporates the aspects of 

everyday life 

5


Housing 

Education 

Leisure & 

Recreation 

Health Care 

Psychiatric 

Rehabilitation 

Protection 

& Advocacy 

Treatment & Supports 

Wellness 

Choice 

Spirituality 

Understanding 

Recovery 

Hope 

Trust 

Community 

Groups & Organizations 

Family 

& Friends 

Respect 

Competence 

Community 

Mobility 

Peer 

Support 

Meaningful 

Work 

Income 

Support 

Principles 

• Consumer-Centered/Consumer- 

Empowered 

• Services are based upon the needs of 

the individual and incorporate self-help 

and other approaches that allow 

consumers to retain the greatest 

possible control over their own lives. 

• Culturally Competent 

• Services are sensitive and responsive 

to racial, ethnic, religious and gender 

differences of consumers and families. 

• Coordinated 

– Services and supports are coordinated on 

both the local system level and on an 

individual consumer basis in order to 

reduce fragmentation and to improve 

efficiency and effectiveness with service 

delivery. Coordination includes linkages 

with consumers, 

– families, advocates and professionals at 

every level of the system of care. 

• Flexible 

– Services are designed to allow people to 

move in and out of the system and within 

the system as needed. 

• Strengths Based 

• Services build upon the assets and 

strengths of consumers and help people 

maintain a sense of identity, self-esteem 

and dignity. 

• Community-Based Natural Supports 

• Services are provided in the least 

coercive manner and in the most natural 

settings possible. Consumers are 

encouraged to use the natural supports 

in the community and to integrate into 

the living, working, learning and leisure 

activities of the community. 

• Accountable 

• Service providers are accountable to the 

users of services and include consumers 

and families in planning, development, 

implementation, monitoring and evaluating 

services. 

• Designed to Meet Special Needs 

• Services are designed to meet the needs of 

persons 

• with mental illness who are also affected by 

such 

• factors as old age, substance abuse, 

physical illness or 

• disability, mental retardation, homelessness 

or 

• involvement with the criminal justice system. 

CSP & County Planning 

County Plan Guidelines Include: 

 

Indicators of the application of 

CSP Principles 

Checklist and signature page for the 

process of CSP committee inclusion in 

annual County planning activities 

6


What Can You Do? 

Promote and encourage Recovery for 

consumers (respect, dignity & hope) 

 

Support involvement of consumers and 

families in CSP activities 

Participate in your County and 

Regional CSP Committee and other 

organizations such as PMHCA, NAMI, and 

PAPSRS 

NEW CSP GROUP ON THE INTERNET 

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