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					     C O -OCC U R R EN C E :
BR I D GI N G TH E G AP FO R
           C H A NG E

            THE NEXT STEP

S t a t e w i d e Ta s k F o r c e O n D u a l D i a g n o s i s
     Final Report And Recommendations




                                Submitted by:
                     Dual Diagnosis Recovery Network
       On behalf of the State of Tennessee Co-occurrence Task Force


                            February 15, 2002
     Co-Occurrence: Bridging the Gap for Change –
                    The Next Step


                                  TABLE OF CONTENTS
PARTICIPANTS                                                                1

OVERVIEW                                                                    1

A.     EXECUTIVE SUMMARY                                                    2

B.     INTRODUCTION                                                         5

C.     STATE HISTORY ON CO-OCCURRING DISORDERS                              5

D.     TASK FORCE KEY OUTCOMES: STATE CONSENSUS AND REGIONAL ISSUES         8

Area 1: Education/Recognition of Need                                       9

Area II: Policy                                                            11

Area III: Provider Capabilities                                            12

Area IV: Oversight                                                         13

Area V: Research and Evaluation                                            14

E.     BACKGROUND AND LITERATURE REVIEW SUPPORTING THE EXTENT OF THE PROBLEM
                                                                           15

APPENDIX 1: FAMILY AND CONSUMER ILLUSTRATIONS OF CO-OCCURRENCE TREATMENT
     NEEDS                                                               22

A Parent’s Story                                                           23

Shelley’s Story                                                            24

My Story                                                                   26

A Family’s Story                                                           27

APPENDIX 2: POSITION PAPERS                                                29

Tennessee Association of Mental Health Organizations                       30

Moccasin Bend Mental Health Institute                                      31



Dual Diagnosis Recovery Network
   Co-Occurrence: Bridging the Gap for Change –
                  The Next Step
Helen Ross McNabb Center, Inc.                                 32

The Region III Provider Task Force on Co-occurring Disorders   34

Knox Area Rescue Ministries                                    38

Peninsula Behavioral Health Position Paper                     40

Frayser Mental Health Center                                   42

Tennessee Voices for Children                                  44

Centerstone Community Mental Health Center                     46

Ridgeview Psychiatric Hospital and Center, Inc.                47

APPENDIX 3: SYNOPSIS REPORTS BY REGION AND TOPIC               48

APPENDIX 4: WORK GROUP DISCUSSION OUTLINE                      60

APPENDIX 5: LITERATURE CITATIONS                               76

APPENDIX 6: SUPPORTIVE DOCUMENTATION                           79




Dual Diagnosis Recovery Network
           Task Force on Co-Occurrence Statewide Membership


                                 Participants
             Lori Abbott, Tennessee Mental Health Consumers’ Association
                      Kimberly Avant, Friendship House Knoxville
                                       Marian Bacon
                                        Eric Baker
                        Cynthia Barker, AdvoCare of Tennessee
                             Kathy Benedetto, Frontier Health
              Bob Benning, Ridgeview Psychiatric Hospital and Center
                               Jodi Bensley, A.I.M. Center
                 Anita Bertrand, Mental Health Association of Tennessee
                              Dottie Blades, Frontier Health
                           Michele Bostwick, Fortwood Center
                              David Bowers, Frontier Health
                               Melanie Boyd, Silver Linings
                      Chere Bradshaw, Behavioral Health Initiatives
            Lynn Bridgman, Tennessee Mental Health Consumers’ Association
   Norma Brinkley, Tennessee Mental Health Consumers' Association (Board of Directors)
                   Catherine Brunson, Metropolitan Drug Commission
                         Becky Buckosh, NAMI Sumner County
                         Bill Bullington, AdvoCare of Tennessee
                 Gloria Bulloch, Moccasin Bend Mental Health Institute
            Anne Burnett Young, Community Development Peninsula Village
                                       Matt Callihan
                                 Valley Behavioral Health
                                    Kimberly Campbell
                           Jim Carter, AdvoCare of Tennessee
                       Michael Cartwright, Foundations Associates
                                       Pat Caruthers
                     Nan Casey, Tennessee Christian Medical Center
                             Patricia Chesnut, Frontier Health
                                     Bradley Chipman
                     Ray Cleek, Tennessee Christian Medical Center
             Marilou Coats, Region III Monitoring & Evaluation Committee
              Sue Coffey-Ramsey, Comprehensive Community Services
                              Linda Cohen, NAMI Nashville
                            Hank Connor, Parthenon Pavilion
                                      Patricia Cooper
                    Michael Coppol, Memphis Mental Health Institute
                               Carl Counts, Frontier Health
                    Carol Cox, Director, Ridgeview Psychiatric Center
                           Kim Cudebec, Woodridge Hospital
                 David Cunningham, Family Psychiatrics PC; TAADAC
            Bonnie Currey, A.I.M. Center & Comprehensive Community Care
              Robert Currie, Alcohol & Drug Council of Middle Tennessee

Dual Diagnosis Recovery Network
             Task Force on Co-Occurrence Statewide Committee

         Deborah Dangerfield, Elam Mental Health Center, Meharry Medical College
                      Sarah Davis, James A Quillen VA Medical Center
                           Sharon Davis, Frayser Family Couseling
                    Sunny Day, Ridgeview Psychiatric Hospital & Center
                         Al Dehart, Comprehensive Community Care
                             John Dennis, Foundations Associates
                                    Karen Dennis, ACARC
                               Sita Diehl, Vanderbilt University
                      Amy Dilworth, Tennessee Protection & Advocacy
                            Randolph Dupont, UT Med Psych Svc
                                            Art Duvall
                               Sherry Falkner, NAMI Tennessee
                      Jim Ferrell, Comprehensive Community Care
                      Donna Fisher, Metropolitan Drug Commission
                           Gregory Fisher, Friends Helping Friends
                            Debbie Follis, Foundations Associates
                              Pat Friedman, Delta Medical Center
            Jane Furlong-Cahill, Region III Monitoring & Evaluation Committee
                              Maribel Gadams, NAMI Tennessee
                           Elliott Garrett, Metro Health Department
                               Jean Gay-Asher, Frontier Health
               David Gettys, Tennessee Mental Health Consumers’ Association
          Butch Glover, Jackson Area Council on Alcoholism and Drug Dependence
    Melissa H. Goldsmith, The Crisis Center (Division of Family Services of the Midsouth)
                                  Mary Gormley, Park Center
                          Leasa Graham, Volunteer Ministry Center
                                            Sue Grant
                Jennifer Green, Centerstone Community Mental Health Center
                         Jim Griffin, Tennessee Voices For Children
                                 Joe Guenry, The Hope House
                  David Guth, Centerstone Community Mental Health Center
                            Barry Hale, Quinco Behavioral Health
                            Patti Hall, Helen Ross McNabb Center
                    Tony Halton, National Health Care For the Homeless
                                         Betty Hamilton
                            Tim Hamilton, Foundations Associates
                                         Lynn Hancock
                           Vickie Harden, Foundations Associates
          Douglas Harr, Jackson Area Council on Alcoholism and Drug Dependence
                Diana Hay, Tennessee Mental Health Consumers’ Association
                            Mary Ann Hea, Metro Client Services
                                Deborah Hillin, Buffalo Valley
                          Bettie Hinson, NAMI Cumberland County
                          Evans Hinson, NAMI Cumberland County
                          Paula Hopper, Serenity Recovery Centers
                           Laura Howard, Hope of East Tennessee

Dual Diagnosis Recovery Network
            Task Force on Co-Occurrence Statewide Committee

                              Daniel Hoyle, The Pathfinders, Inc.
                        Alice Hubbert, Southeast Mental Health Center
                                Pat Humphreys, Frontier Health
                         Sue Ingram, Professional Counseling Services
                               Deanna Irick, Magnolia Ridge
                                   Rod Jackson, Steps House
                                          Sunray Jacobs
                  Jerry Jenkins, Volunteer Behavioral Health Care Services
                          Steve Jenkins, Helen Ross McNabb Center
                                Randall Jessee, Frontier Health
                                          Rose Johnson
                           Barbara Johnson, AdvoCare of Tennessee
                                  Catherine Jones, El Shaddai
                Rebecca Joslin, Tennessee Commission on Aging & Disability
                Rodger Jowers, Tennessee Commission On Children & Youth
                               Doug King, Peninsula Lighthouse
                      Deana Kinnaman, Samaritan Recovery Community
   Frank Kolinsky, E.M. Jellinek Center; Tennessee Association of Alcohol and Drug Abuse
                                             Services
         Kelly Lang-Ramirez, Tennessee Association of Mental Health Organizations
                          Nancy Lawhead, Memphis Mayor’s Office
                   Denise Lester, Baptist Memorial Hospital of Union City
            Connie Levenhagen, Tennessee Mental Health Consumers’ Association
                     Elizabeth Littlefield, Western Mental Health Institute
                    Catie Lott, Moccasin Bend Mental Health Institute
                         Debby Lovin-Buuck, AdvoCare of Tennessee
                          Lisa Lund, Tennessee Voices For Children
                   John Martens, Middle Tennessee Mental Health Institute
                           Truman Masters, Aspell Recovery Center
                      Cathy McCaughan, Tennessee Voices For Children
                                   Doug McCormick, Thasay
      Sheryl McCormick, Foundations Associates/The Dual Diagnosis Recovery Network
                             Linda McDaniel, Friends & Company
                    Reve McDavid, Comprehensive Community Services
                      Mamie McKenzie, Tennessee Voices For Children
                        Mike McLoughlin, Memphis Recovery Centers
                            Carter Miller, Cherokee Health Systems
                            Linda Mobley, AdvoCare of Tennessee
                           Philip Morrison, AdvoCare of Tennessee
                                    Esther Moser, Pathways
                            Jane Mynatt, Volunteer Drop-In Center
                                Vicki Neal, The Pathfinders Inc.
                      Ann Nolen, Alliance for the Mentally Ill , Memphis
                                          Mimi Orange
                                              Al Orr
                              Emily Orr, Foothills Drop-In Center

Dual Diagnosis Recovery Network
            Task Force on Co-Occurrence Statewide Committee

                                   Joe Page, Frontier Health
                                   Tina Patania, Centerpointe
                           Steve Patterson, Aspell Recovery Center
                               Dottie Peagler, NAMI Knoxville
                                 Gene Pool, NAMI Tennessee
                 Keith Potts, Centerstone Community Mental Health Centers
     Lisa Primm, Mental Health Association of Tennessee, TennCare Partners Advocacy
                       Evette Reed-Higgs, Behavioral Health Initiatives
                 Judy Reeves, Centerstone Community Mental Health Center
                                 Bud Regan, Fortwood Center
                         Allen Richardson, Serenity Recovery Center
           Keith Richardson, U.S. Department of Housing and Urban Development
                                   Debra Rogers, Agape, Inc.
                     Carol Ann Rupeka, Comprehensive Communty Care
                              Fred Sackleh, NAMI Coffee County
                              Maggie Samuchin, NAMI Nashville
       Paula Sandidge, M.D., National Mental Health Association (Board of Directors)
                     Sherry Schedler, Memphis/Shelby Co Juvenile Court
                       Mary Schneider, Rutherford County Drug Court
                 Herschel Schwartz, Ph.D., Frayser Family Counseling Center
                                Jackie Scott, Jack Geans Shelter
                Jennifer Scroggins-Flaherty, Comprehensive Community Care
                         Bill Sewell, Western Mental Health Institute
                 Terry Shapiro, Council for Alcohol and Drug Abuse Services
                                  Mary Simons, A.I.M. Center
                         Erin Skaff, U.T. Medical Psychiatric Services
                            Amanda Smart, Foundations Associates
                     Calvaretta Smith, Tennessee Protection & Advocacy
                      Demetria Smith, Comprehensive Community Care
                    Dan Smith, Volunteer Behavioral Health Care Services
                 George Spain, Centerstone Community Mental Health Center
      Cynthia Spann, Department of Health, Bureau of Alcohol & Drug Abuse Services
     Jewel Steele, Tennessee Department of Correction, Deberry Special Needs Facility
                                        Denise Stewart
                                          Sam Stewart
                          Rozann Stewart, Carey Counseling Center
                       Mary Summerhill, BRIDGES Evaluation Project
                           Pamela Swain, Carey Counseling Center
                             Cheryl Talley, Delta Medical Center
                                  Jacques Tate, Harbor House
                       Lee Thomas, Lakeshore Mental Health Institute
                   Henry Thomas, Northwest Community Service Agency
               Ted Thompson, Centerstone Community Mental Health Center
      H. Rogers Thomson, Tennessee Association of Alcohol and Drug Abuse Services
                  Jim Tolley, Whitehaven Southwest Mental Health Center
                         Sharon Trammell, Grace House of Memphis

Dual Diagnosis Recovery Network
            Task Force on Co-Occurrence Statewide Committee

           Karen Turks-Smith, Tennessee Mental Health Consumers’ Association
                               Cindy Tvardy, Frontier Health
   Bob Vanderspek, Department of Mental Health and Developmental Disabilities Office of
                                   Consumer Advocacy
                            Lee Vandewalker, NAMI Knoxville
                           Tammy Vanns, NAMI Sumner County
                             John Vaughn, E.M. Jellinek Center
                        David Vincent, Knox Area Rescue Ministries
                            Stephen Watts, Delta Medical Center
   Irene Weaver, Ph.D., Department of Health, Bureau of Alcohol and Drug/Department of
                                       Mental Health
                          Cynthia West, Cherokee Health Systems
                              Debi Wheatley, NAMI Tennessee
                          Richard Wheeler, Delta Medical Center
                      Lori Wigginton, Tennessee Voices For Children
                     Melissa Wilson, Comprehensive Community Care
                              June Winston, Lowenstein House
                     Jeune Wood, Juvenile Court Memphis/Shelby Co
                        Evelyn Yeargin, Mental Health Cooperative



Appreciation to hosts who provided meeting space for regional work groups:


             Centerstone Community Mental Health Centers, Inc., Nashville
                    Clover Bottom Developmental Center, Nashville
                    Fellowship Evangelical Free Church, Knoxville
                             Frontier Health, Johnson City
       Jackson Area Council on Alcohol and Drug Dependency (JACOA), Jackson
                          Metro Health Department, Nashville
                 Moccasin Bend Mental Health Institute, Chattanooga
                     Tennessee Christian Medical Center, Madison
                             The Power Center, Memphis
                               United Way of Knoxville




Dual Diagnosis Recovery Network
     Co-Occurrence: Bridging the Gap for Change
                   The Next Step
                                              Overview
Prevalence

Referred to as co-occurrence or dual diagnosis, people with combined mental illness and substance use
(alcohol and drug) diagnoses are a fast growing segment of underserved residents in our communities:

   According to SAMHSA’s most recent Statistics Sourcebook (1998), an estimated 20 million people
    have some type of substance use disorder in a given year, 8 million people of whom will also have a
    co-occurring mental health disorder. This comprises 4.7% of the age 15-54 population of the U.S.
   Extending SAMHSA’s national prevalence estimates to Tennessee’s statewide population,
    approximately 179,576 Tennesseans between the ages of 15 and 65 have co-occurring disorders.
   Of those with a substance use disorder during a given year, 42 percent also have a mental health
    diagnosis (52 percent lifetime). Similarly, of those with a mental health diagnosis in a given year, 21
    percent also have a substance use disorder (39 percent lifetime). (SAMHSA Sourcebook, 1998).
   According to the National Comorbidity Study (1991), 56% of all persons aged 15-54 years with a
    mental or addictive disorder have at least one other co-occurring disorder (Kessler, 1994).
   Adolescents with serious emotional problems are nearly four times more likely to be dependent on
    alcohol or illicit drugs than adolescents with low levels of emotional problems. (Greenbaum, Foster-
    Johnson, & Petrila, 1996; Crowely & Riggs, 1999)

Barriers and Consequence Related to Co-occurrence

Increasingly the nation is recognizing that existing systems of care designed to treat people with single
diagnoses are far less effective for people with co-occurring conditions, as they:

   Are at increased risk of relapse in recovery, incarceration, depression, suicide, homelessness,
    HIV/AIDS, and other sexually transmitted and infectious diseases, such as Hepatitis C.
   Have significantly higher physical healthcare costs than consumers with a single disorder (Hoff
    & Rosenheck, 1999) and are over-represented in both our hospitals and judicial systems.
   Are left with the criminal justice system as the “default” system of treatment. (Cocozza &
    Skowyra, 2000).
   Are more likely to be refused admission or to be prematurely discharged from treatment
    facilities in both mental health and alcohol & drug service systems (Ridgely, Goldman &
    Willenbring, 1990).

Solutions

The Task Force on Co-occurrence is an ad hoc committee of approximately 200 stakeholders who met
statewide through a series of forums on co-occurrence that involved over 140 hours of service time.
Committed to identifying effective, low level and low cost, high impact solutions, the Task Force was
represented by expert constituencies who defined The Next Step in Tennessee’s response to address co-
occurrence. Through this document, we request appointment of a legislative subcommittee to evaluate
these recommendations and other researched based data to gain understanding of the growing
individual and societal impact of co-occurrence on Tennesseans. The composite expertise of the Task
Force offers a comprehensive document defining State barriers to effective services and treatment, along
with tangible recommendations for change to meaningfully impact this underserved and growing
population.

Dual Diagnosis Recovery Network                                                             Page 1
     Co-Occurrence: Bridging the Gap for Change
                   The Next Step

A.     Executive Summary

D
        ual Diagnosis or co-occurrence means that an Persons with co-existing disorders are
        individual simultaneously experiences both a        among the highest cost users within the
                                                            publicly funded health care and criminal
        substance use disorder and one or more justice systems…It is imperative that attempts
psychiatric illnesses. Co-occurrence affects at least 8 to address issues of dual diagnoses take
                                                                        integrated and
million U.S. residents each year, and the incidence of place as anservice delivery unified program.
                                                            Integrated                 for both problems
co-occurring conditions continues to increase at an has been shown to be highly cost-effective
alarming rate -- overloading the nation’s public health and (Coley & Reyes, SAMHSA, 2001).
criminal justice systems. Based on extrapolation of
SAMHSA’s national data to the State of Tennessee, there are an estimated 179,576 Tennessee
residents between the ages of 15 and 65 suffering from co-occurring disorders.
Approximately 27% of youth entering Tennessee publicly funded substance abuse programs
meet criteria for co-occurring substance abuse and serious emotional disorders, and roughly
12,000 adolescents have potential co-occurring disorders and are in need of more in depth
screening (Flowers, 2002). Mental Tennessee Mental Health Institute reports that 52% of
individuals admitted have dual diagnoses (Martens, 2001), and Kenneth Minkoff, one of the
nation's leading experts on co-occurring psychiatric and substance disorders, states that co-
occurrence is the “expectation, not the exception.”

People suffering from co-occurring disorders are disproportionately represented among the poor,
homeless, hospitalized, and incarcerated populations. The Substance Abuse and Mental Health
Services Administration (SAMHSA) cites that 10% of the public healthcare population
account for 71% of our nation’s healthcare costs. SAMHSA indicates that as many as two-
thirds of that top 10% are diagnosed with co-occurring mental health and substance use
disorders (Buck, 2001, CMHS Office of Managed Care). People with co-occurring conditions
have significantly higher physical healthcare costs than consumers with a single disorder
(Hoff & Rosenheck, 1999) and are over-represented in both our hospitals and judicial systems.
Because people with co-occurring conditions are more likely to be refused admission or to be
prematurely discharged from treatment facilities in both mental health and alcohol & drug
service systems (Ridgely, Goldman & Willenbring, 1990), the criminal justice system has
become the “default” system of treatment. (Cocozza & Skowyra, 2000).

Treatment innovations for individuals with psychiatric conditions and addictive disorders have
occurred over recent years on separate but parallel paths. This separation, with a distinct lack of a
coherent system of connection and collaboration between the two separate systems of care, has
had substantial ramifications at both the system level (difficulty merging services and developing
integrated programs), and at the individual client level for people who experience co-occurring
conditions. Despite consistent evidence regarding the needs for people with co-occurring
disorders to receive coordinated, comprehensive and integrated services, they are too often told
they must receive treatment from two separate providers or teams of providers. Unfortunately,
individuals sometimes find themselves excluded from one or both systems because of
complicating features of one or a combination of their disorders.

Dual Diagnosis Recovery Network                                                         Page 2
     Co-Occurrence: Bridging the Gap for Change
                   The Next Step
Most recently, there has been increasing national imperative to develop strategies that reduce
both individual and societal costs associated with co-occurrence. Examples of some of these
initiatives include:

   Federally, collaboration between the two associations representing State mental health and
    substance abuse directors occurred through creation of a joint task force that drafted an
    agreement on financing and delivery of services to people with co-occurring conditions
    (Mental Health Weekly, 2000).

   Texas developed a Dual Diagnosis Project in response to Senate Concurrent Resolution 88.
    The project initiated a pilot program to study and evaluate the effectiveness of integrated
    treatment. The pilot has since expanded to 15 dual diagnosis programs across the state of
    Texas and has been nationally recognized as an exemplary example of interagency
    collaboration in the implementation of best practice. Texas also instituted a liaison position to
    further ensure successful communication between departments as they strive to meet the
    needs of individuals with co-occurring disorders.

   Oregon’s initiatives regarding co-occurrence included the development of a statewide Task
    Force to support mutual service enhancements between the Office of Mental Health Services
    and the Office of Alcohol and Drug Abuse Programs. The Dual Diagnosis Task Force was
    created in October of 1998 and submitted its final report in May of 2000. This endeavor was
    the joint work of departmental staff, consumers, families, providers, program administrators,
    academics and other stakeholders and provided a comprehensive view of systemic needs as
    well as recommendations to better service individuals with dual disorders.

   New York’s State Office of Alcoholism and Substance Abuse Services (OASAS) and the
    New York Office of Mental Health (OMH) codified their agencies' intentions to address the
    needs of the growing numbers of individuals with co-occurring mental health and addiction
    disorders found in both systems. The 1998 Memorandum of Understanding established an
    "Interagency Workforce on Co-occurring Disorders" that focused its efforts on: joint
    screening and assessment; development of joint training curricula; inter-system collaboration
    at the local level; and the needs of the most severely affected individuals.

Recently a Tennessee Task Force on Co-occurrence, an ad hoc committee of approximately 200
stakeholders statewide, met through a series of forums to evaluate the number of Tennesseans
with co-occurring conditions, assess the impact of those conditions, and identify any barriers in
obtaining necessary services or treatment. Spending over 140 hours of service time, the Task
Force confirmed that state prevalence and barriers to treatment were consistent with that reported
on a national level. As such, the Task Force was committed to identifying effective, low level
and low cost, high impact solutions to address the needs of our Tennesseans with co-occurring
conditions. The Task Force was represented by expert constituencies who defined The Next Step
in Tennessee’s response to address co-occurrence. The composite expertise of the Task Force
resulted in this comprehensive document that defines State barriers to effective services and


Dual Diagnosis Recovery Network                                                       Page 3
    Co-Occurrence: Bridging the Gap for Change
                  The Next Step
treatment, along with tangible recommendations for change to meaningfully impact this
underserved and growing population.

Given the longstanding history of separate mental health and addictions approaches to treatment,
effort must occur within each state to develop a common language and approach that unifies and
integrates services for people who struggle with dual conditions. With existing initiatives
throughout the country, decision makers have committed to identify obstacles to more accessible
and appropriate services and develop policy and service strategies to better meet the needs of
individuals with co-occurring conditions. Without intersystem communication and positive
provider incentives to develop integrated systems, poor outcomes and a long-term increase in
health care and other societal costs will continue. Much like the recent congressional request
that SAMHSA develop a joint task force on co-occurrence, we request a legislative
subcommittee and local level commitment to investigate and evaluate synergies to improve
the state of co-occurrence services in Tennessee. Additional recommendations of the task
force include:

      Education/Awareness activities: such as university level curricula modifications to better equip
       professional staff to provide treatment for people with co-occurring conditions; public education
       and stigma reduction activities; implementation of prevention and education programs in
       elementary and middle schools; education of decision makers; promotion of activities to build
       synergies among mental health and addictions treatment providers; and resource development to
       increase access to appropriate co-occurrence services.

      Policy recommendations: such as development of a liaison position to facilitate inter-
       departmental collaborations between the Department of Mental Health and Developmental
       Disabilities and the Department of Health, Bureau of Alcohol and Drug Abuse Services; review
       existing laws, regulations, and policies to enhance effective service delivery for people with co-
       occurring conditions; and implement criminal justice system enhancements such as training for
       key staff and officials and development of diversionary treatment services as an alternative to
       incarceration.

      Provider capabilities: such as development of continuums of care that are consistent with
       outcomes based techniques to more effectively serve individuals with co-occurring conditions;
       implementation of statewide provider workshops to facilitate cross-training of mental health and
       alcohol and drug treatment staff.

      Oversight: Application of best practice standards statewide; required outcome measures and
       outcomes based treatment to increase provider accountability for effective treatment practices;
       and development of a stakeholder oversight body to monitor delivery of treatment and services
       for co-occurrence.

      Research and Evaluation: Enhance assessment measures to ensure that people with co-occurring
       disorders are effectively identified and appropriately treated.




Dual Diagnosis Recovery Network                                                          Page 4
     Co-Occurrence: Bridging the Gap for Change
                   The Next Step
B.     Introduction
          espite advances in the individual psychiatric and substance abuse treatment fields, data

D         continues to emerge on an underserved population of people for whom the service
          system has been far less effective --- people with co-occurring conditions. Co-
occurring conditions, or dual diagnoses, involve a combination of one or more psychiatric
diagnoses with one or more substance use disorders. Under most existing systems, people with
co-occurring conditions receive treatment or services through either sequential treatment models
(treating one disorder first at one agency, then the other disorder at another agency) or parallel
models (where two providers at separate locations treat each condition at the same time but
separately). While people with single diagnoses have made marked progress in response to the
advances in their respective treatment fields, the number of people with co-occurring disorders
continues to grow and is disproportionately represented among the disabled, homeless, HIV
infected, and incarcerated. Estimated at 10 to 12 million in the U.S. in any 12 month period,
evidence based data supports that the presence of co-occurring conditions is associated with
higher rates of treatment utilization and an increased use of emergency and hospital services.
Clearly, the separate but distinct advances in the individual fields of Alcohol and Drug (A&D)
and mental health treatment, with divergent training, licensing, academics, and philosophies that
are effective for the individual populations they are designed to serve, do not meet the complex
needs of people with co-occurring conditions.



C.     State History on Co-occurring Disorders

             ost recently the State of Tennessee has made great strides in bringing co-occurrence

M            issues to the forefront and advocating on behalf of individuals needing services.
             Under the leadership of Melanie Hampton, Assistant Commissioner of the
Department of Mental Health and Developmental Disabilities, and Stephanie Perry, MD,
Assistant Commissioner of Health, Bureau of Alcohol and Drug Abuse Services, several state
initiatives have provided a foundation for more effective state practices in co-occurrence
treatment. A key initiative, entitled the “Co-occurrence Project,” was guided by a
comprehensive needs assessment completed in 1997 by The Department of Mental Health and
Developmental Disabilities and the Department of Health, Bureau of Alcohol and Drugs. The
needs assessment resulted in establishment of the Dual Diagnosis Recovery Network (DDRN).
This Department of Mental Health and Developmental Disabilities and Bureau of Alcohol and
Drug Abuse project provides an administrative central office for the initiation of statewide

Dual Diagnosis Recovery Network                                                    Page 5
    Co-Occurrence: Bridging the Gap for Change
                  The Next Step
activities to address issues and needs of people with dual disorders. Other statewide activities
related to co-occurrence include:

 Completion of a “Statewide Dual Diagnosis Service/Resource Directory.”

 Establishment of a “Community Resource Center,” a statewide clearinghouse of books,
  groups and professional organizations located in Nashville.

 Development of a website of resources on dual disorders and dual recovery information and
  services at www.dualdiagnosis.org.

 Completion of a “ Dual Diagnosis Module” for the Tennessee Mental Health Consumers’
  Association’s BRIDGES (Building Recovery of Individual Dreams and Goals Through
  Education and Support) Program.

 Implementation of Dual Recovery Anonymous (DRA) meetings throughout the state. DRA is
  a self-help program based on the principles of Twelve Steps with philosophical modifications
  to meet the needs of the dually diagnosed consumers.

 The Dual Diagnosis Recovery Network hosted Dual Diagnosis statewide conferences
  designed to reach a range of professionals from the community.

 During FY99, presentations at two professional conferences (Tennessee Association of
  Mental Health Organizations and Alcohol and Drug Summit).

 Facilitation of the Annual Southeastern Conference on Co-occurring Disorders.

 In FY 98, training for 300+ mental health and substance abuse professionals across the state
  by Kathleen Sciacca, a national consultant specializing in dual diagnosis.

 In FY 99, training was provided for 125 case managers across the state.

 The Department of Mental Health and Developmental Disabilities initiated a pilot project of
  one case manager for individuals with dual disorders through Foundations Associates, an
  integrated treatment provider for adults with co-occurring disorder of substance abuse and
  mental illness. Foundations serves as the focal point for activities regarding co-occurrence in
  Tennessee.

 In FY 99, the Department of Mental Health and Developmental Disabilities was a recipient
  of a Substance Abuse and Mental Health Services Administration - Center for Substance
  Abuse Treatment (SAMHSA/CSAT) grant. As part of Tennessee’s effort to promote
  integrated services for the dually diagnosed, the Department of Mental Health and
  Developmental Disabilities and the Department of Health Bureau of Alcohol and Drug
  Abuse Services teamed with an integrated treatment provider in Nashville to apply for a
Dual Diagnosis Recovery Network                                                   Page 6
    Co-Occurrence: Bridging the Gap for Change
                  The Next Step
   SAMHSA/CSAT Targeted Capacity Expansion grant to include evaluation of the
   effectiveness of best-practice treatment approaches for dual diagnosis.

 In FY 99, the Department of Mental Health and Developmental Disabilities was awarded a
  Substance Abuse and Mental Health Services Administration - Center for Substance Abuse
  Prevention (SAMHSA/CSAP) grant. The grant’s focus was a prevention service for children
  of dually diagnosed parents. The project provides education and support services to children
  and families affected by dual disorders of parents.

 Mental health and substance abuse service providers from the Chattanooga area (Region III)
  developed a task force on co-occurrence in response to recognition of service limitations in
  that area. This task force remains active and has met regularly to identify solutions and
  synergies in co-occurrence treatment.

Despite these many commendable efforts, people suffering from co-occurrence still have no
unified voice of state level advocacy to ensure adequate and appropriate services. Many service
providers continue to work within one of two frameworks: either consecutive or parallel
treatment of psychiatric illness and substance abuse/dependence. Consumers are often
misdiagnosed, leaving one or more illnesses untreated.

Development of the Task Force on Co-occurring Disorders

The Task Force on Co-occurring Disorders developed as an ad hoc consortium of stakeholders
who had identified of service and treatment barriers for people with co-occurring conditions in
various pockets of the state. Their objective was to determine whether those barriers, in fact,
existed statewide. Involving advocates, service consumers, family members, treatment providers,
state employees, policy makers, representatives from the TennCare Bureau and AdvoCare, and
other expert constituencies, the mission of the Task Force was to conduct a focused statewide
needs assessment, including assessment of the nature and extent of service barriers and, where
appropriate, to identify any consensus-based recommendations. The Task Force met in seven
regions across Tennessee, and membership included approximately two hundred participants
statewide. A primary tenant of the Task Force was to find concrete, low or no cost tasks that
could significantly improve treatment options for individuals with co-occurring disorders.

The first meetings included a review of national trend data and emerging literature on co-
occurrence, followed by subgroup discussion of barriers and needs within the state service
system. During the second meeting phase, the groups devised specific, concrete and operable
actions to address needs within each focus area. The third meeting in each region was to


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assimilate broad based themes, evaluate trending, and develop core recommendations for the
state. The fourth and final meeting was to review contents of the draft document and discuss
action planning. This information was accumulated from each region, and the results are
presented in this document. Approximately 140 hours of service time was provided by the task
force membership through this process.

Each region was represented, a diverse membership was involved, and a statewide description of
the status of Tennessee’s residents with co-occurrence and their families was obtained.
Tennessee has made a series of important strides toward improving co-occurrence delivery
systems at many levels and with many dedicated efforts. Given the enormity and impact of co-
occurrence on both societal and individual levels, however, it was clear that there is still much to
do to address the myriad challenges faced by Tennesseans who struggle with these conditions. In
order to accomplish meaningful change statewide, a comprehensive approach is essential to
simultaneously and concertedly address the multi-level confluences that are barriers to effective
treatment and services.


D.     Task Force Key Outcomes: State Consensus and
       Regional Issues

         he impact of co-occurrence has continued to gain national attention as a result of the

T        associated tremendous individual and societal costs. These are discussed in detail in
         Section D, along with research-based recommendations for developing more effective
local systems of care. Copies of discussion points used to guide task force meetings are provided
in the document appendices, and the following reflects task force meeting sites:




                                                                                    
                                                                  
            
                                                     

While it was recognized that limited prevalence data has been collected in Tennessee, members

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of each region agreed that Tennesseans with co-occurring conditions represent a growing
population with few effective treatment resources. Because task force membership spanned the
continuum of provider, family, consumer, and state policy influencers, broad span representation
allowed for a high level of expertise and insight. Consistently, membership agreed that the
current model of separate and distinct mental health and addictions services, while effective for
individuals with their respective single disorders, offers disconnected services with separate
programs and separate providers that unintentionally increase barriers to care for people with co-
occurring conditions. Participants across the state provided countless examples of systemic
barriers that continue to limit access to or availability of appropriate services and treatment.
Regional differences in key areas of concern varied slightly (e.g., West Tennessee task force
members focused on the disproportionate numbers of incarcerated Tennesseans with co-
occurring conditions and their associated needs; East Tennessee members focused on structural
recommendations to modify approaches to services for people with co-occurring conditions, and
Middle Tennessee members focused on collaborative opportunities among advocacy and
provider groups to enhance the continuum of services). However, there were five areas
consistently identified through the statewide membership as pivotal to modifying the manner in
which the state and its service systems respond to the needs of individuals with co-occurring
conditions and their families: 1) Education/Awareness; 2) Policy; 3) Provider Capabilities; 4)
Oversight; 5) Research and Evaluation.

Area 1: Education/Recognition of Need
General misunderstandings about what co-occurring disorders are, who is affected, and how they
should be treated in both the mental health and substance addiction arenas were reported as
common across regions. Examples of these misunderstandings were consistently identified, and
task force members reinforced that multi-level awareness and education are essential from the
general public to policy makers, funders, licensing bodies, and in academic settings. The Not In
My Back Yard (NIMBY) response is an easily recognizable struggle identified for people with co-
occurring disorders -- the phenomenon where community consensus is present about a special
population’s needs, while that same community simultaneously objects to establishing services
in or around their businesses or homes. However, inadvertent stigmas were also identified
within settings designed to treat people with these conditions, many of which are unequipped to
effectively treat the more complex dual disorders. To that end, it was recognized that the separate
and distinct training programs and educational settings fail to provide any standardized cross
training curricula for treating the counterpart condition, and it is incumbent upon the treatment
providers to adopt common training or expand the knowledge to their staff about co-occurrence.

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This is a significant flaw in our educational system, and change cannot occur without a primary
focus on the educational process for our professionals – an area where efforts have been made in
other states (such as New York with its integrated curricula and Connecticut with its dual
licensure) to develop professional education specific to co-occurrence and integrated treatment
models. Without efforts to develop essential skills within professions such as counseling, social
work, and medicine, people with co-occurring conditions will continue to encounter fundamental
barriers to treatment. The following provides task force recommendations to that end:

I. Awareness
Education at the         Liaison with the Higher Education Commission/Board of Regents officials to
University level to       provide consultation and make recommendations regarding curriculum changes
develop                   that include coursework on co-occurring disorders, integrated treatment, and best
fundamental               practice models of care.
skills for
                         Direct efforts toward widespread curriculum changes in areas of psychology,
emerging
providers
                          social work, criminal justice, education and the medical field.
                         Encourage licensing bodies to revise examinations to include information about
                          co-occurring disorders and integrated treatment.
                         Recommend licensing bodies incorporate information about co-occurring
                          disorders and integrated treatment in training requirements.

Education for the        Identify representatives with influence and/or who are well known and can
general public            articulate about experiences related to co-occurrence.
                         Develop a brief informational sheet to disseminate to the media for use by
                          agencies when discussing co-occurrence. This ensures that the information being
                          shared is consistent and serves to dispel myths about co-occurrence.
                         Develop a press kit about co-occurrence, the task force, and resources as part of a
                          statewide anti-stigma campaign.
                         Representatives from the mental health, substance addiction and integrated
                          treatment fields jointly participate in public presentations to reflect joint support
                          of issues integral to co-occurrence.
                         Increase emphasis on prevention and education programs in elementary and
                          middle schools.

Education for            Implement activities that bring together key providers from both the mental health
policy makers and         and substance addiction treatment fields (e.g., fundraisers such as Walk-a-thons,
legislators               fairs, etc.).
                         Expand awareness of the May 4 Co-occurrence Day proclaimed by the governor.
                         Present the task force report to commissioners of both departments and request
                          consideration of findings.
                         Add policy maker forums as an educational option.

Education for            Provide the press kit and informational sheet to agencies to incorporate into
agencies and              articles and newsletter publications.
service providers
Resource                 Add information about co-occurring disorders and integrated treatment as part of

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I. Awareness
Development –           the community information and referral system.
ensure resources       Create an on-line resource directory that includes a “decision tree” to direct access
and opportunities       to care.
are readily            Develop a curriculum for in-service trainings that agencies can use as part of their
available
                        training plans.
                       Develop a speakers’ bureau to enhance access to expertise in co-occurrence
                        treatment and services.


Area II: Policy

The broader Policy category incorporates recommendations to impact the development of service
standards for Tennesseans with co-occurring disorders with an emphasis on concrete, low, or no
cost improvements. Regional task force members recognized the importance of bridging systems
and developing ongoing dialogue between the Department of Mental Health and Developmental
Disabilities and the Department of Health, Bureau of Alcohol and Drug Abuse Services.
Currently, there are individuals within both departments with significant investment in
collaborative efforts on behalf of individuals experiencing co-occurring disorders. However,
there are limited policy mandates to encourage the continued existence of this collaboration, and
there are no incentives to expand and enhance collaborative efforts between departments. Policy
recommendations for consideration by a legislative subcommittee follow:

II. Policy
Department             Assign and/or develop a dedicated position to act as a liaison and advocate
Collaborations          between key departments (e.g., Co-occurrence State Liaison) with equal, joint
                        responsibility to both departments. Consider external steering committee to
                        oversee liaison activities and ensure recommendations are implemented. Liaison
                        responsibilities should include:
                              Evaluation of contracts with providers, BHOs and other entities to address
                                 co-occurring disorders.
                              Maintenance of training curricula and best practice guidelines so that
                                 providers have equal and ready access to this material.
                              Implementation of a statewide training program made available to
                                 consumers, family members, providers and others with a stake in the
                                 issue.
                              Representation in policy and advocacy.
                              Establishment of coordinated communication between local and state
                                 entities via a standing co-occurrence committee that involves
                                 representation from the Departments of Correction, Health, Mental Health
                                 and Developmental Disabilities, Education, HUD/THDA, and TennCare.
                       Institute a Memorandum of Understanding between the departments that commits
                        to a collaborative effort to address co-occurrence.

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II. Policy

Review existing          Review state facility licensure standards and incorporate wording that allows for
laws, regulations         dual licensing or complimentary licensing options.
and policies to          Review TennCare contract and policies (including provider trainings, best
further encourage         practices, benefit packages) and incorporate wording inclusive of integrated
and enhance
                          treatment.
service delivery to
individuals with         Review insurance regulations and advocate for parity laws to incorporate both
co-occurring              psychiatric illness and substance addiction treatment and services.
disorders                Establish a diverse committee to review mental health and alcohol and drug
                          codes, led by the Co-occurrence State Liaison, and make recommendations for
                          revisions that incorporate wording related to co-occurrence and integrated
                          treatment.

Criminal Justice         Recommend to Criminal Justice Committee that training for attorneys, judges,
system changes            corrections staff, criminal justice liaisons, law enforcement, and treatment
(noted as a               providers incorporate information about co-occurring disorders.
priority among           Review policy regarding inmate discharge and re-instatement of insurance
several regions)
                          benefits so that treatment can be accessed upon release.
                         Evaluate and encourage diversion into treatment rather than jail, when
                          appropriate, and ensure individuals who are jailed receive appropriate services.



Area III: Provider Capabilities

Issues around Provider Capabilities included both agency/provider specific activities and
statewide initiatives that enhance services to individuals with co-occurring disorders. In keeping
with recommendations in the Center for Substance Abuse Treatment publication, Changing the
Conversation: Improving Substance Abuse Treatment: The National Treatment Plan Initiative
(NTP), a “no wrong door” policy was supported as essential as the basis for service delivery
systems across the state. This means that people must be able to access the care they need
regardless of where they enter the service system, and service providers must have the tools they
need to either treat or refer individuals to appropriate care. Within a “wrong door” system,
mental health and drug and alcohol services are not coordinated, and individuals are treated only
for the condition treated in the "door" they entered. Many systems still resemble “wrong door”
models, with either sequential treatment (treating one disorder first, then the other) or parallel
treatment (where two providers at separate locations treat each condition at the same time but
separately). Tennessee’s current service delivery system is system is parallel and, while both
provider groups are effective with their respective populations, neither has capabilities to treat
the complexities associated with co-occurrence.


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As part of a statewide initiative, consumers must have access to a continuum of services based
upon need. Agencies and providers may not be able to provide all services within the continuum,
but seamless collaboration between providers will allow consumers to experience a full
continuum with service delivery responsibilities distributed in a way that maximizes resources in
a given geographic area. The National Dialogue on Co-occurring Mental Health and Substance
Abuse Disorders (1998) reinforces that services should be matched to the individual according to
the severity of his/her conditions and may include services that range from consultation or
collaboration between treatment providers to a fully integrated treatment setting.

III. Provider Capabilities
Incorporate a           Utilize the Co-occurrence State Liaison to establish networking opportunities
Continuum of             between providers, consumers, family members and other entities.
Care philosophy         Implement a formalized statewide needs assessment to determine service gaps,
                         areas of need and areas with resources in order to increase accessibility to those
                         resources.
                        Recommend blended funding opportunities that are flexibly dispensed to ensure
                         consumers receive individualized, integrated care.
                        Provide a continuum of housing options for individuals with co-occurring
                         disorders as part of the continuum of care (ranging from specialized respite
                         services to independent living options).
                        Establish a referral system that is easy to maneuver and provides consumers with
                         treatment and recovery options in a timely and efficient manner.
                        Establish a master calendar of meeting times and dates for various organizations
                         in the mental health and substance addiction arenas to further communication and
                         collaborative efforts among those entities.

Cross-train             Implement statewide co-occurrence workshops for providers, consumers and
through a                family members. Include members of mental health, addiction treatment fields,
curriculum that is       criminal justice, education, medical staff, consumers and family members.
consistent and          Revise contracts and requirements under TennCare, block grant, and other
easy to access for
                         funding sources to include co-occurring disorders.
developing
“dually capable”
provider systems




Area IV: Oversight
The Department of Health, Bureau of Alcohol and Drug Abuse Services established best practice
guidelines for co-occurring disorders within Tennessee, and there are also federal initiatives that
provide best practice guidelines. Unfortunately, there is no single agency or funding source that

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requires application of these standards at the agency level. To ensure services are being provided
within the framework of best practice models, oversight was identified as essential.

IV. Oversight
Best Practice         Review the best practice guidelines for co-occurring disorders established by the
Guidelines             Bureau of Alcohol and Drugs, revise and disseminate to providers as part of the
                       statewide training initiative.
                      Establish a workgroup involving key stakeholders to develop outcome measures
                       that are supported by the Department of Mental Health and Developmental
                       Disabilities and The Bureau of Alcohol and Drug Abuse Services.
                      Include in the TennCare contract, block grants, and other funding contacts the
                       requirements that contractors incorporate best practice standards as part of the
                       Supervised System of Care (SSOC) policies.

Develop an            Establish an oversight body that is representative of entities and individuals with a
oversight body -       stake in co-occurrence.
with a vested         Utilize the Co-occurrence State Liaison position as a lead in an oversight body
interest in co-        that includes representation from various constituencies (mental health, substance
occurrence
                       addiction, criminal justice, consumers, family members, policy-makers,
                       educators).


Area V: Research and Evaluation
Whenever a service is provided, it is important to the recipient and payer to know that the service
is effective. Behavioral health is largely qualitative, and there are a number of challenges in
measuring the effectiveness of services. Variables such as hospitalizations, use of emergency
services, subjective reports of well-being, and service costs provide important and accepted
indicators of success in effecting change. Outcome measures are important to ongoing,
meaningful system improvements and should be included when defining the extent and depth of
treatment issues and needed change. To date, few providers measure service efficacy, and few
payers require that those measures occur. Recommendations of the task force with reference to
this area include:

V. Research and Evaluation
Establishing          Request Alcohol and Drug Management Information Systems data from the
Baseline Data          Bureau of Alcohol and Drug Abuse Services that incorporates diagnostic
                       information about individuals accessing services from providers contracted with
                       them.
                      Request data from the TennCare Bureau and AdvoCare regarding diagnostic
                       information on co-occurring disorders.
                      Track information from area agencies on referrals for service, issues with service
                       access, and general inquiries about treatment of co-occurring disorders.

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V. Research and Evaluation
                      Track consumer data from agencies providing integrated service.
                      Review the study conducted by Middle Tennessee Mental Health Institute and
                       other Regional Mental Health Institutes on consumers admitted with co-occurring
                       disorders.
Ongoing
                      Add information about both substance addiction and psychiatric illness to current
screening and
measurement
                       data gathering tools.
                      Establish a screening tool that captures information easily and can be incorporated
                       into intake assessment processes of both mental health and substance addiction
                       treatment facilities; establish and/or adopt a universal screening tool that assists
                       providers in coordinating appropriate care (i.e., ASI and/or ASAM).
                      Establish a yearly needs assessment project that measures change over time, most
                       especially in the area of the no wrong door treatment philosophy.




E.      Background and Literature Review Supporting the
        Extent of the Problem



R
         esearch supports that every $1 invested in substance abuse treatment saves $7 in
         medical and other social costs (NIDA, 1999). There are more deaths, illnesses and
         disabilities from substance abuse or dependence than from any other preventable health
condition, and at least one in four U.S. deaths is attributable to alcohol, illicit drug or tobacco use
(National Council on Alcoholism and Drug Dependence, 2000).

Of those individuals with substance use disorders, between 41% and 65.5% have at least one co-
occurring psychiatric disorder, and 51% of individuals with a psychiatric illness have at least
one co-occurring addictive disorder (National Comorbidity Study (NCS); Kessler et al., 1995).

According to the National Dialogue on Co-occurring Mental Health and Substance Abuse
Disorders (1998), co-occurring substance use disorders and mental health conditions affect up to
8 million individuals in the U.S. each year. Kessler estimates that three million individuals are
affected by three disorders, and one million individuals have four or more disorders (Kessler,
1995). Kenneth Minkoff, one of the nation's leading experts on co-occurring psychiatric and
substance disorders, states that co-occurrence is the “expectation, not the exception.”

While there has been limited research to assess the prevalence of co-occurrence in Tennessee, a
few state specific studies assist us in identifying the degree of need and prevalence. The

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IMPACT Study, conducted by Vanderbilt University Center for Mental Health Policy in
conjunction with Tennessee Voices for Children and the Tennessee Commission on Children and
Youth, assessed the performance of TennCare and the TennCare Partners’ program for
adolescents in publicly funded substance abuse treatment. This study reported that 27% of youth
entering Tennessee publicly funded substance abuse programs met criteria for co-occurring
substance abuse and serious emotional disorders. Approximately 12,000 adolescents were found
to have potential co-occurring disorders and were in need of more in depth screening (Flowers,
2002). Other findings were consistent with the recommendations developed by this task force,
including the need for provider cross-training and coordinated service delivery. A second study,
conducted at Mental Tennessee Mental Health Institute, reported that 52% of patients surveyed
had dual diagnoses (Martens, 2001). Based on SAMHSA’s Statistics Sourcebook, there are
approximately 179,576 Tennesseans between the ages of 15 and 65 suffering from co-occurring
disorders.

Risks of co-occurrence are well documented in the literature and include:

 Relapse: Dixon, McNary, and Lehman (1998) found higher rates of relapse in persons with
  co-occurring disorders, including increased services and alcohol use.

 Clinical Outcomes: Consumers with co-occurring disorders have poorer functioning and
  poorer outcomes than those with only one disorder (Bartels, Drake, & Wallach, 1995).

 Cost: Consumers with co-occurring disorders incur significantly higher physical healthcare
  costs than consumers with a single disorder (Hoff & Rosenheck, 1999).

 Homelessness: Drake, Osher, & Wallach (1991) estimate that 10-20% of the homeless have
  severe psychiatric illnesses and substance-related disorders. In 1996, the Knoxville Coalition
  for the Homeless study cited that at least one third of homeless individuals suffer from some
  form of serious mental illness, and their more recent 2000 report indicates a rate of over 50
  percent (Nooe, 2000). Dually diagnosed individuals are almost universally refused
  admission or are discharged prematurely from treatment facilities in both mental
  health and alcohol & drug service systems – therefore much more vulnerable to
  homelessness (Ridgely, Goldman & Willenbring, 1990).




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 Risk of HIV infection: Women with co-occurring disorders are at increased risk of sexually
  transmitted diseases, sexual and physical violence (Fullilove & Fullilove, 1994).

 Criminal justice: NIMH estimates that 82% of prison inmates have a history of mental health
  disorder, and 81.6% of this group also had a substance-related disorder (Regier et al., 1990).

 Progression: “If not treated early and effectively, the disorders may become chronic, lead to
  other disorders, may increase symptoms by interacting with each other, may cause
  disability…” (SAMHSA, 1999).

 Impairment: “Among the social role impairments significantly associated with co-morbidity
  are marital separation and divorce, social isolation and exposure to conflictual social
  relationships” (Kessler, 1995).

 Relapse: “The most common cause of psychiatric relapse (in the dually diagnosed
  population) is the use of alcohol, marijuana, and cocaine. The most common cause of relapse
  to substance use/ abuse today is untreated psychiatric disorder.” (SAMHSA, 1997; Kessler,
  1996).

The national failure to address co-occurring conditions has reached critical proportions, as the
needs of individuals with co-occurring disorders now overload the nation’s public health and
criminal justice systems and consistently fail to receive appropriate and adequate services.
However, despite clearly defined need and evidence of key system gaps, there is no entity that
represents the needs of individuals with co-occurring disorders.

While that failure can be attributed to a confluence of historical and cultural factors, clearly
widespread lack of expertise with dual treatment and the stigmatization of both addictions and
psychiatric conditions are central factors. Licensing and regulatory requirements perpetuate that
disconnect, with few incentives for providers to develop dual competencies. Hence, individuals
most in need receive inappropriate or inadequate services through traditional sequential or
parallel models, and individuals with co-occurring disorders bear the burden of yet another
“failed” treatment. With the already existing stigma of dual or multiple diagnoses, the
combination of service inadequacies actually provides a disincentive for individuals with dual
conditions to seek treatment. Despite progress in recent years, most states continue to provide



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treatment systems almost entirely comprised of single-focused alcohol and drug or mental health
agencies. The challenges for states are significant:

 Many addiction and mental health providers are uncomfortable treating the counterpart
  condition. Hence, individuals and their families, already facing myriad challenges due to co-
  occurring disorders, are left to navigate a complex “wrong door” service system before
  treatment can be obtained.

 Recovering individuals with co-occurring disorders have few resources for treatment and
  mutual support, and there continues to be divisiveness within states regarding treatment and
  recovery methodology for co-occurring disorders. Compound stigmas associated with dual
  disorders lead to improper medical treatment, homelessness, and incarceration (The National
  Treatment Plan; SAMHSA, 2000), dis-empowering development of a cohesive recovery
  community of individuals with dual diagnoses, their families, and their allies. Conflicting
  treatment philosophies create unnecessary barriers to recovery and require that consumers
  navigate a complicated and often contradictory treatment system. Consequently, many
  individuals with dual conditions enter the treatment system through the criminal justice
  doorway – as one of the fastest growing and most underserved groups in this country.

 Treatment programs are generally not encouraged or mandated to include consumer input in
  the planning or evaluation of services at a systems level. Most often consumers are asked to
  complete a satisfaction survey at discharge at the provider’s setting, offering the sole
  opportunity to give feedback or recommendations. People with co-occurring disorders are
  less likely to complete treatment, due to service barriers, and therefore their voice is seldom
  heard at even the provider level.

Despite recognition that there is an over-representation of dually diagnosed individuals in our
hospitals and judicial systems, there is little existing support and advocacy for the interests of
individuals with co-occurring conditions. Absent a unified voice that advocates for and educates
about the complexities of dual diagnosis through a shared recovery community membership, we
will continue to fail to provide appropriate and effective services and support for individuals with
dual diagnoses.

The Center for Substance Abuse Treatment publication, Changing the Conversation: Improving
Substance Abuse Treatment: The National Treatment Plan Initiative (NTP), states that “whereas


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all persons who are addicted or are in recovery are stigmatized….the dually diagnosed…are
more prone to be stigmatized than others with addictive disorders.” Despite increasing statistical
evidence that co-occurrence adversely impacts all spheres, is one of the most costly “conditions”
faced by the nation’s constituency, and must be treated through an integrated system of care,
multiple barriers to integration continue to exist:

   Separate State Systems/Absence of State Emphasis or Oversight - Twenty-one
    states/territories have separate mental health and alcohol and drug systems. Reporting to
    separate departments with different administrative structures, licensure, reimbursement, and
    providers, services are fundamentally disconnected. Hence, the myriad differences in
    paradigms and regulations makes coordination of services a national challenge. The State of
    Tennessee has separate controlling bodies via the Bureau of Alcohol and Drug Abuse
    Services (BADAS) in the Department of Health (DOH) and the Department of Mental Health
    and Developmental Disabilities (DMHDD). In recent years the relationship between the
    DMHDD, DOH, BADAS, has strengthened, however, few state programs address integrated
    treatment. Consequently, if no single body exists to emphasize, require, or provide oversight
    for dual diagnosis treatment, no incentive exists on the provider level to deliver those
    services.

   Provider Disincentives – Under the current state system, any Tennessee provider attempting
    to deliver dual diagnosis services experiences multiple barriers within the existing licensure
    divisions. Both Mental Health and Substance Abuse licensing bodies defer the provider to the
    alternative licensure board when a provider reports delivery of dual treatment services. No
    dual diagnosis licensure exists within the state, making it difficult to establish programs that
    provide effective co-occurrence treatment.

   Limited Acknowledgment or Response by Payer Sources – There is considerable variance in
    payer understanding of the population and the importance of integrated treatment, and funds
    typically are not allocated to support integrated treatment. While private sector payers are
    increasingly acknowledging outcomes based treatment, public sector payers (typically the
    primary payers for consumers with dual diagnoses) are directed by the emphasis, or lack
    thereof, at the state level. Again, without a state emphasis, no change in payment system will
    occur.




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   Lack of Trained Staff - A global, fundamental flaw in our educational system frequently
    creates barriers for non-substance abuse treatment healthcare professionals wishing to
    become competent in the treatment of addictive disorders. Several regional universities
    conduct groundbreaking research on addictions, including Johns Hopkins, the University of
    Maryland, the University of Kentucky, and Vanderbilt University. Unfortunately, state-of-
    the-art research in these settings does not always translate to adequate clinical training on
    addictions, even within the same university. Course curricula in many traditional medical
    school settings, departments of psychology, criminal justice, nursing, and social work
    frequently minimize the seriousness of addictions, prioritizing the study of rarer, less-
    stigmatizing diseases, despite the unmatched social costs and associated medical
    consequences of addiction. In medical school physicians are frequently better trained to
    address the “side effects” of addiction (e.g., liver problems, high blood pressure, sexual
    difficulties, dementia, accidents, etc.) than to treat addictive disorders. The same issues are
    common in world-class departments of psychology, nursing, and social work, where the
    seriousness of addiction is often minimized and professionals are trained to rationalize their
    failure to treat addictions (e.g., using terminology such as noncompliant, treatment resistant,
    or altogether refusing psychotherapy until the client abstains from drugs and completes
    treatment).

    Treatment is, therefore, contingent upon the treatment professional’s training, which lends to
    his/her perception of “primary illness.” Howland best describes this paradox as “…conflicts
    arise about the responsibility for the direction of treatment, leaving the patient confused or
    having to choose one over the other.” Conflicting treatment approaches and varied training
    and expertise worsen that confusion. Substance abuse counselors generally know little about
    psychiatric treatment and vice versa. Training programs and licensing bodies for
    professionals typically emphasize either substance abuse or mental health specialties.

   Agency Specialization - As a byproduct of specialized licensing and training, combined with
    the Single State Agency model within most individual states, agencies typically provide
    either mental health or substance abuse treatment. Naturally, agency cultures and the staff
    they employ, in turn, emphasize treatment of the condition that falls within the agency’s
    mission. As such, the counterpart condition must either be treated at a later date (sequential
    treatment) or through a separate provider (parallel treatment). Either way, research
    consistently supports that single system treatment models are ineffective. Hence, impact
    problems addressed earlier will inevitably continue, negatively affecting our judicial system,


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    hospitals, societal costs, and the dually diagnosed individuals and their families. Despite this
    data, states such as Tennessee continue to offer sequential and parallel models, rather than
    moving toward the more effective, integrated and coordinated treatment options.

                                       Treatment Models for Co-occurring Disorders
                               [Adapted from SAMHSA Treatment Improvement Protocol (TIP) #9]
                    First, and historically most common, model used
    SEQUENTIAL




                    Consumer is treated by one system (addiction or mental health), and then by the other
                    Differing views on which disorder to treat first; Treatment depends upon prioritization of disorders
                    Financial coverage and confidentiality laws vary between systems
                    May be appropriate for patients with a severe problem with one disorder, and mild problem with the other
                    Consumers frequently receive conflicting therapeutic messages from separate systems
                    Simultaneous treatment provided to the patient by both mental health and addiction treatment settings
                    Utilizes existing treatment programs and settings
    PARALLEL




                    Financial coverage and confidentiality laws vary between systems
                    Coordination of services between settings varies widely
                    May be appropriate for patients who have a severe problem with one disorder, and mild problem with the
                     other
                    Consumers frequently receive conflicting therapeutic messages from separate systems
                    Combines elements of both mental health and addiction treatment into a unified and comprehensive
                     treatment program for the patient
    INTEGRATED




                    Both disorders treated as primary
                    Consumer receives simultaneous treatment of both disorders in a setting designed to accommodate both
                     problems
                    Clinicians have typically received specialized training in dual disorders
                    Consumer no longer shoulders responsibility for integrating their care


   Consumer Navigation – The various treatment models create unnecessary barriers to
    recovery and require that consumers navigate a complicated and often contradictory
    treatment system. Consequently, many consumers with co-occurring conditions enter the
    treatment system through the criminal justice doorway – as one of the fastest growing and
    most underserved groups in this country.

Clearly, absent a coherent, integrated treatment system that acknowledges the complexities of
co-morbidity, we will continue to fail to provide appropriate and effective treatment for
consumers with dual diagnoses and, as such, we will continue to incur the individual and societal
costs associated with that failure.




Dual Diagnosis Recovery Network                                                                                 Page 21
  Co-Occurrence: Bridging the Gap for Change
                The Next Step

   Appendix 1: Family and Consumer Illustrations of Co-
              Occurrence Treatment Needs




Family and Consumer Illustrations        Appendix 1, Page 22
    Co-Occurrence: Bridging the Gap for Change
                  The Next Step
                                      A Parent’s Story


W        hen my son was in high school he began smoking pot almost daily and experimenting
         with other drugs as they were available to him. As parents, we attributed the mood
swings, erratic behavior, and change of lifestyle to his addiction. Once evaluated and diagnosed
bipolar at age 17, the mental illness took precedence in his treatment. Other than an occasional
AA meeting during his inpatient hospitalizations and cursory discussion about his drug use,
there was no recognition of how addiction complicated and compounded his mental illness.
While as parents we tried to hammer this message home, it was not apparent that the mental
health community of providers were validating our efforts and reinforcing this concept.

My son plays one illness against the other, just like a child plays one parent against the other.
For example, when confronted about the exacerbation of psychiatric symptoms, he will dismiss
this, saying, “I relapsed.” More frustrating from a parent’s perspective is how you persuade
your mentally ill son to comply with legal drugs that have, on more than one occasion produced
horrifying side effects, when simultaneously you are trying to promote abstinence from illegal
drugs and alcohol.

It would be eight years before BOTH illnesses were equally acknowledged and addressed. At the
time, Genesis House was the only game in town when it came to recognition of the interplay of
addiction and mental illness. For the FIRST time, the counselor took a complete drug history.
The interview process was a catharsis for my 25 year-old son, as he held so much guilt about the
drug use. One wonders what a difference it would have made if BOTH serious brain disorders
had been treated aggressively from the beginning.




Family and Consumer Illustrations                                   Appendix 1, Page 23
    Co-Occurrence: Bridging the Gap for Change
                  The Next Step
                                        Shelley’s Story


A
        s I picked up Shelley in front of the office (nicely dressed, articulate, and eager to start
        her new position as residential counselor at Foundations Associates in Memphis), it was
        hard to believe that six years ago she faced a time when she was labeled by her AA
group as the “hopeless case” in the Big Book. “Never say never,” she says as she smiles and
begins to relate her story.

At the age of 15 Shelley began drinking alcohol and using drugs on a regular basis, and by the
age of 18 she was using heavily and rarely had a sober day. Her first emotional breakdown
happened at age 21 and, at the time, no one knew whether the symptoms were drug induced or a
true mental illness. This began her 5-year journey through the system -- with a prescription for
lithium and a devout denial of her problem.

A hazy six weeks in an inpatient mental hospital followed, where Shelley describes herself as
reverting to a “baby” in every way: “I couldn’t even take care of myself; they had to dress me
and bathe me.” After finally becoming stable on medication and being properly diagnosed as
having bipolar disorder, Shelley spent the next two years seeing a psychiatrist on an outpatient
basis. Shelley remained relatively stable for the next year and a half, until a visit to a relative’s
house prompted a serious downfall. The “little bit of rum” in her Coke started the drug and
alcohol abuse over again. Medication was only taken occasionally, and any family efforts to
intervene were seen as an attempt at “control.”

Shelley’s angry outbursts and manic episodes caused a great strain on her living arrangements
with her mother, and she was eventually given an ultimatum of “get help or get out.” While the
“help” she got was a 28-day Alcohol & Drug (A&D) program that Shelley prematurely ended
after 15 days, she learned of the concept of dual diagnosis from a psychiatrist who reported that
50% of individuals in A&D treatment also have a mental illness. Treatment remained
ineffective, however, as Shelley recalls that her mother’s threats, rather than her own motivation,
were the reason she pursued services.

Shelley continued a relapse cycle: “Sometimes I didn’t take my meds because I wanted to have
that manic feeling. I lied to my Mom, and started using all over again.” Eventually Shelley made
it through a 28-day stay at an A&D inpatient facility and started going to AA meetings on a
regular basis after she got out. Believing alcohol and drugs were here sole problem, Shelley felt
that maintaining abstinence would help her “have this thing licked.”

After maintaining sobriety and psychiatric stability for almost a year, Shelley stopped taking her
medications. A series of manic episodes, including many tattoos and “maxed out” credit cards,
followed. Shelley met a “friend” who was also in recovery; he introduced her to crack cocaine.
Again, the addiction cycle followed, as did another ultimatum from her mother. Shelley resumed
another series of treatment in multiple facilities, each of which focused either on A& D or mental
health services -- rarely ever together. While the concept of dual diagnosis was re-introduced to
her during a four-month stay in one facility, it never occurred to her that co-occurrence was her

Family and Consumer Illustrations                                      Appendix 1, Page 24
    Co-Occurrence: Bridging the Gap for Change
                  The Next Step
problem. After six months of sobriety, another relapse landed her in jail and on a five day using
spree: “No one knew where I was or whether I was dead or alive and, honestly, I didn’t care.”
For the first time, “a spiritual awakening” helped her appreciate the impact of her situation on
her family: “God spoke to me and let me know I could be dead and made me think about whether
or not I wanted my family to have to go through my actually being dead.” Although her mother
refused her return home, Shelley began her own journey for recovery: “I was looking for long
term treatment, which was hard to find. I finally heard about Foundations from my case
manager, and I called them every day (for 3 weeks) until they took me.”

Shelley recognized she needed the structure of long-term treatment, and identified its impact on
self-discovery and leisure -- “I learned how to have a good time without drugs. I started using
drugs in the first place to have fun and because I could be a different person with them. I had to
learn how to be myself.” While she reports that the support she needed was provided through the
program, she identifies the dual diagnosis meeting as the most beneficial element: “It was the
first time I had ever talked about the two together. Everywhere else (I had been), you kept them
(A&D and MI) separate. It was so good to see that there were other people that had the same
problems.” Shelley learned about what it meant to be diagnosed with two illnesses. “I never
thought it (being addicted to drugs) could happen to me.” She confesses that the stigma of both
illnesses made them hard to accept, and she acknowledges that taking meds everyday was not a
routine she found easy. After six months of treatment, she went home. This time she knew it
was different.

Her eighteen-month anniversary in recovery just passed and, as we sat at a restaurant and talked
about what finally helped her into recovery, she recounted a story about someone who believed
in her. “One of the leaders at Foundations always said that if he could help just one person, it
was all worth it. I remember him saying this over and over again, but what I didn’t realize, until
someone close to him told me, was that I was that one person. Tears streamed down my face.”
She knows she will always be in recovery, but her whole outlook on life has changed. She loves
herself today and is able to give of herself, something she could never do before.

“I believe there comes a time in recovery where you realize how good your life is without drugs
or alcohol and if you stay on your meds. Drugs and alcohol honestly don’t even appeal to me
anymore, and every time I want to stop taking my meds…I just put it in my mouth and deal with
it. I don’t even want to take a chance at messing up again.”

Today Shelley is active in recovery meetings; she takes her medication every day, has had a
stable job for ten months, and is in her second semester of college. She is not the old Shelley
anymore but the young Shelley, and definitely not a “hopeless case.” She knows she still has a
long road ahead but she’s making it ---- one day at a time.




Family and Consumer Illustrations                                    Appendix 1, Page 25
    Co-Occurrence: Bridging the Gap for Change
                  The Next Step
                                         My Story



M
            y story is reflective of the struggles many addicts and manic-depressive types
            endure. I experimented at age 14 with LSD and Budweiser, and always kept
            secrets from my family. I maintained my own little fantasy world, and even
achieved honors in high school and college. Pushing myself to be “unique,” I developed a
Jeckyl and Hyde personality that lit up when I was.

Venturing into nightclubs and late night “raves” was my favorite venue for scoring drugs and
releasing the power of “mania man.” I loved the rush of dancing all night and then following
my moment-to-moment instincts of how to make it home and crash out. Along the way I
wound up in several mental hospitals and various drug treatment programs, but I still believed
I could maintain my using when I got out.

Finally I hit my bottom when I was arrested for assaulting a close member of my family while
high on crack and ecstasy. I spent 4 long months incarcerated, with no available options to
escape my consequences. I saw the light when my case manager discovered a program that
treated dual-diagnosis, and she recommended to my public defender that it might provide a
successful regimen for me to follow. I had previously never completed any type of structured
program, and thus I always felt “incomplete.”

Over the last year and few months, I have secured a screening position with Foundations
Associates, a job as Manager of my halfway house, and active participation in Narcotics
Anonymous. I still take medication to ensure that my moods remain stable, and I follow all the
guidelines set forth by doctors, mentors, and advisors. I believe that I had to have both of my
problems under check before I could start to build a real life. Now I get to help other people
every day and am realizing that “one day at a time” goes far beyond just a slogan. I thank my
sponsor and extensive support system for keeping me humble and focused on gratitude for
each moment that I am granted to grow and share and help.




Family and Consumer Illustrations                                  Appendix 1, Page 26
     Co-Occurrence: Bridging the Gap for Change
                   The Next Step
                                           A Family’s Story

        M
                     y forty-one-year-old brother-in-law is incarcerated in a federal prison, due in large
                     part because he never had proper diagnosis and treatment for his co-occurring
                     psychiatric and substance abuse disorders. From the age of eleven when I first met
him, it was apparent that something was not right with him. He was already using drugs (LSD,
marijuana, amphetamines, barbiturates), drinking alcohol regularly, and committing petty crimes to
support his habits. His teachers didn’t recognize that he had dyslexia or that he was verbally and
emotionally abused and neglected at home by an alcoholic mother who provided no structure,
supervision, or discipline beyond screaming. The teachers added to his despair by punishing him for
having a learning disability and what was an obvious case of attention deficit hyperactivity disorder
(ADHD).
          All his siblings began using drugs and alcohol before they were ten years old, partly to self-
medicate their uncontrollable feelings and to feel ‘normal,’ a description commonly used by addicted
persons about the effects of their drug of choice. The stress of their lives was contributing to, possibly
even triggered, their psychiatric symptoms.
          His father was a poly-drug user who had abandoned the family when my brother-in-law was a
baby. Both parents exhibited symptoms of serious mental illness throughout their adulthood, although
neither was ever officially diagnosed or treated. The impact of their erratic behavior and emotions left
lasting scars on all four children who now have diagnosable psychiatric disorders that have negatively
impacted their own lives, that of their spouses, children, and the larger community. All have also used
drugs and alcohol to excess. Having co-occurring disorders is a family trait.
          One brother has been diagnosed with ADHD and obsessive-compulsive disorder. Fourteen years
ago he entered a 30-day treatment program for severe substance abuse. Due largely to the intensity of the
treatment, the family education (one whole week!), and three years of weekly family aftercare, he has
been sober ever since, one day at a time. His oldest daughter was diagnosed with the milder form of
bipolar disorder.
          By the time my brother-in-law was fourteen, he was sentenced to live in a group home 180 miles
away. In the intervening years he has lived in the community less than six years, most of those only while
as an escaped prisoner or on the run in violation of parole. We have noted a pattern. When he is released
from jail he then immediately re-offends, usually in a way that is certain to result in his being caught;
because he is institutionalized, jails and prisons are the only places that he feels safe and has structure in
his life.
          Unfortunately he is not safe from drugs or alcohol behind bars, because he tells us that access is
amazingly much easier from within than from the outside. He has tried to help himself. He was the
president of his prison AA group, until a social worker introduced a program that taught the inmates that
they could learn to use alcohol responsibly. After that training, he couldn’t wait to get out of jail to prove
that he could control his drinking. It didn’t work.
          Within weeks he was back to the point of addiction he’d once experienced, ingesting quantities of
alcohol and cocaine that would kill most people. His judgment was so impaired by the substances and by
obvious manic delusions that he could perform humanly impossible feats. We tried to do a family
intervention, but the family erupted during the session with old hurts surfacing, and he ran out of the
building angry and defeated.
          Eventually he did get treatment and even live in a halfway house, but his psychiatric illness still
hadn’t been diagnosed, so only half of the problem was being treated. Understandably he relapsed trying
to control his mental health symptoms with alcohol and was kicked out of the halfway house.
          The last time he was between incarcerations, the correction system released him at the gate of the
rural prison at which he had served his time. They gave him instructions to report within three days to his
parole officer in Knoxville to be fitted with a tracking anklet bracelet. With his history of flight, the action

Family and Consumer Illustrations                                              Appendix 1, Page 27
     Co-Occurrence: Bridging the Gap for Change
                   The Next Step
was irresponsible. We believe they hoped he would leave the state, so they wouldn’t have to deal with
him. That is what happened.
         However, he didn’t stay away long, because he had two options in his mind- suicide by cop or a
promotion. He had told us before that federal time was like a promotion. How sad that in his culture and
state of mind that is the case. He had also bragged of going down in a blaze of glory some day. We knew
he was depressed and desperate at that point.
         Then he robbed a bank. A few hundred yards away he dropped his backpack with his
identification and most of the money inside, on purpose, we are sure. We were concerned that he intended
for the authorities to kill him and felt that with his history that might be their intention as well, to rid
society of this pariah once and for all. So we called every head law enforcement official in the area- the
Sheriff, the Police Chief, the FBI – and warned them of his state of mind and to take care how they caught
him. The man was sick and had been for many years. He was reduced to being tracked like a scared
rabbit or a dangerous predator.
         Certainly he has graduated to crimes that demand he be kept locked away from society. The
reasons he is there are rooted in his childhood, when he literally cried out for help and no one answered.
Over time, he lost all hope of having a normal life. The only place he felt he belonged or had status was
in jail.
         In the 1970s in his late teens he was sent to a psychiatric hospital for evaluation. Because he
feared being labeled ‘crazy’ and was sure he would be (and that he would end up at Lakeshore), he
persuaded his mother to bring him home before a diagnosis could be made. A few months later he began
using heroin and moved out of the house. Before long he had robbed both his mother and older brother of
property totaling more than $200,000. We all knew he was sick, but we didn’t know what to do. The jail
offered no treatment.
         My brother-in-law has a sentimental, loving side that I have seen. But a gentle spirit traumatized
from birth needs mercy and grace. All he has ever received is punishment. He has deserved his separation
from society, but why don’t we help people like him while they are inside in an environment we control? I
don’t understand. We are paying for our lack of attention to his psychiatric and substance abuse
disorders, integrating treatment so he can have hope of a measure of relief and recovery.
         From my own experience as a person with bipolar disorder and because of the strong genetic
history of his family, I know he has a severe form of the illness also known as manic depression. Many
children with ADHD eventually are diagnosed with bipolar disorder. Without early intervention,
treatment, and support, the result can be an adult much like my brother-in-law, who has caused so much
pain to his victims, to his family, while his own deep pain continues unalleviated to this day.
         He has no contact with any of us and no friends. He is alone. Imagine the anger that must burn
inside because of the injustices he has suffered. With no way to deal with thoughts that descend into
madness at times or his feelings of frustration, shame and grief of a life lived largely without hope or
love, he needs intense integrated treatment, including therapy, medication, coping skills, and Dual
Recovery Anonymous support to ever have a chance at a normal life on the outside.
         As a state, we have paid dearly for not assessing his disorders and treating them appropriately.
The cost of his trials, the police time spent tracking him, his incarcerations of about 30 years so far
approaches a million dollars! The human cost is beyond estimate.




Family and Consumer Illustrations                                           Appendix 1, Page 28
   Co-Occurrence: Bridging the Gap for Change
                 The Next Step

                  Appendix 2: Position Papers




Position Papers                            Appendix 2, Page 29
        Co-Occurrence: Bridging the Gap for Change
                      The Next Step



                   TAMHO
               Tennessee Association of Mental Health Organizations
Tennessee Association of Mental Health Organizations
Co-Occurrence of Mental Health and Substance Abuse/Addiction
Disorders

The Tennessee Association of Mental Health Organizations (TAMHO) supports
efforts to improve the provision of behavioral healthcare for persons with co-
occurring mental health (MH) and substance abuse or addiction (SA/A)
disorders. A comprehensive, integrated and well coordinated system of care
benefits all persons with service needs and especially benefits the significant
percentage of persons with co-occurring SA/A and MH disorders (estimates
range from 50-80%). Given that approximately 89% of persons with co-occurring
SA/A and MH disorders experienced the onset of mental illness first1, a system of
care that optimally integrates mental health and substance abuse/addiction
treatment is critical.

Furthermore, TAMHO member provider agencies assert that in order to develop
truly integrated systems of care, funding mechanisms must allow for, and
support, an integrated treatment approach that addresses both mental health and
substance abuse/addiction disorders concurrently. Other barriers, such as
conflicting facility licensure rules and processes, must also be addressed in order
for provider agencies to fully develop integrated systems of care for persons with
co-occurring disorders.

Again, supporting efforts to improve the provision of care for persons with co-
occurring disorders is a priority for TAMHO member agencies. And, TAMHO
applauds the commitment members of the DDRN Task Force on Co-Occurring
Disorders have made to improve such systems of care.




1
    National Comorbidity Survey, February, 1994 Kessler, et. al., in Archives of General Psychiatry.

Position Papers                                                                     Appendix 2, Page 30
     Co-Occurrence: Bridging the Gap for Change
                   The Next Step
Moccasin Bend Mental Health Institute
100 Moccasin Bend Road
Chattanooga, TN. 37405

Moccasin Bend is a 172 bed psychiatric hospital consisting of ninety-one (91) Acute Care beds and eight-
one (81) Subacute beds for adults. The Institute serves a 23 county area extending north to the Kentucky
border. Four community mental health centers—Fortwood, Hiawassee, Joe Johnson and Plateau—serve
as the primary feeder facilities to the Institute and provide outpatient aftercare services to discharged
consumers.

During the most recent quarter beginning October 1,2001 to December 31,2001 and from January 2002 to
present, 40% of the hospital’s average daily admissions have been dually diagnosed with co-occurring
disorders. While the Institute is not certified to provide substance abuse treatment, a number of these
individuals require detoxification and stabilization of symptoms. The hospital does not provide bona fide
substance abuse treatment beyond stabilization of symptoms. Because the Institute is not certified for
substance abuse services, trained staff is also not in place to provide such treatment and deliver the
necessary specialized services. The vast majority of this population requires short-term stabilization of
symptoms with longer-term substance abuse treatment indicated. The recidivism rate is significantly high
among this population due in part to the absence of longer-term treatment. The Council on Alcohol and
Drug Abuse Services (CADAS) is the primary resource for referrals of patients needing longer-term
residential treatment. Bed availability at CADAS is limited due to the variety of community providers
feeding referrals to this agency, including other medical and psychiatric inpatient units at Valley
Psychiatric, Erlanger Medical Center, Parkridge, Eastridge and Memorial hospitals.

Limited residential treatment resources have a significant impact on the Institute and community,
resulting in longer hospital stays while awaiting bed availability at CADAS, Reality House—a halfway
house in Cleveland, or residential treatment facilities outside the Region 3 catchment area, most often in
Knoxville and Nashville. In effect the Institute becomes a holding facility, simply maintaining and
housing these individuals --- many with no place to go until a bed becomes vacant.

As a result of the substance abuse, many have lost jobs and housing, resulting in homelessness; many
have burned all their bridges and no longer have social support systems; many become aggressive and
violent secondary to the substance abuse and exacerbation of the illness; many end up in the criminal
justice system due to public drunkenness, disorderly conduct, trespassing, or conflicts and altercations
with others, including the police; many end up dead; many come to rely on the service system to provide
the necessary supports and to meet their needs.

On the front end, the number of admissions to the RMHIs might be significantly reduced were their
mechanisms in place for triage and crisis stabilization of this population. Once stabilized, further
evaluation would determine if further treatment and care are indicated and refer accordingly thus reducing
the demand for in-patient stays and freeing up more Institute beds for the SPMI population. One such unit
is in the planning stage by Volunteer Mental Health Care System with an anticipated start date by June
2002.




Position Papers                                                            Appendix 2, Page 31
     Co-Occurrence: Bridging the Gap for Change
                   The Next Step
Helen Ross McNabb Center, Inc.

Patricia A. Hall, Vice President
Helen Ross McNabb Center, Inc.
1520 Cherokee Trail
Knoxville, Tennessee 37920
phall@mcnabb.org

The Helen Ross McNabb Center, Inc. (HRMC) has 54 years of experience working with
residents of our community who have both mental illness and substance abuse issues. A merger
between HRMC and the detoxification rehabilitation institute in 1997 brought a wider range of
treatment possibilities into focus. Although this merger has, in and of itself, been quite
successful, professionals in our organization have continued to be frustrated by the difficulties
and barriers we have experienced in developing a structured treatment program, different than
what we had in either AOD or mental health, to serve this population. Some of the barriers
follow:

1.   Treating the dual diagnosed is difficult.... According to Dr. Clifford Tennison, Chief
     Medical Officer at McNabb - it is the most difficult challenge facing mental illness
     professionals at this time. New drugs have enabled many of the difficult disorders, i.e.
     schizophrenia and others, to be more readily controlled. However, there is none of that for
     co-occurring disorders. A (person with) borderline personality disorder and a co-occurring
     substance abuse disorder is, again according to Dr. Tennison, a predictor for the poorest
     outcomes possible - suicide rates climb in this population and symptom complications
     worsen.

2.   Dual disorders pose a terrible complication when treating children, whose symptoms are
     irregular and difficult to diagnose to begin with.

3.   The great majority of persons in the Knox county jail system have complications due to
     substance abuse and mental health illness’ in co-occurrence. HRMC conducts all the court
     ordered forensic evaluations in the Knox County Jail and, although we do mental health and
     AOD screening, we know that many fall through the cracks in getting the help that they
     need.

4.   Dual diagnosis treatment is difficult for providers, i.e. the two types of diseases require
     different training, different values and currently must access separate funding sources.

Our efforts at McNabb to treat this population have not been as extensive or successful as we had
originally envisioned. Although we have the components of a successful program, we have run
into one major problem; that problem is the availability of adequate psychiatric time. Under
TennCare, the valuable time of our doctors is often over used and not paid for if the AOD person
is not on TennCare.


Position Papers                                                     Appendix 2, Page 32
    Co-Occurrence: Bridging the Gap for Change
                  The Next Step
Mixing the different client populations has not proved successful either. Mental health
consumers are not always comfortable in an AOD setting and vice versa. We have lacked the
resources to establish a separate co-occurring treatment facility. It has not bee realistic to expect
an already exhausted, under funded system to add the extra initiative needed to make this type of
programming successful.

Tennessee has taken some steps to address the above-mentioned difficulties. Training supported
by both the department of health and the department of mental health has been significant. What
there hasn’t been from the state departments is an organized and systematic effort to address the
funding and resource issues.

From our experience, we believe a dedicated program is required. One that has a separate
funding source, different monitoring, specific over sight, specific core competency requirements,
and designated standards of care. We believe dual diagnosis programming should be a specific
form of treatment, as is residential care, case management, detoxification, etc. Sequential
treatment does not work for such a debilitating disorder. A framework and structure need to be
developed and supported at a state level.

Without the needed level of support, agencies such as ours will continue to struggle with offering
co-occurring treatment with overwhelming demands for our already existing system, whether it
be mental health or substance abuse -- and will, therefore, fall short of our goal of serving a
specific dual diagnosed population of consumer.




Position Papers                                                        Appendix 2, Page 33
     Co-Occurrence: Bridging the Gap for Change
                   The Next Step
The Region III Provider Task Force on Co-occurring Disorders

The Identification and Treatment of Co-Occurring Mental Illness(es) and
Addictive Disorder(s) – A Perspective from Region III
Situational Analysis

Major stakeholders in the provision of treatment services for the mentally ill or persons with
addictive disorders in Region III have learned the benefits of collaboration and connectivity.
Current stakeholders include: AdvoCare of Tennessee, Tennessee Department of Mental Health
and Developmental Disabilities, Moccasin Bend Mental Health Institute, Valley Behavioral
Health Care System and Valley Psychiatric Hospital, Pine Ridge Treatment Center at Cleveland
Community Hospital, A.I.M. Center, Fortwood Center, Council on Alcohol and Drug Abuse
Services (CADAS), Comprehensive Community Care, National Alliance for the Mentally Ill
(Tennessee) and Volunteer Behavioral Health Care System.

Collaboration by this group has resulted in:

1. The development of comprehensive housing services for high risk/high needs persons with
   severe and persistent mental illness (SPMI).
2. Sharing of resources, e.g., if a case managed consumer from Fortwood Center needs a
   supported living facility placement and the only one available is at a Johnson Mental Health
   facility, the Fortwood consumer gets the placement and maintains case management at
   Fortwood. This promotes continuity of care and meeting needs of consumer.
3. Major reduction in number of long term care consumers at Moccasin Bend Mental Health
   Institute.
4. Strategic planning in addressing co-occurring mental illness and addictive disorders
   treatment needs in Region III.

Collaborators began to formally address the impact of co-occurring mental illnesses and
addictive disorders in July 2001. Following are the findings, recommendations and the current
status of projects in Region III impacting services for persons with co-occurring mental illnesses
and addictive disorders.

Findings

1.     Significant data exists identifying the extent of co-occurring mental and addictive
       disorders. The generally accepted estimate in the United States is 10-12 million.
       Extrapolated to Tennessee, the estimate is approximately 240,000. Extrapolated to
       Region III, the estimate is 34,000. Anecdotal estimates are that 30-50% of Mobile Crisis
       contacts and acute psychiatric care recipients are persons with co-occurring illnesses.




Position Papers                                                      Appendix 2, Page 34
      Co-Occurrence: Bridging the Gap for Change
                    The Next Step

2.     Treatment providers have identified high risk/high needs consumers with either extensive
       or frequent acute psychiatric episodes as persons with co-occurring mental and addictive
       disorders.
3.     Region III is primarily rural in nature, consisting of 23 counties in east central Tennessee
       ranging from the North Carolina, Georgia and Alabama borders to Kentucky. The
       majority of mental and addictive disorders services are in the Hamilton and Bradley
       Counties areas with a limited availability in the Putnam County area of the Upper
       Cumberland. Historically there has been limited coordination of services for co-
       occurring illnesses by providers in the region. Most services are for the adult population.
4.     The Region III Mental Health Planning Council has historically identified the need and
       recommended comprehensive treatment services for persons with co-occurring mental
       and addictive disorders.
5.     Persons with co-occurring disorders frequently have extensive law enforcement contact
       and are at high risk of incarceration.
6.     Limited housing options exist for persons with co-occurring illnesses due to criminal
       history and/or history of drug involvement while residing in public housing, supported
       living facilities, boarding homes, etc.
7.     Numerous treatment professionals fail to assess for, identify, and/or treat co-occurring
       disorders.
8.     Assessment strategies and instruments are available to assist in determining whether a co-
       occurring mental and addictive disorder exists or not, e.g., Comprehensive Addictions
       and Psychological Evaluations (CAAPETM); Practical Adolescent Dual Diagnosis
       Interview (PADDITM).
9.     The strategy for determining the priority adult population (SPMI) in Tennessee (CRG)
       does not include impact of addictive disorders.
10.    Treatment providers primarily utilize a ‘silo approach’ to treating mental illness and
       addictive disorders in Region III. The delivery system exemplifies the parallel and
       sequential approaches. Research shows integrated treatment vastly improves recovery
       potential. Comprehensive Community Care (CCC) provides a SMISA (Severely
       Mentally Ill – Substance Abusing) service consisting of outpatient psychiatric care, case
       management, alcohol and/or drug counseling and other supportive services in an
       integrated model.
11.    Funding streams for treatment services do not facilitate development of co-occurring
       services generally reflecting the ‘silo’ approach previously discussed.
12.    There are limited community support groups for persons with co-occurring mental and
       addictive disorders.
13.    Mental Health treatment providers utilize medical necessity to determine treatment
       intensity while addictive disorders treatment providers use the American Society of
       Addiction Medicine (ASAM) criteria.
14.    There is no formal on-going training initiative to train a cadre of providers in the
       integrated care model.



Position Papers                                                       Appendix 2, Page 35
     Co-Occurrence: Bridging the Gap for Change
                   The Next Step

Recommendations - General

1.       Educate Federal, State and Regional stakeholders on extent of co-occurring mental and
         addictive disorders and need for integrated service delivery system.
2.       Development of strategic plan for the implementation of comprehensive treatment
         services for co-occurring mental and addictive disorders in Tennessee utilizing an
         evidence based integrated model.
3.       Development of a comprehensive and on going training system on integrated care of co-
         occurring disorders for providers/treating professionals.
4.       Development of service funding strategies recognizing nuances of treating persons with
         co-occurring mental and addictive disorders. For instance, funding mechanisms need to
         permit the Tennessee Department of Mental Health and Developmental Disabilities along
         with the Tennessee Department of Health – Bureau of Alcohol & Drug Abuse Services to
         address services for co-occurring illnesses.
5.       Seed community support groups for persons with co-occurring illnesses.

Recommendations – Region III

1.   Regional acceptance of ‘co-occurring’ illnesses by providers and advocates
2.   Crisis Stabilization unit(s) capable of serving persons with co-occurring disorders.
3.   Medical detoxification services sensitive to co-occurring disorders.
4.   Long term residential treatment for persons with co-occurring disorders to be used in
     conjunction with acute and subacute care.
5.   Supervised Residential/Halfway for persons with co-occurring disorders.
6.   Development of housing options specifically targeting needs of persons with co-occurring
     disorders.
7.   Case Management services for persons with co-occurring focus:
     a. Expand SMISA in Hamilton County
     b. Pilot CTT in rural area serving people with co-occurring conditions
8.   Pilot a regional comprehensive treatment continuum of care for persons (adults and
     adolescents) with co-occurring illnesses.

Note: Region III recommendations initially developed during July 2001 Region III Assessment
of Services for Persons with Co-Occurring Mental Illness and Addictive Disorders. Participants
were: Michelle Bostwick, Fortwood Center; Gloria Bulloch, Moccasin Bend Mental Health
Institute; Chandra Fears, formerly with AdvoCare of Tennessee; Pat Fitzpatrick, formerly with
Valley Psychiatric Hospital; Joel Klein, Cleveland Community Hospital; Linda Loy formerly
with CADAS; Melissa Wilson, Comprehensive Community Care; and Dan Smith and Jerry
Jenkins of Volunteer Behavioral Health Care System

Status




Position Papers                                                    Appendix 2, Page 36
    Co-Occurrence: Bridging the Gap for Change
                  The Next Step
1. Walk-in/Police Diversion Center opened by Volunteer Behavioral Health Care System in
   December 2001 as part of comprehensive service continuum for persons with mental
   illness/co-occurring mental and addictive disorders. Stakeholders include Tennessee
   Department of Mental Health and Developmental Disabilities, AdvoCare of Tennessee,
   Hamilton County Sheriff’s Department, Chattanooga Police Department and Erlanger Health
   System.
2. Crisis Stabilization Unit being developed in Hamilton County by Volunteer Behavioral
   Health Care System with capacity of serving persons with co-occurring disorders.
   Stakeholders include Tennessee Department of Mental Health and Developmental
   Disabilities, AdvoCare of Tennessee, Hamilton County Sheriff’s Department, Chattanooga
   Police Department, Erlanger Health System, National Alliance for the Mentally Ill
   (Tennessee), Moccasin Bend Mental Health Institute, Valley Psychiatric Hospital, CADAS,
   Fortwood Center and Comprehensive Community Care. Operational date is projected to be
   June 2002.
3. Medical Detoxification Services – Cleveland Community Hospital and Valley Psychiatric
   Hospital are currently providing services for persons with co-occurring illnesses. The Crisis
   Unit being developed by Volunteer will add ambulatory capacity for detoxification services
   for persons with co-occurring illnesses.
4. Residential Services for Co-occurring Disorders – Volunteer Behavioral Health Care System,
   in collaboration with the Tennessee Department of Mental Health and Developmental
   Disabilities, AdvoCare of Tennessee, National Alliance for the Mentally Ill (Tennessee),
   Moccasin Bend Mental Health Institute, Valley Psychiatric Hospital, CADAS, Fortwood
   Center and Comprehensive Community Care, is pursuing implementation of a Residential
   Treatment facility in Region III.
5. Housing – The CHI – Creating Homes Initiative – of the Tennessee Department of Mental
   Health and Developmental Disabilities is pursuing housing options for persons with co-
   occurring disorders. Specific emphasis is being placed on having resources for persons with
   co-occurring disorders who previously have a criminal history. Stakeholders include
   Moccasin Bend Mental Health Institute, CADAS, Volunteer Behavioral Health Care System,
   Fortwood Center, Chattanooga Housing Authority and the A.I.M. Center.

Respectfully submitted by:

Jerry A. Jenkins, M. Ed., LADAC, MAC
Vice President, Area Operations (Southern Tier)
Volunteer Behavioral Health Care System




Position Papers                                                     Appendix 2, Page 37
      Co-Occurrence: Bridging the Gap for Change –
                     The Next Step

Knox Area Rescue Ministries
Gabrielle Cline
Director or Client Services
Knox Area Rescue Ministries
865.673.6550

        At Knox Area Rescue Ministries, we see a large population of people with co-occurring
disorders in our residential programs for men, women and families and in our overnight
programs for men and for women. For approximately 30% of the people in our residential
programs (about 103 people in 2001) and an unknown number of people in our overnight
programs, the combination of mental illness and addiction has played a significant role in
becoming homeless.
        There are many barriers to helping this population. First, it is extremely difficult to
obtain an accurate diagnosis. Many of our clients are quite transient and receive services from
our shelter on an inconsistent basis. In addition, many of the mental illnesses they suffer from
present a challenge to engaging the client and establishing a helping relationship. The fact that
most of our clients lack access to adequate physical and mental health care is yet another barrier.
The most recent study of the homeless in the Knoxville area, Homelessness in Knoxville/Knox
County: 2000 found that 49% of our clients (or about 1724 people) have no access to health
insurance (Nooe, 2000). These clients must, therefore, rely on the Health Department or hospital
emergency rooms for their medical and psychiatric care. Around 14% (493 people) report
receiving no health care whatsoever in the past year (Nooe, 2000). The 51% of our clients (1794
people) who do have TennCare (Nooe, 2000) have great difficulty locating providers for mental
health or addiction treatment, let alone providers who specialize in the treatment of co-occurring
disorders/dual diagnosis.
        A problem we face frequently with our overnight population is a lack of viable options
when we are unable to serve them. When we cannot safely contain a person due to out-of-
control behavior (frequently the direct product of their co-occurring disorders), we have very
limited options. The best current option is to contact the Mobile Crisis Unit to seek admission to
a psychiatric facility. However, this can only be done if the client is a threat to self or others. If
the client does get admitted to a psychiatric hospital, they are frequently treated only briefly (and
often only for the mental illness) and then released. For the homeless population, the chances of
adequate follow-up with the discharge plan are low. The only other option for a person we
cannot safely serve is to contact the police who may either take the person to jail or simply escort
them off the property. Neither of these options connects people with services that will help treat
their co-occurring disorders.
        There is also a great need for both transitional and permanent supportive housing for our
clients with co-occurring disorders. Many of our clients face difficulties when they complete our
residential program. While they may have achieved recovery and function well in our setting,
they are at high risk for relapse when asked to move out on their own. However, there is a lack
of transitional housing to help them ease into independent living while still receiving support.

    All client numbers are from 2001.

Position Papers                                                         Appendix 2, Page 38
   Co-Occurrence: Bridging the Gap for Change –
                  The Next Step

Yet another segment of our dually diagnosed population is in need of permanent supportive
housing in order to maintain their recovery and function at their highest level. In this area, too,
there is a lack of resources.
        The issue of developing adequate resources for those with co-occurring disorders
becomes that much more important when we consider the impact on children. Approximately
50% of dually diagnosed clients in our residential program have children. Some of these
children have been placed in foster care due to the parents’ inability to care for them. Other
children have suffered from a mother or father who has not been involved in their lives due to the
parent’s dual diagnosis. And still other children are currently spending important childhood
years in a shelter setting while their parents attempt to recover to a point where they can live
independently and adequately take care of their families.
        In summary, the lack of adequate resources for dually diagnosed individuals has a large
and detrimental impact on the homeless population. Such clients often go undiagnosed and,
when they are diagnosed, have difficulty accessing adequate treatment. There are a limited
number of providers in the community that address both the client’s mental health issues and
substance abuse issues. In addition, there are few options in terms of emergency care for this
population. For dually diagnosed clients who do reach a level of stability in their recovery, there
are few support services that will allow them to live independently (when this is possible) or in a
supportive environment that will allow them to minimize the number of re-hospitalizations and
relapses. In creating services for the dually diagnosed, it is important also to include those
outside of the typical mental health arena (such as law enforcement, hospitals, and shelters) in
planning and policy decisions.



Nooe, R. M. (2000) “Homelessness in Knoxville/Knox County: 2000”, Knoxville:
       Knoxville Coalition for the Homeless.




Position Papers                                                       Appendix 2, Page 39
  Co-Occurrence: Bridging the Gap for Change –
                 The Next Step

Peninsula Behavioral Health Position Paper
Co-occurring Psychiatric Illness and Substance Abuse / Chemical
Dependency
Who we are:
 Peninsula Behavioral Health is comprised of Peninsula Hospital, an acute care
 psychiatric facility; Peninsula Village, a residential program serving adolescents;
 Peninsula Lighthouse, which provides partial hospitalization and intensive outpatient
 services; and Peninsula Outpatient Centers, which provides community mental health
 services. These community services include individual, group and family therapy,
 medication management, mobile crisis services, case management, psychiatric
 rehabilitation, supported employment, supported housing, drop-in centers and alcohol
 and drug treatment services. This continuum of care serves children, adolescents and
 adults. Peninsula Behavioral Health is a non-profit member of the Covenant Health
 System, a healthcare delivery organization headquartered in Knoxville, Tennessee.
 Services include acute care hospitals, outpatient facilities, and specialized care in
 areas such as cancer, rehabilitation, physician and specialty clinics, and home care.
 Covenant Health includes approximately 1,500 licensed beds, approximately 8,000
 employees and about 1,700 affiliated physicians.


Barriers to Treating Co-occurring Illness:

 Peninsula Behavioral Health is an integrated system of care that combines elements of
 both mental health and addiction treatment into a unified and comprehensive treatment
 program for our patients. In treating co-occurring illness and chemical dependency or
 substance abuse, two themes emerged as problems or barriers to successful
 treatment. These issues are funding and education / staff training.

 The issue of funding has many aspects that affect the treatment of co-occurring
 disorders.
  The cost of treatment is high. Patients with co-occurring disorders incur significantly
    higher healthcare costs than patients with a single disorder. Emotional and
    physical stability are always compromised by addiction, as is compliance with
    medical and mental health treatment.
  Length of treatment is increased with co-occurring disorders as the patient receives
    concurrent treatment of both illnesses.
  Reimbursement restrictions placed by third party payers also adds a heavy burden
    to both the patient and the agency trying to integrate care.

 The second issue that continues to be a barrier to the treatment of co-occurring
 disorders and chemical dependency is one of staffing / education. Hiring staff who are

Position Papers                                                Appendix 2, Page 40
 Co-Occurrence: Bridging the Gap for Change –
                The Next Step

competent and dedicated to the unified and comprehensive philosophy of co-occurring
illnesses is difficult. Staff typically falls into one of two categories: those who are
trained to treat chemical dependency or those who are trained to treat mental health
issues. Current research has not determined a best approach that has proven to be
successful with all individuals. Therefore, competence of staff to provide treatment
interventions from both perspectives has the potential for producing optimum results
for the client.




Position Papers                                              Appendix 2, Page 41
  Co-Occurrence: Bridging the Gap for Change –
                 The Next Step

Frayser Mental Health Center




Position Papers                  Appendix 2, Page 42
 Co-Occurrence: Bridging the Gap for Change –
                The Next Step




Position Papers                 Appendix 2, Page 43
  Co-Occurrence: Bridging the Gap for Change –
                 The Next Step

Tennessee Voices for Children




Synopsis Reports by Region and Topic   Appendix 3, Page 44
 Co-Occurrence: Bridging the Gap for Change –
                The Next Step




Synopsis Reports by Region and Topic   Appendix 3, Page 45
  Co-Occurrence: Bridging the Gap for Change –
                 The Next Step

Centerstone Community Mental Health Center




Synopsis Reports by Region and Topic         Appendix 3, Page 46
  Co-Occurrence: Bridging the Gap for Change –
                 The Next Step

Ridgeview Psychiatric Hospital and Center, Inc.




Synopsis Reports by Region and Topic              Appendix 3, Page 47
 Co-Occurrence: Bridging the Gap for Change –
                The Next Step

Appendix 3: Synopsis Reports by Region and Topic




Synopsis Reports by Region and Topic    Appendix 3, Page 48
                      Co-Occurrence: Bridging the Gap for Change –
                                     The Next Step
                   Education/Recognition of Need                                                                                               Region 1

                           Change 1                                          Change 2                                      Change 3
              Influential people must be involved                          Develop speakers bureau                      Develop resource materials
    Step 1     Recruit powerful people to join the region          Create speakers bureau by recruiting Create online resource directory with "if this,
                              co-occurrence committee             speakers from mental health, A&D, co-                         then this" flow chart
                                                                      occurrence fields with coordinator
    Step 2              Hold legislative panel event with     Develop talking points that all speakers will   Monthly or quarterly online one-page article
                  policymakers and third party payors to             incorporate into their presentations      that could be downloaded as an insert into
                 educate all about the needs in Region I                                                                                other publications
    Step 3 Recruit powerful people to join the speakers               Develop and coordinate speaking               Distribute article and link to resource
                               bureau to influence others      opportunities with community groups, etc.                   directory via email/mail across
                                                                                                                constituencies, inc. criminal justice, A&D,
                                                                                                                                        mental health, etc.


                   Education/Recognition of Need                                                                                               Region 2

                         Change 1                                          Change 2                                        Change 3
                   Community outreach regarding                    Media champion(s) promote the                   Provider commitment increases
                    resources and how to access                                           cause
    Step 1    Metropolitan Drug Commission, partnering                Identify panel of champions (well-            Recommend that Summit and other
                with A&D Bureau, supported by A&D/MH             known/respected individuals, preferably          A&D/MH trainings include co-occurring
              cmty. has agreed to develop a plan to train           recovering w/ co-occurring disorder)                   disorders training, education
              trainers for outreach to faith cmty., medical
                                                 cmty, etc.

    Step 2 Create a coordinated speakers' bureau with Collaborate w/ champion(s) and key leaders                    Convene local focus groups, possibly
                  bullet points developed that each will                           to do media campaign           through drop-in centers, w/ consumers,
                      present, listing each speaker, inc.                                                          family, advocates and providers to talk
               consumers, family, advocates, providers,                                                                     about dual consumers' needs
                                 etc., by are of expertise




Work Group Discussion Outline                                                     Appendix 4, Page 49
                      Co-Occurrence: Bridging the Gap for Change –
                                     The Next Step
    Step 3 Advertise availability of 211 online directory      List opportunities that currently exist or        Encourage provider organizations to
                      in Region II and continually update       could be created, such as community            embrace co-occurrence in their mission
                                                             events-exhibits and/or speaking- forums,                                     statements
                                                              other venues at which champions could
                                                                          attend to promote the cause


                   Education/Recognition of Need                                                                                          Region 3

                           Change 1                                       Change 2                                        Change 3
                       Cmty Anti-Stigma Campaign                             Targeted education              Criminal Justice System to address
                                                                                                                         co-occurrence humanely
    Step 1    Identify resources in entire region and         Develop a speakers' bureau with all                      Educate in person about the
              compile a directory with the name of a        speakers listed by area(s) of expertise         need/impact of unrecognized/untreated
                 contact person (Chattanooga has a            and agreement to share same basic                co-occurrence to the CJ system (by
              loose-leaf directory that the task force          information about co-occurrence,            sharing statistics and medical aspects)
                                       should review)                       possibly through MHA               and about the treatments/diversions
                                                                                                                   available throughout the region


    Step 2     Media Involvement: A) Print media to Coordinator- possibly Reg. III Advocacy                      Promote diversion as preferable if
               write articles that refer to directory; B) and Public Education Committee- to                                          appropriate
                  TV panel w/ providers, consumers,         advertise availability of speakers,
               sheriff, advocates as a public service;        identify target groups, to set up
               C) PSA on TV and radio; D) Panel on                     speaking engagements
                                     talk radio program
    Step 3 Directories subsidized for distribution or               Town Hall Meetings about co-              Advocate for increased availability of
            available as link to websites with a toll-             occurrence for targeted groups                   psychiatric treatment including
                        free contact number to call                                                          medications, early and in coordination
                                                                                                             with current treatment provider(s) and
                                                                                                                the provision of transition services



                   Education/Recognition of Need                                                                                          Region 4




Work Group Discussion Outline                                                  Appendix 4, Page 50
                  Co-Occurrence: Bridging the Gap for Change –
                                 The Next Step
                                        Change 1                                 Change 2                                Change 3

    Step 1
    Step 2
    Step 3

                Education/Recognition of Need                                                                            Region 5

                                        Change 1                                 Change 2                                Change 3

    Step 1
    Step 2
    Step 3

                Education/Recognition of Need                                                                            Region 6

                                        Change 1                                 Change 2                                Change 3

    Step 1
    Step 2
    Step 3

                Education/Recognition of Need                                                                            Region 7

                                        Change 1                                 Change 2                                 Change 3
                                       Education              Lack of funding/resources        State identification/endorsement
    Step 1   Case management is a huge place to     Gather data from central intake, jails,     Letter to local politicians- mayors,
                  start with dual diagnosis teams AdvoCare, and from everyone who has            Roscoe Dixon, Katherine Bowers
                                                   data to find out specifically what is not
                                                                                  available




Work Group Discussion Outline                                         Appendix 4, Page 51
                    Co-Occurrence: Bridging the Gap for Change –
                                   The Next Step
    Step 2   Reciprocal trainings between A&D and         Present some local numbers to the Public Service Announcements- contact
              mental health once a month (Sharon        legislature and to state A&D and MH TV stations; TN Protection & Advocacy
                   Trammell-Grace House) to open                                    divisions.      to put info in their newsletter; El
                                communication lines                                                  Shaddai- television opportunity


    Step 3   Talk to AdvoCare about dual diagnosis                                    (none)                                    (none)
                     case management, pushing for
             additional resources for co-occurrence
                                             teams


                                            Policy                                                                           Region 1
                                                                                                                             Region 1

                                    Change 1                                    Change 2                                    Change 3
                Combine A&D with Mental Health        Create a co-occurrence state liaison      Create a safety net for co-occurring
                                                                                                                disorders treatment
    Step 1      Recommend combination to MHDD            Recommend combination to MHDD          Ask state co-occurrence committee to
                       Policy & Planning Council                Policy & Planning Council           ask AdvoCare what services and
                                                                                                       supports they are contractually
                                                                                                     obligated to pay and under what
                                                                                                                       circumstances
    Step 2       Inform legislators of the need for a Recommend to Commissioners Wadley           Ask Bob Benning to write a letter co-
                              combined department                            & Rukeyser           signed by Rukeyser & Wadley to the
                                                                                                 governor to ask for establishment of a
                                                                                                     contract change indicating who is
                                                                                               responsible for co-occurrence treatment
                                                                                                                          and supports
    Step 3        Recommend pursuit of joint grant        Inform legislators of the need for a     Go to the TennCare Oversight
                                   opportunities                       combined department Committee of the Legislature asking for
                                                                                                                      a safety net


                                            Policy                                                                           Region 2



Work Group Discussion Outline                                          Appendix 4, Page 52
                    Co-Occurrence: Bridging the Gap for Change –
                                   The Next Step

                                       Change 1                                  Change 2                                      Change 3
                       Licensure changes needed                     Need outcome measures            Criminal justice system is not an
                                                                                                         appropriate treatment venue
    Step 1    Demystify the process of licensure and      Research outcome measures in other               Recommend that DRI-Doc be
             /or examine licensure through TAMHO,           states and how they have affected       reinstituted with mental health crisis
              TAADAS, and the DMHDD Planning &                                          policy                                capabilities
                                      Policy Council
    Step 2     Recommend that licensure rules and         Advocate that desired outcomes drive Recommend training for judges, district
              Title 33 need to facilitate the provision                                 policy    attorneys, and public defenders that
                  of effective co-occurrence services                                           promotes diversion, use of drug court
                                                                                                   where appropriate, and appropriate
                                                                                                                       treatment in jail
    Step 3 Need to create a local media strategy to        Convene a TN committee to develop Appeal to Dept. of Justice to investigate
             educate the public about barriers and                        outcome measures         issues of inmates w/ co-occurring
              bring attention to the issue so public                                         disorders having ADA rights violated by
                sentiment will help insure changes                                               being denied treatment, mistreated,
                                            happen                                              having a lack of both continuing care
                                                                                                              and transition planning


                                               Policy                                                                          Region 3

                                      Change 1                                      Change 2                              Change 3
                Need coordination between state                 Change policy of cutting off       TennCare limits on A&D treatment
                             and local agencies            TennCare in jail without automatic                    should be removed
                                                                                reinstatement
    Step 1     Region III Co-Occurrence committee          Find out more about reasons for this      Advocate for parity in TN by all co-
                               will advocate for this                   policy and alternatives         occurrence committees, with all
                                                                                                        stakeholders being informed of
                                                                                                          current/proposed policies and
                                                                                                     encouraged to act to change policy




Work Group Discussion Outline                                             Appendix 4, Page 53
                    Co-Occurrence: Bridging the Gap for Change –
                                   The Next Step
    Step 2     Develop a flow chart of "if this, then   Advocate for change, inc. suspension,   Advocate for federal parity
                this"... what to do for agencies who                           not revocation
             encounter persons with co-occurrence
                           in various stages of need
    Step 3          Committee to monitor progress          Advocate for services for inmates,                       (none)
                                                                 whatever the payor source

                                              Policy                                                             Region 4

                                          Change 1                                 Change 2                     Change 3

    Step 1
    Step 2
    Step 3

                                              Policy                                                             Region 5

                                          Change 1                                 Change 2                     Change 3

    Step 1
    Step 2
    Step 3

                                              Policy                                                             Region 6

                                          Change 1                                 Change 2                     Change 3

    Step 1
    Step 2
    Step 3

                                              Policy                                                             Region 7



Work Group Discussion Outline                                           Appendix 4, Page 54
                 Co-Occurrence: Bridging the Gap for Change –
                                The Next Step

                                    Change 1                                  Change 2                                      Change 3
                          Clear Identification                                        Jail                        Medical Necessity
    Step 1      Check on how Arizona's plan is Get list of current mental health liaisons     Find out what this currently means and
                                      working.                          by next meeting                        why our clients don't fit
    Step 2   Have A&D and MH divisions clearly    Get input from Nacy Lawhead of the           Find out what the insurance company
                     identify where they stand                  Memphis Mayor's office          policies are regarding dual diagnosis
                                                                                                               and medical necessity
    Step 3    Contact Insurance Commissioner Present info to other task forces around         Recommend to follow ASAM as a part
                                                                             Memphis                         of medical necessity
    Step 4   Care and treatment of clients (care       Find out Drug Court's position                                     (none)
                           home auditing, etc.)

                          Provider Capabilities                                                                              Region 1

                                   Change 1                                     Change 2                               Change 3
              Revise TennCare to follow best                        Cross-train providers        Improve treatment access in jails
                         practice guidelines
    Step 1                          (unclear)            Ask licensure to require A&D and            Recommend that TennCare be
                                                         mental health education at higher      suspended, not revoked, for inmates
                                                      education levels for degrees that are
                                                                   necessary for clinicians
    Step 2                             (unclear)          Provide continuing education for         Find out who provides effective
                                                                                providers services in jail and advocate to replicate
                                                                                             treatment & DRA meetings statewide

    Step 3                             (unclear)    Ask appropriate body to require that all      Recommend that judges facilitate
                                                   state-supported and/or -funded provider transition services so that consumers in
                                                      trainings and conferences have a co-         jail are hooked up with outpatient
                                                                    occurrence component        services immediately upon release


                          Provider Capabilities                                                                              Region 2




Work Group Discussion Outline                                        Appendix 4, Page 55
                     Co-Occurrence: Bridging the Gap for Change –
                                    The Next Step
                                         Change 1                                 Change 2                                    Change 3
                                 Educate providers            Assess capacity to meet needs           Training at Higher Education level
    Step 1
    Step 2
    Step 3

                              Provider Capabilities                                                                              Region 3

                           Change 1                                   Change 2                                   Change 3
                                  Flexible Funding                     Full continuum of care                                     Housing
    Step 1       Advocate for a blended rate for co-                      Identify service gaps       Contact Marie Williams about options
              occurrence treatment so that chemical                                                 for persons with co-occurring disorders
                 dependency is treated, as needed,
                   equal to and in coordination with
                     treatment for psychiatric illness
    Step 2        Advocate for co-equal divisions of       Prioritize specific service needs with    Identify what housing is available and
              Alcohol and Drug Abuse Services and        Planning Councils, TennCare Partners                           where gaps exists
             Mental Health Services within their own       Roundtable, TAMHO, TAADAS, etc.
                                        department
    Step 3 Add a dual diagnosis component to the                  Advocate for needed services            Plan to address housing barriers
            next statewide NAMI conference to be
                                 held in Memphis


                              Provider Capabilities                                                                              Region 4

                           Change 1                                   Change 2                                   Change 3

    Step 1
    Step 2
    Step 3

                              Provider Capabilities                                                                              Region 5



Work Group Discussion Outline                                             Appendix 4, Page 56
                   Co-Occurrence: Bridging the Gap for Change –
                                  The Next Step

                          Change 1                                Change 2                    Change 3

    Step 1
    Step 2
    Step 3

                            Provider Capabilities                                                         Region 6

                          Change 1                                Change 2                    Change 3

    Step 1
    Step 2
    Step 3

                            Provider Capabilities                                                         Region 7

                        Change 1                                 Change 2                     Change 3
                            Cross-training staff                      CEU Requirements             Screening Tools
    Step 1    Come up with dual diagnosis training Propose to state health boards planning
                                                            a dual diagnosis training track

    Step 2 Add a dual diagnosis component to the Propose to the criminal justice system
            TN Protection & Advocacy training for planning a dual diagnosis training track
                              lawyers and judges
    Step 3 Add a dual diagnosis component to the                                    (none)
            next statewide NAMI conference to be
                                 held in Memphis


                                        Oversight                                                         Region 1

                                        Change 1                                 Change 2                Change 3



Work Group Discussion Outline                                        Appendix 4, Page 57
                    Co-Occurrence: Bridging the Gap for Change –
                                   The Next Step

    Step 1                 no recommendation yet                   no recommendation yet              no recommendation yet
    Step 2                 no recommendation yet                   no recommendation yet              no recommendation yet
    Step 3                 no recommendation yet                   no recommendation yet              no recommendation yet

                                        Oversight                                                                   Region 2

                                         Change 1                               Change 2                           Change 3

    Step 1                 no recommendation yet                   no recommendation yet              no recommendation yet
    Step 2                 no recommendation yet                   no recommendation yet              no recommendation yet
    Step 3                 no recommendation yet                   no recommendation yet              no recommendation yet

                                        Oversight                                                                   Region 3

                                         Change 1                               Change 2                             Change 3
                               Outcome Measures                         Monitoring Body        Co-Occurrence Coordinator
    Step 1       Create a short-term work group to     Ask Bureau of A&D and Division of     Ask state to hire a co-occurrence
                  develop outcome measures with       Mental Health Svcs. how they plan to       coordinator under TDMHDD
             support of Bureau of A&D and Division                  monitor dual services?
                             of Mental Health Svcs.
    Step 2                                  (none)                                 (none)                              (none)
    Step 3                                  (none)                                 (none)                              (none)

                                        Oversight                                                                   Region 4

                                         Change 1                               Change 2                           Change 3

    Step 1
    Step 2
    Step 3




Work Group Discussion Outline                                        Appendix 4, Page 58
                   Co-Occurrence: Bridging the Gap for Change –
                                  The Next Step

                                         Oversight                                                                     Region 5

                                         Change 1                               Change 2                              Change 3

    Step 1
    Step 2
    Step 3

                                         Oversight                                                                     Region 6

                                         Change 1                               Change 2                              Change 3

    Step 1
    Step 2
    Step 3

                                         Oversight                                                                     Region 7

                                      Change 1                                   Change 2                             Change 3
                        No oversight or protocol                  Oversight of Continuum No outcome requirements for Mental
                                                                                                                          Health
    Step 1     Identify need for additional research   Give ideas to develop a continuum of Recommend a need for mental health
                                                                                       care                            outcomes
    Step 2 Add a dual diagnosis component to the                                     (none)   Look at what TOADS has to offer in
            TN Protection & Advocacy training for                                                           terms of information
                              lawyers and judges
    Step 3                                   (none)                                (none)                                (none)




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               Appendix 4: Work Group Discussion Outline
Note: These are slide panels from a PowerPoint presentation.




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                      Appendix 5: Literature Citations

Bartels, S.J., Drake, R.E., & Wallach, M.A. (1995). Long-term course of substance use disorders
    among patients with severe mental illness. Psychiatric Services, 46, 248-251.

Barthwell, Andrea, M.D. (2000). Working Together for Recovery, An RCSP Gathering; Plenary
    Presentation: Working Together to Reduce Stigma.

Coley, Carol, M.S. & Reyes, Rosa M (2001). Co-occurring Dialogues Discussion Group, Center
    for Substance Abuse Treatment, SAMHSA.

Cocozza, JJ & Skowyra, KR. (2000). Youth with mental health disorders: Issues and emerging
   responses. Juvenile Justice. 7:3-13.

Crowley, TJ & Riggs, PD. (1999). Adolescent substance use disorder with conduct and comorbid
   conditions. In: Adolescent Drug Abuse: Clinical Assessment and Therapeutic Interventions.
   NIDA Research Monograph, Number 156 Rockville, MD: NIDA.

CSAT. (2000). The Change Book: A Blueprint for Technology Transfer. ATTC National Office:
   Kansas City, MO.

Dixon, L., McNary, S. & Lehman, A. (1998). Remission of substance use disorder among
    psychiatric inpatients with mental illness. American Journal of Psychiatry, 155, 239-243.

Drake, R.E., Osher, F.C., & Wallach, M.A. (1991). Homelessness and dual diagnosis. American
    Psychologist, 46(11), 1149-1152.

Flowers, Andrea. (2002). Co-occurring Mental and Substance Use Disorders Among Tennessee
    Adolescents. IMPACT Study Data Dissemination Project, Tennessee Voices for Children
    and Vanderbilt University Center for Mental Health Policy.

Fullilove, M.T., & Fullilove, R.E. (1994). Post-traumatic stress disorder in women recovering
     from substance abuse, in Anxiety Disorders in African Americans. Edited by S. Friedman.
     New York: Springer.

Gigliotti, Marcus,(1986,October-November) Program Initiatives for Dually Diagnosed at Harlem
    Valley P.C. Quality of Care Newsletter by the N.Y.S. Commission on Quality of Care. Issue
    28, p.9.

Greenbaum, PE, Foster-Johnson, L, Petrila, A. (1996). Co-occurring addictive and mental
    disorders among adolescents: Prevalence research and future directions. Am. J.
    Orthopsychiatry. 66:52-60.


Literature Citations                                               Appendix 5, Page 76
   Co-Occurrence: Bridging the Gap for Change –
                  The Next Step

Hoff, R.A., & Rosenheck, R.A. (1999). The cost of treating substance abuse patients with and
    without comorbid psychiatric disorders. Psychiatric Services, 50(10), 1309-1315.

Kessler, Ronald C. (1995) The Epidemiology of Co-occurring Addictive and Mental Disorders.
    NCS Working Paper #9. Invited conference paper, presented at the SAMHSA sponsored
    conference.

Kessler R, Nelson C, McGonagle K (1996). The epidemiology of co-occurring addictive and
    mental disorders: Implications for prevention and service utilization. American Journal of
    Orthopsychiatry 66:17-31.

Kessler, Ronald C. et.al., "The National Comorbidity Survey of the United States", International
    Review of Psychiatry, 6. (1994): 365-376 (p. 372)

Lofquist, William A. (1983). Discovering the Meaning of Prevention.         AYD Publications,
    Tucson, Arizona.

Lofquist, William A. (1993). The Technology of Prevention Workbook. AYD Publications,
    Tucson, Arizona.

Martens, John J., R.N., C.S., LAODAC (2001). Incidence and Characteristics of Dual Diagnosis
    in a State Psychiatric Institute.

National Advisory Council, Substance Abuse and Mental Health Services Administration
    (1997). US Department of Health and Human Services, Improving Services for Individuals
    at Risk of, or with, Co-occurring Substance-Related and Mental Health Disorders, a
    SAMHSA Conference Report and National Strategy, Washington DC.

National Council on Alcoholism and Drug Dependence (2000). www.ncadd.org/facts/index.html

National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders. White
    paper sponsored by the National Association of State Mental Health Program Directors
    (NASMHPD) and the National Association of State Alcohol and Drug Abuse Directors
    (NASADAD). March, 1999.

NIDA, Principles of Drug Addiction Treatment, 1999.

Nooe, Roger, Ph.D., (2000). The Knoxville Coalition for the Homeless Study, University of
   Tennessee, Knoxville.

Recovery Communities United, Incorporated, an affiliate of National Council on Alcoholism and
    Drug Dependence; http://www.inrecovery.org/.




Literature Citations                                                Appendix 5, Page 77
   Co-Occurrence: Bridging the Gap for Change –
                  The Next Step

Regier, D.A., Farmer, M.E., Rae, D., Locke, B.Z., Keith, S.J., Judd, L.L., & Goodwin, F.K.
    (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Journal of the
    American Medical Association, 246(19), 2511-2518.

Rosenbach, Margo & Young, Cheryl (2000). Care Coordination and Managed Care: Emerging
    Issues for States and Managed Care Organizations.

Sciacca, Kathleen M.A. (1986). On Co-occurring Addictive and Mental Disorders: A Brief
    History of the Origins of Dual Diagnosis Treatment and Program Development.

Substance Abuse and Mental Health Services Administration National Advisory Council. (1998).
    Action for Mental Health and Substance-Related Disorders: Improving Services for
    Individuals at Risk, or With, Co-Occurring Substance-related and Mental Health Disorders.
    Conference Report and Recommended National Strategy. DHHS Publication No. (SMA)
    98-3254.

Substance Abuse and Mental Health Services Administration, Center for Substance Abuse
    Treatment. (1999). Assessment and Treatment of Patients with Coexisting Mental Illness and
    Alcohol and Other Drug Abuse. Treatment Improvement Protocol (TIP) Series, 9. DHHS
    Publication No. (SMA) 99-3307. Rockville, MD: U.S. Department of Health and Human
    Services.

US Substance Abuse and Mental Health Services Administration (SAMHSA) (2000). A.
   Summary of Findings from the 1999 National Household Survey on Drug Abuse. SAMHSA
   Office of Applied Studies. Rockville, MD.

US Substance Abuse and Mental Health Services Administration (SAMHSA) (1999). A.
   Summary of Findings from the 1998 National Household Survey on Drug Abuse. SAMHSA
   Office of Applied Studies. Rockville, MD.

US Substance Abuse and Mental Health Services Administration (SAMHSA) (1999). B. The
   Relationship Between Mental Health and Substance Abuse Among Adolescents. SAMHSA
   Office of Applied Studies. Rockville, MD.

White, W.L. (2000) Toward a New Recovery Movement: Historical Reflections on Recovery,
   Treatment and Advocacy. Prepared for the Center for Substance Abuse Treatment, Recovery
   Community Support Program Conference: “Working Together for Recovery.”




Literature Citations                                              Appendix 5, Page 78
 Co-Occurrence: Bridging the Gap for Change –
                The Next Step

         Appendix 6: Supportive Documentation




Supportive Documentation              Appendix 6, Page 79

				
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