door and they're only treated for that one thing. if we would just slightly change the way we practice as clinicians we would really improve the treatment we're giving people. dr. clark, you're a psychiatrist and you're also the head of the substance abuse and mental health services administration's center for substance abuse treatment. what should we be doing in this country in terms of following up on what mark just said, in terms of getting more individuals in the mental health field knowledgeable about addictions, and the ones in addiction knowledgeable about mental health? and i'm going back to that whole integrated system. do we train each party to recognize the symptoms of the other condition? how do we do it? well, i think the answer is not a simple answer. that's one of the reasons why samhsa has embarked on a multi pronged approach to addressing the issue, working at

the state level, working with provider organizations. we've developed a treatment improvement protocol on co-occurring disorders. we responded to a congressional request by drafting a congressional report on co-occurring disorders, and we have maintained through a policy academies and creation of state incentives symptoms grant, the notion of getting multiple layers involved. so if everyone's involved, and we've also-and i think josh's point is well taken. we've also involved consumers and patients and clients in the discussion. so we want those individuals as well as we want any other individuals to participate because they have a stake in the outcome. we also recognize the criminal justice system and the child welfare system have to be involved because as you know it is illegal to use cocaine and it's illegal to drive under the influence of alcohol, so there are some consequences that you

cannot ignore in the substance abuse delivery system that are not as apparent or as imminent in the-with those people who don't have substance-use disorders. and so the people need to be very much aware of that. so these are kinds of things-partners, if you will-coming together, sorting things out so that we can have a humane and effective delivery system that holds not only the providers accountable but the individuals who are affected by these conditions also accountable because there's a degree of responsibility that needs to be promoted and the notion that the substance abuse delivery system as well as acknowledged because if you don't take your medications, if you drink and use, then there are the consequences of your behavior are going to escalate. so a comprehensive approach, a multi pronged approach, maintaining the voice, involving all the parties-that, i think is

going to produce the outcomes that we want. well, when we come back i want to get back to josh and listen since you've just mentioned the whole notion of involving the person in recovery in the system. he's got a very interesting program that we want to learn about. person in recovery in the swe'll be right back.ry [music] [heavy breathing] feeling overwhelmed by current events? don't turn to drugs and alcohol. hey, how was your run?

great! substance abuse is not the way to manage life. if you or someone you know needs information or treatment referral, call 1-800-662-help. mornings used to be the toughest. before i got treatment for my addiction, it was the little things that were hardest to bear. but now that i'm free of drugs and alcohol, it's the little things that give me the most joy. recovery - it gave me back my life. now i can give back. for drug and alcohol treatment referral for you or someone you know, call 1-800-662-help. [music] [music]

the goals and objectives of green door are to work with adults with serious mental illnesses to help them live and work as independently as possible in the community. green door defines "good care" as addressing both the mental illness and the substance abuse at the same time. you can't address one without the other, and we realize that it is important to look at both the mental illness and the substance abuse. often times our consumers, our members, are using substances to address the symptoms of their mental illness, and what we want to do is to provide the services, the treatment, the support, so that our members are learning that using substances

or abusing substances does not address the symptoms of their mental illness. a lot of times when you talk to folks who have bipolar disorder and substance abuse, you find out that they got involved in using alcohol and other drugs of abuse to try to regulate their mood. people who are diagnosed with schizophrenia, it's not uncommon to hear that they used alcohol because it took the edge off the voices. i used drugs because when i was living with my mother and stepfather, my stepfather used to abuse me, hit me and stuff. that was a relief when i went out and got high and came back in. i didn't care what he would do to me. green door let me learn responsibilities. i could always go to any staff in the building and they will help me if i have a problem. the green door is a saving grace. it helps me to stay out of my head.

it keeps me busy in the present. green door first and foremost has made me more willing to address my inner mental illness in full, knowing that the light at the end of the tunnel is just not institutionalization. you get back to where you were before because you had the tools to do it, and you had the people and the resources here to do it as well. there are many people greatly in need of recovery in this country. once as a country we accept the fact that that's true and people start to recover, changes that can be made within families, within communities, within the nation at large, will be unbelievable and awesome. and i'm one of those people who have managed to get into

recovery 17 years ago, and my entire life changed. so imagine if the whole country could change for the better, and i really think that's possible if people get into recovery. so, josh, tell us about your choice program and how does it involve the person in recovery? we provide three basic direct services. we provide advocacy, we provide case management, and we provide homeless outreach. all of these services are provided by people who have come through the system themselves and experienced the system. we-many of the people who come to us are interested in getting basic services: housing or treatment. they're not that interested in the fact that we're peers. we'll disclose that when it's to the benefit of the client, but we understand what it's like to have gone through the system. i went through the system. i was on medicaid, medicare, ssi-all of those things. and so our insight into having been in the system is able to

help us help them to do what they need to do. even if it means sitting in a cinder block office for five hours in order to see an examiner, we will assist them to do that because we understand what that's like, but we also understand the potential benefits of doing that, and that's what you have to do. do you go with the client to their service delivery location? in advocacy, the clients basically come to us. it's like a form of per diem case management where they can't really tolerate that regular contact in the community. case management is in the community. and then homeless outreach-we go to the shelters and we go to the streets and we literally meet people where they are because they're not really interested in services. we're just trying to engage them and get them to realize that the system has something to offer them. so it depends on the program as to how and where they're engaged.

so for the homeless you'll bring them into the service delivery setting? well, for our homeless clients, we will go out to the shelter and we will meet with them a number of times in the field just to establish that that kind of object constancy, just so they know that, you know, who we are and that we're willing to stay with them. and then it could be six months before they're willing to say, "okay, i'll sit down and i'll do a housing application." so in homeless outreach, it's a little different because these are people who are really running away from us, who want nothing to do with the system, who may have had an experience with the system twenty years ago that was profoundly negative and never went back. and we're trying to show them, hey, it's different. the services are different, the medications are different, we're different, and, you know, but that's going to be a long, difficult process because they're used to their institutional setting which is either the shelter system-or the street is a kind of institution itself-and they're

institutionalized to the street. and i think that's something very important for the families to realize if they've got a loved one that's in a homeless situation. right, kathy? yes, absolutely. mark, tell us about your therapeutic community. how does it handle co-occurring conditions? okay, we provide integrated treatment which means every single treatment plan deals with both the mental illness and addiction together. my staff does not view themselves as either addiction specialists or mental health specialists. they're co-occurring specialists. we modify some of the things that are traditionally done in the therapeutic community to fit this population. and how so? for example, like, traditionally in one of the interventions it might be if someone is exhibiting certain behaviors they might have to wear a sign around their neck that would help them change and/or become aware of that behavior. in my program we have people that get really paranoid so we never have anybody wear a sign. we have to be very, very individualized and get creative with our treatment plans because what works for one schizophrenic

client or one bipolar client might not work for the next client. so there's a lot of training, a lot of meeting with the staff. we have various phases in the program and the clients take on more responsibility as they progress through treatment, eventually getting to the point where they look for jobs and obtain jobs with health benefits because they're going to have to go get mental health and addiction services after they leave us. so about 80% of our people actually get jobs with healthcare benefits. and to sort of piggyback on some of what we've been talking about, put yourself in the place of our consumers, our clients. we are often asking them to do things that it would be hard for anyone to do. you know, go see a psychiatrist in this part of town. go to 12-step meetings in this part of town, you know. go see your medical doctor. go to social services. hold a job without a car.

you know, i think it's a good week for me if i'm able to go to the post office and the bank in the same week. so we're asking an awful lot of our folks. so again, if we're able to change the system somewhat and make it easier for people to get their services in one location, that goes a long way in their bonding and willing to come to the service and not feeling frustrated and then giving up. you know, you wait an hour for the bus and the bus comes late and then you miss your appointment and then you're not going to get your benefits. or, you know, you miss the meeting with your social worker and now you're not going to be able to see your children. so what do they do? they tend to go out and use or quit taking their medicine. and i think it's built into our system that these things are going to happen. kathy, what mark was saying, it really holds true for urban settings. i know that you're in an urban setting and that your program is a pilot program... oh no. it's not. it's been established for quite some time. we actually work with a continuum of patients, some who

are severely mentally ill and are homeless and will not seek treatment, you know, in the community setting. so they-we have a pack team where the clinicians, the doctors, social workers, etc., go out into the community and try to find these people and give the treatment out on the street. we also have other levels of care where people-it's called a continuous care team-where people do come into the clinic for appointments but some, i guess, years ago they would have been institutionalized but now they're treated in an outpatient setting. and so they come to the clinic, maybe three, four or five times a week, and we provide case management services for them. we also attend to our patients' medical needs because many of them have pretty severe physical problems which leads to early death. and so we work with the university and family medicine and we try to get them involved in, you know, getting the proper medical care. and then we have a less layer of care where we have people who just come in for basic psychotherapy maybe once or twice a week. and our treatment program is also integrated and we use what

we call more of a stage-based model, meaning that in the beginning phases of the treatment we have different goals. the primary goal, of course, is treatment engagement, to get the person involved in establishing a rapport with the clinician and coming in and getting psychotherapy and really meeting their needs, their presenting problem. what are their issues that they want help with? and as we establish that relationship with them, then over time we can move into more interventions regarding substance abuse and work towards abstinence. so it-we have a long term psychotherapy model and we're there for our patients regardless of whether they use drugs or not. so... dr. clark, what we've been listening to are the challenges to provide integrated systems even within areas where you can refer people and where you can bring in a team. what's happening in the rural areas to co-occurring patients? well, i think you touch on a very important topic, and what

we hear from rural communities is that [there's] a lack of providers. there are great geographic differences, and what they're requesting is increased focus on developing models so that they can deal with the needs of people in rural areas. there are fewer specialist providers available so it makes it more difficult to deal with individuals. and also it offers an individual who is ambivalent about care greater opportunity to isolate because that individual can seek refuge in the countryside, if you will, without-there are very few resources immediately available in terms of outreach to come get them. some programs recognize that and, as josh pointed out, they're able to go out and get them, but then that requires the cooperation and participation of family members, too.

so we shouldn't forget family members in this dialogue because they can play a critical role in either assisting or hindering efforts to address the problems that individuals have co-occurring disorders. i think that's an excellent point to launch our next panel when we come back. treat me. treat me with understanding. treat me. treat me with courtesy. drug and alcohol addiction is an equal opportunity disease. individuals in recovery come from all walks of life and deserve to be treated with respect and admiration for winning one of the hardest battles there is. treat me without judgment. treat me... ... with humanity. alcohol and drug addiction deserves proper treatment. for drug and alcohol information and treatment referral, call 1-800-662-help. how was school today? how was school today? did your session go alright? you have a good session? want to go to the game with me?

i got tickets to the game. talk with the kids in your life about drugs and alcohol, and if they're in treatment or recovery, support them, even if you have to practice. i am so proud of you. for drug and alcohol information and treatment referral, call 1-800-662-help. the national mental health association is the nation's voice for behavioral health, mental health, and addiction disorders. its mission is really to promote wellness, to bring wellness home. and we do that by a broad range of activities that vary all the way from working with people who have severe mental illnesses

and/or addiction disorders, all the way through programs to help prevent people from ever having to become ill. and so that we hope with this broad-beamed strategy that we'll be able to really improve the overall wellness of our society and the wellness of our culture. have you ever heard the saying, "somebody's addiction takes on a life of its own"? my depression took on a life of its own because one builds on another one that builds on another one that builds on another one. when i'm doing presentations and i use my personal story, i do so primarily to be able to shift the focus into both clinical terms, programmatic terms. they're explaining developmental process but also to share the human dimensions of the process.

i can describe treatment programs. i can describe treatment outcomes, evaluations, the data on it-but that's not people. and the idea is to be able to present some of the universal themes the people can relate to because people aren't diagnoses, collection of symptoms, problems and consequences. they're human beings. persons with co-occurring disorders are-kind of find themselves in double jeopardy in a way because they have both mental illness and substance use disorders, both of which are stigmatized. and it may be-i'm not sure about the science on this-but it may be that persons with addiction disorders are even more stigmatized than people with mental illnesses because there's a sense of choice involved in using substances that's a little different than the way we've come to think about people with mental illnesses. so by working with individuals who have issues both with mental

illness and substance-use disorders, we can really confront the problems of stigma head-on. for more information on national alcohol and drug addiction recovery month, events in your town, and how you can get involved, visit the recovery month web site at recoverymonth.gov. josh, dr. clark brought up an excellent point related to involving the family. talk to us about your experiences in involving the family, and what should families be aware of? i think the number one thing that families need to keep in mind is that recovery is possible. and that could be a very difficult belief to hold after repeated episodes of relapse or repeated disappointments. whether consciously or unconsciously, they stop believing that their family member is going to get better. and it could take ten trips to the rehab. it could take twelve inpatient hospitalizations before a person

enters recovery. but they need to keep going through that system until it takes. we get a lot of family members and they're already making the accommodations for a person who is going to remain severely ill for the rest of their life, and the first thing i have to tell them is, "why are you thinking that way? this is a person who had the potential to recover. you're not dealing with them like a person who can recover anymore." dr. clark. the point that josh is making is a critical one but that's why you need a comprehensive recovery system, because someone can - the advocate or the act team or the pac team-can help negotiate that. the consumer/patient has some responsibilities in the issue, and what that individual needs is to buy some time. but also needs to be able to demonstrate a willingness to become compliant. as you pointed out with regard to substance use, because in

order to continue my habit i'm often stealing or i'm appropriating things and i'm acting out. and so the family members get exhausted. so with- and fearful -and fearful. and with advocates and community action teams, what you've got are individuals who can help negotiate that relationship. and that's why a comprehensive approach is an important one. we want this person to be able to reunite with his family but we also need to acknowledge that the family members that have gone through a lot by the time the person presents to the treatment system. so we can't have people ignoring that because quite frankly people will tell you if you're the advocate you're a do-gooder and you don't know what they've been through, and they'll walk. what we need to do is acknowledge what they've been through and acknowledge that recovery is possible and that, based on your extensive experience as an advocate, as a person in recovery, you're a good role model.

so that gives them hope. you've got to have hope for the client and hope for the family. and with that hope and the collaborative system, we can facilitate the reunion between family members and individuals who suffer from co-occurring disorders. i absolutely agree, and families should not be hesitant to consequence a person for their behavior. if you don't trust your son in your house because he's been stealing from you, don't let him in. that is a consequence of his stealing, okay? and one of the times that i went into treatment was because a family member would literally not let me into the house and i had to remain on the street for 24 hours and that was enough. that was my 24 hours of homelessness, but he was dead set on seeing me in treatment and he was not going to open the doors to his home if i wasn't going to accept that. and then that was back on me. and that's the way we treat anybody. we say, "look, i have choices here. it's my home. i don't have to let you into it." too often i see family members who say, "my son is up in his

bedroom and he sleeps all day and he doesn't do anything." and i say, "well, why isn't he looking for work?" "well, he can't look for work." of course he can look for work, and if he can't look for work he should be in treatment. if he refuses to go into the treatment, why are you letting him - he's 23 years old; why is he living in your house? we find it very hard to engage our families in the actual therapy of our patients. many of our patients still live at home with their families, but to get the families to come in and actually participate in a family-oriented type of therapy is extremely hard. it's very hard for us. we've talked about "any door, the right door." increasingly we see more programs similar to the recovery community services program, similar to community and faith based programs. how do - what do they bring to the mix in terms of co-occurring issues, dr. clark? well, the recovery community services program is designed to involve people in recovery, or organizations facilitating venues for people in recovery to help provide services.

most kinds of services are what some people label "wraparound services" - emotional support, transportation, literacy training. sometimes they just offer opportunities for job placement or job readiness. the key issue is giving the individual who has a problem an opportunity to see that he or she can improve, as josh was pointing out. and the consumer in recovery represents a model. it doesn't represent the individual who has the co-occurring problem, per se, but it's a model of hope. and by reaching out and involving that individual, we offer hope to the individual who's saying, "i'm hopeless. i have no hope. i can never get better." someone like josh says, "well, that's not quite true. you can get better. we can work on that. i'm a model. i'm not you but i'm a model that demonstrates that it's possible."

and so our recovery communities services program involves multiple individuals. you have more than one josh. you have multiple individuals so that individual can see that. involving the faith community, and other community providers is also important because people need emotional support, they need community support. they need people who are willing to acknowledge that they have a brain disorder that can improve in terms of level of functioning. and with that kind of support, again, you're offering hope and you're offering respite so that the family for instance is not the only entity in the community bearing the total brunt of the burden. the fact is untreated co-occurring disorders create a burden for the whole community, not just the family, so the whole community should be involved, so the faith community and community providers also contributing. the family is given that respite necessary to recognize that it can play a legitimate role in that person's recovery. and family members, even though they've been burnt, they still

have a special attraction. it's just that they've been burnt and they don't see any recourse. so if we offer resource through recovery community services program or through the faith community or community services, then we offer the magnet that can help pull family members back in. any final thoughts? well, in terms of my recommendation, i would just say that people need to remember that recovery means recovery of the core self. it's not about recovery of functioning. and if individuals, practioners, legislators, and the general public remember this, i think that is the key to the integration of services for substance abuse and mental health. excellent point. i agree with josh that recovery is possible. working with patients, many of whom have been at our clinic for eight, nine, ten years, we've seen them get well over time. it may take a long time but we see that it happens and it's an inspiration to me in my job every single day to be able to work with these people.

an inspiration is what we look at during september recovery month, and we hope that everyone watching does get involved in the 2006 celebration. thank you so much for being here. thank you. for a copy of this program or other programs in the road to recovery series, on dvd or vhs, call samhsa's national clearinghouse for alcohol and drug information at 1-800-729-6686 or order online at recoverymonth.gov and click "multimedia". [music]