music]

[intro music] hello. i'm ivette torres and welcome to another edition of the road to recovery. millions of americans suffer from co-occurring conditions. today we'll be talking about those issues. joining us in our panel today are: dr. h. westley clark, director, center for substance abuse treatment, substance abuse and mental health services administration, u.s. department of health and human services; josh koerner, executive director, consumers helping others in a caring environment (choice); katherine high, duel diagnosis program coordinator,

community psychiatry, university of maryland medical systems; mark segal, clinical director of co-occurring services, second genesis. dr. clark, about 33 million people in the u.s. live with a mental illness and a substance-use condition. what are co-occurring conditions? co-occurring conditions are conditions that occur in people who have several things going on. they may have a substance-use disorder and they may have an independent psychological problem such as anxiety or depression, or more serious problems like bi-polar affected disorder or schizophrenia. and, kathy, what are the current barriers of care for individuals with co-occurring conditions?

well, there's probably many barriers. one is, you know, accessibility of treatment - availability of treatment programs. you know, certainly in the city there's only so many programs that a person can go to get co-occurring treatment. cost: who's going to pay for the program? you know, is it covered by insurances, you know, is a big barrier. and getting the patients to come to treatment themselves is a significant barrier because many of them are abusing drugs and it may be hard for them to be motivated to go and seek treatment and actually, you know, get involved in the transportation that they need to do in order to get to the program to get the treatment. mark, any others? yes, i would say that in many states the funding sources, the stream of money, comes from two different sources: one mental health, one addiction. and depending on how the consumer is initially identified, either as an addiction patient or a mental

health patient, in many states that's going to influence what kind of services they get. so if they are identified as a mental health patient, they very often can't get into substance abuse because mental health money won't pay for the substance abuse. so that's one of the main barriers. and, josh, can you think of any other barriers for individuals with co-occurring? well, i think that the - when you set up a program to assist the person [to] recover from a mental illness or from a substance-abuse disorder, as soon as you bring in somebody who's not going to be able to go with the program, you have a potential problem. for example, many substance-abuse programs are predicated on groups, on being able to communicate well in a group. if you bring someone in who's having - who has a mental

illness and that's difficult for them, for example somebody with schizophrenia who finds the thoughts of others intrusive, they're not going to be able to communicate the same way, so you're going to have to have certain kinds of communication skills. conversely, you may have mental health programs that are set up for a certain kind of person, and then when you bring someone in who has an addictive disorder, they're not going to fit in and that's where you say, "you know what, this person isn't going with the program," and that becomes a barrier to services. so, dr. clark, i think josh has made a very good point. can you describe for us what-within the united states, what the programs look like right now that serve co-occurring disorders? well, i think one of the most important things is, as mark pointed out, and that is funding is the key issue.

and we have a delivery system that has had different origins. the mental health delivery system, the public mental health delivery system, is generally state-funded through medicaid, medicare, and to a lesser degree the block grant, and focuses on people with severe and persistent mental illness. in other words, there are two tests you have to meet in order to get access to care. one, you have to-there's a means test which means if you make too much money you can't access the public mental health system; and, two, there's a severity test. if you don't have a mental health condition of sufficient severity, you can't really access the public mental health delivery system. on the other hand, the substance abuse delivery system is principally funded by public dollars, and to a large degree by federal dollars through the block grant. most jurisdictions use a means test for that which means that all you have to have is a certain level of poverty and you can access the care. so, as mark pointed out, you've got these two different systems

with two different tests, which means that the programs that are created are created with that in mind. so the public substance abuse programs tend to be group-oriented, as josh pointed out. you're relying less on individual practitioners, more on institutional settings, organized settings, to deliver care. the mental health delivery system tends to be a little more flexible, relying on a wide range of issues depending on the kind of condition with which you present. but the key issue, even in the mental health system, if you have mild to moderate depression you may not be able to access that. so, but if you have a co-occurring disorder-i.e. mild to moderate depression and, let's say, a cocaine disorder-you'd wind up in the substance abuse delivery system because you wouldn't be able to access the mental health delivery system because you don't meet the criteria. so there are a lot of factors that interfere with the delivery of services in the design of the service delivery system. lack of insurance and money constitute major factors in that issue.

so this is one of the things that a recent institute of medicine report-right, kathy? -spoke about in terms of the challenges that the nation faces, as dr. clark has pointed out, with the two different systems of care. and are you familiar with the iom report findings? and can you speak toome of the recommendations that it makes? well, i think, you know, i think it makes recommendations regarding policy, that policies have to be rewritten so that these funding streams that are separated currently, you know, if there can be some co-existing financial resources that can be funneled into programs, and that has to come at a policy level. you know, it has to be written into specific policies so that those funding streams can be changed. what other recommendations, mark? well, treatment providers have to change the way they're viewing the client. instead of, "this is an addicted client that happens to have a

mental illness and we're going to deal with the addiction first and then the mental illness later on," or vice versa, if someone shows up at a public mental health clinic, "we're going to deal with the mental illness and once we stabilize them in that refer them to addiction services," having whichever door their client comes in be the source of treatment which is doing both at the same time. and we call that "integrated care" and we know through a lot of research that the clients have better outcomes when they have one provider providing both services. and, josh, you - all of this may seem quite familiar to you since you were a client of the system at one point, correct? i was a client of both systems. what's interesting to note about my case is that when i entered treatment, i entered as a psychiatric patient. and the first time i was in a locked psychiatric unit, i smuggled drugs onto the unit and yet it was over 11 years later that i actually got treatment for the substance-abuse problem.

it was always seen as an outgrowth of my mental illness, and once you've treated the mental illness, the substance-abuse problem was just supposed to go away. that never happened. they sort of ping-ponged off each other because even though there is a stigma about mental illness and there is a stigma about polysubstance abuse, they're different stigmas and they're different cultures. and so in my background, in my cultural background, it was much better to be seen as somebody who needed therapy and it was not good to be seen as somebody who needed polysubstance-abuse treatmt. and i just kept going through the mental health system, in and out, in and out, and i was never-i never got treatment specifically for my polysubstance abuse. once i did then i was able to combine both of these treatments and both of them got better. were you diagnosed in the mental health facility or were you

assigned to go to an addiction treatment program? i was initially diagnosed in a mental health facility. i-at that point i didn't know what my actions one and my actions two were, i don't know, you know, where the polysubstance abuse came in, but even when i got treatment i actually had to go down the street. i was going mondays, wednesdays and fridays to the mental health facilities, and tuesdays and thursdays i was going for polysubstance abuse, and that's how i was able to get both of those. and if i had not been willing to literally go down the street-and many people are not-you know, once a person makes an engagement in the treatment facility, that's where they should be getting their help. they shouldn't have to go down the street. even if it's literally a couple of blocks, their engagement is wherever they've come into the system. if they've been mandated into the system as a substance abuser and they have concomitant mental illness, that's where they should be getting that help and vice versa. what i see too often is people who come into the mental health arena aren't-they don't really get tested for polysubstance abuse.

no one's asking them so they never get to the other side. well, when we come back i want to continue our dialogue about the two different systems and how do we integrate those two systems to better serve the client. we'll be right back. drug and alcohol addiction, you lose your way. but there is a way out. you can find direction, find support, treatment, find yourself and your life-your direction home. for drug and alcohol treatment referral for you or someone you know, call 1-800-662-help. no one could tell me to my face. i was alone. drugs and alcohol, that's all there was. i found myself in a treatment center getting help for my alcohol and drug addiction. it wasn't easy.

i drew myself a new world to live in, free of alcohol and drugs, and i started to come back to life. and then there were other people. recovery: i need all my colors to paint in. for drug and alcohol information and treatment referral, call 1-800-662-help. people who show up for mental health treatment, an increased number have a substance abuse disorder. so what we know about co-occurring is that it's much more common than people realize. we also know that the assessment for it is a lot less common than people realize. and then finally the various treatment options cannot be adequately pursued because we understate the magnitude of the problem.

kathryn, welcome to the road to recovery show. thank you very much. it's a pleasure to be here. well, it's great having you. kathryn, today we're going to talk about issues related to co-occurring disorders. tell us a little bit about what are co-occurring disorders. when the term "co-occurring disorder" is used, it generally refers to the presence of two disorders-that is, having both a serious mental illness and a serious substance-abuse disorder. so it's a very important condition that people understand that you have two particular serious disorders present in one human being. and do the people with co-occurring disorder face any particular additional burdens in terms of their ability to get care? absolutely. there are many, many additional burdens and barriers, actually, to individuals with co-occurring disorders to get care. and one of them in particular is first of all the individual just acknowledging the presence of two disorders.

certainly a mental illness is an eclipsing disorder. a substance-abuse disorder is also one that takes an enormous amount of toil on the individual. so just an individual recognizing that they might have two disorders at the same time, it's very difficult. secondarily, for people to access a system of care, it becomes very difficult because often times if you enter the substance abuse treatment system, they may only treat the substance-abuse disorder. if you enter the mental health system they may only treat the mental illness. and so recognizing that it is important for service systems to assess appropriately when people come in the door and be knowledgeable about that and expecting that on your own behalf is really an important condition for beginning to look at treating these disorders in the right way. from a recovery community perspective, take us into the whole area of transformation and how does that community begin to be more vocal.

how does it begin to-for both mental health and the addiction side, because someone in a co-occurring scenario would probably interact with both communities. right, right. we've talked before about how the principle of recovery has really been embraced for a long time in the substance abuse system and in the substance abuse world. and it is really a more recent phenomena [sic] in the mental health worlds. it's really only been in the last ten to fifteen years when we have really discovered through the eyes of the consumers and the individuals we serve that there is a very, very powerful galvanizing principle of recovery that needs to be attended to when it comes to mental illness, just as it is in substance abuse and addiction. and i think that as we move forward together we are going to see a much broader embracing not only of the public health model and looking at this as health conditions and looking at this

disease as we would any other disease, but certainly looking at the aspect of recovery and how it applies to the lives of the people that we serve. and particularly when they have a co-occurring disorder this is a hugely important [point]. recovery basically as you know is seen as a journey, a day-to-day, step-by-step journey in which you will focus on your assets and focus on your hopes and your dreams and your aspirations and think of yourself as managing your own care. that's what's important about recovery. it's not a deficit model. it's not a model of just reducing symptoms. it's a model of saying to ourselves and to our families and to our communities, "even though i have this very serious disorder or multiple disorders, i believe that it is possible for me to manage these illnesses and move forward and not be labeled by my illness." kathryn, recently the institute of medicine issued a report that

dealt quite a bit with mental health issues and with addiction issues. tell us specifically what were the mandates related to co-occurring conditions. several years ago, the institute of medicine started a series called crossing the quality chasm, and in those series of reports they talked about how do we improve what our current health conditions are and what we should do-what are some specific steps that we should do to improve the overall quality of healthcare? and they made out a very, very strict framework about looking at healthcare. what we asked them to do last year, and samhsa helped fund this approach, is we asked the iom to take a look specifically at those conditions that they referred to, and they used the terminology of "mental- and substance-use conditions." it's a very interesting use of terms, ivette, that finally an organization with the gravitas of an iom says that we should be thinking about these conditions as health conditions.

and the fact that they used the terminology of "mental and substance-use conditions," i think, is quite innovative and quite a change in the vernacular in the field. that report specifically said that if we do not pay attention to the overall behavioral health-that is, the mental and substance-use conditions of people - in their general healthcare, then we are not doing a service to people's overall health. and so it really was a clarion cry to the field, to the field of policymakers, to the field of purchasers of healthcare, to the field of systems work, to the field of consumers and families to say, "you really do need to be in a position of demanding that co-occurring disorders be assessed appropriately, and you need to understand what are the kinds of current treatments that you should expect for co-occurring disorders." that was a very effective and i think a very powerful institute of medicine mandate. they clearly outlined in their report the specifics for what

makes an effective practice, what makes an efficient practice. is this practice consumer- and family-directed? is this practice safe? and all of those key areas that the institute of medicine has pushed now come into play from mental- and substance-use conditions which is very powerful. and if i had a member of my family that needed care for a co-occurring condition, what methodologies should i use or should i ask them to pursue within the level of care? one of the most important practices that we have discovered in the last few years is that co-occurring disorders respond effectively to what is known as integrated treatment, and integrated treatment is really a broad spectrum of different practices and interventions that address both disorders equally at the same time so that you're not separating out the presence of a substance-abuse disorder and mental illness in a human being.

you're thinking about that human being as a whole person who has really two conditions just as if i had both diabetes and tuberculosis at the same time. i would make sure that my physician is treating me appropriately for both of those conditions and that i was engaged in working with my physician about my care. and all of the unique conditions of my life, all of the needs that i had as an individual, that's what i would tell family members they need to be clear about, that the request for an integrated approach, the request for each of these disorders being seen as primary disorders-you can in fact have two primary disorders at the same time-that's what we need to ask people to do. and we're encouraging through many of our practices, many of the tools that samhsa is producing, that approach called "integrated treatment." and i suspect that particularly if they're getting medicated for their mental health condition and they're also on medication-assisted therapies for their addiction condition,

that's really where the nexus needs to be, you know, monitored quite strongly. is that correct? that's correct, and you need to have the physician community that is treating both of those disorders connected, and in some cases consulting with each other on a regular basis. you need to have practioners and case managers and other therapists who understand the complexities of the interactions just of those medications and certainly of other practices and other interventions. you need to have a workforce within an integrated treatment setting that is knowledgeable, thoroughly knowledgeable, about all of the mental illnesses and their symptoms and certainly the range of substance-abuse disorders and their symptoms. you need to have a really well crafted and thoughtful, responsive individual plan of care, and it's particularly important when you have co-occurring disorders. we have over 4 million people in america with co-occurring disorders, and when you stop to think about that every

vulnerable group of individuals and they are simply not getting the kind of care they need, we need to make sure that more integrated treatment is available throughout our systems no matter which door an individual comes in. we have 15 million people with serious mental illness. we have 15 million people with serious substance abuse disorders. we know that many of them have co-occurring disorders that simply have not been recognized, or they themselves have not recognized it. kathryn, it's been a pleasure to have you here today. thank you so much for addressing this very important issue. i started smoking pot and drinking when i was 18, and my first severe symptoms of mental illness presented when i was 23. and i was in and out of psychiatric institutions, locked

psychiatric institutions-it must have been eight or nine times. i got substance abuse treatment in addition to my mental health treatment and i have not been hospitalized since then. it's been thirteen years since i've had a drink or a drug and it's been twelve years since i've had a cigarette. dr clark, we were just talking about the two different sets of systems. how do we integrate those systems and so that each particular area remains very vibrant within the service delivery system? i think that's one of the things that samhsa is addressing now. in our policy discussions we recognize that co-occurring disorders are very important. the issue now is working with state authorities and the delivery system, the providers, to enhance education, to enhance policy decisions. we've created some funding

so that we incentivize jurisdictions to focus on it. we've had what we call "co-occurring policy academies" where we bring states together and have them meet with their mental health system, substance abuse system, their financing system, so they can deal with the issue. i think josh's point is well taken; you need people who are knowledgeable about both conditions so that you can adequately deal with those conditions. you can't simply dismiss one in favor of the other. the fact is that when we look at some epidemiologic studies, 60% of the people who present at substance abuse treatment programs have a co-occurring independent depression. roughly 40% who present to the substance abuse treatment programs have an independent co-occurring anxiety disorder. i mean, 6 out of 10 people - 4 out of 10 people who show up at the door of the substance abuse treatment program have a co-occurring disorder. so the only question is, "how do you adequately deal with it?"

and the co-occurring disorder spectrum is actually much broader than people think, so we need to have people who are knowledgeable so if someone presents with mild to moderate depression you've got people who are alert to that, who are working with that while they're dealing with the cocaine problem or the marijuana problem or the alcohol problem or the polysubstance-abuse problem. if someone presents with active schizophrenia, that may take a different kind of treatment strategy in addition to the substance abuse - focused treatment strategy. so we need a knowledgeable system. we need a system that allows funding for the services. we need to have a system that essentially has a one-stop shop or, as mark pointed out, every door being the right door so that a person doesn't have to do what josh said, is go to different places on different days and he wakes up, says, "what day is it because if it's tuesday i go to substance abuse, if it's wednesday i go to my psychiatrist," and that is obviously problematic.

he was obviously motivated but there's a limit to motivation. at our program in community psychiatry, it's a mental health program but we-all of our staff members are social workers and nurse psychotherapists are all cross - trained in addictions and mental health. and in order to implement that it's actually mandatory training for them that they must attend, like, two hours of training that we have every single month. and so we educate them about how to detect addictions and we do a very thorough assessment when a person comes in the door on intake because, as i said at the break, addiction is a mental illness and we seem to forget that in the mental health field. so we have a very thorough assessment that covers all systems including, you know, substance abuse. so... let me ask you something. because the underlying causes of mental illness and substance abuse are often the same-there's often trauma-it's not as though your practitioners really need to hold two giant bodies of

knowledge in their head at once, correct? it's not that difficult. but you see, i know a lot of practitioners who know their area and then they'll say, "but i don't understand polysubstance abuse," or, "i don't understand mental illness." but they really understand a lot more than they realize, and if they just had a few additional elements, they would have them both. and it's that anxiety, i think, that causes a lot of practitioners to shy away from one or the other, staying in the area that they're familiar with without realizing that they know a lot more than they know. i run a facility for a long term residential for folks with co-occurring disorders, and when i hire staff very often they come from either an addiction background or a mental health background, and they're surprised after a while that they do know more than they think they do, as josh was pointing out. you know, someone in addiction background understands relapse prevention. relapse prevention's a type of cognitive behavioral therapy, so they're used to talking about triggers and that kind of language. but when they have a depressed patient, if they would just

change their language a little bit-instead of triggers it's an automatic thought and so on-they're actually, they know how to do the treatment. so, a lot of times clinicians don't give themselves the credit that they deserve and i think just because of their comfort zone sometimes feel a little intimidated. so i think part of what we need to do nationally is get people to feel comfortable with people with co-occurring disorders because they're in every single facility. every single outpatient program, they're there. these are the folks that tend not to do well for a variety of reasons that we've talked about, that they come in through one 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