Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Summit for Agency and Program Directors
Evidence-Based Practices for Co-occurring Mental Illness and Substance Abuse Disorders
Trenton , NJ
June 17, 2005
PowerPoint version
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
[SLIDE 1. Title slide]
Good morning. Thank you for inviting me to address your meeting. I’m particularly pleased to share this time with my colleague, Dr. Westley Clark, from the Center of Substance Abuse Treatment. Having the two of us address you jointly really underscores the reason we have gathered here, which is to promote integrated treatment of co-occurring mental and substance abuse disorders.
Mental and substance abuse disorders overlap significantly. Fifty to 75 percent of patients in substance abuse treatment programs have co-occurring mental illnesses. Twenty to 50 percent of those treated in mental health settings have co-occurring substance abuse. Science has yet to confirm the basis for this overlap. Many studies have searched for a genetic vulnerability that would cause both disorders to strike the same person. Conclusive genetic evidence has not been found yet. Some serious mental illnesses, however, may present an increased risk for substance abuse. Substance abuse appears to worsen or hasten psychiatric disorders in persons who are genetically predisposed to mental illnesses.
Research has found that many adults with co-occurring disorders report an environmental cause: they use substances to relieve traumatic memories. One consumer confided that “I used drugs and alcohol to lessen the pain, and as a celebration, as a victory, that the trauma didn’t get me, didn’t get me this time—it’s a reason to get high.” Others abuse substances to lessen the loneliness, discrimination, and loss of self-worth too often associated with a mental illness diagnosis.
Whatever the cause, our job is to give consumers hope in recovery. Co-occurring disorders are so common that they should be considered the norm and not the exception of persons seeking treatment in behavioral health settings. Given this reality, we need to alter dramatically our traditionally separated approaches to mental and substance abuse disorders. We need to use the best science and practice available to deal with these disorders concurrently—not sequentially or in parallel. Concurrently is how a person experiences dual disorders—these disorders can feed off of each other, compounding symptoms and complicating treatment and recovery. Consequently, a person’s best hope for moving along the long and winding road to wellness and recovery is integrated treatment. Integrated treatment is the best evidence-based practice available to us and to them.
I’m delighted that the New Jersey Department of Human Services recently has reorganized in a way that will facilitate planning and implementation of integrated treatment. A year, ago, your Division of Addiction Services joined the Department of Human Services, which also oversees the Division of Mental Health. My good friend Alan Kaufman tells me that your merger has “gone swimmingly.” I’m sure that he, along with Assistant Commissioner Kane-Cavaiola, deserves a great deal of credit for the progress being made.
Ms. Kane-Cavaiola has taken a visionary approach to integrated behavioral services for several years. A full decade ago, she merged outpatient mental health and addiction services so that children and adults could access integrated behavioral services.
Alan/Mr. Kaufman also has long led efforts to improve mental health care. He has served on numerous State and national task forces dealing with such serious issues as homelessness and unemployment among individuals with mental illnesses. He, too, has expanded access to care in the community for adults and adolescents.
I’ll give just one example. Alan/Mr. Kaufman previously was the executive director of the SERV centers for both New Jersey and Pennsylvania. During his tenure, the centers grew from one program serving 40 people into a multi-faceted agency that served 350 people each day in residential programs. He brought care to the consumer, in the community. I sincerely hope that Alan/Mr. Kaufman’s career as a mental health advocate will continue long after his upcoming retirement as director of the Division of Mental Health.
The organizational structure of your Department of Human Services now reflects the harsh reality of co-occurring disorders in your State. According to the National Council on Alcoholism and Drug Dependence—New Jersey, more than 40 percent of consumers treated in your mental health or substance abuse treatment systems have a dual diagnosis.
More important, however, your joined divisions now reflect the hopeful reality of recovery from co-occurring disorders. People can recover from co-occurring disorders. They do recover, and their greatest hope lies in treatment that recognizes and responds to the intertwined complexities of their diseases.
Traditionally, persons with co-occurring disorders have confronted many systemic barriers to integrated treatment and support services. What are these barriers?—Separate administrative structures, eligibility criteria, and funding streams as well as limited resources for both mental health services and substance abuse treatment. By joining divisions under one department, your State has taken a groundbreaking step toward eliminating these barriers.
You now stand poised to provide persons with co-occurring disorders with the comprehensive, integrated treatment they need. You already have created the administrative infrastructure necessary to align programs and to leverage resources. The communication pathways are open. What you will find as you work more closely together—as you develop a stronger commitment to a common approach—is this: what your divisions will be able to accomplish together far outweighs what they might have accomplished separately. Congratulations on the vision and foresight that led your State government to this merger.
I also commend your efforts to develop a joint workplan. Joint planning is a strategic move toward higher quality services as well as greater accountability for the results you achieve. From SAMHSA’s perspective, “quality” of care as well as accountability is measured in terms of positive outcomes for consumers. Do the services you provide produce the results consumers seek?
Steven Covey, the author of The 7 Habits of Highly Effective People, wrote:
[SLIDE 2. Quote]
“Accountability breeds response-ability.” As behavioral health professionals, we are accountable for how effectively we respond to the needs and goals of the people we serve. Develop your workplan carefully, for your decisions will affect the lives and futures of thousands of New Jerseyans. To be most responsive, include consumers, families, and consumer advocates in the decisions being made.
Within the past few years, SAMHSA increasingly has elevated its own goals for addressing co-occurring disorders. Our goals revolve around State and provider implementation of evidence-based practices, which we view as tantamount to uality services. Evidence-based practices are how we know we can move persons with co-occurring disorders toward recovery.
[SLIDE 3. Four redwoods]
SAMHSA has four redwood programs, one of which is co-occurring disorders. A “redwood” is a priority program for investing our resources. Charles Curie, SAMHSA’s administrator, coined this term to emphasize a new agency philosophy and direction. Rather than having a thousand short-lived “flowers” bloom, he wants SAMHSA to focus on developing a few major, long-lived initiatives. A redwood is certainly an apt analogy for co-occurring disorders. Why?—Because the prevalence of these disorders casts a large, dark shadow over our efforts to treat and prevent mental illnesses and substance abuse effectively.
The Center for Mental Health Services, together with the Center for Substance Abuse Treatment, is co-funding grants and conducting policy academies to support State efforts to improve access to integrated treatment. Eleven States so far have been awarded Co-occurring Disorder State Incentive Grants. Nineteen States have attended our co-occurring policy academies. We currently are planning another round of grants as well as another policy academy. I urge your State to apply for both programs.
In addition, SAMHSA has been producing and disseminating evidence-based practices for treating co-occurring disorders. Westley/Dr. Clark will be describing “TIP 42,” a treatment improvement protocol for persons with co-occurring disorders. I’ve been told that your Department of Human Services is developing its own version of TIP 42. Your efforts are a commendable example of Federal-State collaboration in bringing science to service. We at the Federal level have brought together the expertise needed to compile the full spectrum of state-of-the-science practice. You, at the State level, are converting science to service by tailoring practices to the people served in your State. Yours is a very thorough and strategic approach to evidence-based practices for co-occurring disorders.
SAMHSA’s TIP 42 addresses treatment of co-occurring disorders from the substance abuse treatment perspective. The Center for Mental Health Services has produced an evidence-based practice “toolkit” to address treatment of co-occurring disorders from the community-based mental health side. Our goal is to ensure that patients have access to integrated treatment no matter where they enter the system—substance abuse treatment center or mental health facility.
[SLIDE 4. Six toolkits]
Our toolkit is called Co-occurring Disorders: Integrated Dual Diagnosis Treatment. It is one of six kits that we created last year. Each kit includes the resource materials needed by providers to replicate the evidence-based practice, including implementation guidelines and fidelity measures. These kits still are being refined. More than 50 community mental health programs in 18 pilot States currently are helping to evaluate their use in practice. We have asked the pilot States to give us feedback on how effectively the treatments work for different populations in different community settings. Indiana, Kansas, and Ohio are evaluating the integrated treatment toolkit through our 3-year National Demonstration Project. California, Hawaii, Illinois, and Vermont are testing the integrated treatment toolkit through our State Evidence-Based Practice Training and Evaluation Grants.
You also can obtain copies of the toolkits from SAMHSA and provide us with feedback. We welcome your assistance in helping us to create toolkits that respond to the full diversity of individuals who have mental illnesses. All of our evidence-based toolkits are valuable for treating persons with co-occurring disorders. For example, most of these individuals will require medication for their mental illness, so medication management is important. Some will have employment as a goal for recovery, so supported employment is important. Families play a central role in sustaining an individual on his or her journey toward recovery, so family psychotherapy is important.
For the record, we have received more requests for the integrated treatment kitthan for any other kit. States and communities clearly are seeking guidance on how best to serve consumers with co-occurring disorders. I’m elated that more providers are recognizing integrated treatment as the best practice available.
[SLIDE 5. COCE screen grab]
The Center for Mental Health Services also supports the Co-occurring Center for Excellence, or COCE. COCE provides technical, informational, and training resources needed to promote the adoption of evidence-based practices in systems and programs that serve persons with co-occurring disorders. [SLIDE 6. COCE Papers]
This month, COCE will be publishing the third in a series of overview papers. The first two papers are Definitions and Terms Relating to Co-Occurring Disorders and Screening, Assessment, and Treatment Planning for Persons With Co-Occurring Disorders. Both are available from the COCE Web site. The most recent paper will be available online shortly.
[CLICK for title fly-in]
The new overview paper is Principles To Address the Needs of Persons With Co-Occurring Disorders. I encourage you to access this paper and discuss in depth theprinciples presented. Principles are vital to any program, policy, or practice that affects the lives and futures of the people we serve. Principles shape our vision of care. They are the framework for developing the goals and objectives needed to achieve our vision. They are the foundation for planning, delivering, financing, and evaluating the services we provide.
The COCE paper lists 12 principles to guide systemic and clinical responses to persons with co-occurring disorders. These principles will be summarized on my slides according to what I see as three overarching themes of integration. These themes are:
- Integrated treatment,
- Comprehensive services that are integrated throughout the delivery system and within individualized treatment plans, and
- The integration of science and service.
[SLIDE 7. First principle]
The first overarching principle is integrated treatment. As I noted earlier, co-occurring disorders should be the expectation, and not the exception, in all behavioral health settings. Failure to address both as primary illnesses is a failure to respond to the needs of the majority of the people we serve. This is what research and practice tell us about co‑occurring disorders: if one disorder remains untreated, both usually get worse. Clearly, our system of care must evolve to reflect the growing evidence base that promotes an integrated approach to treatment.
The implications of integrated treatment are far reaching. Integrated treatment requires changes at all levels, from administrative to clinical. Both mental health and substance abuse providers must be cross-trained to screen, address, and respond to co-occurring disorders. Any person seeking care for either or both disorders must be accepted and actively engaged no matter which door he or she walks through.
Every point of contact is an opportunity to give consumers hope in recovery.Then they are ready to accept treatment, we must be ready to provide it. Coordinated workforce development is a necessary and pivotal change to ensure that any door becomes the right door to effective treatment.
Planning, policies, programs, and regulations must acknowledge co-occurring disorders explicitly. Financing mechanisms must change. We at SAMHSA recognize that funding options seldom keep pace with the development of new evidence-based practices. Consequently, we are working with the Centers for Medicaid and Medicare Services to explore new financing options for integrated treatment. You at the State level need to explore funding options within your control.
[SLIDE 8. Second principle]
The second overarching principle of care for co-occurring disorders is comprehensive services. Persons with untreated or inadequately treated co-occurring disorders are at increased risk of additional complications. These complications include unemployment, homelessness, incarceration, and loss of families and friends. They include other serious medical problems, such as HIV/AIDS, hepatitis B, and cardiac and pulmonary diseases.
People with co-occurring disorders often are among the most disadvantaged and impoverished members of our society. And, we as a society, suffer with them. The social and economic burdens of their illnesses are carried by both the individuals and our communities.
To ease the burden, our response must be comprehensive care for each individual. At a system and provider level, we must addresses the full spectrum of supports and services needed to support each individual’s recovery. We must consider age, gender, culture, and sexual orientation. We continuously must reassess services required according to a person’s stage of change and phase of treatment. At various times, employment, education, housing, and legal assistance may be part of a person’s integrated treatment plan.
[SLIDE 9. Partnerships]
Consequently, integrated treatment requires partnerships that extend beyond the behavioral health field and across government systems and communities. We need to collaborate with professionals in primary care, social and child welfare, education, housing, criminal justice and other agencies serving adults and children with mental and substance abuse disorders.
[SLIDE 10. Third principle]
The third overarching principle is the integration of science and service. Evidence-based practices represent excellence in treatment. Excellence, however, is not an end state. Instead, excellence is an ongoing process of improvement, refinement, and adjustment to a changing world. Just think about recent advances in the mental health field—better medications, more effective psychotherapies, the absolutely transformational notion that the goal of treatment is not symptom management but recovery! Each advance has changed our perspective on what is the best care available.
The behavioral health field has a rich investment in research to draw upon when providing evidence-based practices. Science is shaping continuously the services we provide. We, however, must increase the dividends for consumers by using service to inform science—to reinvest what is learned through clinical practice to further develop the science and to fill in voids in the knowledge base.
[SLIDE 11. Science to service cycle]
This is the cyclical process, from science to service to science. Through this process, we can ensure that what works under controlled research conditions—or efficacy—is translated into practical, high-quality real-world services—or effectiveness.
This again brings me the topic of training. Grant training has enabled you to conduct training in our integrated dual diagnosis treatment toolkit at three sites, with training at three more pilot sites planned for the next fiscal year. Your training initiative is wonderful. . . .but you must do more. Evidence-based practices are intensive and comprehensive. They represent a long-term investment of resources and workforce. Implementation involves both the application of the new practice and its evaluation, with the results of the evaluation used to inform future planning and service delivery. Consequently, training in integrated treatment is not a one-session deal. Training needs to be conducted onsite and reinforced over a period of time to ensure continuous quality improvement.
A primary challenge to implementing integrated treatment is the alignment of approaches between the mental health and substance abuse treatment fields. Traditional addiction programs tend to be confrontational. Many individuals who have a serious mental illness are too fragile to benefit from this approach. Standard addiction programs also require abstinence from all chemicals, including medications. Persons with mental disorders, however, often need medication to stabilize or improve their condition. As a result, separate treatment of disorders presents conflicting approaches. The power and potential of integrated treatment is that it resolves these conflicts—to the benefit of both providers and consumers.
A second challenge to implementing integrated treatment is that the concept must be embraced at all levels of an organization. Gains made through training of providers will erode if planners and managers aren’t committed firmly to the approach. One of the strongest lessons we’ve learned in the dissemination and sustainability of evidence-based practices is the absolute necessity for buy-in at the administrative level.
Just as you can’t jump a 20-foot chasm in two 10-foot jumps, a State can’t make a half-hearted leap toward integrated treatment. The commitment has to be there at the outset! And this commitment has to be followed with a mighty push for workforce development, program alignment, consumer involvement, and broad-based community collaboration.
What I’m talking about is a systemwide approach to change, which is what the President’s New Freedom Commission called for in its final report. This report is called Achieving the Promise: Transforming Mental Health Care in America. For those of you who are not familiar with the report, I have made copies available at this meeting.
Achieving the Promise is a national call to action. The basis of the report is a detailed assessment of mental health care in this country. The conclusion of the report is this:
[SLIDE 12. Quote]
“For too many Americans with mental illnesses, the mental health services and supports they need are fragmented, disconnected, and often inadequate, frustrating the opportunity for recovery. . . . Instead of ready access to quality care, the system presents barriers that all too often add to the burden of mental illnesses for individuals, their families, and our communities.”
Achieving the Promise calls for a complete transformation of our mental health system. It charges us to fundamentally change what we do and how we go about doing it. The ultimate goal of transformation is to create a system that is consumer and family driven and is focused on recovery.
[SLIDE 13. Definitions]
Consumer- and family-driven care means each adult or child will have access to the full spectrum of services needed to support recovery. It means they will have real and meaningful choices among providers, services, and treatment options. Recovery is a process, sometimes lifelong, through which a consumer achieves independence, self-esteem, and a meaningful life in the community.
As you may recall, mental health transformation is another of SAMHSA’s four redwood programs. For nearly 2 years now, SAMHSA—with the Center for Mental Health Services as the lead agency—has been motivating, facilitating, and compelling changes in the mental health care system at the Federal and State levels. Our new State Incentive Grants for Mental Health Transformation Program is a unique part of our efforts. Transformation grants are designed to help States focus on systemic, infrastructure improvements needed to bridge gaps in the services they provide.
I applaud New Jersey’s intent to apply for a transformation grant during our next round. You already have an excellent foundation in the final report by the Governor’s Task Force on Mental Health. You also have a Governor who has made a personal commitment to improving mental health care for your citizens. Governor Codey has pledged to implement several key recommendations from the task force report. I believe his efforts reflect what is needed to make mental health transformation real; that is, leadership that is practiced more by attitude and actions than by words. We all must demonstrate similar leadership to make transformation happen.
Mental health transformation is our opportunity to shape the future of mental health care for all those who have a mental illness, include those with co-occurring disorders. Persons who have mental and substance abuse disorders are, first and foremost, people like us. They deserve our empathy, respect, and belief in their capacity for recovery.
Too often, they have been excluded from treatment or have received ineffective treatment. They often are demoralized by the systemic barriers they’ve encountered and the limitations imposed by their multiple disorders. It’s a great achievement for a consumer to walk through the doors of a treatment program. That achievement alone needs to be acknowledged and in some way celebrated.
Our role in helping consumers travel down the long and winding road toward wellness and recovery is to help them believe that a better life is possible. A sense that life will improve is one of the most powerful incentives guiding consumers to seek and remain in treatment. Consumers want hope in recovery; many consumers report that having hope was vital to their recovery.
[SLIDE 14. Quote]
As Emily Dickinson, the poet, wrote, “Hope is the thing with feathers—that perches in the soul—and sings the tune without the words—and never stops—at all.” We can give greater hope to persons with mental and substance use disorders by giving them something tangible to believe in. That something, of course, is an evidence-based practice that has been proven effective in helping consumers to achieve recovery. For persons with co-occurring disorders, that practice is integrated treatment. Please do your part to ensure that integrated treatment is available to all who seek and need it. Give their hope new wings. Thank you.
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