# 2.7: Chapter 7: Special Settings & Specific Populations

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### In This Chapter…

Acute Care and Other Medical Settings

Dual Recovery Mutual Self-Help Programs

Specific Populations

# Overview

Building on the programmatic perspective of chapter 6, this chapter describes substance abuse treatment for co-occurring disorders (COD) within special settings and with specific populations. The chapter begins with a discussion of treatment in acute care and other medical settings. While not devoted to drug treatment, important substance abuse treatment does occur there, hence their inclusion in the TIP. Two examples of medical settings in which care is provided for clients with COD are presented: the Harborview Medical Center of Seattle, Washington, a teaching and research county hospital that serves a number of clients with serious mental illness (SMI) and severe substance abuse; and the HIV Integration Project (HIP), run out of The CORE Center, an ambulatory infectious disease clinic in Chicago, Illinois. HIP provides integrated care to persons living with HIV/AIDS who also are diagnosed with cooccurring mental and substance use disorders.

This chapter then turns to a description of the emerging dual recovery mutual self-help programs, and the work of various advocacy groups is highlighted. Finally, specific populations of clients with COD are discussed, including the homeless, women, and those in criminal justice settings. This section highlights the treatment strategies that have proven effective in responding to the needs of these populations. Several examples of programs designed to serve such populations are cited, including a variety of models for trauma. Two such programs for specific populations are illustrated: the Clackamas County programs (Oregon City, Oregon) for persons with COD who are under electronic surveillance or in jail and the Triad Women’s Project, located in a semi-rural area of Florida that spans three counties. The latter program was designed to provide integrated services for women with histories of trauma and abuse who have COD.

Additionally, this chapter contains Advice to the Counselor boxes, to provide readers who have basic backgrounds with the most immediate practical guidance. (For a full listing of these boxes see the table of contents.)

# Acute Care and Other Medical Settings

## Background

Although not substance abuse treatment settings per se, acute care and other medical settings are included here because important substance abuse and mental health treatment do occur in medical units. Acute care refers to short-term care provided in intensive care units, brief hospital stays, and emergency rooms (ERs). Providers in acute care settings usually are not concerned with treating substance use disorders beyond detoxification, stabilization, and/or referral. In other medical settings, such as primary care offices, providers generally lack the resources to provide any kind of extensive substance abuse treatment, but may be able to provide brief interventions (for more information see TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians [Center for Substance Abuse Treatment (CSAT) 1997a]). Exceptions are programs for chronic physical illnesses such as HIV/AIDS, which may have the staff and resources to provide some types of ongoing treatment for mental illness and/or substance abuse. TIP 37, Substance Abuse Treatment for Persons With HIV/AIDS (CSAT 2000e), provides comprehensive information on substance abuse treatment for this population, including integrated treatment for people who have substance use disorders and HIV/AIDS as well as co-occurring mental disorders.

The integration of substance abuse treatment with primary medical care can be effective in reducing both medical problems and levels of substance abuse. More clients can be engaged and retained in substance abuse treatment if that treatment is integrated with medical care than if clients are referred to a separate substance abuse treatment program (Willenbring and Olson 1999). While extensive treatment for substance abuse and co-occurring mental disorders may not be available in acute care settings given the constraints on time and resources, brief assessments, referrals, and interventions can be effective in moving a client to the next level of treatment.

More information on particular issues relating to substance abuse screening and treatment in acute and medical care settings can be found in TIP 16, Alcohol and Other Drug Screening of Hospitalized Trauma Patients (CSAT 1995a); TIP 19, Detoxification From Alcohol and Other Drugs (CSAT 1995c); and TIP 24 (CSAT 1997a). More information on the use and value of brief interventions can be found in TIP 34, Brief Interventions and Brief Therapies for Substance Abuse (CSAT 1999a).

## Examples of Programs

Because acute care and primary care clinics are seeing chronic physical diseases in combination with substance abuse and psychological illness (Wells et al. 1989b), treatment models appropriate to medical settings are emerging. Two programs, the Harborview Medical Center’s Crisis Triage Unit (CTU) in Seattle and The CORE Center (an ambulatory facility for the prevention, care, and research of infectious disease) in Chicago, are examples of two different medical settings in which COD treatment has been effectively integrated. (For a full description of these programs, see the text boxes on pages 185 and 186.) The consensus panel notes that the programs selected have advantages over more typical situations—the Harborview Medical Setting is a teaching and research hospital run by the county and The CORE Center has the support of a research grant. Nonetheless, program features are suggestive of the range of services that can be offered.

The programs featured above typify the “no wrong door” to treatment approach (CSAT 2000a). These providers have the capacity to meet and respond to the client at the location where care is requested, ensuring that each disorder is addressed in the treatment plan.

### Harborview Medical Center’s Crisis Triage Unit, Seattle, Washington

Overview

The Harborview Medical Center is a teaching and research county hospital owned by King County and managed by the University of Washington. As the major trauma center facility in the Seattle area, it receives clients from throughout the Pacific Northwest. The Center has by far the busiest ER in the region, part of which is dedicated to the Crisis Triage Unit for clients with substance abuse and/or mental illness–related emergencies. Across the street from the program is a walk-in crisis center for persons with less severe psychological or sub-stance-related disorders and drug-related emergencies.

Clients Served

The type of clients seen differs at each of the Center’s locations. Although clients representative of each of the four quadrants are served, those seen in the ER fall generally into quadrant IV of the four-quadrant model, that is, those with SMI and severe substance abuse problems (see chapters 2, 3, and 4 for more information about the four-quadrant system).

Services

The focus of services at the CTU is on acute care. Primary goals are to ensure safety, assessment, stabilization, and, as needed, triage to another level of care (either within the facility or outside). The CTU’s treatment can involve intensive medical interventions (which may mean that the client is sent back to the medical/surgical ER), psychiatric interventions (which may include engagement, assessment, acute medications, and even use of restraints), substance abuse–related interventions (emergency detoxification, treatment for withdrawal, and HIV screening and counseling), and holding and referral activities. Clients’ needs vary greatly; while some may only receive a brief crisis intervention, others will require medical care and medication, and still others need social services such as referral to housing.

The Crisis Triage Unit has a 23-hour holding area in the ER where clients can be held long enough to be evaluated (the average length of stay is 4.5 hours). About 1,000 clients come through the CTU each month and close to half of these have co-occurring substance use and mental disorders. Based on the client’s needs, disposition can range from brief evaluation and referral to involuntary acute inpatient hospitalization.

Over the years, staff providing integrated treatment for people with COD have been placed (1) in the CTU, (2) on all three inpatient acute psychiatric units, (3) in the mental health center outpatient program, (4) at the off-site substance abuse treatment detoxification unit, and (5) at the regional substance abuse treatment residential center. Most of the larger mental health centers in the area have developed treatment tracks for persons with COD, and several of the larger substance abuse treatment agencies have hired onsite, part-time psychiatrists.

## Providing Treatment to Clients With COD in Acute Care and Other Medical Settings

Programs that rely on identification (i.e., screening and assessment) and referral have a particular service niche within the treatment system; to be successful, they must have a clear view of their treatment goals and limitations. Effective linkages with various community-based substance abuse treatment facilities are essential to ensure an appropriate response to client needs and to facilitate access to additional services when clients are ready. This section highlights the essential features of providing treatment to clients with COD in acute care and other medical settings.

### The HIV Integration Project of The CORE Center, Chicago, Illinois

Overview

The HIV Integration Project (HIP) is run out of The CORE Center, an ambulatory infectious disease clinic in Chicago, Illinois. It is part of a cooperative agreement funded by six Federal agencies. The goal of this project is to evaluate the impact of the integration of primary care, mental health, and substance abuse treatment services on the healthcare costs, treatment adherence, and health outcomes of persons living with HIV/AIDS who also are diagnosed with co-occurring mental health and substance use disorders.

Clients Served

The center serves more than 3,000 HIV-infected clients annually. Clients predominantly are economically disadvantaged minorities, and include 33 percent women, 73 percent African Americans, 14 percent Hispanics/Latinos, and 12 percent Caucasians. Approximately one-third of the clients present with co-occurring mental health and substance use disorders.

Services

Many settings, despite close proximity, may deliver “co-located” care but not fully integrated care. The HIP model focuses on developing a behavioral science triad that consists of a mental health counselor, a substance abuse treatment counselor, and a case manager. Both medical and social service providers are present during outpatient HIV clinic sessions and clients are screened for eligibility onsite. The triad works together to assess, engage, and facilitate clinically appropriate services for clients with HIV and COD. If clients need immediate services—such as housing, psychiatric hospitalization, or detoxification—the appropriate triad member will facilitate linkage and coordination of care. Outpatient mental health care and substance abuse treatment are offered at the same center where clients receive their primary care.

The triads meet jointly with their clients. They develop joint assessments and treatment plans, communicating regularly with medical providers. Emphasis is placed on facilitating six processes among mental health, chemical dependency, case management, and medical providers: (1) interdisciplinary team identity building, (2) coordination and communication, (3) cross-disciplinary learning, (4) outreach for clients who do not engage initially or sustain mental health or substance abuse care, (5) mental health services, and (6) specialized training in the care of triply diagnosed clients.

### Screening and assessment (in acute and other medical settings)

Clients entering acute care or other medical facilities generally are not seeking substance abuse treatment. Often, treatment providers (primary care and mental health) are not familiar with substance use disorders. Their lack of expertise can lead to unrealistic expectations or frustrations, which may be directed inappropriately toward the client.

The CORE Center serves as a good example of effective screening and assessment. To facilitate early identification of substance abuse and mental disorders within the HIV client population, The CORE Center attempts routine screening of all new clients accessing primary care. Treatment begins at the screening or assessment phase; the triad assesses not only psychological functioning and substance abuse severity, but also readiness for change. The provider will offer only those services that the client is willing to accept. Examples include literature to educate the client on his disorders, case management to address housing or other needs, or referral for detoxification. Next, the triad tries to engage the client, creating a positive experience that encourages return visits. Since continuity of care is important, the triad attempts to follow clients while hospitalized and to work with inpatient medical staff in the same manner as with outpatient staff.

A majority of clients do return to The CORE Center for their primary care treatment. Primary care providers keep the triad informed of client visits so that counselors can build a trusting working relationship with clients that facilitates engagement in mental health or substance abuse care. After meeting with clients, the triad briefs the medical providers on the clinical disposition and treatment strategy. Often, these briefing sessions serve as an opportunity for cross-disciplinary learning. The CORE Center frames its treatment philosophy as holistic, and in one setting treats both the physical and emotional problems the client is experiencing.

At Harborview, clients are given a multidisciplinary evaluation that has medical, mental health, substance abuse, and social work components. Harborview does not employ any dedicated staff for performing evaluation, but rather trains a variety of staff to perform each part of the evaluation. Because of the nature of the setting (the fast-paced world of an emergency room), the basic assessments usually can be performed in 30 minutes, but may take longer in more complicated cases (e.g., if a client cannot communicate because of a speech disorder and information can be gathered only from records or family). Chapter 4 contains a full description of screening and assessment procedures and instruments applicable to COD.

### Accessing services

The CORE Clinic offers clinical interventions focused on crisis counseling, single session treatment, motivational enhancement, short-term mental health services and substance abuse treatment counseling, and psychoeducation as appropriate while the client is in The CORE Center. Primary care providers sometimes are asked to help reinforce treatment recommendations and to join in being “one unified voice” that the client hears.

Given the diversity among people with COD, treatment referrals from The CORE Center are varied, ranging from residential substance abuse treatment to acute psychiatric hospitalization; solid working relationships with treatment communities are needed across settings. When the client is ready for more intensive treatment, the triad provides a critical triage function to the larger substance abuse treatment and mental health services communities.

When Harborview set up its CTU program, part of its contract required that the county mental health and substance abuse treatment systems provide “back door” staff with the authority to ensure client access to other required services. At least one of these staff is onsite 16 hours each day to make referrals for clients being discharged from the CTU. This service has proven extremely important for ensuring both that continuing care for COD is provided to clients leaving the unit and that disposition of CTU clients is efficient.

### Implementation

Administrators who may be considering integrating substance abuse treatment and/or mental health services within existing medical settings should realize that they are introducing a new model of care. The systems and operating culture in place may view changes as unnecessary. Similar to the way in which providers assess a client’s readiness for change (i.e., readiness for treatment), administrators should assess organizational readiness for change prior to implementing a plan of integrated care. This assessment should consider space for additional staff, establish a clear organizational reporting structure, and allow time for providers to work in partnership with other disciplines.

The assessment will inform the planning process. In developing a plan, administrators should:

• Seek input from all stakeholders, especially the clients, a necessary prerequisite to developing or offering services. This information can be gathered through archival data, focus groups, and provider interviews.
• Clarify the role of each of the primary care, substance abuse treatment, and mental health treatment providers.
• Clearly specify the desired outcome(s) for mental health and substance abuse treatment services.
• Outline and pilot both formal and informal communication mechanisms prior to full implementation of services.

When developing and implanting the program, administrators should not minimize or ignore the fact that the medical and social service cultures are very different; opportunities must be provided for relationship and team building (ideally in informal settings). Finally, continued monitoring and flexibility in the development of the model are critical.

### Staffing, supervision, and training

#### Cross-training/cross-disciplinary learning

Cross-training of staff in acute care settings may be more difficult than in other settings because of the greater variety of staff present, but these activities are no less essential. For example, in the Harborview program, staff members include numerous doctors, nurses, physician assistants, psychiatric residents in training, medical students, social workers, social work students, substance abuse treatment counselors, and security officers. Such settings have a greater number of stakeholders than dedicated substance abuse treatment programs—all of whom will need to be involved, at some level, in the development and implementation of a program for clients with COD. Moreover, staff assigned to integrated settings will have varying degrees of commitment to integrated care. Staff also will come into these settings with different definitions of integrated care. They may have varying treatment approaches or may use discipline-specific language that inadvertently can become a barrier to integration. Time and other resource limitations can also pose an obstacle. The CORE Center’s medical care providers cite time constraints as a major impediment to close working relationships with social service staff.

The CORE Center’s staff training program serves to illustrate the potential of cross-training. Staff who work in The CORE Center have begun to look at cross-training more as cross-disciplinary learning. They are discovering what each discipline does, its language and beliefs, and the role of that discipline in the client’s treatment. For example, even though a substance abuse treatment counselor may never serve as a primary care provider, the counselor can appreciate how this provider contributes to the client’s wellbeing. Likewise, primary care providers can learn from case managers about the challenges of finding housing for clients with COD. Social service staff wear lab coats that identify their discipline and team affiliation during clinic sessions; this simple but noticeable change helps social service staff feel a sense of belonging and supports team-building efforts. Mutual respect for the disciplines and a deeper understanding of the interrelatedness of the various staff functions develop over time.

### Team building

Staff training and consultation can help bring all staff on board and unify treatment approaches. To foster team building, The CORE Center has incorporated key components of competent care teams as discussed in the geriatric and oncology literature (Wadsworth and Fall Creek 1999). This effort includes formal and informal team building, training on working in an integrated healthcare team, and clear communication mechanisms.

Effective integrated care teams take time to develop, and a number of institutional and disciplinary barriers make it difficult for staff from different areas of expertise to work together. For instance, differences in philosophies of treatment and traditions of care, as well as differences in how language is used to describe and discuss disorders, can lead to major communication problems. Thus, staff need opportunities to become familiar with the vocabulary of substance abuse treatment, mental health services, and medical treatment.

### Types of training

Specific training needs will vary depending on the type of program, but some mechanism for cross-training activities in acute care settings needs to be in place. The CORE Center has found it useful to have formal training activities where an instructor is invited into the facility (which, in their experience, works better than sending staff out of the facility for training). This strategy may be used in combination with informal training mechanisms, such as providing feedback to medical staff concerning The CORE Center program so they can better understand how medical decisions affect clients’ success in substance abuse treatment and mental health services.

### Continuing care and transition issues

Since medical care is continuous for clients with chronic medical conditions, continuing care (also called aftercare) or transition issues can become blurred for both clients and providers. The CORE Center attempts to facilitate linkage to more intensive services, but realizes that chronically ill clients do not make status transitions in the traditional sense, but rather enter periods of stability when little intervention is required. Because episodic use of services by these clients is the norm, staff need to be flexible and to realize that these clients are likely to return to The CORE Center when in crisis. This reality underscores the requirement for strong linkages to other services for clients who need a more intensive level of care than is available in acute or outpatient care.

### Program evaluation

In developing programs such as the HIV Integration Project or Harborview, it is critical to incorporate program evaluation activities that examine both process and outcome. The evaluation of these programs can prove challenging. Logic models that describe the interrelationship between the conceptual framework, client demographics, treatment services, and expected out-comes are useful to guide evaluation efforts and to identify immediate, short-, and long-term outcomes. Evaluators should add measures such as increased treatment and medication adherence, quality of life, and physical health to the more standard outcome measures such as abstinence or remission of psychiatric symptoms. Since many of the gains involve improvement in quality of life and physical well-being, evaluations that incorporate quantitative and qualitative methods have the best success in capturing the impact of these integrated services. Given the high cost of medical care, economic analyses of the cost and benefits associated with treatment are essential.

Administrators who may be considering integrating substance abuse treatment and/or mental health services within existing medical settings should realize that they are introducing a new model of care.

## Sustaining Programs for Clients With COD in Acute Care Settings

Acute care and other medical care settings generally will rely on very different funding streams than are available to outpatient or residential substance abuse treatment programs. These funding sources will vary depending on the type of program. At Harborview, for example, most funds come from the medical and mental health systems; very little substance abuse treatment money is involved. The program at Harborview has been highly visible and has a number of key county stakeholders (e.g., Department of Mental Health, Department of Alcohol and Drugs, County Hospital), which helps avoid budget cuts. Harborview also has clearly positioned itself as the program of last resort in the region and has developed its programs accordingly. Further, it has created a stateof-the-art integrated information system (each assessment generates a database entry); this enables staff to prepare detailed quality and clinical reports, which are of value to the entire system.

Initial funding for The CORE Center came from the Substance Abuse and Mental Health Services Administration (SAMHSA) through the AIDS demonstration program of SAMHSA’s Center for Mental Health Services (CMHS). Additional funding was provided through other grants through CSAT. Funding from the Health Resources and Services Administration through the Ryan White Care Act supports opportunities to offer more intensive integrated services. Other funding mechanisms, such as private foundation grants, serve as vehicles to secure financial support for these unique integrated services. At present, it is difficult to secure sustained funding from sources such as Medicare or Medicaid. Continuing funding comes from the Ryan White Care Act with some additional funds from the county.

# Dual Recovery Mutual Self-Help Programs

The dual recovery mutual self-help movement is emerging from two cultures: the 12-Step fellowship recovery movement and, more recently, the culture of the mental health consumer movement. This section describes both, as well as other, consumer-driven psychoeducational efforts.

## Background

During the past decade, mutual self-help approaches have emerged for individuals affected by COD. Mutual self-help programs apply a broad spectrum of personal responsibility and peer support principles, usually including 12-Step methods that prescribe a planned regimen of change. These programs are gaining recognition as more meetings are being held in both agency and community settings throughout the United States, Canada, and abroad.

In recent years, dual recovery mutual self-help organizations have emerged as a source of support for people in recovery from COD (DuPont 1994; Ryglewicz and Pepper 1996). Such groups sometimes have been described as special needs groups for people in recovery from substance use disorders (Hendrickson et al. 1996; White 1996). Mental health advocacy organizations—including the National Alliance for the Mentally Ill and the National Mental Health Association—have published articles that have identified dual recovery mutual self-help organizations (Goldfinger 2000; Hamilton 2000). At the Federal level, SAMHSA also has produced documents identifying dual recovery mutual self-help organizations (CMHS 1998; CSAT 1994a).

The new dual recovery mutual self-help organizations are important signs of progress in several respects: First, they encourage men and women who are affected by COD to take responsibility for their personal recovery. Second, they reflect a growing trend toward consumer empowerment (Hendrickson et al. 1994). Finally, they reflect recognition of the importance of peer support in sustained recovery.

Several issues serve as the rationale for establishing dual recovery programs as additions to previously existing 12-Step community groups. To paraphrase Hamilton’s review (Hamilton 2001):

• Stigma and Prejudice: Stigma related to both substance abuse and mental illness continues to be problematic, despite the efforts of many advocacy organizations. Unfortunately, these negative attitudes may surface within a meeting. When this occurs, people in dual recovery may find it difficult to maintain a level of trust and safety in the group setting.
• Inappropriate Advice (Confused Bias): Many members of substance abuse recovery groups recognize the real problem of cross-addiction and are aware that people do use certain prescription medications as intoxicating drugs. Confusion about the appropriate role of psychiatric medication exists, and as a result, some members may offer well-intended, but inappropriate, advice by cautioning newcomers against using medications. Clearly, confused bias against medications may create either of two problems. First, newcomers may follow inappropriate advice and stop taking their medications, causing a recurrence of symptoms. Second, newcomers quickly may recognize confused bias against medications within a meeting, feel uncomfortable, and keep a significant aspect of their recovery a secret.
• Direction for Recovery: A strength of traditional 12-Step fellowships is their ability to offer direction for recovery that is based on years of collective experience. The new dual recovery programs offer an opportunity to begin drawing on the experiences that members have encountered during both the progression of their COD and the process of their dual recovery. In turn, that body of experience can be shared with fellow members and newcomers to provide direction into the pathways to dual recovery.
• Acceptance: Twelve-Step fellowships provide meetings that offer settings for recovery. Dual recovery meetings may offer members and new-comers a setting of emotional acceptance, support, and empowerment. This condition provides opportunities to develop a level of group trust in which people can feel safe and able to share their ideas and feelings honestly while focusing on recovery from both illnesses.

Dual recovery meetings may offer members and newcomers a setting of emotional acceptance, support, and empowerment.

## Dual Recovery Mutual Self-Help Approaches

Dual recovery 12-Step fellowship groups recognize the unique value of people in recovery sharing their personal experiences, strengths, and hope to help other people in recovery. This section provides an overview of emerging self-help fellowships and describes a model self-help psychoeducational group.

### Self-Help Groups

Four dual recovery mutual self-help organizations have gained recognition in the field, as represented in the literature cited in this section. Each of these fellowships is an independent and autonomous membership organization that is guided by the principles of its own steps and traditions (for more information on specific steps, see appendix J for each organization’s contact information). Dual recovery fellowship members are free to interpret, use, or follow the 12 steps in a way that meets their own needs. Members use the steps to learn how to manage their addiction and mental disorders together. The following section provides additional information on each of these specific organizations and the supported mutual self-help model.

1. Double Trouble in Recovery (DTR). This organization provides 12 steps that are based on a traditional adaptation of the original 12 steps. For example, the identified problem in step one is changed to COD, and the population to be assisted is changed in step 12 accordingly. The organization provides a format for meetings that are chaired by members of the fellowship.
2. Dual Disorders Anonymous. This organization follows a similar format to DTR. Like other dual recovery fellowships, the organization provides a meeting format that is used by group members who chair the meetings.
3. Dual Recovery Anonymous. This organization provides 12 steps that are an adapted and expanded version of the traditional 12 steps, similar to those used by DTR and Dual Disorders Anonymous. The terms “assets” and “liabilities” are used instead of the traditional term “character defects.” In addition, it incorporates affirmations into three of the 12 steps. Similar to other dual recovery fellowships, this organization provides a suggested meeting format that is used by group members who chair the meetings.
4. Dual Diagnosis Anonymous. This organization provides a hybrid approach that uses 5 additional steps in conjunction with the traditional 12 steps. The five steps differ from those of other dual recovery groups in underscoring the potential need for medical management, clinical interventions, and therapies. Similar to other dual recovery fellowships, this organization provides a meeting format that is used by group members who chair the meetings.

The dual recovery fellowships are membership organizations rather than consumer service delivery programs. The fellowships function as autonomous networks, providing a system of support parallel to traditional clinical or psychosocial services. Meetings are facilitated by members, who are empowered, responsible, and take turns “chairing” or “leading” the meetings for fellow members and newcomers. Meetings are not led by professional counselors (unless a member happens to be a professional counselor and takes a turn at leading a meeting), nor are members paid to lead meetings. However, the fellowships may develop informal working relationships or linkages with professional providers and consumer organizations.

In keeping with traditional 12-Step principles and traditions, dual recovery 12-Step fellowships do not provide specific clinical or counseling interventions, classes on psychiatric symptoms, or any services similar to case management. Dual recovery fellowships maintain a primary purpose of members helping one another achieve and maintain dual recovery, prevent relapse, and carry the message of recovery to others who experience dual disorders. Dual recovery 12-Step members who take turns chairing their meetings are members of their fellowship as a whole. Anonymity of meeting attendees is preserved because group facilitators do not record the names of their fellow members or newcomers. Fellowship members carry out the primary purpose through the service work of their groups and meetings, some of which are described below.

Groups provide various types of meetings, such as step study meetings, in which the discussion revolves around ways to use the fellowship’s steps for personal recovery. Another type of meeting is a topic discussion meeting, in which members present topics related to dual recovery and discuss how they cope with situations by applying the recovery principles and steps of their fellowship. Hospital and institutional meetings may be provided by fellowship members to individuals currently in hospitals, treatment programs, or correctional facilities.

Fellowship members who are experienced in recovery may act as sponsors to newer members. Newcomers may ask a member they view as experienced to help them learn to use the fellowship’s recovery principles and steps.

Outreach by fellowship members may provide information about their organization to agencies and institutions through in-service programs, workshops, or other types of presentations.

The fellowships are independent organizations based on 12-Step principles and traditions that generally develop cooperative and informal relationships with service providers and other organizations. The fellowships can be seen as providing a source of support that is parallel to formal services, that is, participation while receiving treatment and aftercare services.

Referral to dual recovery fellowships is informal:

• An agency may provide a “host setting” for one of the fellowships to hold its meetings. The agency may arrange for its clients to attend the scheduled meeting.
• An agency may provide transportation for its clients to attend a community meeting provided by one of the fellowships.
• An agency may offer a schedule of community meetings provided by one of the fellowships as a support to referral for clients.

### Common features of dual recovery mutual self-help fellowships

Dual recovery fellowships tend to have the following in common:

• A perspective describing co-occurring disorders and dual recovery.
• A series of steps that provides a plan to achieve and maintain dual recovery, prevent relapse, and organize resources.
• Literature describing the program for members and the public.
• A format to structure and conduct meetings in a way that provides a setting of acceptance and support.
• Plans for establishing an organizational structure to guide the growth of the membership, that is, a central office, fellowship network of area intergroups, groups, and meetings. An “intergroup” is an assembly of people made up of delegates from several groups in an area. It functions as a communications link upward to the central office or offices and outward to all the area groups it serves.

Dual recovery 12-Step fellowship groups recognize the unique value of people in recovery sharing their personal experiences, strengths, and hope to help other people in recovery.

### Empirical evidence

Empirical evidence suggests that participation in DTR contributes substantially to members’ progress in dual recovery and should be encouraged. Specifically, studies found the following positive outcomes:

• A process analysis indicated that DTR involvement at baseline predicted greater levels of subsequent mutual self-help processes (e.g., helper-therapy and reciprocal learning experiences), which were associated with better drug/alcohol abstinence outcomes (Magura et al. 2003).
• An examination of the associations between DTR attendance, psychiatric medication adherence, and mental health outcomes indicated that consistent DTR attendance was associated with better adherence to medication, controlling for other relevant variables. Better adherence to medication was, in turn, associated with lower symptom severity at followup and no psychiatric hospitalization during the follow-up period (Magura et al. 2002).

Supported mutual self-help for dual recovery

Support Together for Emotional/Mental Serenity and Sobriety (STEMSS) is a supported self-help model for people with co-occurring disorders. It is a psychoeducational group intervention rather than a fellowship or membership organization; therefore it has no “parent organization.” STEMSS uses trained facilitators to initiate, implement, and maintain support groups for clients. Facilitators may include professional counselors or trained clinicians, therapists, nurses, or paraprofessionals who are employed at various institutions, treatment programs,hospitals, or community agencies. In some instances, groups may be started and facilitated by other individuals trained in the STEMSS model.

Empirical evidence suggests that participation in DTR contributes substantially to members’ progress in dual recovery and should be encouraged.

The six steps of the program and the support groups are intended to complement participation in traditional 12-Step programs. Facilitators generally are providers who have received training in the theoretical concepts, the six steps for recovery, psychoeducational content, and group approaches. They are encouraged to work with the model in a flexible way, encouraging clients to develop leadership skills to help groups make the transition from psychoeducational groups to sources of mutual self-help. Facilitators may modify the approach, incorporate additional content, develop their own exercises, or incorporate the model into the treatment system. Roles commonly filled by the facilitator include

• Psychoeducation: The facilitator provides information related to recovery topics, psychiatric symptoms, medications, symptom management, coping skills, and other topics.
• Exercises: The facilitator may develop group exercises to stimulate discussions and group interaction, as well as to help maintain the recovery focus.
• Step discussion: Facilitators initiate discussions regarding the STEMSS six-step approach to recovery.

The STEMSS model may be incorporated into the milieu of an agency’s services or may be an autonomous group established in a community setting; thus, STEMSS groups are supported mutual self-help approaches rather than fellowships or consumer service delivery organizations. Due to the anonymous nature of the groups and the way in which an agency uses the model, linkages to STEMSS groups would be established on a group-by-group basis. For more detail about the STEMSS model see TAP 17, Treating Alcohol and Other Drug Abusers in Rural and Frontier Areas (CSAT 1995e).

At this writing, advocacy organizations are at various stages of developing information materials, engaging in advocacy efforts to increase public awareness, coalition building to develop consensus for services, and providing support for dual recovery mutual selfhelp organizations. For contact information on each organization, see appendix J.

### Dual Diagnosis Recovery Network (DDRN)

The DDRN is a program of Foundations Associates that derives part of its funding from the Tennessee Department of Mental Health and Developmental Disabilities and part from the Tennessee Department of Health, Bureau of Alcohol and Drug Abuse Services. DDRN provides

• Dual recovery mutual selfhelp information for all areas of the services that are offered
• Education and training through community programs, inservice training, and workshops, and through State, regional, and national conferences
• Advocacy and coalition building through networking and coordinating a statewide task force that engages chemical dependency and mental health professionals, clients, and family members
• Information dissemination through the Dual Network quarterly journal and through the resource and information clearinghouse

### Dual Recovery Empowerment Foundation (DREF)

The DREF provides training programs and materials to assist treatment providers, consumerrun programs, and consumer advocacy organizations in developing education programs for clients, consumers, and family members. One DREF program is Dual Recovery SelfHelp, which encompasses information on dual recovery 12-Step fellowships, 12-Step principles for personal recovery, coping and life skills, and forming dual recovery 12-Step groups and meetings. DREF also offers Recovery Cultural Cross Training, which provides a cultural competency approach to reframe “philosophical barriers” and explore the histories, common goals, diversity, and accomplishments of both the substance abuse recovery culture and the mental health consumer recovery culture.

### National Mental Health Association

The National Mental Health Association (NMHA) has expanded its mission to include COD. In 1999 the NMHA board of directors adopted a position statement that affirmed NMHA’s commitment to advocacy, public education, and service delivery for consumers with co-occurring substance use and mental disorders. NMHA focuses its efforts in four major areas—prevention, treatment, research, and policy—and is committed to providing leadership in the substance abuse and mental health fields in the area of COD. The organization has a designated area on its Web site—Alcohol and Drug Abuse, Addiction and Co-Occurring Disorders—that contains information, facts, resources, and links to help mental health consumer advocates increase their knowledge about the key issues in COD.

### National Council on Alcoholism and Drug Dependence

The National Council on Alcoholism and Drug Dependence, Inc. (NCADD) was founded in 1944 and works at the national level on policy issues related to barriers in education, prevention, and treatment for people with substance use disorders and their families. NCADD has a nationwide network of nearly 100 affiliates. These affiliates provide information and referrals to local services, including counseling and treatment. NCADD also offers a variety of publications and resources. For more information, visit http://www.ncadd.org.

### Mental health consumer advocacy organizations

The consumer advocacy movement has a history separate from the substance abuse recovery and 12-Step recovery movements. The historical roots of the mental health recovery movement, to a great extent, are related directly to issues in the delivery of mental health services. The modern movement formed in response to concerns about the quality of care, availability of services, and lack of coordination during and following deinstitutionalization. The term “mental health consumer,” though controversial to many people in the movement, clearly reflects both a personal and collective relationship to issues related to mental health care services and support. On the other hand, individuals in substance abuse recovery and those in 12-Step programs do not identify themselves in language that is related to treatment services.

The mental health recovery movement and the substance abuse recovery movement can develop ways to collaborate in an effort to support people affected by COD. In order to collaborate, the movements must engage in a coalition building process that involves

• Shared goals and visions of the movement
• Histories: identifying and valuing diversity
• Experience, strengths, and skills
• Accomplishments and progress
• Shared goals and visions for dual recovery

The consumer advocacy movement has a history separate from the substance abuse recovery and 12-Step recovery movements.

### Consumer Organization and Networking Technical Assistance Center (CONTAC)

The West Virginia Mental Health Consumer’s Association’s CONTAC, which receives funding through SAMHSA’s CMHS, serves as a resource center for consumers/survivors/ex-patients and consumer-run organizations across the United States, promoting self-help, recovery, and empowerment. The services that CONTAC provides include informational materials, onsite training and skills-building curricula, and networking and customized activities promoting self-help, recovery, leadership, business management, and empowerment. CONTAC also offers the Leadership Academy, a training program that is designed to help clients learn how to engage in and develop consumer services.

### National Empowerment Center

The National Empowerment Center has prepared an information packet that includes a series of journal articles, newspaper articles, and a listing of organizations and Federal agencies that provide information, resources, and technical assistance related to substance abuse and dependence, COD, services, and mutual self-help support.

# Specific Populations

In recent years, awareness of COD in subpopulations (such as the homeless, criminal justice clients, women with children, adolescents, and those with HIV/AIDS) and concern about its implications has been growing. This section focuses on three of these subgroups: the homeless, those in criminal justice settings, and women. A complete description of these clients and related programs is beyond the scope of this TIP. However, relevant information can be found in a number of other TIPs, including TIP 17, Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System (CSAT 1995d); TIP 21, Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the Justice System (CSAT 1995b); TIP 30, Continuity of Offender Treatment for Substance Use Disorders From Institution to Community (CSAT 1998c); and the forthcoming TIP’s Substance Abuse Treatment for Adults in the Criminal Justice System (CSAT in development e) and Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT in development b). This section provides background information on the problem of COD in these specific populations, describes some model programs and Federal initiatives, and offers recommendations for programs and services. The purpose of this section is to highlight the emergence of specific-population COD groups and the potential impact of these specialized populations on COD treatment.

## Homeless Persons With COD

### Homelessness

Homelessness continues to be one of the United States’ most intractable and complex social problems. The Urban Institute estimates that 2.3 to 3.5 million people are homeless annually and 842,000 were homeless in February 1996 (Burt and Aron 2000). In New York City alone, more than 33,800 New Yorkers use the city shelter system each night (Bernstein 2002). Despite these statistics, an understanding of the diversity of this population and its service needs is incomplete, and treatment options are still meager.

Homeless people have a variety of medical problems (Institute of Medicine 1988), including HIV (CSAT 2000e). They are frequent victims of and participants in crime (Rahav and Link 1995). They also are disproportionately likely to use substances (Fischer and Breakey 1987) and to have some form of mental illness (Rossi 1990).

### Homelessness and COD

Homeless persons with COD are a particularly problematic subgroup, one that places unique demands on the mental health and substance abuse treatment systems. The number of homeless persons with COD has been estimated to range from 82,215 to 168,000 in any given week (Rahav et al. 1995).

For most, if not all, homeless clients with COD, the impact of substance abuse and mental illness bears a direct relationship to their homeless status. The ability to maintain housing is affected profoundly by substance abuse (Hurlburt et al. 1996). Approximately 70 percent of participants in recent National Institute on Alcohol Abuse and Alcoholism demonstration projects identified substance abuse problems as the primary reason for their homelessness in both the first and most recent episodes (Leaf et al. 1993; Stevens et al. 1993). Among those in shelters, 86 percent are estimated to have alcohol problems and more than 60 percent have problems with illicit drugs (Fischer and Breakey 1991).

### The importance of housing

Another study examined the cost of providing supportive housing versus allowing homeless people to continue in the homeless assistance system, including the cost to the mental health, substance abuse treatment, shelter, hospital, criminal justice, and other public systems. The study reported that psychiatric hospital stays were reduced by 28.2 days (49 percent) for each placement in supportive housing. The study found that supportive housing dramatically reduced use of other public systems by people who were homeless and had SMI, including many who also had substance abuse problems (Culhane et al. 2001).

### Service models for homeless persons with COD

The treatment community has responded positively to the needs of this population. It has developed several models for homeless clients with COD.

#### Supportive housing

Supportive housing typically is housing combined with access to services and supports to address the needs of homeless individuals so that they may live independently in the community. Generally, it is considered an option for individuals and families who have either lived on the streets for longer periods of time and/or who have needs that can be best met by services accessed through their housing. Although the evidence base consists of a small number of studies that vary in methodological rigor and population focus, the results indicate that housing with supports in any form is a powerful intervention that improves the housing stability of individuals with substance abuse and mental disorders, including those who have been homeless (Hurlburt et al. 1996; Rog and Gutman 1997; Shinn et al. 1991). However, many of the same studies also indicate that substance abuse is a major cause of housing loss and that individuals with COD fare less well in housing than those with other disabilities (Shern et al. 1997).

The Pathways to Housing program developed by Tsemberis (Tsemberis et al. 2003; Tsemberis and Eisenberg 2000) is a form of supportive housing designed to serve a highly visible and vulnerable segment of New York’s homeless population (persons with COD who live in the streets, parks, subway tunnels, and similar places). The Pathways program adopts a client perspective and offers clients the option of moving from the streets directly into a furnished apartment of their own (Tsemberis and Eisenberg 2000). However, clients must agree to receive case management and accept a representative payee to ensure that rent/utilities are paid and for resource management. Pathways also uses Assertive Community Treatment teams to offer clients their choice of a wide array of support services in twice-monthly sessions. Vocational, health, psychiatric, substance abuse, and other services are among the options.

A 2-year longitudinal, random assignment, clinical trial study evaluating the effectiveness of the Pathways program as compared to continuum of care programs (i.e., programs where clients move from one level of housing to the next least restrictive level) was conducted with 225 individuals who were homeless and had mental disabilities; 90 percent also had co-occurring substance use disorders. Housing outcomes were significantly better for the Pathways group at the 6-, 12-, 18-, and 24-month followup points. For example, between 18 and 24 months the Pathways group members spent 4 percent of their time literally homeless, compared to 23 percent for the continuum group; they also spent 74 percent of their time in stable housing, compared to 34 percent for the continuum group. In addition, Pathways participants were not more symptomatic at any point, and they did not differ from the continuum group on use of alcohol or other substances. However, the greater effectiveness of the Pathways program in comparison with other programs for the substance abuse, mental health, and other problems of these homeless clients with COD remains to be established.

#### Housing contingent on treatment

Milby and colleagues (1996) found promise in an intervention that added contingent work therapy and housing to a regular day treatment regimen. They compared a standard treatment that featured twice-weekly treatment sessions and referrals for housing and vocational services with an enhanced treatment program that included weekday day treatment (for 5.5 hours per day) and a work therapy component that provided clients with a salary great enough to afford subsidized housing (contingent upon drug-free urine samples). Clients in day treatment with the housing and vocational component had 36 percent fewer cocaine-positive urine toxicologies at 2 months after treatment and 18 percent fewer at 6 months compared to clients in
the standard outpatient program. However, the study did not focus solely on clients with COD; in fact, it excluded clients with active psychosis (Milby et al. 1996).

For most, if not all, homeless clients with COD, the impact of sub-stance abuse and mental illness bears a direct relation-ship to their homeless status.

In a later study, Milby and colleagues (2000) compared two different day treatment programs, one that added abstinent contingent employment and housing and one that did not. Although the study excluded clients with psychotic disorders, three fourths met Axis I diagnostic criteria for other mental disorders. Those who received the extra vocational and housing services achieved longer periods of abstinence than those who did not (the former having a median of approximately 9 consecutive weeks of abstinence out of 24 weeks, and the latter only 3–4 consecutive weeks during the same period). The clients who received these added services also showed greater gains in measures of homelessness and employment (Milby et al. 2000).

#### Housing and treatment integrated

In New York City two specialized shelters are addressing the needs of people who are homeless and who have COD: the Greenhouse Program and the Salvation Army shelter. The Greenhouse Program is a 28-bed modified therapeutic community (TC) shelter for hard-to-reach homeless persons with COD. Staff at the program are trained to address both mental and substance use disorder issues. Developed in 1991 by Bellevue Hospital, this was one of the first specialized shelter programs in the City to treat this population (Galanter et al. 1993; Silberstein et al. 1997). The second is the Salvation Army shelter. Developed in 1998 by the Salvation Army in association with National Development and Research Institutes, Inc., “Kingsboro New Beginnings” is a modified TC for engagement and retention in an 80-bed shelter. Designed for hard-to-reach people who are homeless and have co-occurring mental and substance use disorders—those who are seeking shelter, but not necessarily treatment—this program brought people with COD who were homeless into a specialized shelter setting, using strategies to engage them in mental health services and substance abuse treatment and prepare them for housing (Sacks et al. 2002).

In a series of papers, Sacks and colleagues report on a system of care for people who are homeless that uses a modified therapeutic community (MTC) approach (see chapter 6 for additional information on the MTC model). Clients move from a residential facility to co-located supportive housing as they progress though stages of treatment. Engagement, primary treatment, and planning for re-entry take place in the residential facility; re-entry takes place in the supportive housing program. The research indicated that these clients made significant improvement (compared to treatment-as-usual) on measures of substance use and employment during residential treatment (De Leon et al. 1999, 2000c). These gains appeared to stabilize during the supportive housing phase (Sacks et al. 2003a). The authors concluded:

These pilot findings suggest that the positive behavioral change associated with completion of 12 months of residential treatment can be sustained and, in some cases, strengthened by the use of TC-oriented supported housing as an aftercare strategy. The particular gains in employment and symptom relief are noteworthy in that they speak to core problems of the homeless MICA [mentally ill chemical abusing] population. Combined with the capacity to maintain low levels of crime and substance use, supported housing can be seen as an important and effective way of achieving continuing progress for this population (Sacks et al. 2003a).

### Advice to the Counselor: Working With Homeless Clients With COD

The consensus panel recommends the following in working with homeless clients with COD:

• Address the housing needs of clients.
• Help clients obtain housing.
• Teach clients skills for maintaining housing.
• Work closely with shelter workers and other providers of services to the homeless.
• Address real-life issues in addition to housing, such as substance abuse treatment, legal and pending criminal justice issues, Supplemental Security Insurance/entitlement applications, issues related to children, healthcare needs, and so on.

## Criminal Justice Populations

### Prevalence of COD

Estimates of the rates of severe mental and substance use disorders in jail and prison populations have varied between 3 and 16 percent (Peters and Hills 1993; Regier et al. 1990; Steadman et al. 1987). A U.S. Department of Justice special report (Ditton 1999) estimated that 16 percent of State prison inmates, 7 percent of Federal inmates, 16 percent of those in local jails, and about 16 percent of probationers reported either a mental disorder or an overnight stay in a mental hospital during their lifetime (Ditton 1999). Substance abuse is also common in the criminal justice population. Offenders in the U.S. Department of Justice Survey report a high incidence of drug and alcohol abuse. One third were alcohol dependent, while 6 in 10 were under the influence of alcohol or drugs at the time of offense (Ditton 1999).

### Rationale for treatment

The rationale for providing substance abuse treatment in prisons is based on the well-established relationship between substance abuse and criminal behavior. According to Ditton (1999), offenders with mental illness were likely to be using substances when they committed their convicting offense and likely to be incarcerated for a violent crime. On the other hand, the majority of probationers with mental disorders (approximately three quarters) have not been involved in violent crime. The overall goal of substance abuse treatment for criminal offenders, especially for those who are violent, is to reduce criminality.

### Treatment features and approaches

Several features distinguish the programs currently in place to treat inmates with COD from other substance abuse treatment programs:

• Staff are trained and experienced in treating both mental illness and substance abuse.
• Both disorders are treated as “primary.”
• Treatment services are integrated whenever possible.
• Comprehensive treatment is flexible and individualized.
• The focus of the treatment is long-term.

Treatment approaches used with other populations (e.g., TCs, interventions using cognitive–behavioral approaches, relapse prevention strategies, and support groups) can be adapted to suit the particular needs of offenders with COD. Common modifications described in the literature (Edens et al. 1997; Peters and Hills 1997; Peters and Steinberg 2000; Sacks and Peters 2002) include

• Shorter and simplified meetings
• Special attention to criminal thinking
• Education about medication and COD
• An effort to minimize confrontation

### The importance of post-release treatment and followup

In the last decade, a number of studies have established the importance of linking institutional services to community services (of various kinds). The initial rationale for providing aftercare subsequent to prison-based treatment was to ease the abrupt transition of the offender from prison to community, thus promoting reintegration while monitoring the offender’s behavior in a semi-controlled environment (Clear and Braga 1995; McCarthy and McCarthy 1997). Significant reductions in recidivism were obtained; reductions were larger and sustained for longer periods of time when institutional care was integrated with aftercare programs. Examples are TC work-release (Butzin et al. 2002; Inciardi et al. 2001; Martin et al. 1999) or other community-based treatment such as post-prison TC (Griffith et al. 1999; Hiller et al. 1999; Knight et al. 1997; Wexler et al. 1999) or cognitive– behavioral programs (Johnson and Hunter 1995; Peters et al. 1993; Ross et al. 1988). Longer-term followup studies of TC in-prison plus aftercare programs have reported findings indicating that treatment effects producing lower rates of return to custody may persist for up to 5 years (Prendergast et al. 2004).

Recently, the National Institute on Drug Abuse has established the Criminal Justice Drug Abuse Treatment System. This initiative funds regional research centers that are intended to forge partnerships between substance abuse service providers and the criminal justice system to design and test approaches to the better integration of in-prison treatment and post-prison services.

### Examples of programs in prisons

#### The Clackamas County program (Oregon City, Oregon)

Clackamas County offers two related programs for persons in jails. While incarcerated, inmates are offered pretreatment services in which psychoeducational and preliminary treatment issues are discussed. Discussion sessions are staffed by both a substance abuse treatment counselor, employed by the Mental Health Center, and a corrections counselor who is certified to provide substance abuse treatment services. Inmates are housed in a separate unit, creating some milieu intervention factors.

Many of these inmates are transferred to the Center’s Corrections Substance Abuse Program, when space is available. The Corrections Substance Abuse Program is a residential treatment program within a work release setting. During the first phase clients stay in-house exclusively. With successful progress, they are allowed to seek work in the community. On completion of the program, clients are transitioned to outpatient care in the community with continued monitoring by probation or parole.

Clackamas County also offers intensive outpatient programs focused on different client needs. Through close consultation with the local criminal justice system, offenders under electronic surveillance receive intensive outpatient care. Programming is gender based, with parallel programming for men and women. Sufficient progress transitions the client to less intensive outpatient care.

### Advice to the Counselor: Providing Community Supervision for Offenders With COD

The panel recommends the following strategies for community supervision of offenders with COD:

• Recognize special service needs.
• Give positive reinforcement for small successes and progress.
• Clarify expectations regarding response to supervision.
• Use flexible responses to infractions.
• Give concrete (i.e., not abstract) directions.
• Design highly structured activities.
• Provide ongoing monitoring of symptoms.

Source: Adapted from Peters and Hills 1997.

The Clackamas County program for offenders under electronic surveillance was developed in close consultation with the criminal justice system, with staff members from that system serving as co-facilitators for treatment groups in the program. The highest incidence of personality disorders of any clients in Clackamas County’s substance abuse treatment programs have been found in this particular population of offenders. Consequently, skills building to address such mental health issues as identifying thinking errors, anger management, and conflict resolution are emphasized and form an integral part of this intervention. A subprogram (“Bridges”) works specifically with clients who have COD, providing case management and treatment services. Most Bridges clients have severe and persistent mental illness with histories of school and work failures; consequently, the intervention is intensive, stepwise, and structured, with the opportunity for support in developing social and work skills.

Another effort coordinated with criminal justice has been the intensive outpatient subprogram, drug court. To participate, clients must be of non-felony status and can have their misdemeanor charges expunged by completion of the year-long program. This program, too, is conceived as a stepwise intervention.

In response to the increasing number of inmates with SMI, the Colorado Department of Corrections contracted with a private not-forprofit agency during the mid-1990s to develop Personal Reflections, a modified TC program. A separate 32-bed unit with a planned stay of 15 months, Personal Reflections is located in Pueblo at the San Carlos Correctional Facility, which houses only inmates with mental illness.

The goal of the program is to foster personal change and to reduce the incidence of return to a criminal lifestyle. Personal Reflections uses TC principles and methods as the foundation for recovery and to provide the structure for a cognitive–behavioral curriculum focused on the triple issues of substance abuse, mental illness, and criminal thinking and activity. At the same time, as is central to TC programming, a positive peer culture is employed to facilitate behavior change.

The Personal Reflections modified TC uses psychoeducational classes to increase an inmate’s understanding of mental illness, addiction, the nature of COD, drugs of use and abuse, and the connection between thoughts and behavior. These classes also teach emotional and behavioral coping skills. Therapeutic interventions in the modified TC include (1) core groups to process personal issues, (2) modified encounter groups that address maladaptive behaviors and personal responsibility, and (3) peer groups to provide feedback and support.

#### Empirical evidence

The Personal Reflections program is being evaluated by a study design that randomly assigned and compared two groups, modified TC and services-as-usual (i.e., a mental health services approach). The results obtained from an intent-to-treat analysis of all study entries showed that inmates randomized into the MTC group had significantly lower rates of reincarceration compared to those in the mental health services only group (Sacks et al. 2004).

Because of the stigma associated with the combination of substance abuse, co-occurring mental illness, and a criminal record, this group of offenders will face barriers to being accepted into an aftercare program. They also will have difficulty locating effective programs for their complex problems that require specialized treatment (Broner et al. 2002).

## Women

Women with co-occurring disorders can be served in the same types of mixed-gender co-occurring programs and with the strategies mentioned elsewhere in this TIP. However, specialized programs for women with COD have been developed primarily to address pregnancy and childcare issues as well as certain kinds of trauma, violence, and victimization that may best be dealt with in women-only programs.

Responsibility for care of dependent children is one of the most important barriers to entering treatment according to a major survey of public alcohol dependence authorities, treatment programs, and gatekeepers in 39 communities (CSAT 2001). Women who enter treatment sometimes risk losing public assistance support and custody of their children, making the decision to begin treatment a difficult one (Blume 1997). Women accompanied by their children into treatment can be successful in treatment. A CSAT study of 50 grantees in the Residential Women and Children and Pregnant and Postpartum Women programs reported that the 6- to 12-month treatment program had positive results according to a number of outcome measures (CSAT 2001).

Few women-centered or women-only outpatient co-occurring programs have been described, and most outpatient groups are mixed gender. However, Comtois and Ries (1995) concluded that gender-specific specialized programming may make very significant differences. They found that before specialized programming, women only accounted for 20 percent of group attendance, yet made up 40 percent of census in a large integrated COD treatment program for those with SMI. After women-only specialized programming was developed, the 40 percent census then accounted for 50 percent of group visits. Women attendees commented that they did not feel comfortable in mixed groups, especially in the early phases of treatment, but felt very differently when they had their own groups.

It is the responsibility of the program to address the specific needs of women, and mixed-gender programs need to be made more responsive to women’s needs. Women in mixed-gender outpatient programs require very careful and appropriate counselor matching and the availability of specialized women-only groups to address sensitive issues such as trauma, parenting, stigma, and self-esteem. Strong administrative policies pertaining to sexual harassment, safety, and language must be clearly stated and upheld. These same issues occur in residential programs designed for women who have multiple and complex needs and require a safe environment for stabilization, intensive treatment, and an intensive recovery support structure. Residential treatment for pregnant women with co-occurring disorders should provide integrated co-occurring treatment and primary medical care, as well as attention to other related problems and disorders. The needs of women in residential care depend in part on the severity and complexity of their co-occurring mental disorders. Other issues meriting attention include past or present history of domestic violence or sexual abuse, physical health, and pregnancy or parental status.

### Substance abuse and mental health problems in women

While alcohol, marijuana, and cocaine continue to be problems, heroin, methamphetamine, and new drugs like OxyContin® have gained popularity among women. In general, drugs of abuse today are more available and less expensive than in the past. The previously lower rate of addictions in women compared to men appears to be vanishing, as the rate of substance abuse among young females has become almost equivalent to that of young males. For example, according to SAMHSA’s 2002 National Survey on Drug Use and Health, past-month use of methamphetamine reported by women was 0.2 percent, versus 0.3 percent reported by men (Office of Applied Studies 2003b).

Women and men have differing coping mechanisms and symptom profiles. As compared to their male counterparts, women with substance use disorders have more mental disorders (depression, anxiety, eating disorders, and posttraumatic stress disorder [PTSD]) and lower self-esteem. While women with substance use disorders have more difficulty with emotional problems, their male counterparts have more trouble with functioning (e.g., work, money, legal problems). See the TIP Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT in development b) for more on the psychological impact of substance abuse on women.

Treatment for substance abuse in women should emphasize the importance of relationships, the link between relationships and substance abuse (many women continue to use with a partner), and the importance of relationships with children as a motivator in treatment. The stigma attached to females who abuse substances functions as a barrier to treatment, as does the lack of provision for children.

### Pregnancy and co-occurring disorders

Pregnancy can aggravate or diminish the symptoms of co-occurring mental illness. Worsening symptoms of mental illness can result from hormonal changes that occur during pregnancy; lactation; medications given during pregnancy or delivery; the stresses of pregnancy, labor, and delivery; and adjusting to and bonding with a newborn (Grella 1997). Women with cooccurring disorders sometimes avoid early prenatal care, have difficulty complying with healthcare providers’ instructions, and are unable to plan for their babies or care for them when they arrive. According to the literature, women with anxiety disorders or personality disorders are at increased risk for postpartum depression (Grella 1997).

Many pregnant women with co-occurring disorders are distrustful of substance abuse treatment and mental health service providers, yet they are in need of multiple services (Grella 1997). One concern is whether the mother can care adequately for her newborn. For her to do so requires family-centered, coordinated efforts from such caregivers as social workers, child welfare professionals, and the foster care system.

#### Issues to address with co-occurring mental illness

It is particularly important to make careful treatment plans during pregnancy for women with mental disorders that include planning for childbirth and infant care. Women often are concerned about the effect of their medication on their fetuses. Treatment programs should work to maintain medical and mental stability during the client’s pregnancy and collaborate with other healthcare providers to ensure that treatment is coordinated.

When women are parenting, it can often retrigger their own childhood traumas. Therefore, providers need to balance growth and healing with coping and safety. Focusing on the woman’s interest in and desire to be a good mother, the sensitive counselor will be alert to the inevitable guilt, shame, denial, and resistance to dealing with these issues, as the recovering woman increases her awareness of effective parenting skills. Providers also need to allow for evaluation over time for women with COD. Reassessments should occur as mothers progress through treatment.

#### Pharmacologic considerations

From a clinical standpoint, before giving any medications to pregnant women it is of vital importance that they understand the risks and benefits of taking these medications and that they sign informed consent forms verifying that they have received and understand the information provided to them. Certain psychoactive medications may be associated with birth defects, especially in the first trimester of pregnancy, and weighing potential risk/benefit is important. In most cases, a sensible direction can be found; however, this needs expert advice and consideration by a physician and pharmacist familiar with working with pregnant women with mental disorders. Since pregnant women often present to treatment in mid to late second trimester and polydrug use is the norm rather than the exception (Jones et al. 1999), it is important first to screen these women for dependence on the classes of substances that can produce a life-threatening withdrawal for the mother: alcohol, benzodiazepines, and barbiturates. These substances, as well as opioids, can cause a withdrawal syndrome in the baby, who may need treatment. Pregnant women should be made aware of any and all wraparound services to assist them in managing newborn issues, including food, shelter, medical clinics for innoculations, etc., as well as programs that can help with developmental or physical issues the infant may experience as a result of alcohol/drug exposure. For more on pharmacologic considerations for pregnant women, see appendix F.

#### Postpartum depression

The term “postpartum depression” encompasses:

• Postpartum or maternity “blues,” which affects up to 85 percent of new mothers
• Postpartum depression, which affects between 10 and 15 percent of new mothers
• Postpartum psychosis, which develops following about one per 500–1,000 births, according to some studies (Steiner 1998)

Postpartum “blues” is transient depression occurring most commonly within 3–10 days after delivery. There is evidence that the “blues” are precipitated by progesterone withdrawal (Harris et al. 1994). Prominent in its causes are a woman’s emotional letdown following the excitement and fears of pregnancy and delivery, the discomforts of the period immediately after giving birth, fatigue from loss of sleep during labor and while hospitalized, energy expenditure at labor, anxieties about her ability to care for her child at home, and fears that she may be unattractive to her partner. Symptoms include weepiness, insomnia, depression, anxiety, poor concentration, moodiness, and irritability. These symptoms tend to be mild and transient, and women usually recover completely with rest and reassurance. Anticipation and preventive reassurance throughout pregnancy can prevent postpartum blues from becoming a problem. Women with sleep deprivation should be assisted in getting proper rest. Followup care should ensure that the woman is making sufficient progress and not heading toward a relapse to substance use.

Figure 7-1 lists the criteria for major depressive episode, of which postpartum onset is one specifier. Not all instances of postpartum depression meet the criteria for major depressive episode; they may have fewer than five symptoms.

### Figure 7-1. Criteria for Major Depressive Episode

At least five of the following symptoms present during the same 2-week period, representing a change from previous functioning; one of the symptoms is either depressed mood or loss of interest or pleasure:

• Depressed mood most of the day, nearly every day
• Diminished interest or pleasure in activities
• Significant weight loss
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or inappropriate guilt
• Diminished ability to think or concentrate, or indecisiveness
• Recurrent thoughts of death, recurrent suicidal ideation, or a suicide attempt

Source: APA 2000.

According to the DSM-IV-TR (APA 2000), for a depressive episode to be characterized “with postpartum onset,” it must begin within 4 weeks postpartum. Risk factors for postpartum depression include prior history of non-postpartum depression or psychological distress during pregnancy, other prepregnancy mental diagnosis, or family history of mental disorder (American Psychiatric Association [APA] 2001; Nielsen Forman et al. 2000; Steiner 2002; Webster et al. 2000). Prospects for recovery from postpartum depression are good with supportive psychological counseling accompanied as needed by pharmacological therapy (Chabrol et al. 2002; Cohen et al. 2001; O’Hara et al. 2000). Antidepressants, anxiolytic medications, and even electroconvulsive therapy have all been successful in treating postpartum depression (Griffiths et al. 1989; Oates 1989; Varan et al. 1985). Because some medications pass into breast milk and can cause infant sedation, it is best to consult an experienced psychiatrist or pharmacist for details. Patients with postpartum depression need to be monitored for thoughts of suicide, infanticide, and progression of psychosis in addition to their response to treatment.

Postpartum psychosis is a serious mental disorder. Women with this disorder may lose touch with reality and experience delusions, hallucinations, and/or disorganized speech or behavior. Women most likely to be diagnosed with postpartum psychosis are those with previous diagnoses of bipolar disorder, schizophrenia, or schizoaffective disorder or women who had a major depression in the year preceding the birth (Kumar et al. 1993). Other studies reviewed by Marks and colleagues (1991) indicate that other risk factors for postpartum psychosis include previous depressive illness or postpartum psychosis, first pregnancy, and family history of mental illness. Recurrence of postpartum psychosis in the next pregnancy occurs in 30–50 percent of women (APA 2000). Peak onset is 10–14 days after delivery but can occur any time within 6 months. The severity of the symptoms mandates pharmacological treatment in most cases, and sometimes, hospitalization. The risk of self-harm and/or harm to the baby needs to be assessed, and monitoring of mother–infant pairs by trained personnel can limit these risks.

### Women, trauma, and violence

It is estimated that between 55 and 99 percent of women in substance abuse treatment have had traumatic experiences, typically childhood physical or sexual abuse, domestic violence, or rape. Of these, between 33 and 59 percent have been found to be experiencing current PTSD; yet, historically, few substance abuse treatment programs assess for, treat, or educate clients about trauma (Najavits 2000). This deficiency is a serious one, given the multiplying consequences of failure to address this problem. Greater violence leads to more serious substance abuse and other addictions (e.g., eating disorders, sexual addiction, and compulsive exercise), along with higher rates of depression, self-mutilation, and suicidal impulses. Addiction places women at higher risk of future trauma, through their associations with dangerous people and lowered self-protection when using substances (e.g., going home with a stranger after drinking).

#### Models for women’s trauma recovery

Clearly, effective ways of addressing the trauma-specific needs of women with COD are essential. Fortunately, a number of models are emerging, many with data demonstrating their efficacy. Harris and Fallot have described the core elements of a trauma-informed addictions program as follows (2001, p. 63):

• “The program must have a commitment to teaching explanations that integrate trauma and substance use.” The authors stress the need to help clients understand the interaction between trauma and substance use. They encourage the use of “self-soothing mechanisms” to help trauma survivors deal with symptoms such as flashbacks without resorting to substance use. (See “Grounding” in the discussion of PTSD, appendix D.)
• “The milieu must promote consumer empowerment and relationship building as well as healing.” The authors stress the importance of building strengths, providing an opportunity for caring connections through group work and informal sharing, and establishing a milieu that is “warm, friendly, and nurturing.”
• “Each woman must be encouraged to develop certain crossover skills that are equally important in recovery from trauma and chemical dependency.” Examples of such skills include enhancing self regulation, limit setting, and building self-trust.
• “A series of ancillary services help a woman to continue her recovery once she leaves a structured program.” Examples of areas to be addressed include legal services (e.g., child custody issues, childcare issues), safe housing (e.g., housing that accepts children), and health care (e.g., prenatal care, gynecology, pediatrics).
• “The program avoids the use of recovery tactics that are contraindicated for women recovering from physical and sexual violence.” For many women, these include shaming, moral inventories, confrontation, emphasis on a higher power, and intrusive monitoring. Many practitioners find that alternatives to the 12-Step model are helpful for some women (Kasl 1992; Women for Sobriety 1993). On the other hand, many women have benefited from 12-Step programs. Gender-specific 12-Step meetings may compensate for the shortcoming of mixed gender or predominantly male programs.

While a detailed description of trauma recovery model programs is beyond the scope of this TIP, readers should be aware that there are a number of emerging models available for use. Many are supported by published materials, such as workbooks with session guides that aid in implementation. Examples include the following:

• The Trauma Recovery and Empowerment Model (TREM) is a group approach to healing from the effects of trauma. TREM combines the elements of social skills training, psychoeducational and psychodynamic techniques, and emphasizes peer support, which have proven to be highly effective approaches with survivors. A 33-session guide book for clinicians is available (Harris and Community Connections Trauma Work Group 1998).
• Seeking Safety offers a manual-based, cognitive–behavioral therapy model consisting of 25 sessions which has been used in a number of studies with women who have substance dependence and co-occurring PTSD (Najavits 2000, 2002).
• Helping Women Recover: A Program for Treating Addiction is an integrated program with a separate version for women in the criminal justice system. This model integrates theoretical perspectives of substance abuse and dependence, women’s psychological development, and trauma (Covington 1999).
• The Addiction and Trauma Recovery Integration Model is designed to assess and intervene at the body, mind, and spiritual levels to address key issues linked to trauma and substance abuse experiences (Miller and Guidry 2001).
• Trauma Adaptive Recovery Group Education and Therapy (TARGET) aims to help clients replace their stress responses with a positive approach to personal and relational empowerment. TARGET has been adapted for deaf clients and for those whose primary language is Spanish or Dutch (Ford et al. 2000).

For more detailed information, including individual and other models of trauma healing, see the forthcoming TIPs Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT in development b) and Substance Abuse Treatment and Trauma (CSAT in development d).

### The women, co-occurring disorders, and violence study

Three SAMHSA Centers—CSAT, CMHS, and the Center for Substance Abuse Prevention— collaborated on a nine-site study to develop systems of care for women with co-occurring disorders who also were survivors of violence (the study ended in 2003). Each site was charged with implementing an intervention that models integrated care and conducting a qualitative evaluation of the methods used. The work clearly underlined the need for integrated services, the need to address trauma and violence, and the need to include children with their mothers in treatment. Two of the the participating sites are featured below.

The sites also have identified many issues for children whose mothers had co-occurring disorders. In four of the nine sites in this study, an additional subset study focused on the children of women who participated in the study. The “Cooperative Agreement to Study Children of Women with Alcohol, Drug Abuse and Mental Health (ADM) Disorders who Have Histories of Violence” sought to generate and apply empirical knowledge about the effectiveness of trauma-informed, culturally relevant, age-specific intervention models for children 5 to 10 years of age. The intervention was driven by concern for children who experienced stress as a result of witnessing violence and were at risk for a multitude of problems as they grew older, including COD.

#### Community Connections

Community Connections is a comprehensive nonprofit human services agency serving an urban population in Washington, D.C. Community Connections was the lead agency in the District of Columbia Trauma Collaboration Study (DCTCS), one of nine sites in the SAMHSA research effort to examine the effectiveness of services for female trauma survivors with COD. The DCTCS served more than 150 women in the experimental condition at two agencies in Washington, D.C. All had histories of sexual and/or physical abuse and had co-occurring substance use and mental disorders.

For the past decade, Community Connections has focused both clinical and research efforts on the needs of trauma survivors. The agency has developed trauma-specific services, examined the prevalence and impact of trauma in the lives of individuals diagnosed with serious mental disorders, and developed training and consultation models addressing trauma. In the first 2 years of the SAMHSA project, Community Connections developed a comprehensive, integrated, trauma-focused network of services. A quasi-experimental research project that occurred from 2000 to 2003 assessed the impact of the key intervention components:

1. TREM groups. The TREM group treatment intervention was developed by clinicians at Community Connections with considerable input from consumers. TREM is a 33-session intervention that uses a psychoeducational focus and skill-building approach, emphasizes survivor empowerment and peer support, and teaches techniques for self-soothing, boundary maintenance, and current problemsolving. A more abbreviated version (24 sessions) was developed for agencies to use in a 3- to 6month time frame. TREM has been published as a fully manualized leader’s guide (Harris and Community Connections Trauma Work Group 1998), and in a self-help workbook format titled Healing the Trauma of Abuse (Copeland and Harris 2000).
2. Integrated Trauma Services Teams (ITSTs). ITSTs provide an integrated, comprehensive package of services, include consumer/survivor/recovering persons (C/S/Rs) in central roles, and are responsive to issues of gender and culture. Embedded in an integrated network of programs offering a full range of necessary support services, ITSTs are composed of primary clinicians cross-trained in trauma, mental health, and substance abuse domains. The teams provide services addressing these domains and the complex interactions among them simultaneously and in a closely coordinated way.
3. Collateral Groups. Several additional trauma-informed groups have been developed for women in the study. These modules are explicitly integrative, addressing the relationships among trauma, mental health, and substance abuse concerns. Group modules are: Trauma Informed Addictions Treatment, Parenting Issues, Spirituality and Trauma Recovery, Domestic Violence, Trauma Issues Associated with HIV Infection, and Introduction to Trauma Issues for Women on Inpatient or Short-Stay Units.
4. Women’s Support and Empowerment Center (peer support). Project C/S/Rs developed and offer a variety of peer-run services, including a Peer Representative program providing support, companionship, and advocacy within a women’s peer center, open 5 days a week to women in the program.

Data from the DCTCS suggested that this TREM-based integrative approach was effective in facilitating recovery from substance use disorders and other mental illness. Pilot data from four different clinical sites indicate TREM’s potential benefits in several domains: mental health symptom reduction, decreased utilization of intensive services such as inpatient hospitalization and emergency room visits, decreases in high-risk behavior, and enhanced overall functioning.

### Advice to the Counselor: Treatment Principles and Services for Women With COD

The panel recommends the following treatment principles and services for women.

A report from the National Women’s Resource Center (Finkelstein et al. 1997) reviews the literature on women’s programs and finds that these models have many basic tenets in common. The overarching principle is that the provision of comprehensive services and treatment needs to be in accord with the context and needs of women’s daily lives. Recommendations based on the Center’s review include:

• Identify and build on each woman’s strengths.
• Avoid confrontational approaches (or, as has been stated previously, supportive interventions are preferred to confrontational interventions for persons with COD, especially in the early stages of treatment).
• Teach coping strategies, based on a woman’s experiences, with a willingness to explore the woman’s individual appraisals of stressful situations.
• Arrange to meet the daily needs of women, such as childcare and transportation.
• Have a strong female presence on staff.
• Promote bonding among women.

• Offer program components that help women reduce the stress associated with parenting, and teach parenting skills.
• Develop programs for both women and children.
• Provide interventions that focus on trauma and abuse.
• Foster family reintegration and build positive ties with the extended/kinship family.
• Build healthy support networks with shared family goals.
• Make prevention and emotional support programs available for children.

Source: Adapted from Finkelstein et al. 1997.

This project, featured in the text box above, has found, consistent with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, that the prevalence of depression and anxiety disorders, especially PTSD, is higher among women than men, and that the incidence of borderline personality disorder also is higher (APA 2000).

### The Triad Women’s Project: A Cooperative Agreement Network

Overview

The Triad Women’s Project was developed in 1998 with funds from a SAMHSA collaborative grant on Women, Co-Occurring Disorders, and Violence. The project was designed to provide integrated services for women with histories of trauma and abuse who have COD. Clients were frequent users of mental health and substance abuse treatment services in a semirural area of Florida that spans three counties. Services in the area previously had been delivered by different agencies in a nonintegrated system.

Clients

The program served up to 175 women, many of whom were mandated to treatment by the court.

Services

The three main service components were

• Triad Specialists. The Triad Specialists who provided case management services were located in and funded by their respective mental health or substance abuse treatment programs. They were cross-trained in mental health, substance abuse, and trauma/violence/abuse issues. (A cross-training package was developed on a video that features 16 hours of instruction.) The Triad Specialists met regularly to share information and resources. Caseloads were restricted to 25 clients, all of whom had histories of abuse and were diagnosed with COD. The Triad Specialist became a woman’s case manager at the client’s entrance into the “gateway” agency. The specialist continued to work with her even if she used other services.
• Triad Women’s Group. This component was developed to assist triply diagnosed women with their substance abuse, mental health, and trauma issues. This integrated intervention was designed as a 16-week therapy group, employing a manualized skill development curriculum that could be used in outpatient or residential settings.
• Peer Support Group. The peer support group, called Women of Wisdom, was run by consumers/survivors and served both as a support group for women in treatment and as a continuing support group for those who had left. The groups were based on a 12-Step model for trauma survivors, but addressed substance abuse and mental health recovery issues. They met in community settings and were open to all women in the community.

Preliminary Empirical Evidence

A formal evaluation of the project began in October 2000. Data have shown reductions in mental disorder symptoms, reductions in symptoms related to child sexual abuse, and improvements in “approach or active” coping responses related to substance abuse recovery (as measured by the Coping Responses Inventory [Moos 1993]) as a result of the group intervention.

### Need for increased empirical information

Knowledge about, and understanding of, women with COD needs to be expanded, particularly for those women who experience SMI. The knowledge base should include accurate information on the rates of incidence of COD among women who have SMI, their profiles, and their use of services. In addition, COD outcome studies need to focus on gender differences to further improve treatment protocols for women. Research efforts should address the following questions:

• Medication—Do the problems that women in general have with prescribed psychoactive medication (e.g., concerns about weight gain affecting adherence) hold for women with COD, especially those who have SMI?
• HIV/AIDS risk—Is the current popularity of heroin or methamphetamine translating to increased HIV/AIDS in this subpopulation of women? Are there increasing rates of transmission of HIV/AIDS among females who abuse substances?
• Populations—What differences exist among different populations (e.g. women, teens, lesbian/gay/bisexual, rural, older adults)?
• Drug use—Is the current decline in crack cocaine use reflected in the drug habits of these women?
• Networks—Do social networks of women with COD support recovery, or do they trigger relapse?
• Trauma—Does the severity of mental illness affect the experience of trauma, violence, and victimization? What are the effects of trauma, violence, and abuse on the course of treatment for women with COD?
• Systems—Do existing models meet the complicated service needs of women with COD? Do these models achieve effective linkages with supports based in the community? Do these structures support women with SMI?
• Community connections—How are linkages established and maintained?
• Treatment—What treatment components are effective for women with COD, particularly those who have severe mental disorders?
• Outcomes—Are various treatments differentially effective for women? How do existing strategies and models for the treatment of COD need to be modified to produce the best outcomes for women? (Adapted from Alexander 1996)

2.7: Chapter 7: Special Settings & Specific Populations is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by LibreTexts.