THE CO-OCCURRING DIALOGUES

**DISCUSSION GROUP**

**CENTER FOR SUBSTANCE ABUSE TREATMENT(CSAT)**

(July 2000-February 2001)

######## Carol Coley, M.S.

######## Senior Program Management Advisor

######## 

######## Rosa M. Reyes, Intern

######## Hispanic Association of Colleges and Universities

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION (SAMHSA)

CENTER FOR SUBSTANCE ABUSE TREATMENT

DIVISION OF STATE AND COMMUNITY ASSISTANCE

JULY 2001

THE CO-OCCURRING DIALOGUES

**DISCUSSION GROUP**

**CENTER FOR SUBSTANCE ABUSE TREATMENT(CSAT)**

(July 2000-February 2001)

**[OVERVIEW]{.smallcaps}**

The Co-occurring Dialogues electronic discussion list, which focuses on
issues related to dual diagnosis, represents an expansion of the
services of the CSAT Treatment Improvement Exchange and is a frequently
used service. The impetus for this service was the Co-occurring
Institute discussions at the June 2000 State Systems Development
Programs (SSDP) Conference sponsored by CSAT and the Division of State
and Community Assistance. The initial membership included participants
in the Institute and others who previously expressed an interest in this
topic. For purposes of the discussion list, dual diagnosis is defined as
a mental disorder plus substance abuse. Other issues are obviously
relevant, such as learning disabilities, HIV, and other medical
conditions.

Subscription to the Co-occurring Dialogues discussion list is free and
unrestricted. To subscribe, an individual only needs to send an e-mail
to dualdx@teatment.org. The Co-occurring Dialogues list has over 500
subscribers. Discussion focuses on issues related to dual diagnosis.
Membership is open and the list is moderated. For example, traffic was
heavy in the first 2 weeks of February 2001, when there were 70 messages
posted to the list. With a moderated discussion list, the moderator
screens messages before they are distributed to the members of the list.
This prevents "message loops" and also serves to keep discussions on
topic.

When the discussion list began, much of the communication related to
information regarding meetings, trainings, and announcements. With much
anticipation, the first real question from the field was submitted on
the morning of August 23, 2000. By 2 p.m., the person posing the
question had received many helpful responses. It was amazing to watch!

The purpose of this summary is to provide an overview of the discussion
list activity for the first 6 months of its existence. Little attempt is
made to capture the in-depth philosophical discussions. Rather, the
focus is on collating and saving the resources that were mentioned.
Several resource appendices are attached. These appendices represent a
collection of self-identified field resources that appeared on the
discussion list. Some subscribers may have only provided sketchy
information. Therefore, we have attempted to fill in gaps, when
possible**. *[These resources are not endorsed, reviewed, or approved by
SAMHSA/CSAT/DSCA; they were, however, accurate during the period covered
by this report.]{.underline}*** It is anticipated that these listings
may eventually become free standing, with periodic updates, on the
SAMHSA/CSAT/TIE/Dual Disorders Special Topics Web Page.

**DISCUSSION GROUP WORKGROUP**

A small workgroup consisting of the CSAT Project Officer, the
contractual Web master, and three field representatives was established
to solicit input and guidance regarding the discussion group. The field
representatives were selected by CSAT and include consumers, providers,
and governmental treatment systems. They participate in periodic
conference calls to review activities, communications, and other issues,
as needed.

**MEMBERSHIP**

As of March 1, 2001, there were 528 subscribers. Part of the original
goal was to attract participants from all possible arenas including
providers, clinicians, foundations, consumers/recovery community,
educators, researchers/evaluators, Federal/State/local governmental
agencies, organizations, credentialing entities, and others. (See
attachments A\
and B).

The membership list remains protected by CSAT. Other than
self-identification in communication and resource exchanges, only e-mail
addresses are available to assess the forum in any way. Based on limited
and generic information, we are still very pleased with the diversity of
the subscribers who are partially described below.

-   Thirty-nine States (government entities)

-   International subscribers from at least five countries

-   Public libraries

-   Military

-   Top leaders in the field

-   National organizations such as National Association of State Alcohol
    and Drug Abuse Directors (NASADAD), National Association of State
    Mental Health Program Directors (NASMHP), National Mental Health
    Association (NMHA), Join Together, and American Society of Addiction
    Medicine (ASAM)

-   Nationally recognized research/evaluation organizations

-   Federal agencies such as SAMHSA, FDA, OSOPHS, AHRQ, HRSA, IHS, and
    CDC

-   Many nationally recognized treatment organizations such as Phoenix
    House and Foundations Associates

-   Self-identified consumers

-   Front line treatment staff

-   More than 20 universities including Brown, Dartmouth, Drexel, New
    York University, Brandeis, Columbia, Yale, and Universities of
    Connecticut, Iowa, Washington, Kansas, Maryland, and Pennsylvania

Feedback from the field regarding the electronic discussion list is very
positive, and suggestions for improvement have already been implemented.

A brief sampling of comments includes:

> "\... the list has provided a unique and invaluable opportunity to
> raise issues and to network with other professionals across the nation
> and even around the world. The Center for Substance Abuse Treatment is
> providing leadership and support that is very much appreciated by
> those of us in the field."
>
> "Kudos for a very successful start for this discussion group!"
>
> "The Co-occurring (discussion list) is rapidly becoming, I believe,
> one of the most fruitful and living, breathing on-line vehicles
> created in the field to date."

"You have gotten something hot going with this. Congratulations!"

And, finally, one subscriber ended her communication with a pertinent
thought from the anthropologist , Margaret Mead:

> "*Never doubt that a small group of thoughtful, committed citizens can
> change the world; indeed, it is the only thing that has.*"

**TOPIC SUMMARIES**

The following text has come verbatim from the many subscribers to the
list. It has been edited for grammar, syntax, and clarity.

**DEFINING DUAL DIAGNOSIS**

Over time, dual diagnosis (the older term) has been used to apply to any
number of combinations of disorders from more than one diagnostic
category. An example: a mental illness/substance abuse (MISA) and a
mental illness/chemical abuse (MICA). MISA or MICA does define one
generic dual diagnosis combination and rules out other combination such
as mentally ill/HIV, substance abuse/mental retardation, and so on. Dual
disorder is another term that has been used.

More recently, the term "co-occurring disorders" was developed to
encompass a major mental illness and a substance abuse or dependence
diagnosis, although some would include a broader range of disorders.
There is more than one disorder in need of treatment, neither of which
is pre-eminent and, both of which need treatment, ideally in an
integrated manner. There are a lot of discussions and ideas related to
relative degrees of severity for each disorder. There are some
meaningful approaches to assessment of the relationship between the
disorder and necessary treatment. Also, there is a lot of discussion
about whether or not each disorder needs to be treated and stabilized
before proceeding to address the other(s). Some other discussions even
suggest that co-occurring disorders represent a separate entity, over
and above the inclusive diagnosis. Conventional wisdom is that
co-occurring disorders are the expectation rather than the exception.

Labeling never works well; approaching clients with a holistic view may
work better. But at the same time, it is helpful to have symptoms or
diagnosis stated and developed through clearer language for who/what the
professionals treat.

Integrated treatment needs to deal with everything that is present and
not make assumptions about what might go away. If you have someone with
depression and alcoholism, you shouldn't worry too much at the beginning
about which might be causing which. Deal with both and then, when the
person has some "clean" time, you can make further assessments. The
systemic problem is that when someone presents for treatment with
symptoms of both, it takes time and treatment to sort out the truly
dually disordered from those with a single disorder or from those with a
single disorder-substance abuse-who have psychiatric symptoms. However,
programs pressed by managed care and other payers, are not given the
weeks or even months it takes to get someone clean and dry to see if
there are co-occurring symptoms.

There is much data that suggest addictive disease is actually present
long before the behavioral consequences allow for classification.
However, the data from the national comorbidity survey indicate that the
mental health problem came first most of the time, several years ahead
of the substance abuse, the second disorder, which typically develops 6
to 10 years later. Addressing the matter by diligently addressing
childhood mental health problems seems to be the best bet for targeting
substance abuse prevention efforts. Other studies showed a lot of
evidence about children with diagnosable mental disorders who are at a
higher risk of developing substance abuse disorders than other
children.. The findings with regard to temporal ordering aren't
necessarily uniform across studies or across mental
disorders/substances. For this reason, professionals think that it is a
good idea to address the prevention of addiction with persons at the
earliest stage of their mental illness.

The substance abuse field has a long history of providing prevention
activities for youth and young adults, which focus on increasing their
awareness of the risks involved in using substances and the early
detection of an addictive disorder. The mental health field does not
have such a tradition. If, as many clients report, the substance use
helps at least initially in reducing some of their mental health
symptoms, then many individuals with co-existing disorders may have
introduced and maintained alcohol and other drugs into their lives as a
result of self-medication. Providing information to young people about
how to identify if they have potential symptoms of a mental disorder may
prevent a percentage of this population from developing a second
disorder.

Dual diagnosis historically meant a combination of standard mental
health diagnosis plus one other important group that psychiatrists have
tended to exclude from their interest at some point (for example, mental
illness plus substance abuse, mental illness plus developmental
disability, axis one vs. axis two, and so on). Then, the separation
became institutionalized as the advocates for the excluded groups got
organized. Medical conditions needed to be addressed. Substance abuse
was one of many issues that was part of every psychiatric assessment.
Substance abuse and dependence are part of the DSM (they are psychiatric
diagnoses). Dual diagnosis is an arbitrary political separation that has
done nothing good for the clients with either diagnosis

**WOMEN WITH DUAL DIAGNOSIS**

**Pregnant Women**

In the United States, there are treatment programs that specifically
serve pregnant women with co-occurring disorders. In Florida,
specifically in South Central Florida, the Tri-County Human Services,
Inc. has two residential programs that serve this population. One is the
Residential Assessment and Stabilization Unit for Women services for
pregnant and postpartum women as a priority, and accommodating mothers
with minor children. Primary services orient toward substance abuse,
psycho education, and psychotherapy, and the women are assisted with
psychotropic medications. Women diagnosed with co-occurring mental
illness also receive mental health services through concurrent services
with another provider. The Florida Center for Addictions and Dual
Disorders is another program that serves women and men with co-occurring
mental illness and substance dependence. This program serves pregnant
women, if they are no more than 5 months pregnant and have no major
medical complications at admission. Both programs participate in the
Triad Women's Project, also part of Tri-County Human Services. The
Project is a SAMHSA-funded program to study the outcomes of services
integration and enhanced interventions for women with co-occurring
substance abuse, mental illness, a history of trauma, and their
children.

The States of Virginia, California, and Illinois have programs for
pregnant women with a dual diagnosis. The Project Link program in
Virginia serves women who are pregnant or with very young children who
also have a co-occurring substance abuse or dual diagnosis problem. The
Project Pride Program under East Bay Community Recovery Project in
Oakland, California, serves women who must be California residents and
make a commitment to participate in the program for one year. They also
must be cognitively intact enough to participate in a modified
therapeutic community. The Women's Treatment Center program in Chicago
also provides psychiatric services and case management.

> **Homeless Women**

Journey House in Kentucky is a dual diagnosis residence for homeless
women who have severe, persistent mental illness and chemical
dependency. The outcome and success documented during the 18 months of
this program is remarkable.

**TRAUMA AND DUAL DIAGNOSIS**

Fifty-five percent of dually diagnosed people in Maine report
unrecognized and untreated histories of childhood physical and/or sexual
abuse in both mental health and substance abuse fields, and over 75
percent of people in treatment programs have histories of childhood
physical abuse.

The literature on trauma and dual diagnosis reports prevalence rates
greater than 55 percent. It makes the important point to find programs
that incorporate recognition and treatment of symptoms related to
trauma. Its impact can make a significant difference in the treatment
and recovery of these dually afflicted people. NASMHPD, CSAT and
SAMHSA's Women and Violence (study) published a report on trauma as it
applies to co-occurring disorders. NASMHPD published a report in July of
1998, about behavioral healthcare issues of persons with histories of
physical and sexual abuse, and CSAT published a report about substance
abuse treatment for persons with child abuse and neglect issues.

Programs exist in several States that work with trauma and co-occurring
disorders. One is the SARC House Program in Madison, Wisconsin, which
has a trauma component. Massachusetts has funded three projects related
to trauma and co-occurring disorders in women: one is the WELL Project
in Franklin County. Florida State University has a program for trauma
intervention and works with women with Post Traumatic Stress Disorder
through a variety of therapeutic approaches. For school age children,
there is a nationally evaluated program called Second Step.

**CO-OCCURRING PREVALENCE DATA**

In the early to mid 1990s, researchers investigated the prevalence of
substance abuse and dependence among chronically mentally ill patients.
The results of the research showed that there is 15 to 40 percent of
substance dependence among chronically mental ill patients. The
researchers also investigated the prevalence of mental illness among
substance abusing/ dependent patients and found that 56 percent of
patients with D&A disorders have an Axis I or II psychiatric disorder.

Other investigations show that 70 percent of cocaine abusers were
diagnosed with Axis II personality disorder and 40 percent of opiate
abusers were diagnosed with Axis II personality disorders.

**TRAINING NEEDS FOR PERSONS WITH DEVELOPMENTAL DISABILITIES**

The National Alliance for Developmental Disabilities has information on
provision of substance abuse services to the developmentally disabled
population. Dan Thomasulo, a New Jersey-based psychologist, is training
in the area of developmental disabilities and substance abuse treatment.
The Research and Training Center at Wright State University School of
Medicine (the SARDI program) has resource information about services to
those who are developmentally disabled.

**SUBSTANCE ABUSE LINKED TO EATING DISORDERS**

Experts have estimated that of the five million Americans who suffer
from eating disorders, at least half have an addiction problem. At a
conference sponsored by the National Center for Addiction and Substance
Abuse at Columbia University in New York, Dr. Steven Hyman (National
Institute of Mental Health) said bulimics are more likely to have
substance abuse issues than anorexics. He speculated that addiction and
bulimia could originate in the same area of the brain, because both are
disorders of learning.

Dr. Karen Spedowski (a psychologist at the Kaiser Permanent Chemical
Dependency Recovery Program in Santa Clara, California) says that
treating chemical dependency may be more straightforward than treating
eating disorders, which are much more ambiguous. She explained that an
eating disorder is characterized by a gradual stepping away from
symptoms, and takes longer to develop than the substance abuse problems.
Terence Williams, professor of psychology at Rutgers University in
Piscataway, New Jersey, says that eating disorders and addiction are
linked. He noted that there are superficial similarities, such as
cravings and lack of control. He also says that all eating disorders
should not be lumped in one category, since there are major differences
in the characteristics of anorexics and bulimics.

**DD TREATMENT IN PRISON**

Integrated services for persons with co-occurring disorders are now
considered optimal for individuals with more severe forms of mental
illness and comorbid substance use disorder. Recognizing the need for
identification of and specialized services for individuals who are
dually diagnosed, the Florida Department of Corrections initiated a
collaboration with the Louis de la Parte Florida Mental Health Institute
in 1995 to develop a comprehensive service plan for this population.
Funded by a grant from CSAT's Office of Justice Programs Residential
Substance Abuse Treatment for State Prisoners, this achieved fruition in
1997 with the establishment of two treatment programs for persons with
co-occurring disorders in the Florida prison system. Currently, a
program for males, located at Zephyrhills Correctional Institution,
serves 80 treatment inmates and 10 peer facilitators. A female program
at Broward Correctional Institution serves 40 treatment inmates and 10
peer facilitators. It is important progress to develop a template
matching types of correctional program interventions with types of
individuals with co-occurring disorders. However, the referral for
treatment in prisons/detention settings should not be any less precise
than it would be in the civilian community. A treatment recommendation
needs to be the result of a comprehensive evaluation. Acceptance by the
client of such a referral should be voluntary, but there can be a
variety of ways to positively potentiate a choice for treatment.

**STANDARDS**

There are States planning how to comply with the new Federal regulations
governing opioid treatment programs which should be final and released
to the public soon. The State of Virginia (DMRMHSA) is planning to amend
their State regulations to be in compliance with the new Federal
regulations. Rhode Island currently has policies and procedures under
review in order to comply. Legislation will be prepared if necessary.
However, it is anticipated that the State can accomplish most of the
changes through regulation. Michigan is starting to look at the State
standards and intends to use the new ASAM PPC 2R as a guide.

Some reports of patients who query their clinic managers and counselors
about these important changes in Federal regulations hear comments such
as: "it won't apply to us," "what are you

talking about?", "nothing is changing or doesn't matter" or, "we don't
have to comply." The field may not understand that these are the most
important changes in the opioid addiction field treatment arena in 30
years.

**COORDINATED CARE**

In the redesign or refinement of chemical dependency and mental health
treatment to better address the needs of persons with co-occurring
disorders, it is important to acknowledge the degree to which the
separate systems are doing a commendable job addressing the needs of
some persons who have co-occurring disorders. This foundation of good
mental health and addiction treatment will help to build some much
needed integrated services for persons with co-occurring disorders. It
will be a good way to encourage new funding to help redesign some
programs and to create new ones. This does not mean taking funding from
the separate service systems and handicapping their ability to do good
work with those they are serving who are not dually diagnosed. We should
advocate for additional funding to address the needs of the
un~~-~~served persons with co-occurring disorders. Emphasizing the
strengths of dedicated professionals in the separate systems and
emphasizing evidence-based practice that would help to better address
the needs of persons with co-occurring disorders, the advocacy strategy
should be geared toward the expansion of the work with this population.
New and better integrated services should be funded with new and better
resources. It is a mistake to use an advocacy strategy that shifts
resources from one part of the field to the other or to emphasize that a
small piece of what we do needs a major overhaul. The message ought to
be one that emphasizes the knowledge, experience, success, and
commitment to expand our system using evidence-based strategies to
better address a population of underserved persons whom we continue to
learn more about both from the successes with them and the failures.

The states are devising innovative approaches to ensure that both
psychological and medical needs are being met. Mathematica Policy
Research, Inc., commissioned by the Center for Health Care Strategies,
conducted a study of care coordination in five states, which is
summarized in a new policy brief called "Care Coordination and Managed
Care: Emerging Issues for States and Managed Care Organizations (MCOs)."
This study suggests that most Medicaid managed care programs do
recognize that expanding medical case management to include referrals
for social services may not be enough for individuals with special
health care needs. Shifting the paradigm to ensure creative problem
solving through advocacy is the emerging role for care coordinators in
the context of Medicaid managed care. Achieving this shift will require
collaboration among all stakeholders: the States, MCOs, providers,
advocates, and patients with their families.

Missouri is doing some very interesting and innovative service provision
that braids but does not blend mental health and substance abuse money.
Texas has excellent integrated programs for dual diagnosis.

The National Association of State Mental Health Program Directors
(NASMHPD) and the National Association of State Alcohol and Drug Abuse
Directors (NASADAD) have been collaborating in recent years to help
systems move toward more effective treatment of co-occurring disorders.
CSAT and CMHS support has been critical to these efforts. The strong
relationship between NASADAD and NASMHPD and CMHS and CSAT continues to
be key as some of the thorny issues involved in building collaborations
between the fields are worked through. A number of those issues have
been reflected in the discussion on this discussion list. NASMHPD is
being supported by the CMHS to work closely with NASADAD, States, and
communities to conduct in-depth case studies of successful, integrated
co-occurring service programs and how they are funded. This project will
look closely at the ways in which strong integrated programs managed to
finance co-occurring services. The objective is to duplicate their
successes and make more money available overall for treating
co-occurring disorders rather than further handicap the mental health
and substance abuse systems by taking money from one to give to the
other.

**ANGER**

There was mention of a short intervention program for which each module
is 2 hours long. The purpose of this program is to introduce clients to
anger management issues. At the conclusion of the program, staff will
refer people in need of follow up to the appropriate resources. It is
very important to make the 2-hour periods as dynamic as possible with
some didactic material, a short film, and some experiential exercises.

**MEDICATIONS**

Lithium is a very difficult drug to dose correctly. It has what is
called a "narrow therapeutic window." This drug is not effective when
the dose is too low and can be toxic if too high. The appropriate dose
must be individually set for each patient and the therapeutic dose's
range is small. Many drugs, when taken with Lithium, can affect the
absorption and/or metabolism of Lithium. When any of these changes take
place, it may be necessary to titrate the Lithium dose again.

Adding or subtracting drugs from a regimen that includes methadone
should be done carefully and clients should speak with their physician
or pharmacist before making any changes. Organ function, other drugs,
and other nutritional supplements need to be considered carefully when a
patient takes a drug with a narrow therapeutic window.

People who have used substances for years may have mental disorders that
were caused by the substance use or were exacerbated by the substance
use. These people should be medicated appropriately by a psychiatrist.

Some medications also are helpful in mitigating cravings and withdrawal.
Some people find being on SSRIs helpful in dealing with cravings from
alcohol. A good psychiatrist will not only be able to prescribe
medications for common uses, but also for less well known uses. Examples
are the use of Cloazaril to help Borderline Personality Disorders
clients stop cutting or using SSRIs to help control sexually compulsive
behaviors. One way that the brain will try to maintain homeostasis is by
eliminating receptor sites for neurotransmitters. If someone uses drugs
long enough, will the brain lose the ability to re-establish these
receptors after the substance use stops? If the answer is that the loss
of receptor sites becomes permanent, it may help to explain the high
incidence of depression in alcoholics and why some addicts seem to lose
the ability to feel enjoyment in more normal activities (possibly due to
loss of dopamine sites). For some, the speediness of some of these
medications actually stimulates the cravings. About 30 different
medications have been tried for cocaine cravings in controlled trials
and all have been disappointing. Various things may work for particular
individuals, but be careful about generalizing. The SSRIs are sometimes
quite helpful for sexually compulsive behaviors; however, it is a fine
line, and when men feel it is interfering with performance, they
discontinue taking the medicines, often without mentioning it in
treatment until a relapse episode is explored.

**LEGISLATIVE**

California's Proposition 36 is an important initiative, but it is not
perfect. For the past 16 years, State funding for alcohol and drug
treatment has decreased when you control for inflation and changing
demographics. Without question, there has been a spending increase for
prison construction, with about 27 prisons. Also there are approximately
9,000 people in custody in State treatment beds. However, most have
substantial waiting lists for treatment. It seems immoral to deny
voluntary treatment in the health care system, but to have treatment on
demand in the prison system. All Proposition 36 does is communicate the
will of people in suggesting that it makes more sense to direct finite
resources upstream and, within the health care system, strike a balance
where none has existed.

**TRAINING AND EDUCATIONAL MATERIALS FOR DUAL DIAGNOSIS SERVICES**

There are many educational materials on the topic of dual diagnosis. A
video produced by Hazelden has important information about dual
disorders with many consumers sharing their situations. It also includes
brief but excellent presentations about the purpose of psychiatric
medications, and information about depression, anxiety disorders, and
co-occurring substance abuse. Gerald Rogers Productions has stories of
family/parental alcoholism told from the perspective of children.
Realizations Video concentrates on information about psychiatric
illness; it also is one of the most comprehensive and well done films
about addiction. Ashley Productions has informational materials about
alcohol and alcoholism.

It is very important to provide cross training for staff working with
the dually diagnosed, including a focus on the Axis II population.
Clinicians who work in programs that are not designed to accept
personality disordered/addicted clients still find themselves working
with these individuals as they are often seriously mentally ill as well.
Young staff feel overwhelmed, but are also concerned that other, more
experienced clinicians have burned out from the frustration and
challenge these clients bring to treatment and become punitive.

Training resources may be found through the UNC School of Social Work.
Their Behavioral Healthcare Resource Program collaborated with both the
State Substance Abuse Services Section and Adult Mental Health Services
Section to develop a 5-day training program. The program targets mental
health and substance abuse practitioners in the field and trains
practitioners together as a way to provide both content on dual
disorders and strategies and activities for collaboration across service
systems. In Jackson, Mississippi there was a conference called "Beyond
the Barriers, Annual Conference on Co-occurring Mental Health and
Substance Abuse Disorders" and Foundations Associates presented "Two
Worlds Into One: A National Conference on the Future of Integrated
Mental Health and Substance Abuse," in Las Vegas, Nevada.

**DROPOUT RATES**

Research on dropout and dual diagnosis has produced mixed and
conflicting findings with regard to psychiatric diagnosis and severity
of symptoms. An 18-year study of dual diagnosis treatment groups for
clients with a substance use disorder and a co-existing major mental
illness was completed last fall. The researchers found that on first
admission to the dual diagnosis treatment groups there was a 63 percent
retention rate at 30 days, a 47 percent retention rate at 90 days, a 32
percent retention rate at 60 days, and a 17 percent retention rate at
one year. Second admissions had slightly higher retention rates at the
same intervals and 3rd and subsequent admissions had lower retention
rates. These results were then compared with seven published studies
that were identified addressing group treatment for this population.
Five of them had very similar retention rates and two had much higher
rates but, their *N* was very small and both studies were done by the
same agency. Based on the results, the researchers used the following
target performance standards concerning retention for this population in
groups: 65 percent retention for 30 days, 40 percent for 90 days, 30
percent for 6 months and, 20 percent for one year.

There was another study with participants in St. Louis (a CSAT-funded
initiative) who were assessed at a central intake unit and referred to
treatment. Among these individuals, 25 percent did not show up for
treatment, 15 percent showed but dropped out before the third session,
and 60 percent stayed for three or more sessions. The researchers found
that those with dual diagnosis were about half as likely to show up for
treatment. For participants who showed for treatment, dual diagnosis was
not related to early dropout. In other words, those with dual diagnosis
were as likely as others to engage in treatment once they kept an
initial appointment at the treatment center. In an inpatient hospital
setting, it is highly likely for the patients to stay in the program if
the professionals establish a rapport and gain trust, get the patient to
engage with others of similar interests, and get group support from
their peers. However, keeping them in dual diagnosed treatment in the
community is much more challenging. There are many ways to avoid
patients' dropout from the treatment. One is to keep them in dual
diagnosed treatment in the community, so that they can obtain coping
skills that will better enable them to cope with confrontation and their
fears regarding participation in treatment. Another way to help them
reintegrate into the community is to get them more familiar with the
community, the programs, and counsel them regarding their fears. Also,
if the professionals encourage patients to utilize everyone on their
treatment team, and to not become so reliant upon assistance that they
find difficulty breaking away from, it will be helpful to keep them in
treatment. If discharge is eminent, then discussing how to deal with
these issues should begin long before they are discharged.

The professionals need to be careful using confrontation as a strategy
of intervention in counseling or therapy. The dually diagnosed clients
need and look for something different than the usual treatment. If a
relationship is not present the client will bolt at the traditional
confrontation. They will simply go away mentally or not return to group.
It's better if prior to any gentle confrontation, trust is established
so the client knows she/he is not just being kicked again. One
suggestion is that if the person's defenses rise, immediately try to get
the client to refocus, lower the defense so the client can hear what the
counselor or therapist is saying, make a few suggestions, but always end
the session open-ended with a statement. This will allow the client to
feel as if she/he is in control, which is what the client wants. Almost
always, a person will come back and start a conversation about it.

**CONFIDENTIALITY**

Traversing confidentiality regulations in this era of service
integration, partnership, and co-case management can be complex.
Confidentiality rules are quite different for mental health and
substance abuse. For instance, in the mental health system, parents can
sign consent forms; in the substance abuse treatment system, the client
must sign (including signing consent for the staff to speak with the
client's parents). Children under 14 cannot seek treatment on their own
in the mental health system, whereas any age individual is permitted to
seek treatment under the substance abuse treatment system. For example,
in Virginia, the adolescent can access substance abuse treatment without
parental consent.

Each State sets the confidentiality standards for their mental health
system, but at the same time all States must follow The Code of Federal
Regulations (CFR) unless the State standard is stricter. In
Pennsylvania, there have been struggles with confidentiality issues for
persons with co-occurring disorders for some time. In Oregon, all the
agencies of the Department of Human Services (alcohol and drugs, mental
health, child welfare) have developed a release of information form that
all agree to use. In Alaska, there is a high level of interest among
providers (beyond chemical dependency (CD) providers) in obtaining
training to solve the problem. Some providers have even decided to adopt
the more stringent CD Federal Confidentiality Regulations for use with
all clients in order to facilitate inter-organizational communication.

The client's consent to release information certainly solves many
problems. Problems do persist for clients with co-occurring disorders
when they receive mental health treatment at one organization and
chemical dependency treatment at another. The 42 CFR Part 2 is very
specific about the contents of a valid release and about the fact that a
general medical records release is not sufficient. CD programs are
usually quite adept at sorting this out. Problems sometimes occur in the
organizations attempting to communicate with CD programs when they use
releases that are quite appropriate and legal for their own organization
but do not meet the requirements of 42 CFR Part 2.

One of the problems seems to be the complexity of the rule. It also
raises the bar for confidentiality related to psychotherapy notes and
mental health in general. Confidentiality for substance abuse under 42
CFR Part 2 has been very tight for a long time, and is fairly clear. In
addition, dual diagnosis (especially integrated delivery programs) falls
under two rules, and this is not specifically addressed. It was
addressed generally, but there's still too much room for
misinterpretation. The specified penalties included in the rule are
severe and it is anticipated that this would make clinicians and
policymakers wary, especially with litigious populations.

##### 

##### ALTERNATIVE TREATMENT

The people who work with dual diagnosis patients are moving toward using
other alternative treatment. The Surgeon General's report and the
National Institutes of Health address alternative treatment.

Several of the programs within Regional Behavior Health Authority in
Tucson, Arizona use *acu-detox* (alternative treatment) with positive
results. Acu-detox has a specific protocol, developed over 20 years ago
by Dr. Michael Smith at Lincoln Memorial Hospital in the Bronx. It is
acupuncture of five points on the ear. The National Association of
Detoxification Acupuncture certifies trainers who then train mostly
addiction treatment clinicians to perform this procedure on individuals
withdrawing from alcohol and other drugs. The acupuncture detox protocol
is an alternative treatment that has been used for several years with
patients with co-occurring disorders. This treatment reports to be
effective both subjectively and objectively.

**YOUTH DUAL DIAGNOSIS TREATMENT**

The issue of adolescence is obviously enormous. The adolescents are
technically still children and, therefore, their parents are part of the
picture. Based on study findings, adolescents want their parents to be
involved in their treatment and treatment decisions. It is important to
think about how much responsibility an adolescent can/should shoulder.
Also critical is how to strike the balance between respecting their
input, and giving them some "say" in their treatment, yet recognizing
that they may not yet be ready to shoulder full adult responsibility.
The adolescents need to be treated differently than adults in some
regards. Adolescents want to be heard and respected. They want some
input into their treatment and they want to know their options. An
example of this was the Federation of Families for Children's Mental
Health study that held its annual convention in Washington, D.C. More
than 1500 people at the morning plenary session heard a presentation by
adolescents with dual disorders and their families. They were
dramatizing a SAMHSA/CMHS report of a focus group (100 treated
adolescents and 50 of their family members). The name of their report
was "Blamed and Ashamed." Many ended up in the criminal justice system
for lack of services in their communities. The young people reported
that they had not been able to get integrated or coordinated services.
They all reported that their mental health problem had developed first.
They called for peer counseling and involving their families in their
treatment.

In Colorado, treatment professionals from Adolescent Services (Alcohol
and Drug Abuse Division from Colorado Department of Human Services) have
struggled with the issue around the appropriate treatment approach to
blend MH and SA. They have an Adolescent Co-occurring Committee that
meets monthly to address this issue and recently completed Statewide
focus groups to address the issue.

The adolescent population needs different protocols. It is imperative
that the two fields (mental health/substance abuse) work together to
develop the protocols in something approaching a seamless way. There are
fundamental developmental differences so profound that they require a
liberal analysis of the adolescent population's treatment needs. For
example, children and adolescents are notoriously more difficult to
diagnose than adults, because they are still developing. The diagnostic
criteria have generally been written with adults in mind and, even when
separate criteria have been developed for children, they are sometimes
just miniaturized adult criteria developed without adequate
understanding of maturational developmental processes. Another example
is the dangerousness of labeling, where the risk exists of focusing on
labels rather than on innate resilience and strengths an adolescent may
possess. With youth, these risks are magnified particularly because
there are institutional proclivities to perpetuate an initial incorrect
or inadequate childhood diagnoses/label, and to fail to update the
initial label in light of unfolding events (child with mental health
diagnosis is now abusing alcohol or drugs). Furthermore, youth may buy
into a label for a while, but it is their nature that they come (rightly
or wrongly) to reject it. This has serious disease management
implications and profound striving for health possibilities.

The role of the family is another example to explain the differences
between youth treatment and adult treatment. The youth are embedded in
their families in far more dependent ways than the average adult. Often
adult-based family therapies are premised on a separation model, but
most youth cannot duplicate this model, even if it were desirable.

When treating adolescents, it has been fairly clear that dually
diagnosed adolescents appear to be self-medicating. If that is true, the
professionals need to identify these young people, treat the mental
illness, and spare them the problems that years of substance abuse will
give them. If they abuse substances for a period of time, their brains
will eventually allow for the use of alcohol/drugs and remaining sober
will be difficult. There also is need to find ways to treat the whole
person, rather than simply diagnosing an ailment. In other words,
treatment must be holistic and integrated and respectful.

Programs like the Sanctuary Model address addictive type disorders. The
model is within a milieu of care that integrates trauma theory with
therapeutic community principles in the context of nonviolence. It has
been implemented in five different inpatient psychiatric settings
between

1991 and the present. Three pilot programs are now underway for children
and adolescent

residential settings. Also, there is a manual that includes screening
that has been revised to be

useful for both adults and adolescents . It includes an on-going
evaluation form to assess the predisposition and/or presence of
substance abuse among children and adolescents. The continual contrast
between child/adolescent and adult cases over the course of 2 years has
been extremely enlightening.

#### 

#### TREATMENT

There are numerous references to the need for integrated services
(simultaneous treatment for a substance use disorder and other mental
illness) for patients with severe co-occurring disorders. Research
exists that support this modality for improving treatment outcomes for
that population. But it is important to explain what it means when
people talk about integrated treatment.

A national expert consensus panel as part of the SAMHSA managed care
initiative that generated a report in 1998 entitled, "Co-Occurring
Psychiatric and Substance Disorders in Managed Care Systems: Standards
of Care, Practice Guidelines, Workforce Competences, and Training
Curricula" describes a consensus model for designing a comprehensive,
continuous, integrated system of care. An important part of the
conceptual framework used in this report was to define an integrated
model for service matching, recognizing that there is no correct
integrated "treatment approach" so much as multiple correct
interventions. These interventions have to be matched at any point in
time to individuals according to whether there are continuity of care
interventions or episodic interventions; subtypes of dual diagnoses;
specific diagnosis; stage of change; stage of treatment; severity of
disability and extent of case management required. Also important is the
availability of external supports/external contingencies. And in a
managed care system, separate determination of level of care based on
multidimensional level of care assessment such as ASAM and LOCUS is
important.

Clinical experience, common sense, consumer, and family requests all
call for integrated treatment for the person, which integrates the
disorders within a single self. Only an integrated, holistic assessment
and treatment plan is logically and clinically justified. Dual disorders
are now so prevalent, that they are an expectation, not an exception.
Many programs still focus on the single disorder client. Few have been
designed or redesigned from the ground up to deal with this expectation
or with the reality of interactivity.

The questions are then on the table: Why is there resistance to
integrated treatment among funding, licensing, and provider agencies at
the Federal, State, and local levels? Could it be different training,
different jargons, tradition, protection of traditional ways of working,
fear of change, protection of existing funding sources and allocations,
and separate stigmas?

Simultaneous treatment for MISA does not necessarily mean that services
are integrated. When the availability of services and training dictate
simultaneous versus integrated treatment, the coordination of treatment
is imperative for a positive outcome. The integrated treatment for MISA
clients means that the client can discuss both her/his mental illness
and substance use disorders with the same clinician, within the
perimeters of the group offered at the site, and among the other
clients. The treatment plan will address both issues as well as the
relationship between both disorders. Treatment for MISA means giving
both issues the attention they deserve at any given time. The amount of
attention needed for each issue will fluctuate just as the amount of
attention on any single issue will fluctuate.

**ANNOUNCEMENTS**

The discussion list was created for communication among researchers,
educators, treatment agencies, and others interested in exploring,
investigating, and contributing to the Dual Diagnosis topic. One result
has been to provide the field with information about the different
activities, workshops, conventions, and training related to the topic of
dual diagnosis.

**APPENDICES**

**A. TREATMENT RESOURCES**

**[ADDICTION]{.underline}**

**Center for Addictive Problems**

[http://www.capqualitycare.com](http://www.capqualitycare.com/)

**Addiction Treatment Watchdog**

[http://www.atwatchdog.org](http://www.atwatchdog.org/)

**American Academy of Addiction**

[http://www.aaap.org](http://www.aaap.org/)

**American Society of Addiction Medicine (ASAM)**

[http://www.asam.org](http://www.asam.org/)

####  [ADOLESCENTS]{.underline}

**Adolescent Co-Occurring Committee**

**Addiction Technology Transfer Centers (ATTC)**

[http://nattc.org](http://nattc.org/)

> **Coordinating Center for the Women and Violence Studies**

\(518\) 439-7415

#### National Clearinghouse 

#### [**http://www.health.org/**](http://www.health.org/)

########### National Gains Center {#national-gains-center .unnumbered}

########### [**http://www.prainc.com/gains/**](http://www.prainc.com/gains/) {#httpwww.prainc.comgains .unnumbered}

**National Institute of Drug Abuse (NIDA)**

<http://www.nida.nih.gov/>

#### Setting up Chemical Dependency Component to an Adolescent Psychiatric Unit

Sanctuary Model

Jennings, Ann

<Ann.Jennings@state.me.us>

##################### Successful DD Work with Adolescents with Co-occurring Disorders {#successful-dd-work-with-adolescents-with-co-occurring-disorders .unnumbered}

Kathleen Sciacca

Dual Diagnosis Website <http://www.pobox.com/>

> **Therapeutic Communities of America (TCA)**
>
> <http://www.tcanet.org/>
>
> **[ALTERNATIVE TREATMENT]{.underline}**

#####################   {#section-3 .unnumbered}

#####################  Acu-detox {#acu-detox .unnumbered}

<http://www.acudetox.com/>

<http://www.asianatural.com/acudetox>

[http://www.ursa-major.spdcc.com](http://www.ursa-major.spdcc.com/)

[http://www.jadecampus.com](http://www.jadecampus.com/)

#### 

####  Chapter 18

####  [**http://www.mentalhealth.org/hp2010**](http://www.mentalhealth.org/hp2010)

**DHHS: Healthy People 2010**

<http://www.health.gov/healthypeople/>

####  The Surgeon General's Report [**http://www.surgeongeneral.gov/library/mentalhealth/home.html**](http://www.surgeongeneral.gov/library/mentalhealth/home.html)

> **National Center for Complementary and Alternative Medicine (NCCAM)
> at the National Institute of Health (NIH)\
> **[http://www.nccam.nih.gov](http://www.nccam.nih.gov/)

**[ANGER]{.underline}**

**Margaret Cramer, PhD.**

Department of Psychiatry at Harvard University

Women, PTSD and Chemical Dependence

#### Patrick Reilly

> <reilly.patrick_m@sanfrancisco.va.gov>

\(415\) 750-2004

######### ASSESSMENT

########### Addiction Severity Index (ASI)  {#addiction-severity-index-asi .unnumbered}

<http://www.niaaa.nih.gov/publications/asi.htm>

**HARE Psychopathy Scale**

William "Bill" Sarasin, MA

MDCH-DSAQP

\(517\) 335-8644

**Level of Care Utilization Systems (LOCUS)**

[http://www.comm.psych.pitt.edu](http://www.comm.psych.pitt.edu/)

**Millon Clinical Multiaxial Inventory (MCMI-III NCS)**

1-800-627-7271

> **Patient Placement Criteria for the Treatment of Substance-Related
> Disorders (ASAM PPC-2R)**
>
> <http://www.asam.org/ppc/ppc2.htm>

#####################  Practical Adolescent Dual Diagnostic Interview (PADDI) {#practical-adolescent-dual-diagnostic-interview-paddi .unnumbered}

Norman G. Hoffmann, Ph.D.

Evince Clinical assessments

PO Box 17305, Smithfield, RI 02917

Tel: (401) 231-2055

Toll Free in USA: (800) 755-6299

Clinical Associate Professor of Community Health, Brown University

Recovery Attitude and Treatment Evaluator (RAATE)

<http://www.niaaa.nih.gov/publications/raate.htm>

**Scale of Independent Behavior-Revised (SIB-R)**

<http://www.isd.net/bhill/sibr.html>

University of Rhode Island Change Assessment Scale (URICA)

<http://www.niaaa.nih.gov/piblications/urica.htm>

######### CLUSTER GROUP

Center for Substance Abuse Treatment (CSAT)\'s Co-Occurring and Other
Functional Disorders Cluster Group

[**http://www.dualdiagnosis.org/library/dualnetwork/cofd-granteessummer01.html**](http://www.dualdiagnosis.org/library/dualnetwork/cofd-granteessummer01.html)

**Cluster Grant Activities**

> Contact person: Linda White Young
>
> \(301\) 443-8392

###########  [CO-OCCURRING PREVALENCE DATA]{.underline} {#co-occurring-prevalence-data .unnumbered}

##################### DDX and the Adolescent {#ddx-and-the-adolescent .unnumbered}

[http://www.datos.org](http://www.datos.org/)

> **Mental Health Dissemination Network of Arizona (MHDNA)
> Implementation Forum Co-Occurring Mental Health and Substance Use**
>
> <http://www.asmentalhealth.org/forum/11-9-00/bkground.html>

**[COMMUNITY SUPPORT]{.underline}**

##################### Dual Recovery Anonymous  {#dual-recovery-anonymous .unnumbered}

\(888\) 869-9230

##################### Double Trouble Groups {#double-trouble-groups .unnumbered}

\(800\) 643-7462

##################### MISA Meetings-Chicago Area {#misa-meetings-chicago-area .unnumbered}

Women's Group

-   393 Knollwood Court, Plum Groves Estates, Palatine (Sunday-5pm)

-   Way Back Inn-201 Second Avenue, Maywood (Sunday 8pm)

-   5710 N. Broadway, Room 208, Chicago (Monday 2pm)

-   Open Meeting-2700 N. Lakeview, Room 101, Chicago (Monday 2:15pm)

#### Katie Wells

Adolescent Services

Alcohol and Drug Abuse Division

Colorado Department of Human Services

**Gateway Bellville**

Illinois

\(618\) 234-9002, x. 3001

**[CONFIDENTIALITY]{.underline}**

#### The Legal Action Center

\(212\) 243-1313 (New York City)

\(202\) 544-5478 (Washington, DC)

######### DRUG TESTING

**Patch Drug Testing**

Challenges
[http://www.challenges-program.com](http://www.challenges-program.com/)

**[ELDERLY]{.underline}**

**Michigan Alcoholism Screening Test Geriatric Version (MAST-G)**

> **[HOMELESS]{.underline}**
>
> **Journey House**

Residential program for homeless women with dual diagnosis

> Contact person: Kathy Dobbins
>
> <Dobbinsk@iglou.com>

Louisville, Kentucky

**National Resource Center on Homelessness and Mental Illness (NRC)**

<http://www.prainc.com/nrc/index.html>

**[INTEGRATED TREATMENT PROGRAMS]{.underline}**

**Adult Comprehensive Day Treatment**

Fairfax County Mental Health Service, Mount Vernon

Gary Lupton, LPC, LMFT

\(703\) 799-2755

**Arapahoe House**

8801 Lipan Street

Thornton, Colorado 80221

\(303\) 657-3700

**Behavioral Health Center**

Patt Penn, Director of Research and Evaluation

La Frontera Center, Inc.

Tucson, Az

[http://www.lafrontera.org](http://www.lafrontera.org/)

**Bryn Mawr Program**

More information contact to: Arc of Anchorage

\(907\) 277-6677

**Circle Program**

Colorado Mental Helath Institute at Pueblo

1600 W. 24^th^ Street

Pueblo, Colorado 81003

Dave Stephens, Psy.D., CAC III

Psychologist, Circle Program (719) 546-4797

**Cornerstones**

Adult program

Mellissa Anderson

\(703\) 227-7107

<mellissa_anderson@co.fairfax.va.us>

**Dual Diagnosis Program Directory**

<http://www.cgibin.erols.com/ksciacca/cgi-bin/db.cgi>

**Florida Center for Addictions and Dual Disorders**

Tri-County Human Services, Inc

Dr. Debra King-Ferro, Program Director

<Dking-Ferro@TCHSonline.com>

**Foundation Associates**

\(615\) 742-1000

**Gemini House**

Mental Health center of Greater Manchester

Manchester, NH

Anna Pousland

\(603\) 998-4111 x.4119

**Jack Baker, Psychologist**

Mohawk Valley

\(315\) 797-6800 x. 4114

Jeff Rohacek

McPike Addiction Treatment Center x.4860

**REBT-SMART**

[http://www.smartrecovery.org](http://www.smartrecovery.org/)

**Sunrise II**

Adolescent Program

Tom Cook

\(703\) 648-0884

<tom_cook@co.fairfax.va.us>

**Transitional Living Center**

Rob Mandel, MA

Case manager

Southwest Florida Addiction Services

2917 Grand Avenue

Ft. Myers, Fl 33901

\(941\) 338-2877

**West Central Behavior Health\*\*\***

Mary R. Woods

2 Whippleplace, Suite 202

Lebanon, NH 03766

\(603\) 448-0126

**[LEGISLATIVE]{.underline}**

##### Tom McDaniels

> Legal Action Center
>
> Washington, D.C.

\(202\) 544-5478

**[LICENSURE AND CERTIFICATION]{.underline}**

**Co-Occurring Practitioners Certificate of Competence and Certification
Manual**

Connecticut Certification Board, Inc

<http://www.ccb-inc.org/cooccmanual.html>

**Licensure Legislation HB817-Missouri**

<http://www.house.state.mo.us/bills01/biltx01/intro01/Hbo8171.htm>

> **Mental Illness and Substance Abuse (MISA) Registration**
>
> Illinois Alcohol and Other Drugs Abuse Professional Certification
> Association, Inc. (IAODAPCA)
>
> Nicollette Surico
>
> \(312\) 814-6415

**[METHADONE]{.underline}**

### Lindesmith Center

888 Seventh Avenue, New York, NY, 10106

<lindesmith@sorosny.org>

### Mark Parrino, President

President, American Methadone Treatment Association

**Methadone Today**

[http://www.methadonetoday.org](http://www.methadonetoday.org/)

**Narcotics Anonymous World Services**

<http://www.na.org/bull29.htm>

**Optimizing Response to Methadone Maintenance Treatment (Abstracts)**

<http://www.biopsychiatry.com/methadone.htm>

#### 

####  Therapeuthic Living Facility for clients in a methadone program

State Hawaii alcohol and Drug Abuse Division

**[ORAL SWAB TECHNOLOGY]{.underline}**

Bendiner Labs

47 Third Avenue NY, NY 10003

\(212\) 254-2300

[**http://www.bendinerlab.com**](http://www.bendinerlab.com/)

Comprehensive Toxicology Services

[**http:///www.comtox.com**]()

\(800\) 442-0438

Intercept

Oral drug test that cover substances that also cover the urinalysis.

[**http://www.4intercept.com/press/1_26_2001.html**](http://www.4intercept.com/press/1_26_2001.html)

[PREGNANT WOMEN DUAL DIAGNOSIS]{.underline}

Families in Recovery

\(802\) 258-2806

Fax: (802) 258-2806

**Project Pride East Bay Community Recovery Project**

> Oakland, California

\(510\) 446-7150

[http://www.ebcrp.org](http://www.ebcrp.org/)

**Prototypes**

#######  Culver City, California

########### Rappahannock Area Community Services Board {#rappahannock-area-community-services-board .unnumbered}

> Program for Teen Parents

\(540\) 582-3980

**Tri-County Human Services, Inc.**

> \(863\) 701-1994

#####################  {#section-6 .unnumbered}

#####################  Woman's Treatment Center {#womans-treatment-center .unnumbered}

> Chicago, Illinois

\(312\) 814-6415

**[REGULATIONS]{.underline}**

**Advocates for Recovery through Medicine(ARM)Pamphlets**

<http://www.hometown.aol.com/armconn/myhomepage/news.html>

-Improving trust between programs and patients

-Low Dose? High Dose? What is the effective dose for you?

**[STANDARDS]{.underline}**

##################### Craig Stenning {#craig-stenning .unnumbered}

<Cstenning@mhrh.state.ri.us>

##################### Joyce Washburn {#joyce-washburn .unnumbered}

<washburnjoy@state.mi.us>

**[SCREENING TOOL]{.underline}**

Dartmouth Adult Life Inventory (DALI)

Mental Health Screening Form

[**http://www.asapnys.org/resources.html**](http://www.asapnys.org/resources.html)

Mental Illness Screening Form (MISF)

Mental Illness, Drug Addiction and Alcoholism (MIDAA) Service Manual

[**http://www.pobox.com/\~dualdiagnosis**](http://www.pobox.com/~dualdiagnosis)

UNCOPE

Screening instrument used on arrestees.

[SEVERELLY MENTAL ILLNESS]{.underline}

Mentally Illness Chronically Addicted (MICA)

Richmond State Hospital

Richmond, Indiana

[SEXUAL OFFENDERS AND DUAL DIAGNOSIS]{.underline}

Perpetrators' Group (Court mandated program)

Gordon McInnis

[**Gordon.mcinnis@bowencenter.org**](mailto:Gordon.mcinnis@bowencenter.org)

Tim Nussbaum

[**Tim.nussbaum@bowencenter.org**](mailto:Tim.nussbaum@bowencenter.org)

> **[STATE OF RECOVERY]{.underline}**
>
> **Motivational Interviewing**
>
> [http://www.motivationalinterview.org](http://www.motivationalinterview.org/)

[SUPPORT GROUP]{.underline}

Everyone recovery groups

[**http://www.dualdiagnosisfriendly.org/erg.html**](http://www.dualdiagnosisfriendly.org/erg.html)

Methadone Maintenance Friendly

[**http://www.dualdiagnosisfriendly.org/mmf.html**](http://www.dualdiagnosisfriendly.org/mmf.html)

[SUICIDE]{.underline}

SPANUSA

[**http://www.spanusa.org/home.html**](http://www.spanusa.org/home.html)

[**http://www.nmhag.org/education/suicide_prevention.html**](http://www.nmhag.org/education/suicide_prevention.html)

[TOBACCO]{.underline}

Tobacco Documents Online

[**http://www.tobaccodocuments.org**](http://www.tobaccodocuments.org/)

Tobacco Information and Prevention Source (TIPS)

[**http://www.cdc.gov/tobacco/**](http://www.cdc.gov/tobacco/)

[TREATMENT]{.underline}

Alan Marlatt, Ph.D.

Harm reduction works

Http://www.2.potsdam.edu./alcohol-info/expertopinion/harmreductionworks.html

National Clearinghouse for Alcohol and Drug Information (NCADI)

[**http://www.health.org**](http://www.health.org/)

National Recovery

Affiliated with the American Humanist Association

7 Harwood Drive

PO Box 146, Hamherst, NY 14226-0146

Secular Organizations for Sobriety

PO Box 15781

North Hollywood, CA 91615-5781

Women for Sobriety

PO Box 618

Quakertown, PA 18951

**[TRAINING/EDUCATION]{.underline}**

**Co-Occurring Mental and Substance Use Disorder Online Training**

[http://www.athealth.com](http://www.athealth.com/)

##################### Double Trouble {#double-trouble .unnumbered}

#### (800) 643-7462

####  

**Dual Diagnosis Recovery Network\
** [http://www.foundati@bellsouth.net]()

####  Dual Recovery Anonymous

##  (888) 869-9230

**Fairfax/Falls Church Community Services Board**

Mental Health Services

14150 Park East Circle, Suite 200

Chantilly, VA 20151

\(703\) 968-4027

> [http://www.toad.net](http://www.toad.net/)

## 

> **[Hazelden Distance Learning Center for Addiction
> Studies]{.underline}**
>
> [http://www.dlcas.com](http://www.dlcas.com/)

## Marist College

> Curriculum for the ATTC

Cheryl Whitley

########### Substance Abuse and Mental Health Services Administration (SAMHSA)  {#substance-abuse-and-mental-health-services-administration-samhsa .unnumbered}

###########  [**http://www.samhsa.gov**]() {#httpwww.samhsa.gov .unnumbered}

**Texas Commission on Alcohol and Drug Abuse (TCADA)**

[http://www.tcada.state.tx.us.](http://www.tcada.state.tx.us./)

[**TRAINING** **NEEDS FOR PERSONS WITH DD**]{.underline}

Dan Thomasulo (psychologist)

\(732\) 264-9501

**[VIOLENCE AND SCHOOL AGE KIDS]{.underline}**

##################### Second Step {#second-step .unnumbered}

Program for School Age Kids-CMHS

<http://www.colorado.edu/cspv/blueprint/query/index.html>

> **[WOMEN , CO-OCCURRING DISORDER AND TRAUMA]{.underline}**
>
> **Community Connection in Washington DC**
>
> **TREM Group**
>
> **Consumer-based Model**

Rene Andersen

\(413\) 536-2401

Holyoke, MA

**Program for Trauma Intervention (PTSD and women)**

> Florida State University

\(850\) 644-1588, (850) 681-2255,(850) 644-9598

[cfgley@garnet.acns.fsu.edu]{.underline}

##################### SARC House {#sarc-house .unnumbered}

Madison, Wisconsin

### Substance Abuse and Mntal Health Services Administration (SAMHSA) Women and Violence Project

### Policy Research Association Inc

\(518\) 429-7415

Joe Cocozza

**Sidran Foundation**

Esther Giller

(410)825-8888

### TRIAD Model

> Arthur Cox, Sr., and Colleen Clark
>
> \(813\) 974-9022
>
> <http://www.fmhi.usf.edu/cmh/research/exemplary/triad.html>

Florida, US

**WELL Project**

Franklin County, Massachusetts

**B. PUBLICATIONS**

> **[ADOLESCENTS]{.underline}**
>
> Academy of Addictions Treatment Professionals. (1997). *A
> Professional's Guide to Dual Disorders in Adolescence.* Springfield,
> IL: Author.
>
> Coalition for Juvenile Justice. (2000). *Handle with Care: Serving the
> Mental Health Needs of Young Offenders.* Washington, DC: Author.

Federation of Families for Mental Health. (2000). Blamed and Ashamed:
Treatment Experiences of Youth with Co-Occurring Disorders. VA: Author.

Kessler, R.C. (1994). The National Comorbidity Survey of the United
States.

*International Review of Psychiatry,* 6, 365-376.

Gabe, J. (1999). *Culture of Changes-Recovery and Relapse Prevention for
Dually*

*Diagnosed and Addicted Adolescents.* Indianapolis, IN: Professional
Resource Publications.

> Prescott, L. (1997). *Adolescent Girls with Co-Occurring Disorders in
> the Juvenile Justice System.*

Prescott, L. (1997). *Improving Policy and Practice for Adolescent Girls
with Co-Occurring Disorders in the Juvenile Justice System*.

Weinberg, N.Z., Rahdert, E., Colliver, J.D., and Glantz, M.D. (1998).
Adolescent

substance abuse a review of the past 10 years. *Journal of the American
Academy of Child & Adolescent Psychiatry,* 37, 252-261.

Zimberg, S., Solomon, J., and Shollar, E. (1994). *Dual Diagnosis
Evaluation,*

*Treatment, Training and Program Development.* New York: Plenum.

> (1999). Issues in adolescent alcohol and drug treatment. *Journal of
> Psychoactive Drugs.*

**[ADDICTION STRATEGIES]{.underline}**

> (1997*).* High dose best dose for many. *Addiction Treatment Forum, 6,
> 3. (Summer).*

**[ALCOHOL PROBLEMS]{.underline}**

> Fletcher, A. (2001). *Sober for Good: New Solutions for Drinking
> Problems: Advice from Those Who Have Succeeded*. Houghton Mifflin.
>
> **[ALTERNATIVE TREATMENT]{.underline}**
>
> Bullock, M., Culliton, P.D., and Olander, R.T. (1989). *Controlled
> Trial of Acupuncture for Severe Recidivist Alcoholism.*
>
> **[ANGER]{.underline}**

Vermilyea, E.G. (2000). *Growing beyond Survival: A Self-Help Toolkit
for*

*Managing Traumatic Stress.* Baltimore, MD: Sidran Press.

**[ASSESSMENT]{.underline}**

> American Society of Addiction Medicine. (2001*). ASAM Patient
> Placement Criteria for the Treatment of Substance-Related Disorders.*
> (2nd Ed. Rev.). Annapolis, MD: Author.
>
> Oldham, J., and Morris, L.B. (1995*). The New Personality
> Self-Portrait: Why You Think, Work, Love, and Act the Way You Do.*
> Bantam/Doubleday/Dell.

### Substance Abuse Mental Health Service Administration/Center for Substance Abuse Treatment. (1994*). Assessment and Treatment Planning for Cocaine-Abusing Methadone Maintained Patients. (TIP #10).* Rockville, MD: Author.

**[CLUSTER GROUP]{.underline}**

> CSAT\'s Co-Occurring and Other Functional Disorders Cluster Group.
> (2001). *Co-Occurring and Other Functional Disorders Cluster Group.*
> (Vol. 2, 3d Ed.).

Nashville, TN: Dual Network.

> **\
> [CO-OCCURRING PREVALENCE DATA]{.underline}**
>
> Cacciola, J.S., Alterman, A.I., McKay, J.R., and Rutherford, M.J.
> (2001). Psychiatric comorbity in patients with substance use
> disorders: Do not forget axis two disorders*. Psychiatric Annals,* 31
> (5), 321-331.
>
> Kessler, R. (1996). The epidemiology of co-occurring addictive and
> mental disorders: Implications for prevention and service
> utilization*. American Journal of Orthopsychiatry, 66, 17-31.*

Regier (1990). Co-morbidity of mental disorders with alcohol and other
drug abuse*. Journal of the American Medical Association.*

Schneider, U., Altmann, A., Baumann,M., et al. (2001). Comorbid anxiety
and affective disorder in alcohol-dependent patients seeking treatment:
The first multicentre study in Germany. *Alcohol and Alcoholism,* 36(3),
219-223.

**[CONFIDENTIALITY]{.underline}**

> Legal Action Center. (2000). *Confidentiality and Communications: A
> Guide to Federal Drug and Alcohol Confidentiality Law.* New York:
> Author.
>
> Substance Abuse Mental Health Service Administration/Center for
> Substance Abuse and Treatment. (1994). *Assessment and Treatment of
> Patient with Coexisting Mental Illness and Alcohol and Other Drug
> Abuse. (TIP #9).* Rockville, MD: Author.
>
> Substance Abuse and Mental Health Service Administration/Center for
> Substance Abuse and Treatment. (1995)*. Confidentiality of Patient
> Records for Alcohol and Other Drug Ttreatment. (TIP #13).* Rockville,
> MD: Author.
>
> Substance and Mental Health Service Administration/Center for
> Substance Abuse and Treatment. (1997)*. Welfare Reform and Substance
> Abuse Treatment Confidentiality: General Guidance for Reconciling Need
> to Know and Privacy. (TIP#24).* Rockville, MD: Author.
>
> White, B. (2001). *Balancing Confidentiality Concerns with Quality
> Coordinated Services for the SPMI and Dually Diagnosed Client*. \[PDF
> Format\]\[Word Format\]. Available at:
> [Http://www.treatment.org/topics/dual.html](http://www.treatment.org/topics/dual.html)

####  [DIAGNOSIS]{.underline}

> Christie, K.A. (1988). Epidemiologic evidence for early onset of
> mental disorders and higher risk of drug abuse in young adults*.
> American Journal of Psychiatry,*145, 971-975.
>
> Kessler, R. (1996). The epidemiology of co-occurring addictive and
> mental disorders: Implications for prevention and service
> utilization*. American Journal of Orthopsychiatry,* 66, 17-31.

#####  Merikangas, K. (1998). Comorbidity of substance use disorders with mood and

> anxiety disorders: Results of the international consortium in
> psychiatric epidemiology. *Addictive Behaviors,* 23, 893-907.

##################### [DROPOUT RATE FOR DD PROGRAMS]{.underline} {#dropout-rate-for-dd-programs .unnumbered}

> Stark, M.J. (1992) Dropping out of substance abuse treatment: A
> clinically oriented review*. Clinical Psychological Review*, 12,
> 93-116.
>
> **[HOMELESS]{.underline}**
>
> **Drake, R.E., Osher, F.C., and Wallach, M.A. (1991). Homelessness and
> dual diagnosis. *International Journal of Psychosocial
> Rehabilitation,* 46, 1149-1158.**
>
> Tsemberis, S., and Eisenberg, R.F. (2000). Pathways to housing:
> Supported housing for street-dwelling homeless individuals with
> psychiatric disabilities. 51, 487-493.
>
> **[ELDERLY]{.underline}**
>
> Allen, Goldstein, and Aldarondo (1999). Neurocognitive dysfunction in
> patients diagnosed with schizophrenia and alcoholism.
> *Neuropsychology,* 13, 62-68.
>
> Lehman, A., and Dixon, L. (1995). *Double Jeopardy: Chronic mental
> illness and Substance Abuse Use Disorders.* Newark, NJ: Harwood
> Academic Publishers.
>
> Sheikh, J.I., and Yalom, I.D. (1996). *Treating the Elderly.*
> Jossey-Bass.
>
> Substance Abuse Mental Health Service Administration/Center for
> Substance Abuse and Treatment. (1998). *Substance Abuse Among Older
> Adults. (TIP #26).* Rockville, MD: Author.

####  [EVIDENCED BASED PRACTICES]{.underline}

> Mueser, K.T., Bond, G.R., and Drake, R.E. (2001). Community-based
> treatment of schizophrenia and other mental disorders: Treatment
> outcomes. *Medscape Mental Health*, 6.

######  **[INTEGRATED TREATMENT PROGRAMS]{.underline}**

> Sciacca, K., and Thompson, C. (1996). Program development across
> systems for dual diagnosis: Mental illness, drug addiction and
> alcoholism, MIDAA. *Journal of Mental Health Administration,*
> 3[,]{.underline}
>
> **[METHADONE]{.underline}**
>
> Hser, Y.I., Hoffman, V., Grella, C., and Anglin, M.D. (2001). A 33
> year follow-up of narcotics addicts. *Archives of general Psychiatry,*
> 58, 503-508.
>
> Zweben, J.E. (1999). *Making Residential Treatment Available to
> Methadone Clients.* Available at
> Http://www.treatment.org/topics/dual.html
>
> **[NICOTINE ADDICTION]{.underline}**
>
> Kelly, C. and McCreadie, R.G. (1999). Smoking habits, current
> symptoms, and premorbid characteristics of schizophrenic patients in
> Nithsdale, Scotland. *American Journal of Psychiatry,* 156, 1751-1757.
>
> Lasser, K., Boyd, J.W., Woolhandler, S., et al. (2000). Smoking and
> mental illness: A population-based prevalence study. *Journal of the
> American Medical Association*, 284 (2), 247-254.
>
> Rustin,T.A. (1998). Incporporating nicotine dependence into addiction
> treatment. *Journal of Addicitive Diseases,* 17 (1), 83-108.
>
> Ziedonis, D.M., and George, T.P. (1997). Schizophrenia and nicotine
> use: Report of a pilot smoking cessation program and review of
> neurobiological and clinical issues. *Schizophrenia Bulletin*, 23 (2),
> 247-254.
>
> Ziedonis, D.M., Kosten, T.R., Glazer, W.M., and Frances, R.J. (1994).
> Nicotine dependence and schizophrenia. *Hospital and community
> Psychiatry,* 45 (3), 204-206.
>
> **[OPIATE ADDICTION AND TREATMENT]{.underline}**
>
> Valdivia J.F., and Khattak, S. (2000). Effects of LAAM and methadone
> utilization in an opiate agonist treatment program. *Mount Sinai
> Journal of Medicine*, 67, 4, 333
>
> **[PREVENTION AND TREATMENT COLLABORATION]{.underline}**
>
> Harolyn, Belcher, and Shinitzky, H.E. (1998). Substance abuse in
> children: Prediction, protection, and prevention. *Archives of
> Pediatric Adolescent Medicine,* 12, 1029.

**\
[SCREENING TOOL]{.underline}**

> Peter, R.H., and Green Bartoi, M. (1997). *Screening and Assessment of
> Co-Occurring Disorders in the Justice System*. GAINS Center.

**[STAGE OF RECOVERY]{.underline}**

> Miller, W., and Rollnick, S. (1992). *Motivational Interviewing.* New
> York: Guilford Publications.
>
> Prochaska, J., DiClementi, C., and Norcross, T. (1995). *Changing for
> Good*. Morrow, William & Co.
>
> Sciacca, K., and Thompson, C. (1997). Removing barriers: Dual
> diagnosis treatment and motivational interviewing. *Professional
> Counselor Magazine,* 12.
>
> Van Horn, D.H.A., and Bux, D.A., Jr. (2001). A pilot test of
> motivational interviewing groups for dually diagnosed inpatients.
> *Journal of Substance Abuse Treatment,* 20, 191-195.
>
> **[STANDARDS]{.underline}**
>
> Minkoff, K. (2001). Best practices: Developing standards of care for
> individuals with co-occurring psychiatric and substance use disorders.
> *Psychiatric Services,* 52, 597-599.

#  

#  [TRAINING/EDUCATION]{.underline}

> Sciacca, K. (1996). On co-occurring addictive and mental disorders.
> *American Journal Orthopsychiatry*, 66, 474.

#  Published materials for training

#  

#  Ashley Productions

"Chalk Talk-Revised"

## Gerald T. Rogers Productions 

"Promise of Recovery" (focuses on DD issues)

"Double Trouble" (videos)

"Soft is the Heart of a Child" (older version of the story)

## Hazelden

"Out of the Tunnel: Into the Light" "Twelve Steps and Dual Disorders"

DD Series (videos)

## 

## Illinois Newsletter

## Addiction Technology Transfer Center of New England

## Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) 

## 

## Realizations Video

"Beat the Street"

######### TRAUMA

> Center for Substance Abuse and Treatment. (2000). *Substance Abuse
> Treatment for Persons with Child Abuse and Neglect Issues, (TIP 36).
> Rockville, MD: Author.*
>
> Evans, K., and Sullivan, M. (2000). *Dual Diagnosis.* OR: Guilford
> Press.
>
> Harris, M. (1998). *Trauma Recovery and Empowerment: A Clinician's
> Guide for Working with Women in Groups.* Free Press.
>
> National Association of State Mental Health Program Directors. (1998).
> *Responding to the Behavioral Healthcare Issues of Persons with
> Histories of Physical and Sexual Abuse.*
>
> Vermilyea, E.G. (2000). *Growing Beyond Survival: A Self-Help Toolkit
> for Managing Traumatic Stress.* Baltimore, MD: Sidran Press.

### [TREATMENT]{.underline} 

> Alcoholics Anonymous. *The AA Member-Medications and Others Drugs.*
> (Pamphlet). New York: Author.
>
> Barry, L. (1997). *Yesterday\'s Tomorrow: Recovery Meditations for
> Hard Cases.* Hazelden Information & Educational Services.
>
> Cleveland, M., and Arlys, G. (1992). *The Alternative 12 Step: A
> Secular Guide to Recovery.* Health Communications.
>
> Galanter, M. (1999). *Network Therapy for Alcohol and Drug Abuse*.
> Guilford Publications.
>
> Kasl, C.D. (1992). *Many Roads, One Journey: Moving Beyond the 12
> Steps*. Harperperennial Library
>
> Marlatt, G.A., and Roberts, L.J. (1998). Introduction to special issue
> on treatment of comorbid addictive behaviors: Harm reduction as an
> alternative to abstinence. In session: *Psychotherapy in Practice,* 4,
> 1-8.
>
> Peluso, E., and Silvay Peluso, L. (1988). *Women and Drugs: Getting
> Hooked, Getting Clean.* Hazelden Information & Educational Services.
>
> Trimpey, J., and Ellis, A. (1995). *The Small Book: A Revolutionary
> Alternative for Overcoming Alcohol and Drug Dependence.* Dell
> Publishing Company.

**[WAITING LIST FOR INTEGRATED PROGRAMS]{.underline}**

> Miller, W.R., and Meyers, R.J. with Hiller-Sturmhofel, S. (1999). The
> Community-Reinforcement Approach. *Alcohol Research and Health,* 23,
> 166-220.

######  **[WOMEN , CO-OCCURRING DISORDER AND TRAUMA]{.underline}**

> Harris, M. (1998). *Trauma Recovery and Empowerment: A Clinicians
> Guide for Working with Women in Groups.* Washington, DC: Community
> Connections.
>
> Najavits, L.M., Weiss, R.D., and Liese, B.S. (1996). Group
> cognitive-behavioral therapy for women with PTSD and substance use
> disorder. *Journal of Substance Abuse Treatment,* [13
> (1)](../../../../../../../../cdweb/journals/07405472/viewer.htt%3Fvol=13&viewtype=issue&iss=1#074054729502025),
> 13-22.
>
> **CENTER FOR SUBSTANCE ABUSE TREATMENT**
>
> **ELECTRONIC DISCUSSION LIST**
>
> As an expansion of services to the CSAT Treatment Improvement Exchange
> on the World Wide Web
> ([http://www.treatment.org](http://www.treatment.org/)), the Division
> of State and Community Assistance has established an electronic
> discussion list titled "Co-occurring Dialogues." This new Discussion
> Group focuses on issues related to dual diagnosis. For the purposes of
> this activity, dual diagnosis is defined as a mental disorder and
> substance abuse.
>
> Subscription to the "Co-occurring Dialogues" discussion list
> (dualdx@treatment.org) is free and unrestricted. Please send an e-mail
> to info@treatment.org if you desire to subscribe to this ListServ.
> Guidelines that further describe membership, purpose, and utilization
> will follow with your subscription. Please read these carefully.
>
> This Electronic Discussion Group belongs to the field. Membership is
> open to anyone, but CSAT reserves the right to remove someone not
> interacting in a professional manner. Individuals on an international
> level from the research community, educators, treatment agencies and
> providers, the recovery community, and all levels of government are
> participating. CSAT/DSCA is offering the discussion list as a means of
> communication, idea sharing, brainstorming, sharing of exciting
> publications and opportunities, and so on. The "Co-occurring
> Dialogues" will be used to make announcements and to broadcast
> information, and will be used by subscribers to ask questions of their
> peers, to seek information, and to respond to one another's needs.
>
> You are invited to subscribe and to forward this notice to anyone who
> may be interested. For further information, contact Carol Coley at
> (301) 443‑6539 or ccoley@samhsa.gov.
>
> **dualdx@treatment.org**

WELCOME TO THE CO-OCCURRING COMMUNIQUES ELECTRONIC MAILING LIST!!

> Please save this message for future reference, especially if you are
> not

familiar with discussion lists and list servers.

FAQ/GUIDELINES for the Co-occurring Communiques

(July 2000)

A periodic posting to explain the purpose and use of

the Co-occurring Communiques list.

Contents:

> A. PURPOSE AND MEMBERSHIP
>
> B. GUIDELINES FOR MESSAGES
>
> C. HOW TO GET HELP WITH YOUR SUBSCRIPTION

**A. PURPOSE AND MEMBERSHIP**

The Co-occurring Communiques is an open vehicle sponsored by the
Division of

State and Community Assistance (DSCA) at CSAT for communication between
and among researchers, educators, treatment agencies, the recovery
community, treatment providers, and all levels of government. This
moderated list focuses on ideas, questions, announcements, and concerns
specific to the field of dual diagnosis. Dual diagnosis is defined as a
mental disorder and substance abuse. Other issues are obviously
relevant, such as learning disabilities, HIV/AIDS, other medical
conditions, and so on.

> DCSA/CSAT may establish a task force of up to three individuals from
> the field to assist with planning and implementing this discussion
> list.
>
> **WHO CAN SUBSCRIBE:** Subscription and posting to the Co-occurring
> Communiques

list is unrestricted, but content and appropriateness will be moderated
and CSAT reserves the right to remove a subscriber.

> If you want to subscribe or unsubscribe to the Co-occurring
> Communiques list, send a message to info@treatment.org. Nonmembers
> wanting to post an announcement on the list should send a message to
> the same address.

**B. GUIDELINES FOR MESSAGES**

**1) Only subscribed users are invited to post messages.**

> To post a message to all the current Co-occurring Communiques
> subscribers use the

address: dualdx@treatment.org

2)  Keep postings within the scope of the list.

> The Co-occurring Communiques list should be used for messages of
> professional interest

to persons in the dual diagnosis treatment field. Postings to this list
should be limited to issues that are specific to dual diagnosis
treatment or to the improvement of the health of those undergoing such
treatment. No self-promotion, advertising of services or facilities, or
lobbying will be permitted. Any subscriber who violates these rules may
be removed from the list.

**3) Always use a descriptive subject line.**

The more descriptive you are, the more likely it is the right people
will read and respond to your posting.

**4) When replying, double-check the original subject line to see if it
is understandable and fits your posting.**

If the original subject line was meaningless or misleading, retype an

appropriate subject line. If you are using the reply function to post
something on a new topic, retype a new subject line.

**5) Always give your postings a full signature.**

Include your name, e-mail address, title, and organizational
affiliation. Try to limit your signature to four (4) lines.

**6) Send personal replies to the individual, not to the whole list.**

**Co-occurring Communiques is configured so that replies are sent to the
entire list, not just to the individual who posted the message**. This
is done to facilitate group discussion. Of course, mistakes are going to
be made (by new users, and/or experienced networkers when we are just
too fast with the Reply key!) Unfortunately, these errors sometimes
cannot be caught before they reach the entire list.

**7)** When you wish to send a personal reply to the individual who
contributed a Co-occurring Communiques message, **you must manually
replace the list address with the individual's address in the address
field**. CAUTION: Your mail system may appear to have a command that
will direct your reply to the individual rather than the list, but often
this selects Co-occurring Communiques as "sender," instead of the
individual.

8\) Examples of messages that should be sent back as personal replies
(posted to an individual):

a)  All requests for copies of offered materials. These should be sent
    directly to the offerer.

b)  "Thank you" messages, unless they are intended to halt other list
    members from continuing to fill a request.

c)  Messages consisting of "Me too" or a synonym thereof.

d)  Survey responses.

e)  Very specific answers to very specific questions that are unlikely
    to be of general interest.

9\) Be brief: Keep paragraphs and messages short and to the point.

Do not send long documents to the list. Instead, describe the document
and give instructions for retrieving it or offer to send it to those
interested. For conference announcements, send a brief message with an
e-mail address for further information.

10\) Read all the incoming mail from the List before responding; someone
may have already sent a reply similar to your own.

**11)** When sending a reply to the list, do not include the header from
the previous

message in the body of your message (this is the part that includes
"Sender", "From", and so on.). The list server may not distribute the
message. It may end up with the dualdx@treatment.org delivery errors,
never to be seen again.

**12)** When sending a reply to the list, do not include the entire
previous message. Extract only those brief portions of the message that
are necessary to identify the issue and make your point. Repeating long
messages and headers needlessly clogs Co-occurring Communiques archives
with repetitions of the same message.

**13)** Messages appearing on Co-occurring Communiques may be forwarded
to other lists or individuals, as long as proper credit is given to the
author.

**14)** CSAT accepts no responsibility for the opinions and information
posted by users.

C. HOW TO GET HELP WITH YOUR TIE-FORUM SUBSCRIPTION:

Co-occurring Communiques subscribers who have TECHNICAL/SUBSCRIPTION
questions should contact: info@treatment.org